The Impact of Weight Bias & Stigma: Dr. Angela Alberga

– Welcome back to Scale Up Your Practice, the podcast from Obesity Canada, where we bring together evidence, lived experience, and clinical insight to reimagine obesity care. I’m Dr. Roshan Abraham.

– And I’m Michelle McMillan. In our last episode, we introduced you to Dr. Angela Alberga, a national leader in obesity research. Today we’re diving deeper with a special focus on weight bias and stigma.

– Weight bias shows up everywhere, from classrooms and clinics to policies and playgrounds, and its impact is far reaching, especially for kids and teens.

– Dr. Alberga is back with us to unpack where weight bias hides, how it harms, and what we can do differently. So welcome. So let’s start at the top. We know the way bias is widespread, it’s everywhere. It’s around us from the headless people on the news with larger bodies, to children’s cartoons, to books, to our conversations at our family tables, right? But what are some of the less obvious places that you see that weight bias shows up?

– Thanks Michelle and Roshan for having me again. And this conversation, there’s so many examples of of weight bias and stigma that are everywhere, and maybe not so obvious ones, but they’re so ingrained in basically everything that sometimes it’s hard to even think about how this could weight bias and stigma. So, let’s think about first of all, maybe our environment and some of the things like surrounding us. Maybe we’ll start with healthcare and then maybe we’ll switch to some education examples too. In healthcare, we just notice our environment of our chairs surrounding us, like that our chairs are, you know, closed in with armrest. It basically showcases that not all bodies are welcome here, or that our system was not created or built to accommodate safely and comfortably bodies of all shapes and sizes. Same thing with like other medical equipment. So there’s even, you know, healthcare professionals who have challenged some of the issues with some of the equipment saying that we can’t get accurate measurements because we don’t have the right blood pressure cuffs to accommodate a larger arm circumference. We don’t have the right examinations table. We don’t have the right speculums to be able to do tests appropriately, comfortably, safely, and accurately too, for people living in larger bodies. So there’s examples of this that have been, you know, in our healthcare system for so long that really need to be changed, but it’s just unfortunately the status quo. That’s just been existed for so long, it’s so ingrained, but when we think about it critically, there’s so many examples of stigma that exists already there. And then when we think about education, I mean, I don’t even know where to start, how long do we have? There’s so many examples in the education system. Like, let’s think about, same thing, chairs and how our classrooms are created. In university settings, like, I just think at my university, we don’t necessarily have chairs that accommodate all body shapes and sizes. If we do, they may be at the front of the classroom or really at the back of the classroom, almost like ostracizing people too who may not seem to fit in. You know, when we think about gym equipment and in the gym and fitness centers and stuff, we think about bikes and treadmills and you know, desks, not desks. When we think about bench press and we want to lie down and we want to be on an exercise mat that accommodate all shapes and sizes. We don’t necessarily have the equipment that safely and comfortably accommodates everybody. And same thing in the education system, when we think about uniforms. Like there’s kids and teens who may not fit in certain uniforms, but it’s just the status quo that those are the t-shirts that we have. And you know, if it doesn’t fit you, I’m sorry, but we don’t have that type of clothing that accommodates you. And then we could even see that in the clothing industry and businesses. I mean, there’s so much lack of diversity and different sizing for different types of clothing from different companies, that too is ingrained weight bias and stigma. You know, we’re not even thinking about offering different sizes to accommodate everyone safely, comfortably and in a like diverse way. So those are some examples of that. I mean, I guess my last example I’ll give in the interest of time, not to go on too much here, but you know, there’s internalized stigma too. And this is something where we start really believing that we deserve to be stigmatized and we self stigmatize and that can affect a lot of our mental health. So internalized weight stigma is something as well, thinking negatively about our bodies, that we deserve less because we live in larger bodies and even things that we say. So if we say, I’m sure you’ve heard this saying before where people say, “You look great, have you lost weight?” You know, and what does that imply? When we really think deeply about what that means, it means that you look better when you live in a smaller body. And that’s deeply ingrained stigma when we associate negative bodies with less success, you know, less beautiful, less romantically attractive partners, but when people live in smaller bodies, they’re more preferred and there’s, you know, positive comments about that. You know, we can’t think that this is all bad intentions. People mean well. They don’t mean to say something to make people feel badly about themselves, but when we think about deeply ingrained stigma, those are some of the ways that they can appear.

– I’m really glad you brought that up. I mean, you’ve highlighted numerous examples of how stigma plays out for our young colleagues, friends, kids, both in schools as well in sports. Your comment about, hey, you’re looking well because you’ve lost weight. Definitely hits a nerve for me. Culturally, that’s something that is deeply ingrained in the culture that I’m from as is the case in a lot of other cultures. And that’s sometimes the first thing you would hear when you are younger and you would walk into the door to see a family member or a family. And even when I bring it up now with my family and trying to challenge that, it’s not met with any sort of disdain. It’s met with confusion.

– Right,

– Right. It’s not really understood why that knee-jerk response actually has harmful effects, not just right then and there, but for years afterwards. It actually sits with you for years because you feel afraid to actually walk into that door or see those people, not because you don’t love them, but because you’re afraid that they’re just going to talk about your weight the whole time. And as a young person, how do you experience safety then, if you’re expected to feel that in the places that your family exist?

– Exactly.

– So I mean, it’s everywhere and I’m so glad you bring that up as well as just sort of the seemingly innocuous ways in which stigma rears its head. The sports jersey one is just so powerful, being someone involved in sports for my whole life, that is just a powerful example. I mean, we would see that time and time again. What a better way, what a what a horrible way to actually ostracize somebody than to actually show that you are different right in the team setting, right?

– Yeah, yeah.

– And I would add even, you know, because I’ve lived in a larger body my whole life, I hope the world has gotten slightly better. But you know, there used to be very strict school dress for physical activity of which I will say, particularly that the female uniforms were very short and you know, very expected to be in a small slim body to fit properly.

– Yeah.

– And so, are you really going to encourage anyone who doesn’t fit that stereotype to try out, to try to move their body? No, it’s embarrassing enough, right, to go and try out. If the uniform doesn’t even fit you, how long do you think you’re going to continue, try to be engaged in that activity? Which only compounds other health issues, right? Because it’s healthy for everyone to move.

– Exactly.

– Regardless of the size of body you’re in, right?

– Oh yeah. There’s tons of examples of this too. Like if kids don’t even want to wear the uniform, they may not want to participate in the activity.

– Exactly.

– So why are we creating barriers to suggest that, you know, you’re not included here or we’re not considering that. Why is that so important as a barrier to activity, you know?

– So I think moving on to something that a lot of my patients who are younger experience on probably a regular basis is mental health. What are some of those mental health or long-term health impacts of chronic exposure to weight bias, especially in youth?

– Yeah, so they are widespread, these consequences. And like you said, like you alluded to before, these stay with kids a really long time. These are not just short-term effects of weight-based teasing and stigma. These can last, like kids and teens can recollect times specific things that people have said years and years down the line. There’s actually been quite a bit of research on this too, if I can just remember one of the studies that I could think of is from Project EAT. So they looked at kids and teens and they followed them up for 15 years. So Dianne Neumark-Sztainer is the leader of Project EAT with a colleague, Rebecca Puhl, I mentioned before. And they did an examination where they looked at kids 15 years after they had had experience of weight-based teasing. And they found that weight-based teasing was a predictor of obesity 15 years later. It was a predictor of having a higher BMI, it was a predictor of binge eating, a predictor of eating to cope with negative feelings. It was a predictor of so many harmful mental health outcomes because of experiences of weight-based teasing. And there were some gender differences as well where girls were particularly traumatized and particularly affected by weight-based teasing. Boys did too, but in different ways. And when I could think of another, some research that our lab did, one of my graduate students did a big systematic review where she looked at the experiences of weight-based teasing over the short and long-term into adulthood. And she looked at depressive symptoms over time. And she found that whether you were stigmatized or weight-based teased for your weight as a kid, by your family, or by your peers, the more experiences you had by either peer-based teasing or family-based teasing, the worse off your depressive symptoms would be. And girls tend to have worse off depressive symptoms than boys did from experiences of weight-based teasing. And that was compounded by if you were teased by your family and your immediate circle, but also by your peers as well. So there’s so many long-term effects of this that are really diverse and can affect so many aspects of kids’ mental health over the long-term, like into adulthood.

– Wow.

– Yeah.

– I mean all of the examples that you’ve talked about are spirals, right? You know, you have someone in a larger body, they experience weight bias and weight stigma. It leads to less movement, more depression, which the literature tells us, then leads to more weight gain and disordered eating. I mean it’s like we’re setting up this terrible spiral. Given that, you know, one of the things we like to do for our listeners here is that, you know, and I know this is impossible, but we like to offer, is there one thing that you could offer to them to take back to their practice or their classrooms or wherever they’re going to be professionally tomorrow, that they could implement tomorrow that would make a difference regarding weight bias and weight stigma?

– I think that’s a hard challenge to just do one thing, but you know, maybe what I would say, and this is an uncomfortable topic, I think we first have to acknowledge that talking about bias and stigma and talking about our own biases and stigma is not a good feeling. We don’t like to acknowledge that we have biases. But the unfortunate truth is that we all have biases. I have biases, you both have biases. Everyone has our own biases that we have to acknowledge. Honestly, I think the first thing about weight bias and stigma is to look inward, is to look at ourselves and reflect on our own attitudes and biases because we all have them. And because they’re so ingrained, I mean it’s hard not to have biases when we literally live in a world where bias is literally everywhere. It’s surrounded with us in our culture, in our society, in our environment, everything we’re being exposed to. We don’t live in a bubble. And healthcare providers also are exposed to all this stuff as well. So we have to recognize that. And that’s uncomfortable. It’s not fun to talk about this, it’s not fun to acknowledge our own biases and stigma. But I think that’s the first thing I would say is look inwards and just, you know, self-reflect on some of those assumptions we make about people living in larger bodies. And start questioning, be curious, like we mentioned before, about what are those automatic reflections that are coming to our mind? What are the automatic assumptions, the automatic statements that we’re making about a person? Just because we see them, automatically, what do we think? And if we start reflecting on that and we start questioning our own assumptions, I think that could be helpful in trying to change what we understand about obesity, about the person in front of us. And then so that it doesn’t also affect how we treat people, because these assumptions that we make quickly in our mind, sometimes they’re so automatic, we don’t even have control over them. But if we start reflecting on those, then maybe it’ll also change how we start making prescriptions, how we start thinking about interventions, what we start promoting, what we start talking about to make sure it’s sensitive and non-judgmental and open-minded. And there’s a lot of ways to do this. Like there’s the Project Implicit through Harvard. You can do a Project Implicit weight bias test, so it’s an implicit association test. And honestly, when I first did this test, I was really surprised by my own scores. It was kind of depressing to see I had biases as well. But being able to do this test over and over, you can also see how your attitudes may change and you may also see positive change in yourself. And that’s really good self-reflection you can make about yourself. And then we could all really do this. So maybe that’s my one kind of tip I would say, even though it’s hard to choose just one about weight bias and stigma for now.

– I think addressing weight bias also is a bit of a team effort too, because of how much of it’s ingrained. And I just reflect as an educator in medical education about how so much the expectation is on individual to change themselves and change the system where the team is actually, and recruiting the right team members and people to address the issues that are in front of you, and in this case, weight bias and bias in general. Are there training programs, campaigns, policies, anything to I guess broaden that community that you think people should know about to help address that? Because I think, I mean, speaking from experience, my own work with Obesity Canada has dramatically influenced how I perceive not only weight bias and stigma, but bias in general. And it’s that larger community that’s been able to help me with that self-reflection. Can you think of any sort of one or two sort of salient points that we can sort of leave our listeners with?

– Yeah, so I think there’s so much we still have to do ’cause we actually have to undo a lot of harm that’s already been done.

– Yeah.

– And you know, when we think about public health and what’s been done in the past, unfortunately, it’s been highly criticized for obesity prevention type campaigns where there’s been stigmatizing language, aggressive framing, using alarmist epidemic of obesity type language, war-like language. So there’s a lot of harm we have to undo before we could still do good. And I totally agree, it’s about communities, it’s about higher level upstream approaches to actually address weight bias and stigma. And I think something really important to remember is that addressing weight bias and stigma is not about management of obesity. Weight bias and stigma is a social justice issue. It is an important public health issue regardless of what’s happening in healthcare. It’s an equity issue, it’s a human rights issue. It’s about addressing discrimination and equity and allowing opportunities for people to thrive regardless of their body shape and size. So I think that’s a really important piece. So a salient point, I guess would be to speak up and be an advocate, like we mentioned before. And I totally agree, we can’t just change individuals. We have to change systems, we have to change our environments, we have to change policies, upstream approaches to try to have trickle down larger effects on communities. And there’s so many great programs from Obesity Canada and there’s lots of education and training programs. And if we think about the Canadian pediatric obesity guidelines that just came out in April, I mean, that’s an awesome resource that’s was just created for healthcare professionals to address pediatric obesity sensitively. And if I could give a little plug for looking at the good practice statements in the pediatric obesity guidelines, that would be a good start to be able to look at resources that currently exist that address, you know, weight bias and stigma. And I think what we could do also is we can provide maybe some resources here with the podcast. So I’d be happy to share lots of resources that currently exist to try to address weight bias and stigma that have been created with lots of colleagues of mine, like internationally renowned. From the University of Connecticut, there’s lots of stuff from Obesity Canada where there’s training resources, manuals, and even training sessions that healthcare professionals can take to try to address our biases too and make an impact on a larger community level, wherever you’re working. So I think it’s really important to also recognize that we want to involve people with lived experience from the start. And you know, even though there’s tons of resources and campaigns and educational training opportunities for healthcare providers, I think also including the patient voice is so important. Whether they have lived experience, they consider themselves as a patient living with overweight and obesity, that is really key in also addressing weight bias and stigma because you’re getting a person’s lived experience perspective to make sure we’re not doing harm. You know, our first goal is first do no harm, so I think that the first thing that we could do is including lived experience, including that voice, and that will also help make sure that a lot of our policies, campaigns, initiatives, programs, interventions are sensitive and are including if this is okay and sensitive and caring for people living with obesity.

– Dr. Alberga, thank you for guiding us through this important conversation. Tackling weight bias isn’t just about better care. As you said, it’s about equity, dignity, and justice.

– And again, we again, ask our listeners to share this episode, start a conversation as we’ve discussed today, and ask the hard questions in your own setting. The more we talk about bias, the better we get at addressing it. We appreciate the time that you’ve given us today.

– Thanks Roshan and Michelle, it was a pleasure to be here.

– Don’t forget to subscribe on your favourite podcast platform. And if you’ve got ideas for future episodes, we’d love to hear them.

– Until next time, stay curious, stay kind, and keep scaling up your practice.

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