Along with all the other changes it has wrought, the COVID-19 pandemic has now been linked to weight gain among children, adolescents, and adults (Woolford, S. J., et al., JAMAopens in new window, Vol. 326, No. 14, 2021; Lin, A. L., et al., JAMA Network Openopens in new window, Vol. 4, No. 3, 2021). Those physical changes are taking a psychological toll, because weight stigma—bias against individuals because of their body size—is also on the rise (Lessard, L. M., & Puhl, R. M., Journal of Pediatric Psychologyopens in new window, Vol. 46, No. 8, 2021).
More than 40% of U.S. adults, across a range of body sizes—and even greater numbers abroad—report experiencing weight stigma at some point in their life (Lee, K. M., et al., International Journal of Obesityopens in new window, Vol. 45, 2021;Puhl, R. M., et al., PLOS ONEopens in new window, Vol. 16, No. 6, 2021). Like other forms of bias and discrimination, weight stigma, also called sizeism, leads to suffering and psychological distress. Sizeism increases a person’s risk for mental health problems such as substance use and suicidality (Hatzenbuehler, M. L., et al., Obesityopens in new window, Vol. 17, No. 11, 2009; Brochu, P. M., International Journal of Obesityopens in new window, Vol. 44, 2020).
Weight stigma also undermines health behaviors and preventive care, causing disordered eating, decreased physical activity, health care avoidance, and weight gain (Tomiyama, A. J., Appetiteopens in new window, Vol. 82, 2014). Over the long term, it even increases the risk of mortality (Sutin, A. R., et al., Psychological Scienceopens in new window, Vol. 26, No. 11, 2015).
“There’s a perception that weight stigma might feel bad but [that] it’s tough love and it’s going to motivate people,” said Sarah Novak, PhD, an associate professor of psychology at Hofstra University in Hempstead, New York. “But research shows that this isn’t true.”
Adults face sizeism at work, at the doctor’s office, and in romantic relationships; at school, it tops the list of reasons why children are bullied. And unlike many other forms of bias that pervade American culture—including racism, sexism, and ageism—discrimination based on body size is legal in almost every state.
“Simply put, weight stigma is damaging to both emotional and physical health, and it decreases quality of life,” said psychologist Rebecca Puhl, PhD, a professor at the University of Connecticut and deputy director of the university’s Rudd Center for Food Policy and Healthopens in new window. “This tells us that we need to address weight stigma not only as a social justice issue but also as a public health issue.”
Effects of sizeism
Sizeism is one of the most deeply entrenched stigmas in today’s society, partly because of sociocultural ideals tying thinness to core American values such as hard work and individualism, said Puhl. The implication is that people in larger bodies lack willpower and discipline.
“People can’t change the color of their skin, but there’s this perception that people can diet their way out of obesity—that if somebody has a larger body, it’s 100% their fault,” said Janet Tomiyama, PhD, a professor of health and social psychology at the University of California, Los Angeles.
Forty-two percent of U.S. adults say they have faced some form of weight stigma, such as being teased about their weight or treated unfairly because of it, with physicians and coworkers listed as some of the most common sources (Lee, K. M., et al., International Journal of Obesityopens in new window, Vol. 45, 2021; Puhl, R. M., et al., International Journal of Obesityopens in new window, Vol. 45, 2021). Among children, weight-based bullying is more common than bullying based on race, sexual orientation, or disability status (Bucchianeri, M. M., et al., Journal of Adolescenceopens in new window, Vol. 51, 2016). And unlike many other types of stigma, family members and romantic partners are high on the list of perpetrators.
“This is a unique thing about weight stigma: The people who are closest to you and should be the sources of social support are often the ones who are most stigmatizing,” Tomiyama said.
Sizeism is more frequently directed at women (Spahlholz, J., et al., Obesity Reviewsopens in new window, Vol. 17, No. 1, 2016) and individuals living with multiple stigmatized identities, such as gay or transgender people (Puhl, R. M., et al., Health Psychologyopens in new window, Vol. 38, No. 8, 2019).
Perhaps ironically, weight stigma actually leads to a decrease in health-seeking behaviors—and an increase in weight—over time. Regardless of their body mass index (BMI), people who face weight stigma are more likely to engage in disordered eating or unhealthy eating behaviors, such as binge eating (Vartanian, L. R., & Porter, A. M., Appetiteopens in new window, Vol. 102, 2016). They are also more likely to avoid exercising and to report feeling uncomfortable exercising in public (Vartanian, L. R., & Novak, S. A., Obesityopens in new window, Vol. 19, No. 4, 2012).
These behavioral changes may explain why both adults and children who are victims of sizeism tend to gain weight (Jackson, S. E., et al., Obesityopens in new window, Vol. 22, No. 12, 2014; Hunger, J. M., & Tomiyama, A. J., JAMA Pediatricsopens in new window, Vol. 168, No. 6, 2014). Weight stigma leads to higher cortisol levels, a condition linked to fat deposition and numerous chronic health problems (Tomiyama, A. J., Appetiteopens in new window, Vol. 82, 2014). It also increases risk for psychological problems including depression, anxiety, substance use, and suicidality, particularly when people internalize sizeist attitudes and begin to self-stigmatize (Pearl, R. L., & Puhl, R. M., Obesity Reviewsopens in new window, Vol. 19, No. 8, 2018).
Such health issues are compounded by the fact that many people who have faced weight stigma from health care providers avoid seeking further treatment (Phelan, S. M., et al., Obesity Reviewsopens in new window, Vol. 16, No. 4, 2015). For example, patients commonly report that physicians attribute all health problems to excess weight and make assumptions about patients’ health behaviors, such as assuming that they overeat. Experiencing bias in health care settings can cause patients to trust their providers less, practice “doctor shopping,” and delay or avoid seeking treatment for various health issues (Alberga, A. S., et al., Primary Health Care Research & Developmentopens in new window, Vol. 20, 2019).
“Every bit of weight stigma a person encounters from their doctor makes it less likely that they’re going to go back, and that is a bad outcome,” said Traci Mann, PhD, a professor of psychology at the University of Minnesota.
In mental health care settings, early data suggest that eating disorders such as anorexia and bulimia are underdiagnosed among higher-weight patients (Sonneville, K. R., & Lipson, S. K., International Journal of Eating Disordersopens in new window, Vol. 51, No. 6, 2018; Spotts-De Lazzer, A., & Muhlheim, L., Journal of Health Service Psychologyopens in new window, Vol. 45, 2019). Patients with higher BMIs who report restrictive eating behaviors to their therapists often go undiagnosed for years, and they may even be encouraged to diet, said Catharine Devlin, PsyD, a Chicago-based clinical psychologist and owner of Birch Tree Psychotherapy, an outpatient practice focused on eating disorder treatment. They can also face difficulties with insurance reimbursement if they seek treatment for an eating disorder that is perceived to be inconsistent with their body size.
“If people with anorexia recover into larger bodies, they are often shamed by providers, which makes recovery so much harder,” said clinical psychologist Lauren Muhlheim, PsyD, who owns Eating Disorder Therapy LA, an outpatient practice in Los Angeles.
Sizeism is so harmful that even anticipating it is linked to psychological problems. Jeffrey Hunger, PhD, an assistant professor of psychology at Miami University in Oxford, Ohio, tests this experimentally by manipulating whether participants’ body sizes are visible in fictional dating profiles that they believe potential partners will see. Hunger and his colleagues have documented increases in anxiety symptoms and decreases in cognitive performance among participants who anticipate facing weight stigma (Body Imageopens in new window, Vol. 27, 2018; Journal of Experimental Social Psychologyopens in new window, Vol. 63, 2016).
Disrupting stigma
Psychologists have tested a range of interventions for sizeism that have proven effective with other types of stigma: encouraging empathy for people with overweight, delivering education about the many factors that determine body weight, and even inviting participants to don a body suit and “walk a mile” in the shoes of a heavier person (Incollingo Rodriguez, A. C., Obesityopens in new window, Vol. 24, No. 9, 2016). Most have only a small effect, if any, on anti-fat attitudes and beliefs (Lee, M., et al., Body Imageopens in new window, Vol. 11, No. 3, 2014).
“The types of interventions that tend to work for decreasing racism and sexism don’t seem to work here,” Tomiyama said.
Part of the reason for that, experts say, is that it remains legal to discriminate against people because of their weight. Only Michigan, Washington state, and a handful of cities—including San Francisco and Washington, D.C.—ban weight-based discrimination in the workplace. As a result, individuals with overweight are less likely to be hired and promoted than their thinner counterparts (Rudolph, C. W., et al., Journal of Vocational Behavioropens in new window, Vol. 74, No. 1, 2009), and they often make less money (Judge, T. A. & Cable, D. M., Journal of Applied Psychologyopens in new window, Vol. 96, No. 1, 2011).
“Legal protections have been passed to reduce disadvantages for various stigmatized groups, but we don’t see the same thing happening for weight,” Puhl said. “That essentially sends a message that this is a tolerable form of unfair treatment.”
At school, children face a similar landscape. Though body size is one of the main reasons children are bullied, only a handful of states and districts include language about weight in their anti-bullying policies.
Protective laws and policies may be scarce, but public support for them is not. Puhl and her colleagues have found that about three quarters of U.S. adults support expanding anti-sizeism protections in the workplace (International Journal of Obesityopens in new window, Vol. 40, 2016) and that 81% of U.S. parents support addressing weight-based bullying at the state and federal levels (Pediatric Obesityopens in new window, Vol. 12, No. 2, 2017).
“We know the public support is there, but the policy change is not happening fast enough,” Puhl said.
Health care providers can also help shift attitudes about body weight and improve physical and mental health outcomes. Clinicians, including psychologists, should start by exploring stigmatizing views they may hold, including whether they make different recommendations for patients based on body size, Devlin said. The Implicit Associations Test offers one of several self-assessmentsopens in new window on weight stigma. Early evidence also suggests that psychologists can help clients identify and address their own internalized weight stigma using cognitive behavioral therapy or acceptance and commitment therapy (Pearl, R. L., et al., Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesityopens in new window, Vol. 23, 2018; Levin, M. E., et al, Cognitive and Behavioral Practiceopens in new window, Vol. 25, No. 1, 2018).
Research indicates that patients who engage in supportive conversations with their physicians, rather than stigmatizing ones, are more motivated to comply with subsequent recommendations (Hayward, L. E., et al., Stigma and Healthopens in new window, Vol. 5, No. 1, 2020). Physicians can also help people of all body sizes improve their health without making recommendations based on weight.
The same goes for public health messaging. Puhl and her colleagues found that when messages focus on health behaviors—such as replacing sugary drinks with water or improving fruit and vegetable consumption—without mentioning weight or obesity, participants report higher motivation and intent to change their behavior (International Journal of Obesityopens in new window, Vol. 37, 2013).
“Weight doesn’t need to be part of the message in order to motivate and encourage people to engage in health behavior change,” she said. “Rather than blaming and shaming people for their larger body size, we need to instead support and empower people to be healthy, regardless of what body size they have.”
