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The Current Landscape of Obesity Services: a Report from the All-Parliamentary Group on Obesity
"With the number of people with obesity projected to rise significantly in the coming years, action must be taken to treat patients with severe and complex obesity now, as well as strengthening prevention programmes and childhood obesity programmes to reverse this escalating trend." From the Chair of the All-Parliamentary Group on Obesity.
2021
Abstract
This report from the All-Party Parliamentary Group on Obesity is part of an inquiry into the current landscape of obesity services. It is designed to highlight barriers and opportunities for government, commissioners and other stakeholders to improve equitable access to obesity prevention and treatment programmes.
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The Effect of a Food Addiction Explanation Model for Weight Control and Obesity on Weight Stigma.
O'Brien, KS, Puhl, RM, Latner, JD, Lynott, D, Reid, JD, Vakhitova, Z, Hunter, JA, Scarf, D, Jeanes, R, Bouguettaya, A, et al
Nutrients. 2020;12(2)
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Research suggests that weight stigma is increasing and is associated with multiple negative health and psychological outcomes. Public health messaging presently emphasises weight gain as lack of personal control of diet and exercise, which contributes to the stigma and ignores the myriad of uncontrollable factors that also contribute to weight gain. One component of weight gain is food addiction, in which food is shown to be as rewarding to the brain as other addictive substances. It is currently unclear whether an explanation of the food addiction model (FAM) will affect weight stigma, and there is a need to understand the factors that contribute and reinforce weight stigmatisation. The aim of this study is to assess whether providing a FAM explanation for weight gain would impact expressions of weight stigma. Two experiments were done in which college students were randomly allocated to read a simulated article that focused on either food addiction or diet and exercise as contributing factors to obesity. The participants then completed a survey assessing their perception of obesity. This study found the FAM explanation resulted in a significantly lower weight stigma. Based on these results, the authors suggest current public health messaging that attributes obesity to lack of personal control needs to be changed as it exacerbates weight stigma.
Abstract
There is increasing scientific and public support for the notion that some foods may be addictive, and that poor weight control and obesity may, for some people, stem from having a food addiction. However, it remains unclear how a food addiction model (FAM) explanation for obesity and weight control will affect weight stigma. In two experiments (N = 530 and N = 690), we tested the effect of a food addiction explanation for obesity and weight control on weight stigma. In Experiment 1, participants who received a FAM explanation for weight control and obesity reported lower weight stigma scores (e.g., less dislike of 'fat people', and lower personal willpower blame) than those receiving an explanation emphasizing diet and exercise (F(4,525) = 7.675, p = 0.006; and F(4,525) = 5.393, p = 0.021, respectively). In Experiment 2, there was a significant group difference for the dislike of 'fat people' stigma measure (F(5,684) = 5.157, p = 0.006), but not for personal willpower weight stigma (F(5,684) = 0.217, p = 0.81). Participants receiving the diet and exercise explanation had greater dislike of 'fat people' than those in the FAM explanation and control group (p values < 0.05), with no difference between the FAM and control groups (p >0.05). The FAM explanation for weight control and obesity did not increase weight stigma and resulted in lower stigma than the diet and exercise explanation that attributes obesity to personal control. The results highlight the importance of health messaging about the causes of obesity and the need for communications that do not exacerbate weight stigma.
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Does weight-related stigmatisation and discrimination depend on educational attainment and level of income? A systematic review.
Bernard, M, Fankhänel, T, Riedel-Heller, SG, Luck-Sikorski, C
BMJ open. 2019;9(11):e027673
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Obesity is a global health issue due to its association with many chronic diseases, including type 2 diabetes, cardiovascular disease and certain cancers. Stigmatisation and discrimination against people with obesity has increased over the past few decades. According to the “Theory of class” a person’s “habitus”, that is their general attitude, lifestyle and even body shape, can be seen as a metaphor for social status. The aim of this systematic review of 17 studies was to investigate whether socioeconomic status is associated with “weight bias”, that is stigmatising and discriminating attitudes towards people with obesity. 11 of the 17 studies found a significant association between educational attainment and/or income with stigmatising and/or discriminatory attitudes, but results were mixed, with some studies showing that people with higher education and/or income level were more likely to display stigmatising and/or discriminating attitudes, whilst other studies showed the opposite. The authors conclude that the findings have to be discussed in the cultural context, including cultural and governmental differences.
Abstract
OBJECTIVES Obesity is considered a global health issue, because of its health-related consequences and also because of its impact on social status as a result of stigma. This study aims to review the quantitative state of research regarding socioeconomic characteristics' influence on weight-related stigmatisation and discrimination. Based on Bourdieu's Theory of Class and his concept of 'habitus', it is assumed that people with a higher level of education and income show stronger negative attitudes towards people with obesity. METHOD A narrative systematic literature review was conducted in 2017 using PubMed, PsychINFO, Web of Science and the Cochrane Library. Seventeen studies that measured weight bias and either educational attainment or level of income were included in the analysis. RESULTS The results of the studies included were inconsistent: six of these studies were found to support the hypothesis, whereas two of the studies contradicted it. The remaining seven studies did not show any significant correlation between weight bias and either education or income. CONCLUSION In light of the inconsistent and heterogeneous results of the studies that report a significant association between weight bias and socioeconomic variables, the findings must be discussed concerning their cultural context, that is, cultural and governmental differences. Furthermore, educational attainment seems to be more likely to predict weight bias than income. The review revealed a lack of research when it came to examining the impact of socioeconomic capital on weight bias.
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Potential unintended consequences of graphic warning labels on sugary drinks: do they promote obesity stigma?
Hayward, LE, Vartanian, LR
Obesity science & practice. 2019;5(4):333-341
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Consumption of sugar-sweetened beverages is associated with increased body weight and poor nutrition and health outcomes, including Type 2 diabetes and coronary heart disease. The aim of this study was to test the hypothesis that the graphic warning promotes weight bias (Study 1) and is also viewed as stigmatizing by people with overweight and obesity (Study 2). Study 1 Participants were randomly allocated to one of two conditions: a warning label condition (n = 324) or a control condition (n = 357). Results indicate that participants who were presented with the graphic warning label were more likely to intend to purchase water (instead of the soda) than participants who were presented with the standard label. Study 2 Participants (n=561) were randomly assigned to one of two conditions – overweight or obese. Results show that the majority of participants rated the warning label as personally stigmatizing. Moreover, after being exposed to the label, the participants experienced worse mood. Authors conclude that it is important for policymakers to strike a balance between the benefits and costs of public health interventions.
Abstract
INTRODUCTION Public health interventions need to balance the benefits with any potential harms. One proposed intervention for reducing sugar-sweetened beverage consumption involves placing graphic warning labels on products and advertisements. A recent study found that a graphic warning label that contained negative imagery of obesity reduced purchases of sugar-sweetened beverages. However, these labels may also promote obesity stigma, which is concerning given that weight stigma is associated with harmful health consequences including weight gain and increased risk of mortality. METHODS In Study 1 (n = 681), participants viewed a standard soda label or the graphic warning label online and then completed measures of disgust and prejudice towards people with obesity. In Study 2 (n = 506), participants who identified as having overweight or obesity viewed the graphic warning label online before or after completing measures of mood and state self-esteem. RESULTS In Study 1, participants who had viewed the graphic warning label reported higher disgust and weight bias. In Study 2, the majority of participants perceived the warning label to be stigmatizing, and participants displayed worse mood and, through this, lower self-esteem after viewing the label. CONCLUSIONS Although the graphic warning label has been found to reduce sugary drink purchases, it also promotes obesity stigma and is perceived as stigmatizing by individuals with overweight and obesity. Given that weight stigma predicts harmful health and well-being consequences, the benefits of graphic warning labels need to be balanced against the potential costs.
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"90% of the time, it's not just weight": General practitioner and practice staff perspectives regarding the barriers and enablers to obesity guideline implementation.
Mazza, D, McCarthy, E, Carey, M, Turner, L, Harris, M
Obesity research & clinical practice. 2019;13(4):398-403
Abstract
OBJECTIVE To identify the views of GPs and general practice staff regarding barriers and enablers to implementation of obesity guideline recommendations in general practice. METHODS Twenty general practitioners (GPs) and 18 practice staff from inner-eastern Melbourne, Australia, participated in semi-structured telephone interviews. The interview schedule was informed by the Theoretical Domains Framework (TDF). Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis. RESULTS Participants lacked familiarity with and knowledge of the NHMRC obesity guidelines. Barriers and enablers were predominantly related to five theoretical domains: (1) environmental context and resources, (2) knowledge, (3) emotion, (4) beliefs about consequences, and (5) motivation and goals. Time pressures in consultations, costs for the patient, reluctance to add to patient burden particularly in those with comorbidities such as mental health issues, lack of awareness about services to refer patients to and GPs' fear of embarrassing patients and losing them were significant barriers. Enablers included having a strong doctor-patient relationship and a sense of responsibility to the patient to address weight. CONCLUSIONS Obesity guidelines and policy makers need to better engage with issues of multimorbidity, socioeconomic disadvantage and workforce issues if recommendations are to be widely adopted in general practice. Tasksharing, teamwork and technology are potential solutions to some of the barriers. Patient perspectives and approaches to being able to overcome stigma and legitimise obesity management in primary care consultations could also assist.
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How and why weight stigma drives the obesity 'epidemic' and harms health.
Tomiyama, AJ, Carr, D, Granberg, EM, Major, B, Robinson, E, Sutin, AR, Brewis, A
BMC medicine. 2018;16(1):123
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Weight stigma is defined as the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape. In this opinion-based study, authors discuss that: • Latest literature indicates that weight stigma can trigger physiological and behavioural changes linked to poor metabolic health and increased weight gain. • Healthcare is a setting in which weight stigma is particularly pervasive, with significant consequences for the health of higher-weight patients. This stigma has direct and observable consequences for the quality and nature of services provided to those with obesity. • Stigma may be an unintended consequence of anti-obesity efforts, undermining their intended effect. Moreover, focusing solely on obesity treatment runs the risk of missing other diagnoses. • The science of weight stigma crystallizes a key point for future success – to tackle the obesity ‘epidemic’ we must tackle the parallel epidemic of weight stigma. • Public service messages are needed to educate people about the stigma, discrimination, and challenges facing higher-weight individuals. Authors conclude that to advance as an equal society, healthcare providers should lead the way for weight stigma eradication.
Abstract
BACKGROUND In an era when obesity prevalence is high throughout much of the world, there is a correspondingly pervasive and strong culture of weight stigma. For example, representative studies show that some forms of weight discrimination are more prevalent even than discrimination based on race or ethnicity. DISCUSSION In this Opinion article, we review compelling evidence that weight stigma is harmful to health, over and above objective body mass index. Weight stigma is prospectively related to heightened mortality and other chronic diseases and conditions. Most ironically, it actually begets heightened risk of obesity through multiple obesogenic pathways. Weight stigma is particularly prevalent and detrimental in healthcare settings, with documented high levels of 'anti-fat' bias in healthcare providers, patients with obesity receiving poorer care and having worse outcomes, and medical students with obesity reporting high levels of alcohol and substance use to cope with internalized weight stigma. In terms of solutions, the most effective and ethical approaches should be aimed at changing the behaviors and attitudes of those who stigmatize, rather than towards the targets of weight stigma. Medical training must address weight bias, training healthcare professionals about how it is perpetuated and on its potentially harmful effects on their patients. CONCLUSION Weight stigma is likely to drive weight gain and poor health and thus should be eradicated. This effort can begin by training compassionate and knowledgeable healthcare providers who will deliver better care and ultimately lessen the negative effects of weight stigma.
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Shame and avoidance as barriers in midwives' communication about body weight with pregnant women: A qualitative interview study.
Christenson, A, Johansson, E, Reynisdottir, S, Torgerson, J, Hemmingsson, E
Midwifery. 2018;63:1-7
Abstract
INTRODUCTION Excessive gestational weight gain, regardless of initial BMI, is associated with perinatal risks for both mother and offspring and contributes to obesity in women. Studies report that healthcare professionals find it difficult to communicate about weight and pregnant women perceive healthcare professionals as unconcerned, leaving many women uninformed about weight recommendations and risks. We aimed to explore how midwives approach communication about gestational weight gain recommendations, and to characterize communication barriers and facilitators. METHODS Seventeen midwives from different areas in Sweden were interviewed by a therapist using semi-structured interviews. Interviews were transcribed verbatim and analysed by three researchers using latent content analysis. Recurrent themes were identified and formulated. RESULTS The main theme identified in the latent part of the analysis was "midwives use avoidant behaviours to cope with fear of inflicting worries, shame or feelings of guilt in pregnant women". Avoidant behaviours include: adjusting weight recommendations, toning down risks and avoid talking about weight. Subthemes identified were (I) Conflicting responsibilities in midwives' professional identity (II) Perceived deficiencies in the working situation. CONCLUSION Midwives' empathy and awareness of weight stigma strongly affects communication about weight with pregnant women, and midwives' use of avoidant behaviours constitutes salient information barriers. More research is needed on whether gestational weight guidelines and weighing routines for all women, resources for extra visits, training in specific communication skills and backup access to other professions can facilitate for midwives to initiate and communicate about healthy gestational weight development, enabling more pregnant women to make well-informed lifestyle choices.
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Predictors of weight stigma experienced by middle-older aged, general-practice patients with obesity in disadvantaged areas of Australia: a cross-sectional study.
Spooner, C, Jayasinghe, UW, Faruqi, N, Stocks, N, Harris, MF
BMC public health. 2018;18(1):640
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People in higher categories of obesity are at substantially increased health risk because mortality increases sharply as body mass index rises above 30. In addition to physical health risks, people with obesity commonly experience weight-related stigma. The aim of this study was to identify predictors of perceived weight stigma among patients with obesity attending general practices in socioeconomically disadvantaged urban areas of Australia. This is a cross-sectional study for which data from telephone interviews with patients with obesity were used. Patients were recruited from 17 general practices in socioeconomically disadvantaged areas of Sydney and Adelaide. Results indicate that one-third of the sample had experienced direct forms of weight discrimination in the week before being interviewed. Furthermore, weight discrimination was more likely to be experienced by patients in higher obesity categories, who were not employed, who spoke a language other than English at home and who had lower scores on the Health Literacy Questionnaire domain (that measures the ability to actively engage with healthcare providers). Authors conclude that weight stigma may compound other forms of social disadvantage. Thus, strategies are needed to address weight stigma at the individual, system and population levels and to educate primary care providers to be more alert to the needs of their patients with obesity.
Abstract
BACKGROUND Rates of obesity have increased globally and weight stigma is commonly experienced by people with obesity. Feeling stigmatised because of one's weight can be a barrier to healthy eating, physical activity and to seeking help for weight management. The aim of this study was to identify predictors of perceived weight among middle-older aged patients with obesity attending general practices in socioeconomically disadvantaged urban areas of Australia. METHODS As part of a randomised clinical trial in Australia, telephone interviews were conducted with 120 patients from 17 general practices in socioeconomically disadvantaged of Sydney and Adelaide. Patients were aged 40-70 years with a BMI ≥ 30 kg/m2. The interviews included questions relating to socio-demographic variables (e.g. gender, language spoken at home), experiences of weight-related discrimination, and the Health Literacy Questionnaire (HLQ). Multi-level logistic regression data analysis was undertaken to examine predictors of recent experiences of weight-related discrimination ("weight stigma"). RESULTS The multi-level model showed that weight stigma was positively associated with obesity category 2 (BMI = 35 to < 40; OR 4.47 (95% CI 1.03 to 19.40)) and obesity category 3 (BMI = ≥ 40; OR 27.06 (95% CI 4.85 to 150.95)), not being employed (OR 7.70 (95% CI 2.17 to 27.25)), non-English speaking backgrounds (OR 5.74 (95% CI 1.35 to 24.45)) and negatively associated with the HLQ domain: ability to actively engage with healthcare providers (OR 0.12 (95% CI 0.05 to 0.28)). There was no association between weight stigma and gender, age, education or the other HLQ domains examined. CONCLUSIONS Weight stigma disproportionately affected the patients with obesity most in need of support to manage their weight: those with more severe obesity, from non-English speaking backgrounds and who were not in employment. Additionally, those who had experienced weight stigma were less able to actively engage with healthcare providers further compounding their disadvantage. This suggests the need for a more proactive approach to identify weight stigma by healthcare providers. Addressing weight stigma at the individual, system and population levels is recommended. TRIAL REGISTRATION The trial was registered with the Australian Clinical Trials Registry ACTRN126400102162 .
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A sympathetic nervous system evaluation of obesity stigma.
Oliver, MD, Datta, S, Baldwin, DR
PloS one. 2017;12(10):e0185703
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The negative health consequences of obesity are well known. Those classified as obese also suffer from discrimination which has further negative psychological and physiological effects on well-being. The aim of this study was to see if attitudes to obesity can be modified at the physiological and psychological level by priming. 70 people aged 18-53 were randomly assigned to 2 groups. One group was shown images of obesity in negative settings, the other in positive settings. All participants then viewed an actual obesity discrimination incident. Levels of the digestive enzyme salivary alpha amylase (sAA) and skin conductance (SC) were taken as measures of sympathetic nervous system (SNS) activity. Individuals in the negative priming group had significantly more SC arousal and exhibited the highest overall sAA response after viewing the incident when compared to the positively primed group. The authors conclude that clinicians addressing stigma issues should consider the use of positively primed images as a method for reducing the possible long-term physiological consequences of the negative attitudes surrounding obesity.
Abstract
The portrayal of obesity in the media is often one of negativity. Consequently, it may generate an increase in stigma. Obesity stigma, a form of social discrimination, is responsible for many of the negative psychological and physiological effects on individual wellness. These effects not only impact individual health, but also affect the economy, and ultimately, societal wellness. In an attempt to examine the influence of the media on obesity stigma, this study tested the hypothesis that positive priming would lead to a reduction in obesity stigma. To further our understanding of this relationship, we: 1) examined the role of priming on physiological measures (e.g. salivary alpha amylase and skin conductance) in 70 college students by introducing positive and negative media images of individuals with obesity, and 2) assessed psychological measures (e.g. perceived stress, need to belong, and self-esteem, and Body Mass Index). After the priming manipulation, participants read a vignette depicting the discrimination of an individual with obesity and answered subsequent questions assessing participants' attributional blame of obesity. Results of this study revealed that priming affects physiological responding to obesity stigmatization. In conclusion, these findings suggest that incorporating positive media images of individuals with obesity may be an effective tool for reducing stigma and the various physiological consequences associated with it, which in turn, can enhance societal health and wellness.
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Association between weight bias internalization and metabolic syndrome among treatment-seeking individuals with obesity.
Pearl, RL, Wadden, TA, Hopkins, CM, Shaw, JA, Hayes, MR, Bakizada, ZM, Alfaris, N, Chao, AM, Pinkasavage, E, Berkowitz, RI, et al
Obesity (Silver Spring, Md.). 2017;25(2):317-322
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Weight stigma is a psychosocial consequence in which individuals with obesity experience public discrimination and devaluation. Some individuals apply these negative stereotypes to themselves, which creates a self-directed stigma referred to as weight bias internalization (WBI). While studies have found perceived weight discrimination to be associated with an increased risk of mortality, no study has investigated the relationship between WBI and obesity on the risk of developing metabolic syndrome (MetS). The aim of this study is to examine the relationship between WBI and MetS. The authors hypothesised that among obese individuals, higher levels of WBI would be associated with increased odds of having MetS. Among the 178 obese adults recruited, 159 completed the study. Tests included anthropometric measurements, blood analysis, the Weight Bias Internalization Scale (WBIS) and the Patient Health Questionnaire. This study found that individuals who self-stigmatise may have a heightened risk of dyslipidemia, one component of MetS. Based on these results, the authors conclude that weight stigma is a chronic stressor and may contribute to poor health. Future studies are needed to identify specific pathways in which WBI exacerbates cardiometaoblic risk factors.
Abstract
OBJECTIVE Weight stigma is a chronic stressor that may increase cardiometabolic risk. Some individuals with obesity self-stigmatize (i.e., weight bias internalization, WBI). No study to date has examined whether WBI is associated with metabolic syndrome. METHODS Blood pressure, waist circumference, and fasting glucose, triglycerides, and high-density lipoprotein cholesterol were measured at baseline in 178 adults with obesity enrolled in a weight-loss trial. Medication use for hypertension, dyslipidemia, and prediabetes was included in criteria for metabolic syndrome. One hundred fifty-nine participants (88.1% female, 67.3% black, mean BMI = 41.1 kg/m2 ) completed the Weight Bias Internalization Scale and Patient Health Questionnaire (PHQ-9, to assess depressive symptoms). Odds ratios and partial correlations were calculated adjusting for demographics, BMI, and PHQ-9 scores. RESULTS Fifty-one participants (32.1%) met criteria for metabolic syndrome. Odds of meeting criteria for metabolic syndrome were greater among participants with higher WBI, but not when controlling for all covariates (OR = 1.46, 95% CI = 1.00-2.13, P = 0.052). Higher WBI predicted greater odds of having high triglycerides (OR = 1.88, 95% CI = 1.14-3.09, P = 0.043). Analyzed categorically, high (vs. low) WBI predicted greater odds of metabolic syndrome and high triglycerides (Ps < 0.05). CONCLUSIONS Individuals with obesity who self-stigmatize may have heightened cardiometabolic risk. Biological and behavioral pathways linking WBI and metabolic syndrome require further exploration.