DR AMANDA HUGHES, DR HELEN BOULD AND PROF LAURA HOWE, MEDICAL RESEARCH COUNCIL (MRC) INTEGRATIVE EPIDEMIOLOGY UNIT AT UNIVERSITY OF BRISTOL - WRITTEN EVIDENCE (FDO0022)

The MRC Integrative Epidemiology Unit (IEU) at the University of Bristol conducts some of the UK's most advanced population health science research. It uses population data, genetics and experimental interventions to improve our understanding of how social, environmental, and genetic factors act jointly to influence health.

 
This response covers two main themes: 

1. the impacts of obesity on health, including on children and adolescent health outcomes, and the influence of pre- and post-natal nutrition on the risk of subsequent obesity,
2. The effectiveness of Government planning and policymaking processes in relation to food and drink policy and tackling obesity, including the impact of recent policy tools and legislative measures intended to prevent obesity.

This response describes the implications of obesity-related stigma for population health and for health inequalities, and the potential for anti-obesity measures to exacerbate stigma.

Summary

• Despite being common, obesity is highly stigmatized.
• Stigma and discrimination towards people living with obesity contribute substantially to the negative consequences of obesity for population health.
• Obesity stigma disproportionately impacts already disadvantaged groups and is therefore likely to exacerbate health inequalities.
• Initiatives aiming to tackle obesity can inadvertently add to stigma, with counterproductive results.
• It is crucial to avoid obesity-stigmatizing messaging in interventions targeting children and adolescents, for whom psychological impacts may be especially long-lasting.
• Interventions which tackle the food environment and physical activity at a societal level, rather than targeting individuals, are likely to have fewer adverse effects.

Obesity is highly stigmatized, and this stigmatization contributes to the negative consequences of obesity for population health.

Obesity-related stigma and discrimination are widespread across society. Negative stereotypes about people living with obesity are prominent in public discourse, which often present people living with obesity as lazy, undisciplined, unintelligent, and immoral[1],[2] . Consequently, obesity-related stigma and discrimination is observed in almost every area of life, including employment[3] , educational[4] , and medical settings[5] .

Obesity-related stigma and discrimination add to the implications of obesity for health, through:

• Healthcare avoidance. People living with obesity may delay or avoid seeking medical treatment for fear of stigmatizing interactions with doctors[6] .
• Reduced physical activity. People living with obesity may avoid exercising in public for fear of shaming and abuse[7],[8]  
• Consuming more high-calorie foods[9] and weight gain over time[10]
• Reduced efficacy of weight-control measures[11]
• Psychological effects, including higher levels of depression, even in children and adolescents[12]
• Internalized weight stigma. This is when people come to agree with negative obesity-related stereotypes and apply them to themselves, often leading to reduced self-worth[13] .

Obesity-related stigma does not only harm people living with obesity. Internalized weight stigma can also affect individuals whose body weight is low (BMI <18.5kg/m2) or within the recommended range (BMI 18.5-24.9kg/m2)[14], where it is linked with disordered eating and drive for thinness[15],[16]  .

Obesity stigma disproportionately impacts already disadvantaged groups and is therefore likely to exacerbate health inequalities.

The UK has stark inequalities in health between socioeconomic groups, genders, and ethnicities. Obesity stigma is likely to worsen health inequalities in several ways:

• Obesity is more common among disadvantaged groups, including adults and children living in more deprived areas, and some minority ethnic groups. Consequently, obesity stigma disproportionately impacts already marginalized populations.

• Even comparing people of the same weight, our research shows psychological impacts of weight stigma may be worse for several disadvantaged groups[17]. At a given weight, a person is more likely to ‘internalize’ weight stigma if they are:

a)      female

b)      have spent more time not in education, employment or training (NEET)

c)      are not heterosexual

• Since women, people who have been unemployed[18] and sexual minorities[19] are already at higher risk of mental illness, the psychological impacts of weight stigma are likely to compound these health inequalities.

• Stigmatization of obesity is closely intertwined with stigmatization of poverty, which is independently linked to poor health outcomes[20]. For example, people with stigmatizing attitudes about obesity also tend to stigmatize people receiving state benefits[21]. This reflects a prominent narrative in media and politics which links obesity and poverty as similar kinds of moral failure, or as resulting from poor choices.

Initiatives aiming to tackle obesity can inadvertently add to stigma, with counterproductive results.

Some public health initiatives which aim to reduce obesity may contribute to weight stigma[22]. One example is using graphic warning labels with negative imagery of obesity to reduce purchases of sugar sweetened beverages. In experiments, such labels have been shown to increase feelings of disgust towards people living with obesity, and to reduce self-esteem among people living with obesity[23]  .

Such approaches are also likely to backfire: in experiments, exposure to weight stigmatizing content causes people to consume more high-calorie foods[24], and people who report more experiences of weight stigma in everyday life have been shown to gain more weight over time[25] .

Particular care must be taken when designing measures aimed at children and adolescents: evidence suggests that stigmatizing messages about weight at age 13 can continue to impact psychological health almost two decades later[26] .

Unintended consequences can be broad: a quasi-experimental study showed that sending ‘weight report cards’ to UK children aged 10-11 did not lead to weight loss, but did cause overweight children to skip breakfast. Impact on breakfast skipping was more pronounced in single-parent and low-income families, and among overweight children from deprived neighbourhoods, who were also more likely to feel tired and unhappy at school following the intervention.

In the context of a youth mental health crisis, where 1 in 5 children and young people have a probable mental disorder, and 1 in 5 women aged 17-19 have an eating disorder, it is paramount that measures taken to tackle obesity do not add to these problems.

Ways to avoid increasing weight stigma may include:

• Not using imagery which presents people with obesity in a dehumanising manner, such as headless, in unflattering positions, or with negative facial expressions[27] 
• Using respectful and person-centred language when discussing obesity and body weight more widely[28]
• Recognition that weight is influenced by many factors beyond an individual’s control, including structural and economic constraints as well as genetic influences. For example, nutrient-poor, calorie-dense foods are often chosen to stretch a restricted food budget[29], and cost can be a barrier to physical activity for individuals on a low income. Besides direct effects of income, stress associated with poverty and food insecurity can further impede ability to prepare food that is nutritionally balanced.
• Prioritisation of interventions that tackle the food environment and physical activity at a societal, rather than an individual, level. This includes taking action to improve the availability of healthy food choices, and facilities for affordable physical activity, especially in deprived areas[30].

Dr Amanda Hughes, Professor Laura Howe and Dr Helen Bould

Dr Amanda Hughes is a social epidemiologist and a Research Fellow at Bristol Medical School. She leads an ESRC-funded grant exploring causes and consequences of weight stigma using causal inference methods and general population survey data. https://www.bristol.ac.uk/people/person/Amanda-Hughes-ce051e7c-0779-4cb2-8c81-68cefa9dfd11/

Professor Laura Howe is a statistical epidemiologist, whose research draws on life course and causal inference approaches to understand the development of physical and mental health across the life course, with a particular focus on social influences on health. https://research-information.bris.ac.uk/en/persons/laura-d-howe

Dr Helen Bould is a Consultant Senior Lecturer in Child and Adolescent Psychiatry and NIHR Advanced Fellow, with research expertise in eating disorders and disordered eating. https://www.bristolbrc.nihr.ac.uk/people/helen-bould/

2 April 2024