Weight Stigma and Food Bias

We all live in diet culture, a society obsessed with thinness and dieting. Weight and food biases permeate the air we breathe, tingeing our thoughts and actions in ways sometimes hard to notice. Providers, patients—none of us—are immune to these biases. They’re often subtle and deeply embedded, and left unexamined and unchecked, they can manifest in interactions between patients and even the most capable, well-intentioned providers.

In this article, we define and discuss weight and food bias, including its perpetuating factors and health consequences. Learn the impact of weight stigma and how to recognize and counter implicit and explicit bias in yourself, your practice, and in our larger society.

What are weight bias and stigma?

Weight bias refers to negative attitudes, beliefs, or assumptions about others based on body weight or size. Internalized weight bias occurs when these negative weight-related beliefs are absorbed and held about oneself.

Weight bias can lead to weight stigma, or the disapproval of someone based on their weight. Stigma is seeing someone negatively because of their weight, which can in turn lead to treating someone negatively because of it. Stigma manifests in stereotyping, bullying, and discrimination on the basis of weight, as well as exclusion and marginalization in media, professional, health care, and other settings. While weight bias harms people of all sizes, those who live in bodies that do not conform to “normal” body size expectations experience the greatest weight stigmatization.

The Centers for Disease Control and Prevention (CDC) describes body sizes using body mass index (BMI), a measure of a person’s weight relative to their height. Importantly, the BMI does not account for sex and racial differences, muscle mass, or overall body composition, and as the CDC acknowledges, it is “not diagnostic of body fatness or the health of an individual.”

The CDC’s BMI categories include:

• For children and teens, “overweight” is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. “Obesity” is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
• For adults, “overweight” is defined as a BMI between 25 to <30, and “obesity” is defined as a BMI of 30 or greater. Three classes exist within “obesity”: 30 to <35, 35 to <40, and 40+.

The impact of stigma

Weight stigma manifests in all areas of life. It can be expressed in both private and public settings by family members, friends and peers, employers, health care and other professionals, and institutions. Comments, images, or behaviors that indicate disapproval of, make judgments about, or outright harass or exclude those in larger bodies are examples of stigmatization. Other examples include a reluctance to serve, accommodate, work with, or care for a person because of their weight, as well as marketing and other messages that tout diet products as a way to “fix” the assumed problem of weight.

Additional examples of weight stigma in everyday life include:

• A person in a larger body visiting the doctor for an injury or common illness, and instead of receiving a proper exam or evidence-based intervention, is asked to lose weight [See Rachel Wiley’s ‘The Fat Joke’]
• Airplane seats that do not accommodate people in larger bodies, airlines asking them to purchase a second seat, and judgment from people in seats nearby
• Limited (or no) clothing options at popular retailers, and plus-size sections often hidden away in a quieter part of the store
• Weight-based discrimination in hiring and promotion opportunities
• Comments from family or friends such as “You run fast for your size” or “You’re not fat, you’re beautiful,” which implies that a person cannot be both
• Unsolicited weight loss advice

These examples make visible weight-biased beliefs that associate people in higher-weight bodies with laziness, lack of willpower, poor lifestyle choices, lack of moral character, bad hygiene, a low level of intelligence, and unattractiveness.

Ample research confirms that weight stigmatization is not only pervasive but incredibly harmful. Studies show that people categorized with BMIs considered “overweight” or “obese” are at much greater risk of being stigmatized. According to one such study from the Rudd Center for Food Policy and Obesity (as reported by the WHO):

• School-aged children categorized as “overweight” or “obese” experience a 63% higher chance of being bullied
• 54% of adults categorized as “obese” report being stigmatized by co-workers
• 69% of adults categorized as “obese” report being stigmatized by health care professionals

Weight stigma in media

Popular narratives may contribute to weight stigma by oversimplifying body weight, suggesting that it is a direct result of personal habits and a determinant of a person’s health or character. Such narratives often focus on individual behaviors and perceived failures. With messages like “eat less; move more,” they neglect to take into consideration important biological, social, economic, and environmental factors, including food security, economic stability, and community resources.

As a primary cultural storyteller, media often reinforce weight stigma by perpetuating negative, stereotypical portrayals of higher-weight people. Research shows that 72% of media images and 77% of videos include these stereotypical portrayals. Larger-bodied characters are also severely underrepresented in media. When they do appear, they are often punchlines (“Fat Monica” in Friends, for example), villains (The Little Mermaid’s Ursula), or portrayed as dim-witted (Homer Simpson). They rarely have fully developed characters or storylines.

Health consequences of weight stigma

Shaming, harassing, or criticizing people about their weight and/or eating patterns is often done to “motivate” people to change their behavior. However, research and lived experience reveal the opposite effect.

Like other types of stigmatization and discrimination, weight stigma is associated with significant physiological and psychological consequences. They include:

• maladaptive eating patterns
• poor body image and body dissatisfaction
• low self-esteem and self-confidence
• feelings of worthlessness and loneliness
• avoidance of physical activity
• avoidance of medical care
• suicidal thoughts and actions
• depression and anxiety

Weight stigma can also affect the quality of care for patients who receive it, ultimately leading to poor health outcomes and increased risk of mortality.

Food bias

Weight bias isn’t the only bias pushed by diet culture—food bias exists as well. Our culture often thinks of food in terms of moral terms:

• “Good” vs. “bad”
• “Guilt-free” vs. “sinful”
• “Clean food” vs. “junk food”

Moreover, too often people assign value to themselves for eating so-called “bad” foods. Comments like “I’m being so bad tonight, ordering the pizza instead of a salad” or “I’m cheating tonight” imply that we are better or worse people depending on the food decisions we make.

How can we make a difference?

Know ourselves

As with many changes, the first place to look is at ourselves. The thoughts and feelings we have about our own and others’ bodies influence how we interact with patients, colleagues, and others in our lives.

A good starting point is to examine our implicit biases, which we all have. The Harvard Weight Implicit Association Test (IAT) is a validated measure of unconscious attitudes and beliefs about weight. It is available to take for free.

Other questions to ask yourself include:

• Do I make assumptions about a person’s health based on their weight or size?
• When I say “healthy” and “unhealthy,” do I mean “thin” and “fat”?

Social media and purchasing power

Choose which individuals and organizations to give your social media “likes” and real-life dollars to. Here are some questions to ask yourself when interacting with brands and social media accounts:

• Does this person share diet culture messages that position thinness as superior to fatness?
• Is this brand committed to weight and size inclusivity? Does it offer clothes for a wide range of body sizes?
• Is this company trying to sell me something to “fix” a perceived problem with my size, shape, or weight?
• Who benefits from me feeling bad about my weight or size?

To broaden acceptance of the diversity of sizes, we can also curate our feeds with messages that recognize and appreciate size diversity. We can unfollow or restrict accounts that perpetuate stereotypes about people in higher-weight bodies (or don’t represent them at all), and curate our feed so that it includes weight-inclusive and diverse accounts.

Some body positive spaces and influencers include:

• The Body is Not an Apology: Instagram, Facebook, Twitter
• The Body Positive: Instagram, Facebook, Twitter
• Ragen Chastain: Instagram, Facebook, Twitter
• Jessamyn Stanley: Instagram, Facebook
• Kimmie Singh, MS, RD: Instagram, Twitter
• Michelle Rogers: Facebook, Twitter, Instagram
• Aaron Flores, RDN: Instagram, Facebook

Activism and Advocacy

Another way to influence change is by lending your voice to activist and advocacy efforts. Suggestions include:

• Connect with organizations like the Association for Size Diversity and Health® (ASDA) or the National Association to Advance Fat Acceptance (NAAFA)
• Rally around awareness campaigns, such as Weight Stigma Awareness Week (WSAW) or hashtags like #losehatenotweight and #endweighthate
• Speak up in your own life:
  • Have difficult conversations that challenge the idea that thinner is always better
  • Interrupt instances of weight discrimination
  • Advocate for accessible and size-friendly seating, equipment, and layouts at your school, workplace, gym, and the places you shop
  • Let media producers, content creators, or business owners know when you recognize an image or message that is not (or is) weight-inclusive

Ensure eating disorder treatment is weight stigma-informed

Treatment for eating disorders of all types—including binge eating disorder—should not focus on weight loss. Though all of us live in a weight-obsessed world, the importance of weight is compounded for people with eating disorders; the preoccupation is often part of these illnesses.

What’s more, weight is not a behavior, and intentional weight loss does not heal an unhealthy relationship with food or the body. In fact, it often does just the opposite. Recovery, just like eating disorders, looks different on all patients. Some patients experience weight gain, others experience weight loss, and others still experience little to no weight changes at all.

Some practical considerations for eating disorder and other health professionals include:

• Allow patients to get blind-weighed, and ensure their weight remains invisible to them, even on visit summaries
• Ensure your facility has size-inclusive chairs, exam tables, gowns, and blood pressure cuffs
• Recommend evidence-based interventions to people in larger bodies as you do to people in smaller bodies
• Equip patients with tools to develop resistance to diet culture and strategies for handling instances of weight stigma

Remove judgment from food

Adopt an “all foods fit” approach free from food judgment. Removing moral value from food is an important part of a healthy relationship with food for all of us, and especially when challenging distortions present in disordered thoughts and behaviors. 

Ellyn Sattler’s hierarchy of food needs is another way to understand food decisions in a less-biased way. Like Maslow’s hierarchy of needs, Sattler’s hierarchy positions the elements that matter first at the bottom of the pyramid; at the top are more complex needs.

In Sattler’s pyramid, the most basic food need is having enough food to eat. Once that need is met, people can seek food that is acceptable (e.g., not spoiled or rotten), then food that is accessible and reliable. As people move up the pyramid, they can seek food that is good-tasting, then novel, then instrumental.

Embrace health-based focus to care

Weight-inclusive care accepts and respects body diversity and focuses on health instead of weight. Health At Every Size® (HAES) offers an approach that promotes health-related behaviors that improve well-being in a holistic sense. Its basic principles include:

• Weight inclusivity
• Health enhancement
• Eating for well-being
• Respectful care
• Life-enhancing movement

Weight bias and stigma are prevalent and consequential—and it’s on all of us to recognize, acknowledge, and challenge it in ourselves, in others, and in the places and institutions we inhabit.

To help your patient make peace with food and their body, connect them to eating disorder specialty care as soon as possible. Make a referral online or by calling 1-888-364-5977 today.