On April 14, 2022, the Aletta Jacobs School of Public Health will host the Aletta Research Meet-up on the topic of obesity. Leading up to the event, Aletta has been interviewing the event keynote speakers. For this interview we’re delving deeper into the stigma surrounding being overweight. Stuart Flint, Associate Professor of Psychology at the University of Leeds, specialises in understanding, measuring and intervening with subconscious processes that govern behaviour. Applied primarily in the space of obesity, diet and physical activity.

Can you tell us something about yourself and your field of expertise?

I have been focused on the research area of weight stigma for over 15 years. It has been a passion of mine from a research and a practical perspective. I work with different governments, policy makers, as well as healthcare, the NHS here in the UK, community groups and more locally with government authorities. Furthermore, I lead an artificial intelligence company where we provide insight about who people are based on personality attributes and values. We use that information to provide greater information about who people are and how they potentially interact and behave, which can be used to personalise and tailor approaches, for instance, in healthcare (e.g. to improve uptake adherence to medications). We're also using it in other spaces such as finance and education.

What exactly is the stigma around being overweight?

There is ultimately a stigma that is attached to body size and shape more generally. The first thing is that people of all body shapes and sizes experience weight stigma. When we're coining this term, 'weight stigma', it is typically directed towards people who would fall into the overweight or obesity ranges, so people with a higher weight status. A lot of this is subconscious. People all across the weight spectrum experience weight stigma and are internalising stigmatising attitudes and perceptions. This is impacting people whether they know it or not. This can lead to several outcomes and influence behaviour such as people's dietary and food choice approaches. It is impacting people's perspectives of themselves and their body shape and self esteem. It can lead to disordered eating behaviour. It is not isolated to people with a higher weight status in terms of the impact, but certainly it is directed towards people who fall within those categories because society typically views overweight and obesity as undesirable. 

There are a lot of stereotypes that are associated with people who fall within the overweight and obesity range. An obvious one that you will be aware of from the media and other sources is the stereotype of laziness and gluttony. But actually, there are a lot of other ones that, again, are very ingrained in the language that is used around obesity. Including lacking intelligence, being unattractive, being socially inept and I could go on. It is very pervasive in our society and we know that people of all ages and backgrounds are reporting stigmatising attitudes. Weight stigma attitudes are a predictor for discriminatory behaviour, which plays out across different settings, whether it is workplaces, education or other spaces within society such as healthcare settings.

Is this stigma justified?

The question is, is any social injustice justified? The answer, ultimately, is no. What I like to do to help politicians understand what this stigma really is, is if you take weight stigma experiences and remove weight as the key topic and look at the experiences; these experiences represent bullying, teasing, harassment, victimisation, it's direct and indirect. What we have in the UK, which will be very similar in the Netherlands, is the Equality Act (2010) that describes what discrimination represents and what policies are ultimatly there to protect people from victimization, harrasment and bullying. They are all part of how discrimination is described within this policy. Those are the experiences that people living with obesity report. If we're talking about bullying, harassment or victimisation, if somebody is being victimised in a workplace for instance, would we accept that? The answer, ultimately, is no. We wouldn't accept it if it was about a different topic. But it is so ingrained and almost accepted within society that we treat people differently based on body shape and size that we're often actually unaware and not even recognizing that people are experiencing this social injustice.

Does it happen in the subconscious?

Exactly. Language that we use, which we see maybe in the media, or politicians may use. It may even be evident within policies, which would be very inappropriate, because it is disrespectful and derogatory. We would pick that up again if it was about a different topic. But we don't even recognize that this is a very inappropriate and disrespectful way to talk about a group of people or a certain individual who's been portrayed, for instance in a media article. It really is unconscious, it really is ingrained in society.

Has this ever been different?

The stigma has always been a thing. It has always been there. You can trace weight stigma back to Shakespearean literature. This morning I was lecturing Master students and we've been talking about some of the evidence within really old English literature where different attributes are assigned to people based on weight status and body shape. We're really highlighting weight stigma in the literature over, in particular, the last 30 to 40 years. The first evidence really, was published right around the 1960s, where they were looking at friendship choices within children. Children were asked to rank different silhouette images of children based on who they wanted to be friends with, who they wanted to play with. The researchers thought that the child in the wheelchair would be ranked last. What they actually saw was that the child with obesity was ranked last. The researchers almost fell upon this because they did not expect that the child with obesity would be ranked last. That study was then replicated 40 years later. Whilst you saw some differences between the other children that were displayed, the child with obesity was still ranked last, but actually significantly lower. Stigma is getting worse and there are several studies that have shown that stigma has got worse over time.

This common narrative, which I think is a myth in society, in which we are told that we are normalising obesity, that we are starting to accept obesity, is not true at all. The evidence tells us something totally different. As obesity prevalence has increased, stigma has also increased. We are not becoming more accepting. It is not a matter of normalising. You will probably have seen, not so long ago, the discussions about the first plus size model who was featured on the Cosmopolitan. There was a lot of backlash about that. The rhetoric there was very much, we're normalising, celebrating and almost glorifying obesity. That is not happening at all. Stigma is getting worse.

How do you think policy can be used to tackle the stigma?

I think there are several ways. I have alluded to some of the discimination related laws and policies that need to be tightened. In the Equality Act that I was referring to, which was published in 2010 in the UK, I identified a loophole in the act in 2012. That ultimately means people within the obesity range who are discriminated against based on their weight status, if they don't have a disability that is specifically related to their weight status then they are not technically supported by the policy. Tightening of policy is needed from a legislative perspective. 

The second area, which I think is critically important, is that healthcare has been a consistent enviroment where discrimination is playing out, whether that is direct discrimination from healthcare professionals, or being overlooked for referral to different services or for potentially different forms of treatment. How can we actually improve the training and the equity of treatment that is being offered to people in healthcare? Because healthcare is a space that should always be considered a safe space that is free from judgement, free from discrimination, that everybody is able to access and isn't judged. That is not playing out, it is not what we see. Unfortunately, what that is leading to is disengagement with healthcare, less effective healthcare. For those reasons, and others, in some instances it actually exacerbates health inequalities.

We want to tackle the obesity pandemic while also solving the stigma surrounding being overweight. What is the balance between accepting being overweight and solving obesity as a social problem?

That is a big question. I think there is a lot that needs to be done. One of the first and probably most important things is that we need to really think about how policy is developed and what it is trying to achieve. A lot of the policies that we see at the moment are very much focused on individual behaviour, individual change. They are focussed on responsibility purely at the door of the individual. That is inconsistent with the research evidence, which tells us that the factors that contribute to our weight status and mainly to weight gain, just like overall health of course, are often outside or partially outside of an individual's control. To focus everything solely on trying to enforce individuals to change isn't going to be effective. We need to be thinking about the wider determinants of obesity. What can we do that structurally is going to change and support people in making changes as a society as well as individuals? We see that there are factors such as deprivation. Across all countries, deprivation is one of the consistently high and important factors that contribute to a higher prevalence of obesity. Some of the work in the US actually shows that house prices are one of the best predictors of the level of prevalence of obesity. So, there are wider determinants, whether it is economic, social or environmental which we need to be addressing. Policies currently focus on individuals changing solely and have this simplistic rhetoric that by eating less and moving more, we can change weight statuses. That is not going to be effective. History tells us that, evidence tells us that. We need to move away from this simplistic rhetoric that contributes to increased stigma and individual blame, to something that more accurately demonstrates the complexity of obesity that is multifactorial and multi-level. 

The reality is that millions of people, every day, are dieting, millions of people are trying to manage their weight, and millions of people are trying to lose weight. If weight loss or weight management was so easy and so simple, we just wouldn't have the prevalence of overweight and obesity. That is exacerbated by the fact that 99% of people, and we can go into whether it is right or wrong, do not want to gain weight. The fact that we have 67% of the population in that range, while they don't want to move into that range. And so many millions of people are dieting and trying to be physically active and all those types of things tell us that it is really not so simple. 

The second point I will make here, if you think about all the definitions of obesity, they all have the word long term or chronic in the definition. That is what obesity is. But then we have all these interventions, from a government and local perspective, that are acute. They are short term. A few weeks, or 12 week interventions. The reality is that people don't gain weight over 4 weeks or 12 weeks. It happens over a much longer period. So it makes sense that if you gain weight over that period of time, that we would need equally a longer term support system. I think we set ourselves up for failure by not recognizing that this is a chronic outcome. It is not a short term, acute outcome. My question is always; Are acute solutions suitable for a chronic outcome?

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