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Building Bridges: Interview with Rebecca Puhl (Part 2)

by Dr. Jenny Copeland, PsyD

From the ASDAH Blog Committee: Last month, the Health At Every Size® Blog initiated a series of “Building Bridges” interviews which will explore the impact and influence on the Health At Every Size model of work being done by professionals who are not HAES®-identified. The first of these posts was Building Bridges: Interview with Rebecca Puhl (Part 1), by Dr. Jenny Copeland.

As expected, this post was controversial, and many readers commented asking Dr. Puhl some direct questions about her work and the work of the Yale Rudd Center. Unfortunately, Dr. Puhl’s schedule constraints kept her from being able to respond in an effective manner at this time. We regret that we did not anticipate the demands of being able to engage with the comments in advance when enlisting her for the interview. Although we recognize there are lingering questions from the initial post, we decided to post the remainder of the interview in fairness with the hope that Dr. Puhl’s schedule will decrease at some point in the near future to where she can respond.

We once again thank Dr. Copeland for writing this first entry in the Building Bridges series and present to you the second part of her interview with Dr. Puhl below.

Jenny Copeland, PsyD: What do you see as the most critical issues that need to be addressed to decrease the weight stigma that exists in the general culture?

Rebecca Puhl, Ph.D.: Essentially, the objective we have in front of us is to change societal attitudes and eradicate a form of stigma that has become socially acceptable and tolerated. That’s a big goal, and so we need to “think big” if we want to achieve it. In my mind, there are a number of factors that contribute to, and reinforce, weight stigma in our culture. Several key areas will be important to address if we want to decrease it. First, we need to challenge sociocultural ideals of thinness, which promote stigma. Thinness has come to symbolize core values in American culture, and if a person is thin he or she is perceived to be disciplined, attractive, ambitious, and desirable. Unfortunately, if a person is not thin, they are perceived to be lacking in these qualities, which in turn reinforce negative weight-based stereotypes that individuals are lacking in willpower, discipline, ambition, etc. These ideals are frequently promoted in the dieting and fashion industries, as well as in the media, which is a particularly pervasive source of weight bias. We see numerous stigmatizing portrayals of people with obesity in television and film, and even in news reporting. So we need to challenge and change the way that the media reports on and portrays people of different body sizes.

Another issue that needs to be addressed is the public perception of the causes of obesity and body weight. There is a widespread perception that body weight is simply an issue of personal willpower or discipline, and that if a person gains weight it is his/her fault, and he or she is deserving of blame and shame for having a body weight that deviates from the stringent societal ideals of thinness. This is extremely problematic, and promotes an inaccurate and oversimplified notion of body weight. In reality, factors that influence body weight are multiple and complex, and involve interactions between the environment, genetics, biology, and behavior. Instead of messages that reflect the complexity of body weight, we are bombarded by messages (again, often by the diet industry and mass media) that a person can (and should) have the ideal body simply through hard work and discipline, or the latest fad diet. These messages absolutely have to change in order to reduce stigma.

Given the pervasiveness of weight stigma in our society, we also need to address this problem from a legal perspective. We know that weight discrimination is prevalent in employment settings, health care facilities, educational institutions, and many other areas. For this to stop, legal intervention is necessary. Currently there are no federal laws that exist to prohibit weight discrimination. There is only one state law (in Michigan), and a handful of local jurisdictions across the country, that prohibit discrimination on the basis of weight. We are far from where we need to be. We need laws to make it illegal to discriminate on the basis of weight; laws that will treat weight bias as a legitimate form of discrimination. Our research shows that there is substantial public support for laws to prohibit weight discrimination, especially in the workplace. And there seems to be increasing interest from other states to consider adopting such laws. This past June, for example, Massachusetts held a state hearing regarding a proposed law that would prohibit weight discrimination in employment. The verdict is not yet out, but this would be an important victory if it passes.

Finally, we have to address the issue of weight stigma in children and youth. Our research has found that weight-based bullying is the most frequent form of teasing observed at school by adolescents, and that parents also perceive it to be the most common form of bullying in youth, regardless of the weight of their own child. A report in 2011 by the National Education Association also found that teachers perceive weight-based bullying to be the most problematic form of bullying at school. So, teachers, parents, and youth all agree that this is a pervasive problem, and potentially the most common form of bullying in youth. But it has largely been ignored in the national discourse about bullying prevention. No media campaigns have emerged to fight weight-based bullying. We do not have a “Lady Gaga” or an “It Gets Better” movement to help youth who are bullied because of their weight. Instead, weight-based bullying is often absent from (or not adequately addressed) in school-based anti-bullying policies, and of the anti-bullying laws that exist in each state in this country, only four state laws mention body weight as a trait that is vulnerable to bullying. Clearly this is an area where change is badly needed.

So, there is a lot of work to be done. To reduce stigmatizing societal attitudes, we need to change our society. We need to challenge sociocultural values, change media depictions, dispute messages from industry, fight for legislation to prohibit discrimination, and enact policies that adequately protect youth from being bullied about their weight.

JC: What do you see as the major barriers to eliminating the weight bias that many health care providers have towards their patients/clients?

RP: Some of the barriers that I believe contribute to weight bias among health providers include the lack of training and knowledge among many providers regarding nutrition and body weight regulation, and the absence of important clinical skills like motivational interviewing which can empower and support patients in their efforts to engage in health behaviors. Lack of training in these areas can easily lead providers to engage in communication styles that are judgmental or insensitive, and can reinforce biases stemming from misperceptions about the complexities of body weight, difficulties of achieving sustainable and significant weight loss, and inaccurate assumptions about weight and health. For example, too often, providers stereotype patients as being ‘noncompliant’ if they don’t successfully lose weight, or they rely on BMI as the primary indicator of a patient’s health without consideration of other health indices. Like the public, health providers also need to obtain an accurate understanding of the multiple and complex factors that contribute to a person’s body weight, and a broader recognition that a person’s body weight is not an automatic indicator of health status. Ideally, providers should be addressing and emphasizing health behaviors of their patients, and not making the main focus be about the number on the scale.

At the same time, I’m optimistic that the health care setting is a place where real improvements can happen to reduce weight bias. I’ve noticed a shift in the past five years or so, where there has been increasing interest and commitment to addressing the issue of weight bias among health providers. As one example, educational training to reduce weight bias has become increasingly implemented (and in some cases, even required) for providers and staff in health care facilities. Of all the requests for information about weight bias that I receive at the Rudd Center, it’s most often from health providers who are seeking resources on weight bias and want to improve the culture of their health setting for patients of all body sizes. I haven’t seen this level of interest from other groups, such as employers, for instance.

I do also want to point out that there is another aspect to this challenge. Our research has found that patients also endorse weight bias toward their health care providers. If a doctor is perceived to be ‘overweight’ or ‘obese’, patients report more mistrust of physicians, are less inclined to follow their medical advice, and are more likely change providers. In contrast, physicians who are thinner elicit more favorable opinions from patients. We found that these biases toward doctors remained consistent regardless of participants’ own body weight, and were more pronounced among individuals who demonstrated stronger weight bias in general. So, the bottom line is that if we want to reduce weight bias in health care, we need to address this from both sides of the patient-provider relationship.

JC: What are your perceptions regarding the evolution of workplace wellness programs to use weight as a proxy for health, providing incentives or punishments due to weight status, etc.?

RP: I have serious concerns about workplace wellness programs that provide incentives or punishments based on weight status or only focus on BMI as the primary indicator of health. These approaches will unfairly discriminate against employees, and will do little to effectively improve public health. Employers should avoidusing BMI as the basis for financial penalties or incentives, and should not make determinations about employee health based on body size alone without consideration of other health indices. Furthermore, BMI, and other biometric markers of health such as blood pressure and cholesterol, are influenced by genetics and environmental determinants that do not have equal effects across our population. So penalizing individuals based on these factors ignores the complex genetic and environmental contributors of body weight that are largely beyond personal control. Instead, employers should create health initiatives where the goal is to improve wellness for all employees, regardless of their body weight, and avoid singling out or penalizing employees based on size. To do this effectively, employers need to ensure that they create a supportive workplace environment that provides opportunities for all employees to be healthy and engage in health behaviors (e.g., having healthy foods in cafeterias, providing gym discounts, etc.). More broadly, it would be great for more employers to support policy initiatives that aim to create a healthier environment, so that our society can become a place where opportunities for engaging in healthy eating and exercise behaviors are the default, rather than the exception.

JC: What advice would you give to professionals who are mindful of weight and size dynamics, but working in an environment that is not or that may in fact perpetuate these biases?

RP: As professionals committed to reducing weight bias, we have a responsibility to raise awareness about this issue with our colleagues, co-workers, and staff. One of the strategies that has been useful for me when trying to “convince” others that weight stigma is a legitimate problem, is to consider who I’m speaking to and to select my message carefully. For example, when I speak to health professionals who aren’t aware of weight bias, I have found that talking about weight stigma as a social injustice usually doesn’t get me very far. However, when I focus instead on the negative impact that weight bias has on the emotional and physical health of their patients, and that patients will even avoid health care to escape weight stigma from providers, then they are much more willing to listen and are more receptive to strategies that they can use to reduce bias in their clinical practice. So I would suggest thinking about what kinds of messages will resonate most in the specific environment that you’d like to see change. Again, placing the emphasis on the benefits of using alternative strategies is a proactive and positive way to instill change, rather than just pointing fingers or making others feel defensive.

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