How can we tackle weight discrimination?
Clear strategies are needed for addressing it effectively and ending it for good. At the recent Diabetes UK Professional Conference, Dr Paul Chadwick looked at our efforts so far and outlined what needs to be done. Lisa Buckingham reports.
Weight discrimination is a social justice issue, said Dr Paul Chadwick, deputy director at the UCL Centre for Behaviour Change and a clinical and health psychologist. We need to be interested in it not because it affects people’s ability to lose weight, but because it devalues people.
What might a behavioural science approach offer to size discrimination? A starting point is to look at our attempts to tackle it so far. The current offerings in terms of guidelines all follow a similar pattern and haven’t changed much over the years – they all include some form of checklist.
The problem with this approach, said Dr Chadwick, is that checklists ignore the complexity of behaviours involved in challenging weight bias. ‘Speaking up’ when you experience or witness weight bias is a good example – it may sound simple but it’s actually a difficult behaviour to carry out. For policy-related elements of checklists, they only work if people enact the policy. Policy doesn’t implement itself.
He explained that weight discrimination exists on a continuum: implicit bias that is uncovered when tested for, explicit (when people enact obvious discriminatory behaviour), and complicit – for this, he used the example of an offensive meme about a person who was overweight being posted in a WhatsApp group for his triathlon club and nobody said anything. We won’t see the changes we want to see until complicity is addressed.
There is a discrimination ecosystem that consists of perpetrators, those who are discriminated against and those who are witnessing the discrimination. We may all occupy different positions within that system at different times.
The behaviours to target in each of these roles are:
- Perpetrator: accept feedback, adapt behaviour, apologise
- Witness: name it, challenge it, offer support, report it
- Person in receipt: name it, challenge it, report it, respond in ways that promote wellbeing
He went on to explain the under-explored area of ‘behaviours of omission’ or being complicit. In order for a bystander to intervene, they need to know what weight discrimination is and understand its impact on people above a healthy weight. They need to know how to be an ally (i.e. what words can be used to challenge without making the situation worse). It must be linked to their personal and professional values; i.e. it should be part of being a good healthcare professional (HCP), but Dr Chadwick thinks that it currently isn’t.
Emotions are also a factor – challenging will often be met with resistance, so a bystander needs to be tolerant of that emotional discomfort. Infrastructure must be in place in the form of policies and regulation to reinforce the above. At present, there are few models of how to challenge weight discrimination effectively, he said, which makes all of this difficult.
This circled back to his point about checklists. ‘Speaking up’ is what we should all be doing, but the above demonstrated that it’s a complex and high-risk behaviour. With that in mind, he moved on to outline how we can overcome the emotional barriers to challenging weight discrimination for both the person on the receiving end or the witness. There are many barriers, such as fear of not being taken seriously or making things worse, and shame (‘I deserve it’). The good news is that there is a range of cognitive and behavioural strategies to tackle them.
It’s an entire field of work that you could write a book about, but it includes asking yourself questions such as ‘do I know for certain or am I predicting how people will respond?; ‘what can I learn from other occasions when I have faced a situation like this?’ and ‘what information or support do I need to ensure that I’m taken seriously?’.
For feelings of shame, there are compassion and trauma-focused cognitive and behavioural therapies that are proven to work. The downside is that these are only available to people who can access tier 3 and 4 services, but should be made more widely available as part of tackling internalised weight bias.
For years, he said, we have sought to find a discomfort-free way of challenging weight discrimination – but he believes that there isn’t one. Until society learns to accept people above a healthy weight, we must accept that challenging discrimination will come with some discomfort.
However, we can learn from social-justice approaches about what a really effective challenge looks like and then work to develop advocacy within communities. Dr Chadwick broke down the elements of a successful challenge within healthcare:
- Name it: without this, we can’t do anything; state that the person’s actions are stigmatising or discriminatory
- Challenge it: state why you think that behaviour is stigmatising/discriminatory; recruit support; if there are witnesses, try to involve them; ask ‘is anyone else uncomfortable with the tone of this discussion?’
- Request an apology: ‘I would like recognition that this was not a helpful thing to say.’ Draw your boundaries: state that you would like to be seen by someone who has a better understanding of your condition; that may not be possible, but it’s important to say it anyway
Dr Chadwick acknowledged that none of this is easy but what he termed the work of advocacy aims to make doing difficult things a bit easier. It boils down to preparation. Practice having conversations within safe spaces in your life to get used to expressing yourself, rehearsing your arguments and checking in with how that makes you feel emotionally and physically. Develop your ally network – there will be people who witness what is going on but feel like they may need your permission to intervene on your behalf. Lean into the discomfort but make choices that are wise for you – you don’t have to challenge all the time, but even once or twice can make a difference. Lastly, resist perfectionism – not every challenge has to be effective but each time you do it, it will make a small difference.
To summarise, Dr Chadwick believes that we need two pillars in the approach to tackling weight discrimination. The first pillar is a change in narrative: we need to educate ourselves and others about the complexity of obesity and include the chronic disease narrative, which identifies factors beyond individual control.
The second pillar is protest-based approaches, including framing weight bias as a social justice/human rights issue, venturing into spaces where people with obesity are typically excluded or unwelcome, and creating new communities of support to resist oppressive narratives and damaged identities.
Each of these two pillars feeds into the other and does not stand alone. Protest creates energy in and movement in the system, he said. And reframing lends legitimacy to our right to protest.
He concluded by highlighting that to support these changes, there need to be funding streams for research into interventions, more psychologists to collaborate with specialists in public health, and service providers must provide training on things such as how to respond as an ally and reinforcing policies to make people accountable for weight-based discrimination.
His call to action at the end of the presentation was to ask the audience to think about one way in which they can act as an ally to someone who is above a healthy weight, regardless of their own weight status.
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Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.