Weight Stigma Research: Linda Bacon, PhD and Lucy Aphramor, PhD, RD

BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change.  The views expressed by our featured bloggers are their own.

Linda BaconLinda Bacon, Ph.D., is an internationally-recognized authority on topics related to nutrition, weight and health. A nutrition professor and researcher, she holds graduate degrees in physiology, psychology, and exercise metabolism, with a specialty in nutrition, has conducted federally funded studies on diet and health, and is well-published in top scientific journals.

With Dr. Lucy Aphramor, she offers the powerful Passing the Message On HAES facilitators’ training workshop, helping people become change agents in three countries and around the U.S. Linda’s advocacy for Health at Every Size® has generated a large following on social media platforms like Facebook and Twitter, health and nutrition listservs and specialty blogs, and the international lecture circuit. She and her work are quoted regularly in national and international (France, Israel, Canada, Australia, New Zealand, and the U.K.) publications, with recent appearances in the New York Times, London’s Sunday Times, ABC Nightly News with Diane Sawyer, Good Morning America, and magazines including Prevention, Glamour, Cooking Light, Newsweek, Fitness Magazine, Utne Reader, and National Geographic.


Lucy Aphramore 1Lucy Aphramor Ph.D. pioneered the use of a health at every size approach in the U.K. National Health Service developing an 8 weeks HAES course that has since been adopted by NHS Highlands and is now available internationally. A registered dietitian, Lucy works to advance and expand health at every size theory and practice in and beyond the U.K. through training, research, community engagement and scholarship. Dr. Aphramor is also a visiting research fellow at Glyndwr University and a visiting lecturer at Surrey University. 

She has published extensively, often in collaboration with colleagues, and her co-authored papers and chapters appear in a range of publications from the U.S., U.K., Canada and New Zealand. Her article with co-author Dr Linda Bacon and a second single authored dietetics article have combined hits of over 87,000. In addition she is co-editor of the academic text Debating Obesity: Critical Perspectives showcasing practitioner, social science, researcher and activist contributions. Dr. Aphramor is the only U.K. dietitian with publishing and teaching expertise in critical weight science and as such is recognized as a credible and approachable authority among colleagues with growing numbers of enthusiastic supporters. She is also at the forefront of the new international Critical Dietetics movement where her work blending critical thinking and compassionate self-care is enthusiastically received. A hallmark of her work is finding ways to make sense of the impact of our social positioning and  biographies on our health and wellbeing so we develop relevant, equitable practice. Her influence extends to coverage in the popular press and her reputation as an outspoken scientist gains her interviews across the board from women’s magazines to the broadsheets.


Stress Mess: How “Fighting Fat” Makes People Sick

 The World Health Organization uses the term ‘globesity’ to describe a supposed epidemic threatening millions across the world with the specter of serious metabolic health disorders.

We cry foul: Those menaced “overweight” millions, it turns out, come disproportionately from disadvantaged populations, and no matter how fat or thin they are, it’s their marginalized status itself that harms health. “Fighting obesity” as a health target not only adds insult to the injury of poverty and stigmatization, it worsens the situation. Fat, while an expediently visible marker, is not the actual enemy. The move to banish it flouts scientific evidence while honoring half-hidden aesthetic and moralistic biases.

The incessant drumming about obesity mutes the fact that the root cause of the diabetes, heart disease, and other chronic afflictions disproportionately burdening the poor and socially disregarded may be the status quo. “Obesity-related” disease actually tracks your social status more than what size clothing you wear. In developed nations, data show, members of stigmatized groups, including those who are economically disadvantaged and people of color, are the most common victims of illnesses typically grouped under the “metabolic” umbrella. They are not only more commonly ill, but when they do get sick, can expect poorer prognoses than more socioeconomically advantaged people with similar conditions.  And for all that, current medical interventions prove more effective for more advantaged patients, further widening the gap between healthy and sick, rich and poor, powerful and marginalized.

It is also true that members of marginalized groups are more likely to be fat, but it’s a false leap of logic to assume, based on that association, that fat causes metabolic disease. Too many other factors are lost when we simply conflate weight and health and close our minds to the other, more pernicious (less visually obvious) effects at work.

Before we can acknowledge the damage it does, it helps to understand that our collective concern about fat is strongly influenced by aesthetic and moral judgments. Try the Implicit Attitudes Test to see just how deeply this bias runs. These attitudes affect medical care, the reporting of science, and the type of research that gets funded, reinforcing a pseudo-scientific rationale centered on weight control as if were evidence based. As if we needed any more social stigmas, weight discrimination has been outpacing even race and gender discrimination. Deploring fatness, rather than leading to improved health for fat people, worsens health for all of us and increases inequalities.

All forms of discrimination rely on stereotypes that lead to unfair prejudice, and weight discrimination is no exception.  Scapegoating fatness and fatter people leads to disadvantage throughout the life-course, from education through to the workplace, travel, adoption, healthcare, insurance – and research increasingly shows, this bias in itself promotes metabolic disease. Is it coincidence or just irony that these diseases happen to be the ones we usually blame on weight? Metabolic syndrome tracks inversely with social status: The lower you fall on the social scale, the more likely you are to develop symptoms. The phenomenon has often been blamed on poverty-induced “bad habits,” where poor nutrition and a lack of exercise are assumed to lead to weight gain. But even when we control for health behaviors and BMI, studies show the health discrepancies persist. (In a sampling of studies, health-related behaviors accounted for only 5 to 18 percent of neuroendocrine differences that lead to metabolic syndrome.) So what can be making disadvantaged and stigmatized people sicker, or more accurately, fatter and sicker, than the rest of us?

Poverty and lack of opportunity matter more to public health outcomes than weight, diet or exercise behaviors. For most disadvantaged people, if it’s Weight Watchers versus welfare, welfare wins, and no amount of extra gym time can outweigh time in the unemployment line. The day in day out strain of living in poverty and the experience of oppression and stigma lead to chronic physiological stress. We’re not talking long-line-at-Starbucks stress but the hyper-hormonal “fight or flight” chased-by-a-tiger rush that tenses your entire system for survival – at the expense of ordinary, necessary biological functions. Extensive research documents that chronic stress of this type can raise cholesterol, blood pressure, triglyceride levels, stimulate inflammation, and impair insulin sensitivity, all of which can lead to the metabolic conditions associated with obesity, including hypertension, diabetes, and coronary heart disease.

Do eating, exercise, and drinking patterns also affect these conditions? Sure, but contrary to mainstream spin, their impact is somewhere below 25 percent of measured causation, far below the impact of social status and daily psychological stress. With social status comes control over one’s circumstances – success at work, fostering loved ones’ well-being, being able to plan for the future, or even next week. The absence of those, no matter how punctilious our lifestyle habits, stresses our systems in disease-promoting ways.  In contrast, being able to exert an influence over what matters to us is health-promoting.

Hectoring the population to “eat better, exercise and lose weight” misleads and has proven harmful, so it’s time for new approaches that cultivate equality and don’t harp on body size. Health – and social  – policy must focus instead on equalizing life chances, reducing stigma and mitigating the physiological impact of stress. (Telling a patient she’s too fat, by the way? Not stress-reducing.)

Policies promoting weight loss as a solution – or even as possible in sustainable ways –perpetuate damaging stereotypes and a “healthist,” moralizing attitude. What’s needed are better, socially-integrated approaches to health. The most ethical, effective public health alternative to emerge to date is Health at Every Size®, or HAES, which challenges fat bias and fosters self-care behaviors rooted in respect and nurture, not shame and denial. HAES practices have been shown in controlled trials to improve health habits, self-esteem and mental wellbeing as well as metabolic health. All without weight loss. And all without introducing weight bias or weight stigma. HAES practice abandons weight as an outcome in favor of markers of wellbeing. Treating oneself fairly and dispensing with fat shame, HAES studies show, lead to better self-care and – this should surprise no one who’s been told to lose weight – reduced stress. It helps people of all shapes and sizes learn to make peace with food and their bodies and, by supporting acceptance and preferring respect over bias, leads us closer to the fair societies that form the cornerstone of healthy communities.