Obesity: An Empathy Blind Spot

Obesity stigma and the collective blindness to its consequences

This report examines society’s damaging obesity narrative, its impact and why obesity is not as simple as a lifestyle choice. “I have to say, I don’t really respect fat people. It shows a weakness and a lack of self-control. I was a bit overweight myself and I managed to get myself back on track. Why can’t they?” — Matt, ethnography participant.

These words are from a recent Ipsos study on the lived experience of obesity, conducted in conjunction with Johnson & Johnson Medical Devices Companies. What our research has highlighted is that obesity is seen as a topic that anyone feels they can comment on, make judgments about and even express hatred towards.

“Obesity is a free for all, you can say what you like, do what you like … there are (TV) programmes where every opening shot is an obese person eating McDonald’s … and before the programme even starts everyone has an opinion that we feed our faces with the wrong things constantly and it’s our fault. It’s seen as a choice.” — Angela, ethnography participant.

This is perpetuated in part by a fundamental disconnect between the actual drivers of obesity such as health conditions, trauma, finances, genetics and the food industry, and what society sees as the causes of obesity: laziness, greed and lack of intelligence, to name a few. As Stuart Flint writes, obesity is:

“… a complex, multifaceted health condition that can be caused by, for instance, genetics, epigenetics, biological, environmental, and societal factors.” 1 — Dr Stuart Flint, Associate Professor of Psychology, University of Leeds and Director of Obesity UK.

Professor Francesco Rubino, Consultant Bariatric and Metabolic Surgeon, King’s College London explains, weight control can be compared to controlling one’s body temperature. There are certain things we can do to regulate our body temperatures to an extent; we can go outside, turn up the heating or open windows. But ultimately if we have a high temperature, there is an underlying cause which is generally out of our control. This, he argues, is how we need to think about obesity.

This blame narrative that someone’s obesity is their own fault creates a systemic bullying culture around size, and serves to legitimise the collective blindness that exists around obesity stigma – we do not realise just how prejudiced we are. This prejudice has serious consequences: it can lead to systemic harm such as negative interactions with the healthcare system, earning less, and even being treated less sympathetically by a jury. As reported by the Institute of Employment Studies in November 2020, there is even an obesity pay gap, especially for women: “When people living with obesity are employed, the evidence suggests that many (especially women living with obesity) are subject to a wage penalty compared to other women, averaging between 8-10 percent (but which can be as large as 20 percent).” 2

Blame and disgust

Our research highlighted that we have a societal blind spot when it comes obesity stigma. The generic discourse around obesity is that it is caused by individuals’ bad choices. Indeed, 94% of the general public consider individuals responsible for tackling their obesity, ‘if only they tried’.3 As Sarah Le Brocq writes:

“In the UK, obesity is frequently portrayed as a lifestyle choice, where people with obesity are blamed, ridiculed and suggested to have a lack of willpower. This shows a basic misunderstanding of the complex causes of obesity. In reality, obesity is a very complex disease; over one hundred factors can be contributing causes of obesity.” 4 — Sarah Le Brocq, Obesity Advocate and Patient Leader

We live in a culture that idolises aesthetics, self-control and productivity, and obesity is positioned as the antithesis of those: a weakness and a drain on society’s resources. What sits behind obesity stigma are the notions of poor self-control, disgust and an attempt to distance ourselves from being associated with the perceived weakness of others. As one doctor from our research suggested:

“Everybody knows they should eat healthily, don’t smoke, and exercise. The issue is that we all make excuses because something comes up … It’s about being disciplined.” — General practitioner, UK

This narrative of blame and disgust is not a niche occurrence, it is widespread and prevalent throughout the UK media, as demonstrated by broadcaster Michael Buerk’s comment in early 2021: “Give them the facts to make informed decisions, by all means, ‘nudge’ all you like, but in the end – leave couch potatoes alone. They’re weak, not ill.” — Michael Buerk, Broadcaster

For many, the stigma surrounding obesity is so deep we do not recognise it in ourselves, or at least we often don’t examine our own views. We all have an opinion on obesity, its causes and what we think it signifies about people. Our obsession with ‘good’ weight and ‘bad’ weight starts from an early age; weighing children at school, being weighed by doctors and nurses, trying on clothes, watching TV and films such as Peppa Pig, The Biggest Loser, Shallow Hal and The Nutty Professor where people living with obesity are portrayed in a degrading fashion. Nobody is immune from thinking about it, and currently our views are heavily influenced by a particular discourse of stigma that is hard to step out of or is sometimes hard to see.

Internalising a punishing narrative

A very serious consequence of obesity stigma is that the narrative of individual blame is often internalised by people living with obesity. If you are constantly told that the body you are living in is wrong and unhealthy, it is hard not to listen. As a participant who also has Parkinson’s disease told us, she felt like a failure for not being able to ‘fix herself’, despite experiencing everyday struggles with her comorbidities:

“I hate my body, I really do. If I look in the mirror I see ugly. I look like a baboon in the wild. I’m telling you how much I hate myself. But I don’t understand why I’m not doing anything about it. I tell myself I can’t but I probably could … a lot of the Parkinson’s medication makes you hungry. But I can’t blame that.” — Mandy, ethnography participant

Self-blame was a common pattern among participants, most of whom had neither psychological or medical support – leaving them living in a limbo as to what to do next, and a perpetual cycle of self-loathing because they can’t ‘solve’ things alone. Heide told us:

“I can’t believe I’ve let myself look this bad again. I know I’ve got to do something and I don’t know where to turn next. I’ve struggled with depression in the past … and it’s happening again. I’m trying to fight it.” — Heide, ethnography participant

In her book, What We Don’t Talk About When We Talk About Fat, Aubrey Gordon suggests that the mental health impact of living with obesity stigma can be more detrimental to a person’s health than obesity itself. As we saw in our research, participants often felt very isolated, feeling without a safe place to share their feelings and experiences, and for some this research allowed them to open up for the first time. As Sarah Le Brocq describes:

“People rarely talk about psychological aspects of living with obesity, the feeling of failure, the low self-worth, the self-hate … or physiological aspects, such as weight ‘set point’ and hormonal imbalance. A simplistic view of obesity has contributed to widespread weight stigma and discrimination that people with obesity experience on a daily basis.” — Sarah Le Brocq, Obesity Advocate and Patient Leader

Concern, contempt or a justification for inaction

Our research showed that expressing negative opinions directly to people living with obesity is broadly seen as valid and that obese or ‘fat’ bodies are often seen as something that other people have the right to comment on. One participant describes how she is often the recipient of daily opinions on how she looks and what she should be doing to lose weight,

These opinions and comments can also easily shift into public displays of anger, legitimised in the eyes of the protagonist as ‘standing up for society’ against something that the individual living with obesity should be managing better.

“I’m a massive strain on the NHS. I get that all the time, not just from medical professionals but also people with an opinion.” — Angela, ethnography participant

This type of public abuse can be a regular occurrence. The quote below is also from Angela, who was recently stopped in a supermarket and shouted at.

“This chap stopped me in the aisle and said have you had your first jab yet? I said yeah. He said that’s ridiculous! I said what’s ridiculous? He said you know they put everyone into groups and you’re getting your jab before people in a certain age group just because you’re fat!” — Angela, ethnography participant

Journalist and author Aubrey Gordon notes that giving an unsolicited opinion is legitimised as ‘concern’, but is often poorly veiled anger and disgust. She says: “Concern does its work delicately with great care … concern is not rooted in power, paternalism, and open contempt.” 5 This ‘concern’ not only stems from individuals but is also seen in mainstream media, where there have been discussions about whether actually further stigmatising people living with obesity is the solution ‘to help them change their ways’. A recent example is this Tweet from Good Morning Britain (May 2021), which read: “Fat shaming? We need to turn this around and call it lifesaving. Should we stop serving overweight people unhealthy food? Is it fat shaming or ‘tough love?’”

Sabrina Strings is a US-based author and Professor of Sociology at the University of California, Irvine who writes about how ‘concern’ about obesity can also perpetuate racism. She highlights that Black (particularly African American) women have been shown to be healthier than white people at heavier weights, which means standardised measurements such as BMI are not useful cross-racially. Strings disputes the frequent correlation drawn in the media between negative COVID-19 outcomes for African Americans and obesity to explain Black people dying ‘at rates of 2.4 to seven times that of white populations’. She points out that while weight may be a contributing factor, it is not causal, and it may be masking other causes that need tackling but are perhaps less palatable.

“There’s plenty of evidence to suggest that COVID fatalities or maybe even serious complications with COVID-19 are being influenced by people’s environments. Are they essential workers? Do they have access to enough soap and water … or hand sanitiser ... And Black people tend to live in communities without access to a lot of different healthy and life-giving resources.” — Sabrina Strings, Professor of Sociology at the University of California, Irvine

What is now becoming evident, as pointed out in the magazine Sapiens, is that this drive to get people to lose weight does not actually help people lose weight. As the authors note in the edition ‘The World Hates Fat People’, no country has yet succeeded in reversing weight trends.

The medical field is not above culture

In 2019, Ipsos published data that showed ‘nurses and doctors remain the most trusted professions in Britain. Doctors remain highly trusted with 91% of the public trusting them.’ However, this notion of trust becomes problematic for some people living with obesity. Doctors often don’t sit outside the cultural narratives of blame and can also fail to see obesity stigma. As one surgeon interviewed for this research commented:

“Obesity suffers from a lot of stigma, it’s as bad in the medical profession as others ... they write patients off with: ‘Oh it’s just obesity, it’s not my problem.’” — Emergency and bariatric surgeon, UK

This surgeon’s view is that prejudice among GPs is so prevalent and ingrained that the views of a whole generation of doctors should be disregarded when discussing obesity, and we would be better to redefine what is taught about obesity in medical school to educate a new and hopefully more open-minded generation of doctors.

Equally troubling is that our research shows people living with obesity can be reluctant to seek medical help or support for fear of judgment. Our participants often felt they weren’t taken seriously and the doctor was impatient with them, and as a result were reluctant to return or seek medical support at all.

“I went to the doctors and I poured my heart out … I already had a referral for exercise which had led to a slipped disc, I had been taking orlistat which is an awful drug. I said I don’t know what else to try. He said I wasn’t unhealthy enough [to qualify for further treatment] and I needed to put more weight on to make myself more unhealthy.” — Mandy, ethnography participant

Some of our participants also worried that they were wasting NHS or healthcare provider time with something they should be fixing themselves. This stigma has a general health knock-on effect. As Dr Stuart Flint said in The Lancet, weight stigma can mean people avoid seeking medical help in general.

“When weight stigma is experienced in healthcare settings, this can lead to avoidance of future care, reduced adherence to services, and lower trust and communication with healthcare professionals, which may contribute to reduced quality of care and exacerbate health disparities.” 6 — Dr Stuart Flint, Associate Professor of Psychology, University of Leeds and Director of Obesity UK

Living with obesity can affect how healthcare professionals treat patients. Professor of Psychology Joan Chrisler raises the issue that doctors can misattribute certain patient symptoms to their weight, resulting in a lack of further investigation or misdiagnosis of serious ailments. The consequences of this are that health problems can be missed:

“In one study of over 300 autopsy reports, obese patients were 1.65 times more likely than others to have significant undiagnosed medical conditions (e.g. endocarditis, ischemic bowel disease or lung carcinoma), indicating misdiagnosis or inadequate access to health care.”

We also saw a lot of stigma around bariatric surgery. People can be embarrassed to talk to friends or family as it is seen as a failure to beat something of their own making. As a surgeon we interviewed reported:

“The only type of surgery people have asked me to hide is weight loss surgery. No one has asked me to hide other types of surgery. It’s stigmatised.” — Bariatric surgeon, UK

There seems to be a widespread belief that surgery is the end of the journey, rather than the patient needing ongoing support. As one bariatric surgeon told us, a large number of people put weight back on after surgery. This lack of understanding contributes to the narrative of people living with obesity being a burden to society, and contributes to a dearth in empathy towards those who have had the difficult experience of surgery and who may need support.

“If I refer someone to have surgery and they put the weight back on, I do feel annoyed and that they are draining – like they are a drain to the NHS.” — General Practitioner, UK

Moving forward

We have demonstrated that the level of collective blindness towards obesity stigma has very real consequences and the public discourse around obesity needs to change. Suggestions have been made by numerous professionals. In 2017, Flint, Nobles, Gately and Sahota put forward a case in The Lancet for better media regulation, stating that media sources do not adhere to the ethical standards of the Society of Professional Journalists when reporting obesity.

In the International Journal of Discrimination and the Law, Flint and Snook (2014) proposed that hatred towards those living with obesity should be taken more seriously, with legal measures in line with the Disability, Sex and Race Relations Acts: “Given the widespread nature of anti-fat attitudes and the clear lack of policing to deter individuals from behaving in a discriminatory manner towards the overweight and obese, it may be more beneficial to manage rather than attempt to modify the effects.”

Other experts such as Sarah Le Brocq call for obesity to be recognised as a disease – it is currently classified as a disease, but the lack of recognition means that doctors do not have to support and provide treatment for those living with obesity. This point is backed up by the All Party Parliamentary Group on Obesity which reported that just one in four people with obesity feel they have been ‘treated with dignity and respect’ when seeking advice or care from healthcare professionals about their weight.

Whatever the next steps are, it is clear that focusing on and stigmatising individuals is not working as a strategy. There need to be more systemic solutions such as facilitating healthy environments and focusing on overall health not just weight. As we know, people with healthy weights can suffer from diabetes and cholesterol issues, whereas those living with obesity may have healthy metabolic profiles.

We also need to move away from the collective blindness that currently exists, provide more local and national support to people living with obesity (where it is wanted) and facilitate discussions without of hate and discrimination.

References

1. https://www.leeds.ac.uk/news/article/4554/changing_the_debate_around_ obesity

2. https://www.employment-studies.co.uk/resource/obesity-and-work

3. Ipsos KnowledgePanel, 2021 https://www.ipsos.com/en-us/solutions/publicaffairs/knowledgepanel

4. https://easo.org/obesity-is-a-chronic-disease-sarah-lebrocq-speaks-out-onthe-uk-royal-college-of-physicians-decision/

5. https://www.yourfatfriend.com/home/book 6. https://www.thelancet.com/pdfs/journals/eclinm/PIIS2589-5370(21)00090-0.pdf

About this research An Ipsos MORI report commissioned by Johnson & Johnson Medical Devices Companies. The research took place in 2021 and involved ethnographic research with 15 UK-based adults living with obesity and also their families, and 35 in-depth interviews with primary care physicians, surgeons and commissioners.

About Johnson & Johnson Medical Devices Companies At Johnson & Johnson Medical Devices Companies, we are helping people live their best lives. Building on more than a century of expertise, we tackle pressing healthcare challenges, and take bold steps that lead to new standards of care while improving people’s healthcare experiences. In surgery, orthopaedics, vision and interventional solutions, we are helping to save lives and paving the way to a healthier future for everyone, everywhere. We are dedicated to collaborating with pioneering experts who are leading the science, research and treatment of people living with obesity in order to address the significant challenges for patients and healthcare systems alike.