Weight Bias + Diabetes: “Stigma does not motivate anyone”

Coverage of the American Diabetes Association (ADA) Scientific Sessions is brought to you by the ADA x BT1 Collab.

This coverage focuses on information shared in the session: “Stigma in Diabetes Care–Evidence and Solutions (With Richard R. Rubin Award Lecture).” Presenters included:

• Paula Trief, Ph.D. (State University of New York Upstate Medical University)
• Alan Delamater, Ph.D. (University of Miami Miller School of Medicine)

• Jane Speight, MSC, Ph.D., CPSYCHOL, FBPSS (Deakin University)

• Rebecca Pearl, Ph.D. (University of Florida)

• Susan Guzman, Ph.D. (Behavioral Diabetes Institute)

• Kevin Joiner, Ph.D., APRN, ANP-BC, CDCES (University of Michigan)

• Gretchen Piatt, Ph.D., MPH (University of Michigan)

The second part of this session coverage focuses on findings presented by Rebecca Pearl, Ph.D.

Among the many stigmas that people with diabetes face, weight bias is one. In a session on “Stigma in Diabetes Care” presented at the ADA’s 82nd Scientific Sessions, Rebecca Pearl, Ph.D., focused on this topic and what steps we can take as a society to address our structural, interpersonal and intrapersonal biases on weight.

Weight should not facilitate shame or blame

Before diving into the findings presented during this part of the session, it is important to keep the following in mind: 

• First, it is critical to remember that just because you have diabetes does not mean you are or will become overweight, and just because you are overweight does not mean you will develop diabetes. 
• Second, being overweight while living with any form of diabetes does not mean you are bad at managing it or deserve negative feedback or hate from anyone.
• Third, many factors contribute to weight, which were explored throughout this presentation. Weight gain or being overweight should not facilitate shame or blame.

The weight bias problem

There are many moral judgments that people with diabetes who are overweight face. Pearl addressed the following:

• Weight bias and stigma: There are negative attitudes towards people with higher body weight. People tend to assume weight is within someone’s control when it’s not. Stereotypes that people who are overweight are “lazy, lack willpower or self-discipline, unintelligent, or unattractive” still exist. 
• Weight isn’t simple—many factors contribute to it, including: The media, food, activity, infrastructure and social, psychological, economic, developmental, biological and medical factors.

Pearl notes that there has been more attention to weight bias in research in recent years, but that attention is not yet reflected in public attitudes. That needs to change.

When patterns of implicit and explicit attitudes were analyzed by Tessa E.S. Charlesworth and Mahzarin R. Banaji in the Department of Psychology at Harvard University, researchers deduced weight was the only implicit bias that had gotten worse. Instead of skewing away from neutrality, public attitudes became more implicitly negative over a decade.

There are three main types of stigma that exist and revolve around weight bias:

• Structural stigma: laws, policies and the media
• Interpersonal stigma: teasing, bullying and discrminitaion
• Intrapersonal stigma: anticipation and internalization (how someone feels about their weight)

Unmistakable examples of weight bias in society

To drive the point home, Pearl shared the following articles on weight bias.

• “Texas Hospital Won’t Hire Obese Applicants”: When a Texas hospital would not hire a person who was overweight, it made national news. The facility would not hire people with a body mass index (BMI) of 35 or higher. Alarmingly, this is not illegal in the state. 
• “When You’re Told You’re Too Fat to Get Pregnant”: This is another saddening form of healthcare discrimination, featured in The New York Times, which highlighted a mother who was told she would not get pregnant because she was “too fat.” Fertility clinics like the one referenced in this article have denied people care due to a “BMI cut-off.”
• “B.C. Woman Ellen Maud Bennett’s Obituary Urges Overweight Women to Fight for Their Health”: In this scenario, Bennett was told she needed to lose weight to feel better, though she knew something was deeply wrong. By the time she was diagnosed with cancer, it was too late. She requested a testament about healthcare discrimination be read at her funeral instead of a typical obituary. Her “final plea” was for “society to start taking the health concerns of overweight women more seriously.”

Pearl identified that these articles raise the ethical question, “Who has the right to healthcare?”

She followed that, in many cases, weight loss is not something patients can achieve independently or strictly through behavioral intervention. They should not be discriminated against for their weight. 

The impact of internalizing weight bias

When Pearl and her team polled people who were overweight about how they felt about themselves, the feedback was significantly impactful. 

Here is what some of the participants had to say:

• “People look at and treat you differently.”
• “I feel lazy.”
• “I don’t have willpower.”
• “(I feel) less competent professionally.”
• “(I) hate myself for not having self-control.”
• “(I see) fault in my character.”
• “(I feel) like a failure; weakling.”
• “(I am) ashamed.”
• “(I feel) inadequate as a grandmother.”
• “(I feel) ugly and disgusting.”

This touches the surface of the heartbreaking feedback that Pearl and her team received. 

Biases like these shape every healthcare interaction people with diabetes who are overweight face, how others treat them, and how they treat themselves. Negative attitudes from healthcare providers don’t help.

“Stigma is harmful to health”

While stigmas have been addressed broadly in regards to HIV/AIDs, mental health, substance use and cancer, there are “hesitancies” and “pushback” among healthcare professionals in addressing obesity stigmas, Pearl says 

“There is concern that if we destigmatize obesity, people won’t be motivated to lose weight, but stigma does not motivate people to be healthy,” Pearl said. “Stigma has the opposite impact—it undermines health.”

There are many pathways in which this occurs. It is well-documented in many forms of diabetes stigma. Pearl shared that weight bias in people with diabetes can lead to:

• A lack of access to resources, social determinants of health—people with diabetes are less likely to attend their diabetes check-ups
• Poorer quality of healthcare
• Psychological distress
• Reduced engagement in health behaviors
• Chronic stress, inflammation, immune dysfunction

In people with type 2 diabetes especially, Pearl noted there is an assumption that “poor choices” and “unhealthy behaviors” cause diabetes. But this is not accurate. This notion is relevant to people with type 1 and type 2 diabetes.

How can we stop weight bias for people with diabetes?

Pearl proposed the following solutions to eliminate weight bias for people with diabetes:

• Media guidelines and internal training (for those in prominent institutions) around weight bias should be instated.
• Campaigns to reduce public stigmas like weight bias should be amplified.
• People with diabetes who have experienced intrapersonal weight bias should consider counseling and look for peer support.

The bottom line is: To help people with diabetes thrive, empathy and awareness of the internal diabetes experience need to drive the future of patient care. 

Diabetes stigma can lead to many different negative health outcomes. If you have been personally impacted by diabetes stigma and need support, utilize these resources:

• BT1 Community App

• Diabetes Distress

• Burnout

• Mental Health

• Anxiety

• Eating Disorders