Sarah Nutter, PhD
Assistant professor, Department of Educational Psychology and Leadership Studies, University of Victoria, BC, Canada. Member of EveryBODY Matters, a multidisciplinary partnership of weight bias and obesity stigma researchers engaging in advocacy and outreach.
Dr. Nutter has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: You’ve done extensive research in the areas of weight stigma, body image, and eating disorders. Can you start by defining the terms weight stigma and fat shaming for us?
Dr. Nutter: Weight stigma includes the stereotypes, negative attitudes/beliefs, and discrimination that all occur based on someone’s weight, typically when someone is perceived as too heavy. Internalized weight stigma occurs when someone directs these stereotypes, attitudes, and beliefs toward the self. Fat shaming is a form of weight stigma, where someone is made to feel badly about themselves due to their weight.
CCPR: How are culture and gender related to fat shaming and weight stigma?
Dr. Nutter: Western culture carries rigid body ideals of thin, toned women and lean, muscular men. People who don’t conform to these ideals often feel ashamed. Women experience weight stigma at lower body weights compared to men, but men also experience it—and they are experiencing it more often compared to the past (Himmelstein MS et al, Obesity (Silver Spring) 2018;26(6):968–976).
CCPR: How does weight stigma affect the mental health of children and adolescents?
Dr. Nutter: Weight stigma leads to increased body dissatisfaction, body shame, risk of eating disorders, symptoms of anxiety and depression, and risk of suicide (Jendrzyca A and Warschburger P, Appetite 2016;102:51–59). Children as young as 4 demonstrate friendship preferences and social exclusion based on weight (Parnell J et al, Stigma and Health 2021;6(3):344–353). Weight-based bullying is a serious problem for both children and adolescents. Kids might feel that it’s more socially acceptable to shun or make fun of peers about their weight versus attacking people about, say, their gender identity or race. Weight stigma and discrimination also leads to self-exclusion from sport and exercise settings for teens and adults, as well as discrimination in employment (Thedinga HK et al, BMC Public Health 2021;21(1):565).
CCPR: Are there specific psychiatric disorders associated with weight stigma?
Dr. Nutter: Body dissatisfaction and shame contribute to disordered eating behaviors, which can lead to clinical eating disorders. Anxiety and depression can co-occur, and these mental health challenges can carry forward into adulthood, influencing a person’s mental health and relationship with their body. In a longitudinal study, adolescents who perceived themselves to be overweight had a 7.7% higher risk of suicide, and that risk increased over time (Daly M et al, Int J Obes 2020;44(10):2075–2079).
CCPR: We typically track obesity using body mass index (BMI). What are your thoughts about BMI?
Dr. Nutter: BMI uses height and weight to come up with a number that is supposed to predict your risk of weight-related health problems. It’s calculated by dividing your weight in kilograms by your height in meters squared. It’s convenient as a population-level screening tool since you don’t need to draw blood. But weight is not a good proxy for health, and it doesn’t predict metabolic health of people across the weight spectrum (Tomiyama AJ et al, Int J Obes (Lond) 2016;40(5):883–886). BMI data can also enable discrimination. People at all ages have been denied insurance coverage and healthcare based on BMI.
CCPR: Are major health organizations moving away from using BMI?
Dr. Nutter: Yes. The new Canadian Clinical Practice Guidelines for the Treatment of Obesity in Adults define obesity as “adiposity that may impair health” (www.tinyurl.com/267m4s3s), although those guidelines aren’t for kids. The word “may” is important because not all people with higher body weights have obesity. Many people are perfectly healthy at higher body weights. This broadening focus on health independent of weight might reduce weight stigma for children and teens too. That said, the World Health Organization still uses a BMI-based definition of obesity.
CCPR: As clinicians, we may inadvertently contribute to weight stigma by focusing on these numbers as well as other preconceived ideas about higher weights. Should we stop using BMI?
Dr. Nutter: Even if you are required to document BMI, frame your care in a way that avoids focusing on BMI. Instead, help your patient to cultivate positive attitudes about their body and engage in healthy living habits (Editor’s note: See “What Is Body Positivity?” sidebar on page 6). Weight stigma and fat shaming can permeate care, including how you conceptualize your patient’s problem list, track their progress, and create treatment plans. Examine your own beliefs about weight and how those beliefs shape your attitudes and actions with patients. Support healthy attitudes and behaviors as opposed to focusing solely on weight.
CCPR: What are some better ways to talk with our patients about weight and health?
Dr. Nutter: Help children, teens, and families rethink their ideas about weight and health. Break the association between weight and identity: “Weight is complex, and a lot of it is genetic. Your weight doesn’t make you good or bad. It isn’t a moral failing.” Focus on health independent of weight: “Your weight doesn’t tell us how healthy you are. Health is more about things like blood pressure and cholesterol levels.” Tell them about weight stigma and its influence on health: “When we make people feel badly about their weight, that shame is actually bad for their health.”
CCPR: How can we help our patients and families change their attitudes about their bodies?
Dr. Nutter: Actively remove the emphasis on thinness and replace it with an emphasis on self-acceptance. In our culture, beauty and weight are interconnected. Many teens weigh themselves frequently or dwell on social media content that promotes unhealthy ideals of weight. These behaviors only make them feel worse. Ask your patients: “What is beauty?” “Tell me what you are seeing in the media about beauty and weight—do you believe it? How come?” “Do you really think that everyone who doesn’t fit the mold can’t be beautiful?” “What things make you feel sad or ashamed of your body? How would you like things to be different?” (Editor’s note: See resource tables for clinicians and families on page 4.)
CCPR: When kids and families ask about dieting, how should we respond?
Dr. Nutter: Remind them that 95% of people who lose weight through dieting and exercise gain it back, often exceeding their original weight, in three to five years (Nordmo M et al, Obes Rev 2020;21(1):e12949). Don’t engage in talk about dieting. Instead, say something like, “Let’s forget about dieting and talk about intuitive eating—how to listen to your body and what your body needs.” Or, “Let’s focus on eating well so that we can give your body the nutrition it needs to be healthy.”
CCPR: Can you say more about intuitive eating?
Dr. Nutter: Intuitive eating uses mindful eating behaviors to help a person recognize their body’s hunger and satiety cues, and other kinds of hunger (not nutritional). Help kids and teens pay attention to hunger, not deny it or deprive themselves. For example, if a teen is experiencing cravings for certain kinds of foods, say, “Eat when you are hungry. It’s OK to eat what you like.” Then consider the other reasons the patient is eating aside from hunger. Is it anxiety? Boredom? Is it medication related? Part of the family culture?
CCPR: How do we work with patients to figure out these reasons? Kids aren’t always self-aware that they are eating out of boredom, for example.
Dr. Nutter: With boredom, three emotions might be at play: feeling dissatisfied, feeling restless, or feeling unchallenged. Before thinking about solutions, ask the patient about these possibilities one by one (Moynihan AB et al, Front Psychol 2015;6:369). Differentiate with the patient or parents whether the eating is related to being physically hungry (eg, growling stomach, a headache, feeling shaky); craving a specific food, which may indicate a need for something in that food; being stressed, which often includes craving sweet, salty, or fatty food; or mindless eating, such as when a person munches on food while their attention is more focused on other activities like watching videos or sports.
CCPR: Let’s say we have confirmed that a kid is eating out of boredom. What do we do to help?
Dr. Nutter: Create a judgment-free zone while increasing awareness and understanding. Find supportive words that avoid shaming the patient. Don’t say: “There’s so much you could be doing instead of eating.” Say instead: “Let’s think about the situations where you feel bored.” Maybe there are other issues behind the boredom, such as loneliness or anger. Take time to unpack those issues. Then brainstorm other ways to respond to boredom, including cultivating social connection and moving their body.
CCPR: Kids who don’t enjoy sports or aren’t active often have trouble exercising. How do we approach that?
Dr. Nutter: Change the conversation. Rather than talking about exercise for weight loss, talk about building joy in the act of movement: “Let’s find activities that you enjoy for the sake of the activity, not to lose weight, and in places where you won’t feel judged or shamed.” Brainstorm ways to incorporate movement that make kids feel good in their day-to-day lives. This becomes something positive to track. On follow-up I’ll ask: “You’ve made some changes—do you have more energy? Are you sleeping better? Do you feel more in tune with or more capable in your body?”
CCPR: How should we respond to requests for weight loss medication or bariatric surgery?
Dr. Nutter: Look at the reason for the request. For a patient who will do whatever it takes to lose weight, the weight loss isn’t going to fix them. Is the request a reflection of internalized weight stigma? Educate your patients and create a plan that improves their health independent of weight. This includes intuitive eating, meaningful activities, and addressing social determinants of health. If you use medication, use it to promote health, not weight loss. For patients who ask for bariatric surgery, be sure they know that they will have lifelong physiological changes from the surgery and that many people who receive a bariatric procedure regain weight or don’t lose as much weight as they’d hoped. Patients who undergo bariatric surgery are often disappointed with their weight loss because they have a specific weight in mind and they don’t meet that magic number.
CCPR: How do you address social determinants that impact health and weight?
Dr. Nutter: People hold all sorts of identities—they can identify by race, gender, sex, socioeconomic status, weight, and more. Develop treatment plans that respond to the individual and their circumstances. Look at social forces like food environment and socioeconomic status. What food is available in the neighborhood? What can the patient afford? How does that influence health and weight? Do people have the physical space or the time to engage in physical activity? In some families, parents have multiple part-time jobs trying to keep afloat from month to month.
CCPR: Any final thoughts?
Dr. Nutter: Weight stigma impacts patients, and we are all culpable to a degree. Shift your practice from an emphasis on weight toward helping children and families develop positive and accepting attitudes about their bodies and healthier approaches to living.
CCPR: Thank you for your time, Dr. Nutter.
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