The fact that viruses do not discriminate, people do, has become crystal clear during the coronavirus disease 2019 (COVID-19) pandemic. Health-associated stigma, or the negative association between a person or group of people who share certain characteristics and a specific disease, much like a disease itself, crosses generations, societies, and cultures.
In this issue of The Lancet Diabetes & Endocrinology, we present a collection of pieces that raise awareness of obesity-related stigma and propose ways to mitigate it. The results of a multinational research survey, reported by O'Keefe and colleagues, indicate that obesity-related stigma is common among both the general public and health-care professionals (HCPs). Most respondents tended to conflate obesity with laziness, and reported believing that obesity could be prevented or cured by a commitment to a healthy lifestyle. These results suggest that many HCPs lack a proper understanding of the underlying biological causes of obesity. In some instances, their choice of language and tone might even re-enforce stigma. However, HCPs are also in a unique position to help address the stigma of obesity. Albury and colleagues, on behalf of The Language Matters working group, identify language that should be avoided in a health-care setting and suggest alternative non-stigmatising approaches for HCPs to lead constructive conversations about obesity. Importantly, the recommendations proposed by The Language Matters working group also draw on the experience of people living with obesity, who are part of the group themselves.
Although health-related stigma is a widespread phenomenon, certain health conditions are more stigmatised than others. In a Comment contrasting the differences in the narrative used for cancer and obesity in the UK's National Health Service long-term plan, Stuart Flint reflects on how conversations about cancer use a hopeful and optimistic tone, while the language used to discuss obesity is negative and pessimistic.
Health-related stigma is an added burden to those who are most vulnerable. People with obesity who feel stigmatised because of their weight are more likely to engage in behaviours that promote weight gain and to experience increased depression and anxiety. Additionally, stigma can also lead to reduced access or avoidance of healthcare in groups who are already at increased risk of adverse health outcomes. Patients with obesity are at higher risk for certain types of cancer, such as colorectal cancer, yet they are less likely to undergo a sigmoidoscopy or a colonoscopy because of fear and embarrassment.
Health-related stigma spreads far and wide. American politicians repeatedly blame mental illness for the recurrent mass shootings, creating the stereotype that people with mental illnesses are dangerous. Frequently, politicians, policy-makers, and the media use stigmatising language when addressing the skyrocketing global obesity rates. Even friends and families can, often unconsciously, associate excessive weight with lack of self-control and failure when communicating with someone with obesity.
The public health campaign record is also replete with examples that contributed to the stigmatisation of the same health condition they aimed to tackle. Several of the early HIV/AIDS awareness campaigns elicited shame and fear, and undermined, rather than facilitated, effective HIV prevention strategies. In 2009, Public Health England launched the Change4life campaign, the country's first anti-obesity national social marketing campaign. Change4Life purposefully focused more on messages about healthy lifestyles, rather than directly on weight or obesity. Yet, the choice of the slogan “eat well, move more, live longer” was heavily criticised for undermining obesity as a multifactorial condition and assuming that everyone can afford healthy options. Also, the charity Cancer Research UK has received criticism for their campaigns comparing obesity to smoking to emphasise the link between obesity and cancer. The perfect anti-obesity campaign may not exist, but it has become evident that stigma and fear-based messaging to change behaviour is ineffective and damaging.
Health-related stigma is a significant social, even political, determinant of health. Being dismissive about it is no longer an option. We hope that by highlighting the issue of obesity-related stigma we can raise awareness and reduce its harmful effects, although we also recognise that small efforts and goodwill are insufficient. Eradicating this stigma will require education and self-awareness, and significant and long-lasting changes in community and individual behaviour, which we now know we are capable of.
© 2020 Darrel Rees