The Scarlet F

The young woman strides down a city sidewalk gripping a textbook and folder. Maybe she’s worrying about missing class, but probably not about being photographed. Nevertheless, she is caught in a camera’s viewfinder. The lens zooms in, focusing on the body part that will come to define her—a fold of belly revealed by her tight top. Her head is cropped out of the resulting photograph, which will go on to be picked up by news sites across the internet. You can now see her body next to headlines like “Too Fat to Graduate” and “Junk in the Trunk”—an anonymous symbol of disgrace.

“Headless fatty photos have got to go,” says Monica Kriete, MPH ’18. “The message they send is so harmful.” A student of social and behavioral sciences at the Harvard T.H. Chan School of Public Health, Kriete is also a passionate activist. Last fall, she helped mobilize student support for striking Harvard dining hall workers, talking into a bullhorn, her corkscrew curls bouncing.

But despite her outspokenness, Kriete, who identifies as fat, has long been attuned to the cultural signals, both subtle and blatant, that her body is not acceptable. After immersing herself in fat activism blogs as an undergraduate biochemistry and women’s studies major, she’s come to the School to acquire the tools to help change the conversation around weight and health. A key part of that is attacking stigma and shame.

Kriete describes weight stigma as a toxic exposure, like air pollution. The more you breathe it in, the more it puts your physical and emotional health at risk—from depression to hormonal changes that can lead to long-term physical damage. It can come from a nasty comment on the street, a blunt physician, or a family member practicing “tough love.” And there’s mounting evidence showing that it’s not just cruel, it’s also counterproductive.

From tight seats to “concern trolls”

One might think fat shaming would be trending down as the size of the average American has gone up, but perceived weight bias is actually rising. Among women, it’s now even more common than racial discrimination, according to work by Rebecca Puhl and colleagues at the Rudd Center for Food Policy and Obesity at the University of Connecticut. They and others have found that most Americans see weight as a matter of personal choice and willpower—and people with larger bodies as undisciplined and lazy. Being formerly obese does not make one immune to biased thinking about people who still carry excess pounds, Puhl has found. It can even make newly thin individuals more likely to feel contempt, because having successfully lost weight themselves, they may be more likely to scorn those who have not. According to Puhl’s research, the factor most likely to protect against biased attitudes toward overweight is having a friend or loved one with obesity.

A 2016 study in Medical Anthropology documented the ways that weight stigma weaves through people’s daily interactions with other people and the environment. Study participants with obesity described the need to meticulously plan trips outside the house and scan for hazards like too-tight seating that will inevitably draw derisive looks and comments.

Even the anonymity of the internet provides no safe haven. Fat shaming is rife online, from snarky social media comments on the latest celebrity weight gain to websites devoted to sharing “funny” photos and stories of fat people and their gluttonous behavior. On fat-acceptance blogs, the comment sections are often filled by a creature known as the “concern troll,” a source of unsolicited advice wrapped in a mantle of moral superiority. They say, for example: “She should really be exercising and eating better! Her joints must be taking a beating!” and “As one of my favorite quotes says, ‘Treat your body like it belongs to someone you love.’ Those who can’t—criticize them for being an illogical, unhealthy danger to everyone.”

Weight stigma raises people’s risk of being bullied as children and impairs their prospects in education, careers, and successful romantic relationships. It also increases risk of depression and suicide, and of disordered eating and avoidance of physical activity that can ultimately lead to more weight gain.

What’s more, the chronic stress from living with such encounters can lead to dysfunction across multiple body systems. The body adapts to stressful situations by sending out hormones, including epinephrine and cortisol, and by triggering other stress-mediating changes to the heart, muscles, and gastrointestinal tract—the so-called fight-or-flight response. But when the process is initiated too often, it disrupts the body’s capacity to achieve stability, or “allostasis.” Ongoing stress in daily life can lead to cellular wear and tear—termed allostatic load—and increased risk of heart disease, type 2 diabetes, and premature death.

Some researchers view allostatic load as an alternative explanation for at least part of the link between obesity and chronic disease. A recent paper by Josiemer Mattei, assistant professor of nutrition at the Harvard Chan School, and Maya Vadiveloo of the University of Rhode Island, found that study participants who experienced weight discrimination doubled their risk of high allostatic load over a 10-year period, compared with those who did not. Mattei says these findings suggest that weight stigma may be as harmful to the body in itself as poor diet and physical inactivity.

First, do no harm

“The biggest assumption physicians—and others—make is that I’m not very bright, because smart people would not choose to be fat,” says Rachel Wacks, 30, of Boston, a recent graduate in epidemiology from Boston University School of Public Health. A leader in several volunteer organizations and an advocate for girls’ health, Wacks sometimes hesitates to attend events focused on health issues because she anticipates judgmental looks from fellow audience members. At the doctor’s office, she says, “I’m blamed for my fatness before the health screening even begins.”

Indeed, fat shaming abounds in clinical medicine, according to Puhl and others. One study found that physicians were the second-most-common source of weight bias (after family members). Some doctors report feeling frustration toward heavier patients, which can lead them to spend less time with these individuals during appointments and fail to refer them for diagnostic tests.

Wacks has obesity and several medical conditions, including Hashimoto’s thyroiditis, that contribute to weight gain and make weight loss difficult. As an epidemiologist, she’s well aware of the importance of keeping an eye on her health, and she exercises regularly. But even she admits to ignoring potential health issues out of the fear of meeting with a doctor for the first time—a common experience for patients with obesity.

“I’ve had a lot of compassionate physicians who have been upfront but not rude,” she says. “They emphasize that my weight is an issue and I need to find a weight-loss program that works for me. On the other hand, I’ve also had physicians tell me that I shouldn’t worry about my thyroid because I’m going to die from being ‘so fat.’” One refused to surgically treat her endometriosis and suggested that she find a doctor who could perform that operation and gastric bypass at the same time. “I just cried. I vowed that I would never go back to that doctor—and I didn’t.”

A medical history without humiliation 

An alternative approach to speaking with patients whose weight may be harming their health, recommended by the American Academy of Pediatrics, is motivational interviewing—a counseling technique that engages the patient in developing his or her own goals for beneficial behavior change. Physician Brian Frank uses it with his patients in Portland, Oregon. While he directly raises the topic of weight with his patients, he tries to do so without making them feel humiliated.

“We feel the same frustration that patients feel when they are not able to lose weight. But it stems from the feeling that we can’t do anything to help,” he says. “We need to check that reaction, take a step back, and see how we can do something productive.”

According to Erica Kenney, SD ’13, a researcher with the Harvard Chan School’s Prevention Research Center on Nutrition and Physical Activity, focusing on healthy habits rather than numbers on a scale may be more effective for both weight and health in the long run. Interventions that single out kids who are overweight—such as sending them home with body mass index (BMI) report cards—may actually trigger compulsive eating and weight gain.

In 2016, Kenney facilitated a workshop at the School aimed at changing the ways clinicians talk about obesity and frame their research. The event was hosted by the Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED), based at Harvard Chan and Boston Children’s Hospital. Among the tips: Talk about “healthy” rather than “normal” weight and adopt “people first” language. That means, for example, referring to “people with obesity” rather than “obese people.” Above all, don’t blame individuals for their weight.

“We have to recognize that in the real world, it can be difficult to stay healthy and to lose weight once you’ve gained it,” she says. “And we have to look at the upstream drivers. What’s going on in the environment that makes it so difficult to adopt healthy habits?”

Bryn Austin, director of STRIPED and professor in the Department of Social and Behavioral Sciences, agrees. Too much emphasis on weight loss, she says, sets people up for failure and increases their risk of shame. She believes that health care providers should focus less on BMI as a proxy for health and more on individual health indicators such as blood pressure, blood lipid levels, and aerobic fitness—which a 2016 report by the American Heart Association confirmed was more predictive than height-weight calculations of cardiovascular health.

“BMI has its greatest value in large epidemiological studies where you are not communicating with individuals about their personal health,” Austin says. “But it’s been used as a bludgeon to stigmatize and to terrify people into achieving a lower weight. What if, instead, physicians said, ‘Your weight may never change, but I want to support you in creating a healthy and balanced life for yourself’? I think it would take us to a better place.”

The protective effect of positive body image

Tracy Richmond, assistant professor of pediatrics at Harvard Medical School, analyzes these issues from the perspective of a physician and public health researcher. Director of the PREP (PREParing for a healthy life) obesity intervention program at Boston Children’s Hospital, she works with kids from racial and ethnic minorities who are predominantly low income and have severe obesity. When Richmond started, she and her colleagues tried to help their patients understand the health risks of their weight status. The responses she received surprised her.

“We got back a lot of body positivity. We heard, ‘You can call me big, you can call me thick, but don’t call me obese.’ And ‘I would be happy to lose some weight as long as I can keep my curves.’”

Richmond and her colleagues, Kendrin Sonneville and Idia Thurston, decided to explore this response empirically, using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). They found that among kids who had excess weight, those who considered themselves “just about right” with regards to weight were less apt to suffer depression and less likely to engage in disordered weight control behaviors than those who accurately evaluated their excess weight. Over a 12-year study period, these self-affirming teens also gained less weight as they moved into young adulthood; indeed, weight “misperceivers” of both genders scored about 1.5 BMI units less than those who perceived their weight status accurately.

This finding led to what Richmond calls a “paradigm shift” four or five years ago in the way her clinic staff approached weight-based discussions. “We stopped talking to the kids about pounds and BMI categories, and instead we’ve been focused on promoting positive body image and satisfaction at every size.” As a result, she’s seen improvement in patients’ engagement with the program and in their psychological health.

“There is some protective impact from body satisfaction—no matter what you weigh,” Richmond says. How kids feel about their bodies is greatly influenced by how well they fit in with those around them, she adds. Many of the teens Richmond works with live in neighborhoods and attend schools where more people have larger bodies. Weight stigma is less an issue—unless they transfer to schools outside their neighborhoods, with different norms around body size. Richmond also hypothesizes that increasing diversity in body ideals among popular stars and sports figures like Kim Kardashian and Serena Williams may improve how kids feel about their own bodies.

Body positivity may lead to less weight gain, Richmond says, because kids eat less when they are psychologically healthy—either because they don’t feel the need to eat for comfort, or because they are less likely to get caught in a destructive cycle of unsustainable dieting followed by overeating.

At PREP, if adolescents have metabolic risk factors for diabetes and other complications, the staff counsels them on losing weight. But for those who are physically healthy—the majority, Richmond says—the focus is on building habits that will help them stop gaining. “We haven’t given up on weight loss,” she says. “But we are trying to move people toward adopting healthy behaviors like eliminating sugary beverages and incorporating more movement in their days, and to live a life that’s as psychologically healthy as possible—at whatever size they are. If and when they want to make lifestyle changes, we are here to support them.”

Richmond is still working to identify what inspires people to overhaul their lifestyle. Kids change for a variety of reasons, she says. Seeing a parent or other family member develop health complications because of their weight can be a powerful motivator. But rarely do those driven by a sense of shame about their bodies succeed. “We know that feeling self-defeated makes people engage in unhealthy behaviors. So if we can get people to feel positive every day, to feel empowered yet still want to make changes to improve their health, that’s the ultimate.”

Harvard Chan’s Monica Kriete is also looking for that tipping point. In the world she imagines, the language around food and physical activity would be less fraught with value judgment. Healthy choices would spring less from gritty determination and self-denial and more from self-nurturing and caring for the body—all in a culture that fosters rather than impedes access to good food and physical activity. And media images of people with larger bodies would show them looking happy and active and engaged in their lives—with their heads attached.

Amy Roeder is assistant editor of Harvard Public Health.