You re Too Fat. Esther Lerman Freeman, Psy.D. Clinical Associate Professor Department of Psychiatry OHSU

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1 You re Too Fat Esther Lerman Freeman, Psy.D. Clinical Associate Professor Department of Psychiatry OHSU Linda M Fishman, Ph.D. Insight Psychological Services, LLC Shilo George, MS Lush Kumtux Tumtum Consulting

2 Disclosure/Conflict of Interest I have no disclosures or conflict of interest

3 OK, One Disclosure I refuse to be weighed at medical appointments

4 Today s Agenda 1. Boring but necessary 2. Important and persuasive N=1 data, AKA the Lived Experience

5 Objectives Explain the impact that weight shaming and stigma in the medical community have on the health of those with high body weight. Discuss ways that our attempts to help patients have a "healthy body weight" actually create iatrogenic problems. Learn what the lived experience is like for people with high body weights to seek medical care.

6 Personal Wake Up Calls 1. Letter about iatrogenic public health problem 2. Bariatric surgery evaluations 3. Being called out by young social justice activist 4. Watching myself and how I look at others and myself

7 Interest Groups Identified So Far Psychology Family Medicine Bariatric Surgery Physiology Internal Medicine Psychiatry Surgery Nutrition Obstetrics and Gynecology Gastroenterology

8 The Vision OHSU as a shame-free environment in which healing, teaching and discovery come together to reduce health care inequities and health disparities for people who have high body weights.

9 The Mission The overarching goal is to make OHSU physically and psychologically a barrier-free environment for all patients regardless of their weight. Address implicit and attributional biases leading to poorer quality of care Provide compassionate, informed, effective health care for people regardless of their weight or BMI Include the lived experience of persons living with obesity and high body weight into the curriculum Educate the faculty on health risks associated with bias, stigma and shaming of this population

10 Our focus in NOT on weight loss for those with high body weights. Why shouldn t we want to help people who are overweight, obese, morbidly obese lose weight? What will happen if we do not tell people they are overweight? What will happen if we don t tell them their weight is contributing to their health problems? What if we stop weighing people?

11 Beneficence Beneficence is action that is done for the benefit of others. Clinical Applications: Physicians are expected to refrain from causing harm, but they also have an obligation to help their patients.

12 Autonomy Individuals come to doctors for guidance in making choices because they do not have the necessary background or information for making informed choices. Physicians educate patients so that they understand the situation adequately.

13 War on Obesity vs War on The Obese (Fat)

20 Bacon and Aphramor, Nutrition Journal (2011) Concern has arisen that weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self esteem, eating disorders and other health decrements..

21 Perceived Weight Discrimination and Obesity Weight discrimination is associated with behaviors that increase the risk of weight gain including excessive food intake and physical inactivity. There is robust evidence that internalizing weight-based stereotypes, teasing and stigmatizing experiences are associated with more binge eating. Sutin, AR and Terracciano (2013)

22 Ironic Effects of Weight Stigma Major, Brenda, Hunger, Jeffrey M, et al (2014) This experiment tested the prediction that exposure to weightstigmatizing messages threatens the social identity of individuals who perceive themselves as overweight, depleting executive resources necessary for exercising self-control when presented with high calorie food.

23 Ironic? Or Intuitively Obvious? Depends upon whether you have experienced this yourself or not. Interesting that our own perceptions and experiences once again are inflicted on our beliefs about our patients.

24 The more an individual deviates from a societal ideal, the more likely they are to be perceived (by self and others) as personal failures and less physically and socially attractive. (Klaczynski, et al (2004)) Weight stigma is manifested in the opinions that individuals hold about the personality characteristics of obese individuals. Obese individuals are assumed to be unsuccessful, unintelligent, unhappy, sloppy, lack willpower and personal control (Puhl and Brownell, 2006) Ratcliffe, D and Ellison, N (2015)

25 Obesity and Internalized Weight Stigma Insert Figure 1 from article here Ratcliffe, D and Ellison, E (2015)

26 Vicious Cycle Individual perception of being overweight Plus media messages that stigmatize obesity Increase their concerns about being stigmatized because of their weight Can have paradoxical effects of increasing their consumption of calorie-rich foods AND reducing their feelings of self-efficacy for being able to control their diets

28 Stigma experience is associated with risk for binge eating and decreased interest in physical exercise and dieting for children and adults Nolan, LJ and Eshleman,A (2016)

29 Associations of Weight Stigma With Cortisol and Oxidative Stress Independent of Adiposity Preliminary findings show that weight stigma is associated with greater biochemical stress, independent of level of adiposity. It is possible that the weight stigma may contribute to poor health underlying some forms of obesity. These findings are consistent with the notion that weight stigma may not only be harmful for obese individuals, but in fact may also affect women who are nearer to what is considered normal weight. In other words, it is likely the self-perception or appraisal of weight rather than objective BMI that is most relevant in the weight stigma domain. Tomiyama, J, et al (2014)

30 Obesity Bias in Training: Attitudes, Beliefs and Observations Among Advanced Trainees in Professional Health Disciplines Students reported that patients with obesity are a common target of negative attitudes and derogatory humor by peers (63%), health care providers (65%) and instructors (40%) Puhl,RM,Luedicke, J and Grilo, C (2014)

31 The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey n=4687, with 1,126 obese/overweight Perceived and internalized weight stigma was found to be potential contributor to worse well-being among overweight and obese medical students Phelan, Sean M, et al (June 2012)

32 Stigma as a Fundamental Cause of Population Health Inequalities Because of its pervasiveness, its disruption of multiple domains (eg, resources, social relationships, and coping behaviors) and its corrosive impact on the health of populations stigma should be considered alongside the other major organizing concepts for research on social determinants of population health. Halzenbuehler, ML, Phelan, JC and Link, BG (2013)

33 Obesity Stigma: Important Considerations for Public Health Stigma and discrimination toward obese persons are pervasive Weight stigma is both a social justice issue and a priority for public health Ruhl, RM, Heuer, CA (2010)

34 Practical Advice for Family Physicians to Help Overweight Patients AN AMERICAN FAMILY PHYSICIAN MONOGRAPH (2003) Prepared by Susanna E. Guzman, in consultation with: The American Academy of Family Physicians Panel on Obesity BMI should be considered to be comparable to blood pressure as a vital sign that is measured and recorded at each visit during which weight is also obtained.. To do so for every patient (or to increase the number of patients for whom this is done) is an example of a successful process measure.

35 Implications for psychological treatment of internalized weight stigma Prevention is societal and educational Intervention is aimed at decreasing the internalized weight stigma in the individual Not only does the weight stigma contribute to increased weight but it also contributes to anxiety, avoidance and depression Ratcliffe, D and Ellison, N (2015)

36 One family s story Linda M Fishman, PhD

45 Obesity and Internalized Weight Stigma Insert Figure 1 from article here Ratcliffe, D and Ellison, E (2015)

57 One person s story Shilo George, MS

61 Resources ASDH: Association for Size Diversity and Health The Body is Not an Apology Fostering radical unapologetic self love, body empowerment, and health around the world Do No Harm Podcast:

62 Books Shrill by Lindey West Hungry by Roxane Gay The End Of Overeating by David Kessler Rethinking Thin by Gina Kolata

63 How do we create a new culture? Welcoming physical environment Being aware of our own biases Learning a new language Questioning whose goals we are trying to meet and remembering the data

64 Image References Born to be Fat. (2017, March 22). Retrieved October 26, 2017, from Guglielmetti, P. (n.d.). This Powerful Photo Series Proves That "Fat" Is Beautiful. Retrieved October 26, 2017, from Stand4Kids Tumblr. (2012, March 23). Retrieved November 21, 2017, from Wasylko, Z. B. (2016, September 21). Jessamyn Stanley Is Changing The Yoga World, One Pose At A Time. Retrieved November 21, 2017, from

66 A Big Thank You To: Amy Forester, MFA Faculty Development Specialist Teaching and Learning Center Oregon Health & Science University

What's Eating You? What Science Tells Us About Food and Weight Issues. Brown School of Professional Development, September 1, 2017

What's Eating You? What Science Tells Us About Food and Weight Issues Brown School of Professional Development, September 1, 2017 Confirmation Bias The tendency to embrace information we agree with and