“Move more, eat less.”
For Canadians living with obesity, that is often the advice given by medical professionals, the media, family, friends and other outlets when they are trying to manage their weight. But according to Ximena Ramos Salas, recent doctor of philosophy (PhD) graduate in health promotion and socio-behavioural sciences, this oversimplifies a very complex issue that about six million Canadians may be dealing with.
“Saying obesity is simply an issue of diet and exercise trivializes the disease,” explains Ramos Salas. “It makes those living with obesity feel like it is a lifestyle or behavioural choice, and therefore their fault. This causes them to feel judged and shamed, and to internalize the stigma of weight bias.”
Weight bias refers to an individual’s attitudes or beliefs about a person because of their weight. For the last 10 years, Ramos Salas and her team at the Canadian Obesity Network have been trying to develop a comprehensive national strategy for obesity prevention and management. In doing so, they discovered that one of the greatest barriers for advancing the obesity field in Canada has been weight bias. It is pervasive in Canadian society.
While pursuing her PhD, Ramos Salas looked at how or whether public health contributes to weight bias in Canada. She did this using a three-pronged approach. First, she critically reviewed all Canadian policies from all provinces and territories that addressed obesity prevention.
“We looked at the policy’s language, discourse and narrative to uncover assumptions behind the narrative and consider whether it contributes to weight bias,” explains Ramos Salas.
For example, if a strategy recommends educating people with obesity about healthy eating and physical activity, the main assumption is that people with obesity don’t know how to eat healthy or that it is important to stay active. She dissected where that assumption came from, how it might impact people with obesity and what that might be causing people with obesity to experience.
Second, Ramos Salas tested that message. She interviewed people living with obesity and asked them what they thought about public health narrative about eating healthy and exercising.
“People told me that the public health messages were not relevant to their experiences,” says Ramos Salas. “They didn’t relate to the messaging, they felt it didn’t consider other factors that contribute to their obesity that are unique to them, like genetics, mental health, medications and so on. It did not reflect the challenges that they faced while trying to manage their weight on a daily basis.”
Ramos Salas interviewed public health policy makers to understand their experiences with obesity narratives.
“Policy makers told me that obesity prevention policies and programs are developed in a highly political context and there is a general lack of understanding of obesity as a chronic disease. Obesity is viewed as a risk factor for other chronic diseases but not as a chronic disease in itself”.
Finally, Ramos Salas hosted a two-day workshop in Edmonton in collaboration with the Canadian Obesity Network EveryBODY Matters Collaborative and the Public Engagement Committee where invited people living with obesity, obesity researchers and health professionals, public health policy makers and patient advocates from other areas that have experienced stigma in their communities (i.e. diabetes, mental illness, HIV/AIDS, and LGBTQ communities). At the workshop, they looked at the current obesity narrative in Canada , compared them to patient experiences and current obesity scientific understanding and then looked at evidence surrounding stigma and population health outcomes.
Through her research, Ramos Salas discovered that the way public health conceptualizes obesity and forms policies may have unintended consequences for people living with obesity. She also found that people living with obesity found public health messaging to be unhelpful and stigmatizing. As a result, she came up with three recommendations for public health policy, programs, strategies and practices to help people with obesity:
1. In public health policies, obesity needs to be discussed and recognized as a chronic disease, not as a self-inflicted lifestyle choice.
“We need to talk about all of the factors that contribute to obesity, not just diet and exercise,” says Ramos Salas. “Not everyone will develop obesity for the same reasons as another person. We cannot generalize behaviours based on body size and we can certainly not assume that everybody living in a larger body is making the wrong eating and physical activity choices”
2. People living with obesity need to be consulted and engaged with when developing public health policies.
“If we include the people living with this disease, we can ask them how we can make sure a policy or program doesn’t have unintended consequences for them and the community,” explains Ramos Salas.
3. It is critical to distinguish between obesity and size. Obesity is a chronic disease that impairs someone’s health, whereas size is not a disease and many people live healthily in larger body sizes.
“Not everyone who is big has obesity,” says Ramos Salas. “People come in different shapes and sizes, so the idea that we categorize people based on their size as ‘healthy’ or ‘unhealthy’ is not accurate.”
Now graduated, Ramos Salas will continue her work as the managing director of the Canadian Obesity Network and as technical consultant for the World Health Organization–Regional Office for Europe where they will put forward her recommendations to public health policy makers.
“This is a social justice issue,” says Ramos Salas. “If we don’t address weight bias, we are driving discrimination against people with obesity. This not only impacts that person’s individual health, but also population health outcomes.”
“Weight stigma is a social determinant of health. It’s a key issue in public health—we need to start addressing it on a broader scale.”