I think, therefore I am: Part Three

Part One, Part Two

The health conditions found disproportionately among society’s most oppressed and discriminated peoples, including the obese, are those very same conditions also associated with the stress response, according to Dr. Peter Muennig, M.D., MPH, and colleagues at Mailman School of Public Health. Numerous studies have examined a variety of social stressors, including discrimination, stigma and low socioeconomic status, all of which have been linked to poor health outcomes, they wrote in the American Journal of Public Health. The health among those who’ve internalized these stressors and the negative attitudes surrounding social acceptability and desirability, including negative feelings about their bodies and weight, appear most adversely affected.

Their study, as they noted, builds on a growing body of evidence that calls upon us to examine our own stereotypes of obesity as inherently unhealthy, unacceptable and the fault of the fat person, as well as the unsound health messages that reinforce these prejudices.

Examinations of negative stigma, prejudices and discrimination endured by any group are difficult, uncomfortable and painful. They can require us to examine, question and set aside our own prejudgments about people based on some arbitrary characteristic; and demand we move beyond those stereotypes that allow the discrimination and oppression to continue and replace them with scientific facts.

The vehemence of the incredulity, hostility and denialism in response to the mere suggestion that fat stigma, prejudice and discrimination even share similarities with the prejudices and discrimination experienced by other oppressed groups is an illustration of just how entrenched the stereotypes and prejudices surrounding obesity are held in our culture. While the experiences, struggles and social contexts of those targeted by prejudice are never exactly alike for each group — be it race, gender, sexual orientation, age, social and economic status, or body size — they share valuable and insightful similarities and differences.

Physiological stress responses

The health effects of negative social stresses have, as Dr. Muennig and colleagues noted, been reported in considerable research.

Persistent negative stress, itself, has been shown to result in a cascade of physiological events resulting in inflammatory responses that accelerate aging and worsen chronic diseases of aging, such as heart disease, osteoporosis and type 2 diabetes, according to Dr. William B. Malarkey, M.D. of Ohio State University. The two-year study by the Harvard School of Public Health which followed nearly 34,000 male health professionals, for example, found that those with high levels of fears and anxiety had triple the fatal heart attacks and six times the incidences of sudden death compared to men with low levels of anxiety.

Autoimmune illnesses, such as arthritis, asthma, allergies and skin problems, also appear vulnerable to negative stress. People in stressful situations show prolonged healing times, a decreased ability of their immune systems, and an increased susceptibility to viral infections, according to Dr. Esther Sternberg, M.D., director of the Integrative Neural Immune Program at NIH’s National Institute of Mental Health.

Children living in the most socially disadvantaged settings (poor, minority, low-education and without parents) have four times the risks of poor health, regardless of health insurance and access to healthcare. One study of Canadian children, ages 6 to 10, found that those from low socioeconomic families had significantly higher stress cortisol levels than same-age children from high socioeconomic families.

Social status

While stereotypes about poor people’s lifestyles creep into popular discourse, research has shown that lifestyles and behaviors, such as diet and physical activity, do not explain the influence of social-economic disadvantage on health or higher rates of premature deaths. Health is complex but not so easily a matter of ‘good’ behaviors. In the Americans’ Changing Lives study, for instance, even controlling for age, education, race, gender and healthy/unhealthy behaviors, the risk of dying was still nearly three-times higher among those in the lowest incomes compared to those of middle-incomes. They found that the popular belief that greater health problems among socioeconomically disadvantaged can be blamed on health risk behaviors was not supported.

Repeated studies have also found that it’s not just socioeconomic status or lifestyle habits that correlate with better health and longer life. Perceptions of social desirability and feelings of being accepted appear to have an underappreciated healthful role, just as was seen among the Rosetans. You’ll remember that study of half a century of Nobel prize winners and nominees, all of whom shared similarly high incomes, lifestyles and education levels. It found that simply the recognition from winning the prize added two years to the recipients’ lives as compared to nominees.

Another study found that deaths from heart disease are nearly four times higher among Brits in the lower end of each civil service job grade, even after accounting for the traditional risk factors such as smoking, weight, blood pressure, blood cholesterols, etc. The status effect was found even within the uppermost grades where everyone in that group was well-educated and high-income. Perceived social status and acceptance, and its psychobiological consequences, including social support and stress levels, appear to account for the health differences, the authors reported.

Social stigma

Just as prestige and status appears healthful, stigma appears unhealthful. Being the target of hostility, mockery and social shunning serves to demean, traumatize and marginalize people, adding to the oppression they feel. In this way, all targets of stigma are the same, and, so too, are the hurtful affects on their health and well being.

Studies of social discrimination have found it to be a much stronger predictor of hardening of the arteries than BMI (body mass index) or any of the classic cardiac risk factors like blood pressure or cholesterol, said obesity researcher Dr. Paul Ernsberger, Ph.D., Department of Nutrition, Case Western University, Cleveland, Ohio. Disparities in physical health among discriminated groups can’t be totally accounted for by socioeconomic or lifestyle differences, either, found University of Dayton School of Law authors of “Physical consequences of discrimination” in The Many Costs of Discrimination (2001). “As seen by all our respondents, blocked opportunities and discrimination not only generate psychological pain and suffering, but also link to many different bodily conditions,” they wrote.

An examination of the Study of Womens Health Across the Nation (SWAN) Heart data found that African-American women perceiving more discrimination had 2.8 times the risks for atherosclerosis, even after adjusting for smoking, blood pressure, cholesterol levels, age and BMI. Chronic exposure to discrimination appears to be an important risk factor for heart disease and adverse health outcomes, the researchers told cardiologists at the 2005 Conference on Cardiovascular Disease Epidemiology and Prevention. Similarly, Agency for Healthcare Research and Quality research examining disparities of diabetes diagnosed among minorities, found that incidences are exceedingly higher among minorities compared to whites, and that complications and deaths run as much as 50% higher. Yet, a Boston Public Health Commission study found that African-Americans are more than twice as likely to be diagnosed with diabetes as whites, even when the risk factors for diabetes are controlled for, including obesity.

In a multi-ethnic study of 6,814 adults, those experiencing the most societal prejudices and widespread hostility had significantly higher physiological markers for inflammation and atherosclerosis. In another study of successful minorities, those with certain cultural backgrounds who reported experiencing the highest levels of mistreatment, including disrespect, discourteousness, insulting behaviors, harassment, poor service, fearful reactions, and/or assumptions of dishonesty or stupidity, had more health problems, including cardiovascular, respiratory and pain-related health troubles. The associations were not related to age, education, income levels or job status.

“Post-civil rights, most people think of discrimination as the commitment of a hate crime,” said Dr. Gilbert C. Gee, Ph.D., assistant professor at the University of Michigan School of Public Health, who led the study of 2,100 Asian minorities. But “it’s important to realize that discrimination occurs on a daily basis. What the research is showing is that everyday slights can turn into long-term health effects,” he said. “For people to be suffering from premature illness and death related to exposure to discrimination is not acceptable."

In another review, hypertension among African-American women was attributed to being repeatedly passed over for promotions. In a study of nurses, most of the African-American nurses thought about race at least daily and many reported being constantly aware of their racial classification. Harvard epidemiologist Dr. Camara Jones, M.D., MPH, Ph.D., said this constant awareness contributed to undue stress responses and their higher blood pressures compared to the white nurses. This is just like the constant awareness of their weight status experienced by extremely fat women.

Yet, according to Harvard School of Public Health professor, Dr. Norman Anderson, Ph.D., hypertension has been found to be nearly nonexistent in rural African communities and black population studies of other cultures, compared to African-Americans.

In An American Health Dilemma, A Medical History of African Americans and the Problem of Race, its authors documented America’s social culture and its legacy of racism that’s left pervasive health disparities between minorities and whites. They catalogued how the higher rates of death, disease and disability among minorities were met with an “ethical blind spot” among the medical establishment. Rather than acknowledge the impact of prejudice and deprivation, the medical establishment “used racist science to establish poor black health as natural,” not unlike the disease status given obesity; a viewpoint they said was justified by pseudoscientific theories of inferiority and prejudices that degraded African-Americans, Native Americans and other minorities to “subhuman” status.

Harvard School of Public Health social epidemiologist Dr. Nancy Krieger, Ph.D., found that 80% of 2,000 African-Americans with high blood pressure had experienced race-based discrimination, including in getting a job, at work, at school, finding housing, in medical care, from police to the courts, and on the street or social settings. Putting this discrimination into context, she referenced hundreds of studies and media stories of blatant prejudices, including a 1990 General Social Survey that found 75 percent of white Americans agreed that “black and hispanic people are more likely than whites to prefer living on welfare” and most concurred that “black and hispanic people are more likely than whites to be lazy, violence-prone, less intelligent, and less patriotic.”

One only has to open any paper to read disparaging commentary of obese accused of ignorance in how to eat or too lazy to exercise, lacking personal responsibility, and even being accused by the Surgeon General as threatening national security and by the World Health Organization as contributing to global warming!

Dr. Krieger’s research found that it is the internalization of prejudicial experiences, and not talking about them with others or taking action, that raised blood pressure even more. Her findings have since been replicated. Repressed inner turmoil after an encounter of discrimination appears to set off a surge of physiological stress responses. As Dr. Krieger said, these are “ugly social facts, with profound implications for not only our body politic but also the very bodies in which we live, love, rejoice, suffer and die.”

Viewing prejudice and discrimination as a health risk could open the door to understanding how other climates of chronic mistreatment or fear seep into the body, said scientists at the Institute for Social Research at the University of Michigan. Perhaps it could explain why, for instance, pregnant women in California with Arabic names were suddenly more likely than any other group to deliver low birth-weight babies after 9/11.

Clearly, the negative stereotypes and prejudices experienced and internalized by fat people, just as those of other oppressed groups, can play a role in explaining their higher risks for health problems seen in some studies, as Dr. Muennig suggests. Yet few studies control for these factors. Dr. Sara Golda Bracha Fishman, Ph.D., is not the only professional, however, to note that studies showing poor health of fat people have most often studied people in medical settings, those experiencing intense anxiety about their weight and health, most beaten down by the oppression, and seeking help for their obesity.

Research on prejudices, discrimination and social stressors is controversial because the definitions can appear nebulous and based on recipients’ perceptions, rather than objectively verified incidences. Scientists at Harvard have found that it is difficult to get funding for such research, not only because it’s potentially polarizing and not profitable lines of research, but the National Institutes of Health and public health officials say changing societal prejudices also cannot be legislated by addressing discriminatory acts.

Prejudices can be invisible to those who aren’t its targets. But as Dr. Stephen Thomas, Ph.D., director of the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health, said: “Even though the human genome project has basically concluded that genetically we’re the same, the fact is, that the way in which we look, the color of our skin, and the accent that we carry affects the way in which we are treated in the social environment of American society. And this impacts us in ways that can have detrimental effects on our health.”

Fat stigma and stereotypes

“The social stigma against obesity is extraordinary in its magnitude and pervasiveness,” wrote professors and clinicians David Garner, Ph.D., and Susan Wooley, Ph.D., in their 1991 review of 500 studies on obesity, “Confronting the Failure of Behavior and Dietary Treatments for Obesity.”

Stigma against obesity isn’t mild or incidental. In fact, people of all sizes are unlikely to go a single day ... for their entire lives ... without encountering anti-fat messages and prejudicial beliefs about fat people. Sadly, research has shown that cultural negative stereotypes of fat people are learned and children as young as 3 years old already hold anti-fat attitudes.

Fat prejudicial beliefs are carried into adulthood and are even held by medical professionals who have access to the vast amounts of science that’s been published over the last half century.

The seminal review of research on fat stigma conducted by professors Rebecca Puhl and Kelly D. Brownell from the Rudd Center for Food Policy & Obesity, published in the 2001 issue of Obesity Research, found anti-fat attitudes prevalent among healthcare professionals and nearly unchanged since the 1960s. Anonymous surveys of physicians revealed that one-third associated obesity with “poor hygiene, noncompliance, hostility, and dishonesty,” two-thirds of family physicians thought their obese patients lacked self-control and 39% said they saw them as lazy. Among dietary professionals, most thought obese people were indulgent and had emotional problems and “overeat” to compensate for lack of love and attention, and one-third believed they lacked willpower. Nurses held similar prejudices, with most agreeing that obesity can be prevented by self-control, and nearly half feeling uncomfortable caring for obese patients, with one out of four saying that caring for an obese patient “repulsed them.” Those at the highest end of the weight bell-curve continue to be most stigmatized.

These prejudices have been documented as adversely affecting medical care that obese people receive and seek, their symptoms more likely to be viewed more severely than average-weight patients by health care professionals, and any health problem more frequently attributed to their weight and bad behavior.

An important point to note is that prejudicial beliefs about fat people are unrelated to one’s professional or academic credentials, and they are also “weight blind.” Puhl and Brownell pointed out that the heavier the nurses and more dissatisfied they felt about their own weights, the more negative attitudes they held about fat people.

It’s as Dr. Jeffrey M. Friedman, M.D., Ph.D., head of the Laboratory of Molecular Genetics at Rockefeller University, said: Conventional wisdom on obesity’s cause hasn’t changed appreciably from the time of Galen, who held obese individuals responsible for their size.

Social stigma and prejudicial beliefs surrounding obesity haven’t changed, but have notably increased over the past four decades. One only has to note the 31.17 million websites now for “obesity” and “overweight” — about 99.8% of a random sampling are perpetuating negative stereotypes and misinformation — to see how pervasive anti-fat sentiment has become in our culture. Media is similarly focused on showing endless unflattering, headless images of those at the uppermost extremes in the natural diversities of size, which have been present throughout history, to heighten stigma and exaggerate perceptions of an epidemic. People believe what they think they see.

Sadly, “harsh attitudes toward the obese depend on the assumption that they bring their condition on themselves through lack of will-power and self-control,” concluded doctors Garner and Wooley. Not only is their failure to lose weight after dietary, exercise and behavioral weight loss interventions widely blamed on “patient noncompliance,” but several respected researchers have actually concluded that social pressure on obesity needs to be increased, they said, purportedly to incentivize them to lose weight. “Obesity treatments have at times [even] included social shaming procedures as a treatment principle,” said Garner and Wooley.

As Dr. Friedman lamented in an article in Nature Medicine on the stigma of obesity, obese people continue to be victimized by social stigma and prejudicial beliefs that weight can be controlled simply by eating less and exercising, while the known science on the natural diversity of human sizes and shapes, like other physical characteristics, continues to not find its way into the minds of the public and even a significant proportion of the scientific community. “The heritability of obesity is equivalent to that of height and greater than that of almost every other condition that has been studied — greater than for schizophrenia, greater than for breast cancer,” he wrote.

Fat people are blamed for “overeating,” eating “unhealthy” foods (defined a myriad of ways), or being sedentary, despite the fact that a “tremendous body of research employing a great variety of methodologies that has failed to yield any meaningful or replicable differences in the caloric intake or eating patterns of the obese compared to the nonobese,” found Garner and Wooley. Convinced that obesity is caused by food, fat people are accused of having emotional “issues” with food and repeatedly told that they must be overeating, despite the fact they eat no differently than thin people to explain their size.

The renowned rigorous clinical research of doctors Michael Rosenbaum, Rudolph Leibel and Jules Hirsch at the Laboratory of Human Behavior and Metabolism, Rockefeller University in New York, for example, found nondieting fat and lean people eat and expend the same amount of calories per unit of lean body mass and that the proportions of protein, carbohydrates and fat do not determine (cause) obesity, either. This goes for children, too, as has been extensively covered here. The preponderance of clinical research has, and continues to demonstrate, that fat and thin children do not eat any differently or have any differences in their activity levels to explain the difference in their sizes.

The biological science of the natural diversities of human sizes hasn’t found its way into the minds of many in the scientific community, as Dr. Friedman noted, nor medical and dietary professionals, as professors Puhl and Brownell noted, nor even those specializing in the care of obese people. A NAAFA Board of Advisor member told members in its summer 2006 newsletter that the majority of obese people are not healthy. “These individuals become obese due to a variety of behaviors including: consuming a calorically dense diet, practicing a sedentary lifestyle...”

Stereotypes of obesity are reinforced by people’s personal experiences with dieting, said Dr. Friedman. When starved (calories restricted, regardless of the method) for a period of time any body will lose some weight, but biological mechanisms that enable survival and health also maintain body weight within a fairly narrow range will return them to their natural weight; similarly, excessive eating may result in some weight gain, but biological mechanisms also work to return them in the long run to their natural weight range. Just through a lifetime of eating and activity (a lot or a little) people only have a level of long-term control over their weight within a 10-, or at most 15-, pound range, he said. That's never going to change someone into a different body type. Weight loss interventions don't work. It’s a myth, but a popular fear, that by relinquishing control of eating and failing to 'watch what you eat,' people will continue to grow larger than their hereditary predispositions or become obese.

Fat oppression doesn't just affect fat people or fat women. It really works to keep everyone in line. It's a whole system of social control that keeps thin women absolutely terrified of being fat or thinking they are fat, and a whole lot of energy goes into dealing with fat. It keeps women who are medium-sized absolutely panic-stricken because they are right on the border. Those of us who are fat are over that border into some state of evil, basically, very much outside of what is permissible within white American culture. If you are fat, then what you are supposed to do is strive desperately to get non-fat. — Judith Stein, Fat Liberation Movement, 1981

The most harmful stereotype of obesity is that their size is dangerous and deadly. But this conclusion “represents a selective review of the data,” found Garner and Wooley. In fact, examinations of actual mortality data makes it clear that across studies there is no reliable pattern of association between premature death and relative weight, they said. Dr. Paul Ernsberger and Paul Haskew in their comprehensive review of more than 400 papers published in The Journal of Obesity and Weight Regulations, for example, found that “the preponderance of evidence fails to support the contention that obesity is associated with an elevated mortality risk,” said Garner and Wooley. “Neither coronary heart disease nor cancer, the two leading causes of death, was significantly associated with BMI.” Adiposity is not a risk factor for atherosclerosis or coronary heart disease, concluded nearly one hundred studies. “Moreover, it is rarely emphasized that cardiovascular health risks, when they do exist, may not necessarily translate into higher mortality rates...[and] obesity appears to protect against overall cancer death and against death from specific cancer types which are the leading causes of cancer death.”

According to Dr. Wooley, “fatness is an ethical, political problem more than a medical, psychiatric or behavioral problem.” There is a need for drastically revised attitudes toward obesity, she urged.

In Part Four (the last one), we’ll look at advocacy for fat people versus discrimination.

© 2008 Sandy Szwarc. All rights reserved.