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Three Steps to Challenge Internalized Weight Stigma
By Karen R. Koenig, MEd, LCSW

As an eating disorders therapist, I treat many high-weight clients. Some are 40 pounds heavier than they would like to be, while others weigh more than 300 pounds. In either case—in fact, in most cases—clients who weigh more than the norm have internalized culturally induced weight stigma that is damaging to both their physical and mental health. Our job as social workers is to help them stop internalizing negative feelings about their size or shape by understanding how they came to adopt these false perceptions in the first place.

During initial sessions with high-weight clients, I listen for their feelings about their bodies. They may tell me that they accept them, enjoy a social life, and even run 5K or 10K marathons—but generally, they hold the same negative prejudices about their bodies as society does. Because attuning to appetite and making healthier food choices consistently takes time and practice, I raise the issue of internalized weight stigma to offer clients a healthier way to view their bodies right now.

Step #1: Factors That Affect Weight Other Than Food and Activity
Clients are usually surprised to learn that the long-accepted weight theory of calories-in and energy-out is old hat and that there are myriad factors that contribute to what a person weighs, including the following:

1. Genetics: “Research suggests that for some people, genes account for just 25% of the predisposition to be overweight, while for others the genetic influence is as high as 70% to 80%” (Harvard Health, 2019).

2. Body fat composition: Because brown fat burns more calories than white fat does, studies suggest that having more brown fat may explain why it’s easier for some people to lose weight than for others to do so.

3. Lipid metabolism: Breakdown and storage rates of fat affect weight loss and regain.

4. Microbiome: Differences in our gut’s bacterial mix may impact what we weigh.

5. Neurotransmitters: Deficits in serotonin and other biochemicals underlying depression and anxiety may trigger cravings for high sugar/fat food.

6. Adverse Childhood Experiences: There is a correlation between emotional eating and experiences of abuse, neglect, and trauma.

7. Parental thinness focus: Parents overfocusing on thinness, dieting, nutrition, and fitness early in children’s lives may incline them, paradoxically, toward unhealthy views of food and their bodies.

8. Parent-centered focus: Controlling, demanding, critical, or shaming parents, or those who suffer from anxiety or depressive disorders may cause their children to be unattuned to or rebel against what is good for them in eating and other aspects of life.

9. Habituation: Children who were raised on high fat/sugar/salt diets may become physically habituated to and emotionally dependent on them as adults.

10. Poverty: People living in food deserts or lacking money to buy nutritious food may habituate to low-nutrition food that is usually high in sugar and fat.

11. Pregnancy: What a mother eats during pregnancy may affect her child’s weight as an adult.

12. Sleep deprivation: Lack of sleep increases production of ghrelin, the hunger hormone, and decreases production of leptin, the satiation hormone.

13. Ineffective life skills: Being unable to self-comfort, self-soothe, enjoy pleasure, self-regulate, or be comfortable with intimacy and sexuality may trigger food seeking to manage life’s ups and downs.

14. Unhealthy personality traits: All/nothing thinking, perfectionism, caring for others rather than self, approval-seeking/people-pleasing, impulsivity, low frustration tolerance, and difficulty delaying gratification distort honoring normal appetite cues.

15. Food industry: This aggressively profit-driven industry is largely responsible for habituating the public to sugar/fat/salt.

16. Nutrigenetics: Different bodies interact differently with nutrients, leading to a conclusion that people do not process nutrients uniformly.

17. Unresolved psychological conflicts: Mixed feelings about deservedness and self-worth, being productive, shoulds and shouldn’ts, and intimacy/sexuality may be played out via eating and body size.

18. Temperature: How cold it is where people live (indoors and outdoors) may affect how many calories they burn, as being cold burns more calories.

19. Hormones: Many women gain weight after menopause.

20. Medications: Steroids, antidepressants, and other medicines may cause weight gain.

21. Chemicals: Synthetic chemicals appear to cause weight gain if ingested in sufficiently high doses.

After discussing the possibility that some or many of these factors have affected their weight, I ask clients whether that makes them feel any differently about their body size. For many, considering these factors begins to challenge their inner narrative of having done something (or many things) wrong to become a large-size person. For example, they see how for generations, their relatives were big people, large-boned and strong. Some recognize how a childhood spent eating delicious Southern cooking or cheap fast food due to poverty set the stage for craving high-fat, high-sugar foods. Some connect being sexually assaulted or bullied as a teenager with their need for weight to act as a buffer between them and the world. Many open their minds a crack to the idea that the way their body functions—such as storing fat efficiently rather than burning it off quickly—may be different from the way their size 2 best friend’s body functions. Others realize that all the fat shaming they endured from parents only made them want to eat more.

Step #2: Why Weight-Loss Diets Fail Long-Term
Next I talk with clients about why diets do not work for permanent weight-loss and may, in fact, put pounds on them. I start with the following four quotes from psychiatrist Randolph M. Nesse’s enlightening book, Good Reasons for Bad Feelings: Insights From the Frontier of Evolutionary Psychiatry:

• “The main evolutionary explanation for the obesity epidemic is obvious: the mechanisms that regulate body weight are poorly suited for our modern environments.”

• “The systems that have evolved to regulate eating protect against starvation superbly. It used to be that when they detected a caloric deficit, they had to go to extreme efforts to get food and eat it. Now, not so much. The systems that protect against excess body weight are feeble by comparison … the brain mechanisms that protect against obesity are weaker than those that protect against starvation.”

• “… strenuous dieting arouses famine protection mechanisms that are prone to initiate a positive feedback spiral.”

• “Worse yet, dieting resets the weight set point upward. It also slows down metabolism.”

Usually, I can see a light go on in clients’ heads as they realize—often for the first time—that it is not their innate laziness, substandard self-care, lack of discipline, poor self-control, stubbornness, or greed for pleasure that has made them the size they are. Most are both saddened and regretful about this realization. Substantially shame-based clients blame themselves, believing they brought on the problem by dieting—as though they should have known better. But many are angry at the media, their parents, and our culture for duping them into thinking that weight-loss diets are bound to succeed.

We spend a good deal of time talking about their dieting efforts and I reframe their failures as our bodies doing their thing—that is, slowing down metabolism to conserve calories to survive. For some clients, this is both the good and bad news, bringing them relief because it means they are not bad people after all, but also generating fear and helplessness at how on Earth they will slim down without dieting. Most welcome my introducing them to intuitive eating and health, not weight goals, and the idea that our bodies can lose weight and keep it off if we stop depriving them of the nutrients they need and the pleasures that food may bring.

Step #3: Understanding the Origins of Weight Stigma
Once higher-weight clients recognize that weight has many determinants they were never aware of and that the restrictive diets they have endured for years have likely been the cause of weight regain, they are ready to explore what causes weight stigma. I tell them that a major factor is their bad luck to be born into the most fat-phobic, thin-obsessed culture in the history of the world, a culture that is, paradoxically, also oddly fixated on food. In many ways, it is just a matter of biology and rotten timing.

However, there are other factors as well. Our culture (well, most of it) is gradually accepting that it is wrong to ridicule people of color, women, Jews, Muslims, LGBTQ people, physically or mentally challenged people, and many other minority groups and vulnerable people. Why, then, are people not called out for humiliating and denigrating higher-weight folks? One answer is that because we have learned to demonize fat, we have also learned to demonize those who carry it around. Weight stigma is as institutionalized as racism, religion still teaches that gluttony is one of the seven deadly sins, and our culture blames the victim in accordance with its “you broke it, you fix it” mentality.

Moreover, we are stuck with the very human trait of confirmation bias, a form of selective attention that allows us to see what we want to see and little else. Many people refuse to recognize that we do not know what we do not know and that includes biases that run deep below our radar. Our blame/shame-oriented culture believes in a virtually equal playing field, personal responsibility above all else, and that if one person can do something, so can everyone else. What a perfect recipe for weight stigma.

It is essential that higher-weight clients understand that the root of weight stigma stems from outside of themselves. They are not the cause of it and have the choice to not buy into it. Substituting curiosity and compassion for blame and shame, our clients need to develop their own rational, true narratives of how they came to be their current size. By helping them discover their own stories of how they got to where they are (even as they were trying to get somewhere else through dieting), and to block out and shut off society’s weight stigma introject, we give clients the gift of body acceptance as they can go on to learn how to become “normal” eaters and live a healthy life.

— Karen R. Koenig, MEd, LCSW, is a licensed psychotherapist, motivational speaker, and international author who has specialized in the field of compulsive, emotional, and restrictive eating for more than 30 years.

References
Harvard Health.(2019, June 24) Why people become overweight. Retrieved June 26, 2019, from https://www.health.harvard.edu/staying-healthy/why-people-become-overweight.

Nesse, Randolph M. (2019). Good reasons for bad feelings: Insights from the frontier of evolutionary psychiatry. New York City, NY: Penguin Random House.