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Promoting Change in Culture and Perception About Body Weight

The fifth and final session, moderated by Nico Pronk, included two presentations on strategies to promote culture change and perceptions about body weight. A moderated discussion and question-and-answer period with participants followed.

A SOCIOECOLOGICAL APPROACH TO ADDRESSING STRUCTURAL RACISM AND WEIGHT DISCRIMINATION

The first presentation was on the intersection of structural racism and weight discrimination using a sociocultural or socioecological approach. Natalie Slopen, an assistant professor in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health and affiliated faculty member at the Center on the Developing Child at Harvard University, introduced the socioecological model (SEM) (Bronfenbrenner, 1979) to guide the presentation and the systems of oppression for structural racism and obesity stigma.

Slopen referenced SEM, which nests layers of systems for the developing individual across a lifetime. She described additional layers for children, who may be nested in a family unit, school setting, community, and state, which may have policies that impact one another.

Slopen asserted that many interconnected systems of structural racism exist in medicine and health care, education, banking, and housing and neighborhoods. She explained that the systems have downstream implications and consequences for if and how people interact with each other, which

impacts their health and development across a lifetime. SEM also identifies areas and places to address inequities through interventions, she said.

Slopen underscored that “structural racism shapes the environment in which people grow up, learn, work, and play, affecting access to healthy foods, a safe environment, and physical activity.” She continued that it has created and perpetuated inequitable social environments, shaped social determinants of health (SDOH), and led to the discriminatory treatment of minoritized individuals, resulting in differences in body size and long-term health:

Slopen explained that structural racism contributes to racial and ethnic disparities in health; marginalized communities have a higher prevalence of obesity because of their limited access to affordable nutritious food in their neighborhoods, more marketing of unhealthy food, limited access to safe places for physical activity, etc.

Slopen asserted that some researchers believe socioeconomic status can wholly explain neighborhood patterns, although racism is central. To illustrate, she presented data on U.S. children residing in poverty, stratified by levels in Dolores Acevedo-Garcia’s Child Opportunity Index, a metric developed to characterize contextual advantages and disadvantages for children’s health that ranks neighborhoods based on 29 dimensions of opportunity, such as the number and quality of schools, early education centers, graduation rates, home ownership, green space, healthy food outlets, and walkability.

Slopen highlighted that the differences in the environment cannot be explained by income. When she filtered the data for children living below the poverty line, she found striking disparities: 66 percent of poor Black children and 50 percent of poor Hispanic Latino children live in neighborhoods with very low opportunity compared to 20 percent of White children (Acevedo-Garcia et al., 2020).

Slopen shifted to focus on discriminatory treatment that minoritized individuals endure due to their multiple social identities. She explained that the intersection of structural racism and obesity stigma overlap and serve as independent sources of discrimination and disadvantage or preference and advantage for subgroups. People stigmatized for their overlapping social identities face compounded effects on their health and well-being.

Slopen shared four priorities to address the stark disparities in environment and health outcomes. First, she emphasized the importance of comprehensive approaches to address the root causes of structural racism

and obesity stigma. The second priority is to design equitable social and structural environments for all communities. The third is to develop strategies that foster awareness, empathy, and understanding to challenge weight-related bias and stigma. The fourth is to create strategies that inspire political will and commitment for a more equitable future.

A LIVED-EXPERIENCE PERSPECTIVE ON THE CULTURE AND PERCEPTION ABOUT BODY WEIGHT

Brian Castrucci, president and chief executive officer (CEO) of the de Beaumont Foundation and public health advocate with lived experience, was the final presenter. He shared his story as a person who has lived his entire life with obesity, from childhood to adulthood.

He gained and lost weight throughout his life and experienced ridicule and stigma from providers. He recalled losing 50 pounds as a 13-year-old. At his next doctor’s visit, his pediatrician did not encourage him but rather said that he was still fat and needed to lose more weight. Castrucci remembers that experience vividly from 36 years ago, and it shaped his future relationship with health care providers; he did not go to the doctor as often as he should, fearing he would be stigmatized and ridiculed.

Castrucci described how weight stigma persists in U.S. culture. He suffered from a heart attack in adulthood and worked hard to lose 70 pounds. When he visited with his endocrinologist, his doctor commented that he was still fat and needed to lose more weight.

According to Castrucci, the pervasive and persistent acceptance of weight stigma is palpable. To illustrate his point, Castrucci searched the Internet for the term “conversion therapy” (which aims to convert children who identify as LGBTQ to be heteronormative). His search yielded results of several websites condemning it and offering support. Castrucci then searched the Internet for the term “fat camp.” The first result advertised “the best fat camp for families…” Castrucci stressed the blatant difference in how society and culture view overweight and obesity in children versus other forms of therapy that try to change children.

Castrucci highlighted that this is partly due to the medicalization of obesity that shifted the blame to individuals, like the medicalization of drug use. Demedicalizing language, actions, and policies would require acknowledging SDOH as critical in determining housing, salary, and availability of healthy foods and directly impacting nutrition and possibly weight, he said.

Castrucci said that he thinks about how to feed his children healthy foods. As a CEO of a private philanthropy, he admitted that he has the privilege to live near his workplace in an expensive housing market, whereas some of his staff live 1 hour away, meaning they have 1 hour less to cook dinner, clean up, and get ready for the next day. Castrucci emphasized

that the intersectionality of housing costs, salary, and housing availability impacts how parents feed their children, their nutrition, weight, and health.

Castrucci called out an earlier comment that misinformation in medicine only happened during the COVID-19 pandemic. Castrucci pointed to social media advertisements that prey on fears (e.g., “Overnight ways to lose weight,” keto or low-carbohydrate diets). Castrucci noted that conflicting information from influencers, who are not experts, has proliferated with social media, but misinformation has always been an issue. He said that to have obesity is a deep fear, with a societal resistance to change.

Castrucci then posed a paradox to demonstrate that health information is not valued or regulated in the United States. He gave the example that if a layperson were to open a primary care clinic, they would go to jail for impersonating a physician. However, it is legal for them to give nutrition advice without any training in nutrition. Castrucci closed by asking the audience:

PANEL AND AUDIENCE DISCUSSION

Pronk led the audience and panel in a moderated discussion. Questions from the audience focused on SEM when planning interventions, trust and shared values concerning people living with obesity, and reasons for low attendance at healthy eating classes.

Using SEM in Interventions

The first question was for Slopen. When applying SEM to understand and address health disparities, how can it be incorporated into interventions?

Slopen replied that SEM applies across the life span. She said to consider how individuals’ lives connect with one another across generations, within families, and their communities when planning an intervention. The social environments and structures that impact individuals are distinct and unique, she continued, and neighborhoods may be more influential than the work environment. Slopen said that the challenge is determining the best leverage point.

Building a Language That Prioritizes Chronic Disease

The next question was for Castrucci. Health communication is core to public health. How has it worked in campaigns for chronic health concerns,

such as obesity? Castrucci answered that it is necessary to build a language. He pointed to the presentation from Day-Burget about RWJF’s work to build a language that prioritizes chronic disease rather than blaming the individual. Castrucci recalled his son coming home after school asking him about his diet. He responded that it was okay and questioned why his son was asking. His son had learned in class that all people with type 2 diabetes have bad diets. Castrucci said that even though this is scientifically inaccurate, that narrative is being built in schools, and elsewhere, with our youngest children. This belief will be difficult to deprogram, he said.

Castrucci continued by talking about how through criminalization and medicalization, U.S. culture has shifted responsibility to the individual and away from society. The diet industry or the vitamin and supplement industry are the biggest purveyors of misinformation, he said. As an example, ivermectin and hydroxychloroquine were advertised to treat COVID-19, which is factually incorrect yet appeared on the front page of a newspaper. Castrucci continued with the example of diet misinformation, and how Dexatrim and other weight-loss drugs are treated with equal veracity, when they should not be. Castrucci also pointed to how the diabetes drug, Ozempic, has been difficult for him to get as a diabetic because it is also being prescribed off label for weight loss and is constantly in the news. U.S. culture prioritizes thin bodies as the normative ideal and when obesity is medicalized, people are showing their disease all day, Castrucci said.

Trust, Shared Values, and People Living in Larger Bodies

Pronk followed up with a comment and question to Castrucci and Slopen. The idea of shared values from the Robert Wood Johnson Foundation (RWJF) seems to make sense when thinking about people as well as societal organizations and government. In the context of SEM, how can shared values be identified? How can clinicians create an authentic and trustworthy dialogue to uncover shared values across different levels of SEM?

Slopen responded that she believes shared values exist and can be identified through more dialogue and cross-sector collaborations. Some organizations are working in silos, and strategic connections could reveal their shared values, she said.

Castrucci agreed that the shared values model works well but pointed out that larger bodies are not accepted in U.S. culture; the shared value is that they should be eradicated. He noted the example of Jack Black, who became a leading man in movies after he lost weight. Castrucci asserted that leading men cannot be overweight. He added two more examples of entertainers who became more desirable after they lost weight: the actor Brendan Fraser and the singer Adele. Castrucci added that it is not a shared value among grandparents for their grandchildren’s bodies to be any size or

a larger size. Castrucci urged clinicians, scientists, and others to be thoughtful and honest when talking about shared values. It is still acceptable to openly mock people living in larger bodies, he said.

Reasons for Low Attendance at Healthy Eating Classes

An audience member introduced herself as a registered dietitian and long-time educator and shared that she has trouble getting people to attend her healthy eating classes that focus on habits and do not discuss diets, weight, etc. She asked Slopen and Castrucci for their reactions.

Castrucci responded that when he had his heart attack, he was prescribed cardiac rehabilitation, which was inconvenient and time intensive. He said that no one asked how he would fit 108 hours (three times a week for 12 weeks) into his work schedule or travel to and from the facility. He was congratulated by medical professionals who told him that most patients who have a heart attack do not go to cardiac rehabilitation. Castrucci admitted that he could do so because of his privilege as an economically stable White man, not because of diet or exercise.

Castrucci wagered that virtual participants in this workshop were likely working on three tasks while listening into his presentation. He conceded that it is hard to find time for health and that people learn and engage more on social media, such as TikTok. Castrucci highlighted that stress is the culprit of poor health, with demands from children, partners, and spouses. He said that diabetes, chronic disease, and obesity happen over a long period, and people have other immediate priorities to address, such as rent, getting kids to a field trip, or figuring out a partner or spouse’s calendar. Castrucci underscored that health care professionals must be more thoughtful about how to make education and trainings more accessible and easier to attend. He summarized by quoting author Michael Pollan: “make the healthy choice the easy choice.”

Slopen said that people may not feel comfortable in a healthy eating class. She was reminded of the personal stories from the workshop of people who have had negative experiences in health care and are hesitant to attend such events, fearful they will be singled out or embarrassed. Slopen urged health professionals to think about how they can design programs that create trust, so people feel comfortable about attending.

Castrucci pointed out that characters in movies drive the narrative with obesity. Castrucci explained the societal context using the example of the Little Mermaid: Ariel is an attractive, young, and innocent mermaid, and Ursula is the heavy, ugly sea witch with a low voice. Until racism, sexism, or ableism are broken down, the United States will not make progress, he said.

CLOSING REMARKS

Pronk delivered the final remarks. He recalled that the workshop began with presentations that outlined the problems with using body mass index (BMI) as a clinical parameter. The diagnostic term “obesity” must be redefined and reconceptualized using the criteria established by the American Medical Association: (1) signs or symptoms, (2) harm or morbidity, and (3) dysregulation of body functions. Standardized criteria coupled with a clinical and functional staging system could specify the severity and related complications for a more precise diagnosis, leading to more targeted and efficient strategies to prevent and treat it. Pronk emphasized that scientific evidence must be translated for medically actionable clinical treatment in the International Classification of Diseases, Tenth Revision coding system that directs treatment and reimbursement for clinicians.

Pronk also highlighted the George Washington University curriculum for medical students or learners to recognize their bias and stigma. He reminded the audience of the results from an anonymous self-assessment that jarred medical students who attended the Public Health Summit on Obesity. Pronk highlighted that students experienced a range of reactions, such as denial and overt bias, which aligns with the goal of the summit to grow awareness of weight bias in the clinical field and refocus health care treatment on improving health through 10 steps.

Pronk reiterated that weight bias and stigma extend beyond the clinical setting and are pervasive in U.S. culture, marginalizing people living in large bodies. It is socially acceptable in the United States to view bodies with overweight or obesity as problematic. He was reminded of the example of online advertisements for summer “fat camps” for children and families. It is paradoxical, Pronk stated, that other programs, such as conversion therapy, are unacceptable in U.S. culture.

Broadening the scope, Pronk discussed the paradigm shift in the clinical field. He explained that the goal of the traditional weight-normative approach emphasizes weight and weight loss to achieve health. Pronk shared the modernized weight-inclusive approach that aims to improve a person’s health and well-being through various other strategies.

According to Pronk, the evidence was clear that clinicians must communicate more compassionately and effectively. He recalled the presentations that pointed to the language and words clinicians use to discuss obesity, overweight, and health that are linked to behavior and health outcomes. Pronk underlined people-first language as a starting point. Although clinicians have a technical understanding of obesity, he said, they may not know how to talk to their patients. This is partly due to the prevailing narrative that body size is a personal responsibility and obesity results from a lack of restraint—the shift in perspective centers on the role of systems and

the environment. Pronk recalled the RWJF evidence-based communication strategy that adjusts the narrative on obesity and health to focus on shared values using three steps to create messages and images.

Pronk noted that research shows that ethics and trust are paramount in health and that patients want to trust their providers. For such a relationship, he reiterated that three elements must be present: authenticity, empathy, and logic. Pronk pointed to the research showing a bidirectional relationship with trust, meaning the more courteous and respectful a provider is to their patient and trusts their patient’s perspective and opinion, the more the patient trusts them.

Pronk stated that policy and political will must be required to change the perceptions of overweight and obesity in U.S. society and culture. He reminded participants that the nation has one of the lowest life expectancy rates of high-income countries worldwide because public health programs are underfunded. Pronk shared the desperate need to educate and advocate to decision makers on funding public health adequately and emphasized Trust for America’s Health’s effective communication strategy through storytelling with people and data to “make the case” for it.

Policy work is complicated, Pronk said, and some policies that aim to improve equity could unintentionally lead to inequitable circumstances, such as the SNAP-related policy that aims to dissuade the purchase of sugar-sweetened beverages by increasing the price. However, if consumers continue to buy them at a higher price point, they will spend more money and not purchase healthier beverages, which would be inequitable.

Pronk underscored the broader context of structural racism and obesity stigma as interconnected systems of oppression that perpetuate harm. He pointed to SEM as a means to identify critical points and issues for study and intervention. Pronk concluded by outlining the priorities to address structural racism and obesity stigma through a comprehensive approach using strategies to foster awareness, empathy, and understanding and a political will that addresses the root causes to create a more equitable future for all.