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Weight Bias and Great Expectations

Given that the majority of folks with excess weight face weight bias and discrimination on a regular basis, it is not hard to imagine that the stronger the perceived weight bias, the greater the desire to lose weight.

One can also imagine that the lengths and perhaps risks that these individuals will go to, will be far greater than in people who are more comfortable with their excess weight and may have faced less societal pressure.

According to a study by Saaqshi Sharma (no relation) and colleagues from Ontario, published in Clinical Obesity, not only does the experience of weight bias apparently drive patients to seek out riskier and more drastic treatments but also perhaps promotes notions of weight loss that are even more unrealistic than harboured by most people seeking obesity treatments.

In this study, Sharma and colleagues studied 115 patients of the Wharton Medical Clinic with an average BMI of 40, 85% of who were female and 77% of who reported weight discrimination regarding their weight loss goals as well as their acceptance of different obesity treatments.

Specifically, the participants were asked to chose between increasingly ‘severe’ treatment options that they would consider:

Severity class I: Lifestyle changes (i.e. eat less, eat better, more physical activity, more will-power)
Severity class II: Pharmacotherapy and meal replacements
Severity class III: Bariatric surgery
Severity class IV: Genetic modification (i.e. something that is currently not even possible)

Overall, participants considered a weight loss of about 33% (or about 38 Kg) as ‘ideal’ and the majority thought that this could be achieved through lifestyle changes such as improved physical activity (80%) or diet (52%), with fewer reporting pharmacotherapy (8%), surgery (12%) or genetic modification (7%) as necessary for achieving this degree of weight loss.

Thus, participants selecting lifestyle changes or pharmacotherapy for weight loss reported ideal weight loss goals that would generally only be achievable through surgical means (i.e. 32% and 33%, respectively), and participants selecting surgical intervention reported ideal goals at the upper end of what is generally achievable even with surgery (38%).

Participants selecting surgery or genetic modifications were also more likely to report experiencing weight discrimination.

These findings have two important messages, which although perhaps not unexpected, should provide pause for discussion.

Firstly, it is evident that patients (and perhaps many health professionals) vastly overestimate the weight loss results of lifestyle interventions – an average outcome for these are in the 3-5% range – patients expect almost 10 times more than is realistically possible (anecdotal exceptions just prove how difficult this actually is).

Interestingly, even patients seeking surgery, grossly overestimate the degree of weight loss with this intervention.

Secondly, patients, who report weight bias not only have even more unrealistic weight loss expectations, they are also much more likely to opt for more drastic treatments.

To me, unrealistic expectations can only end in one way – disappointment!

Frankly, if I were to begin a treatment expecting a 40 Kg weight loss and find out that even 5 Kg (irrespective of any health benefits) is all that I can realistically hope to sustain, I would not be surprised if I fully abandon both hope and effort (especially if I also happen to be an ‘all-or-none’ thinker).

Indeed, I can only concur with the authors conclusions that:

“These findings may be explained by representations of obesity as easily modified with diet and exercise, which suggests that weight problems can be overcome through such modifications.

Patients and the public at large may need to be educated on realistic weight loss expectations for the various interventions in order to better balance the risk associated with each intervention against the risks associated with obesity, so that patients can make an informed and rational decision regarding their weight management.”

The latter can perhaps also be said for the majority of health professionals, decision makers, and funders of obesity services.

I wonder who the winner is.

Edmonton, Alberta


  1. This is my favorite “read” since joining the CON. The bottom line statement is the big gem of wisdom. I sincerely have hope that Obesity, the chronic disease, can be seen by the general public as honestly as described related to wt loss. Obese clients need so much encouragement and be directed to see wt loss wisdom realistically and move toward fulfillment in life vs a perfect world philosophy. None of the chronic diseases are that easily managed and a dynamic client centered long term approach is important and hopefully sustainable. There is no holy grail! Thanks for this one this am. Hmm…..what small change can I make today to make my world better. What choice will I make today to move my body…..chocolate[treadmill], strawberry[pool], or vanilla[ walk the dog]? Just saying what it takes…..:)

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  2. I’ve always thought that BMI is a crock and that the definition of “healthy weight” for each individual is the weight that they arrive at when they have healthy, enjoyable and sustainable habits.

    Weight bias throws a wrench into that for most people. Size prejudice uses health as an excuse and as a metaphorical bludgeon, but it is actually destructive to health. Appearance based stereotyping and discrimination, in and of itself, causes health problems. This has been confirmed in several studies.

    But it’s actually much worse than that. Adopting healthy habits does not result in a dramatic weight loss for most people. Losing 5-20% of our weight will not make most people who are classified as obese “normal weight.” It may not change our weight category at all, and it almost certainly won’t make others perceive us as thin. However, having healthy habits will make us healthier. In fact, it will often make us just as healthy as we’d be if we were “normal weight.”

    However, thin=healthy and fat=unhealthy is so hardwired into people’s minds that most people can’t parse the idea of an active fat person who eats a healthy diet. Many fat people are willing to take on almost any risk to their health in order to appear “healthy” (thin) to others.

    After all, those of us who take care of our larger than average bodies don’t get any brownie points for it from doctors or from society at large. In fact, we experience just as much prejudice and discrimination as any other fat person. At worst, if we discuss our habits or answer questions about them, we’re accused of lying or being delusional. At best, people think that our normal habits are attempts at weight loss and try to be patronisingly “supportive.”

    As long as weight bias keeps running rampant, only the most self motivated, independent minded fat people are going to be looking after their health properly. The rest will either seek out dramatic weight loss at any cost or fail to look after their health, since there’s so little social or medical support or acknowledgement for doing so.

    Anyone who is truly concerned about fat people’s health should probably be seeing this as the number one barrier to better outcomes and quality of life.

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