shouldn’t be talking about weight

Dr Claire Pearce, University of Canberra

Reviews of the literature have suggested that occupational therapists have a role in working with people living with obesity (Nielsen, Klokker, Guidetti, & Wæhrens, 2019). At an individual level, this can include being part of multidisciplinary teams whose focus is weight loss, supporting environmental modifications, providing education as part of prevention, and introducing or adapting occupations to increase physical activity or support dietary changes (Haracz, Ryan, Hazelton, & James, 2013).

But, in undertaking these roles, are occupational therapists just adding to the stigma and discrimination all too commonly experienced by people living in larger bodies?

Overweight and obesity affects two-thirds of Australian adults (AIHW, 2022) and yet it is commonly framed as an issue of individual responsibility – people are told they simply need to make ‘better choices’. In truth, the causes of obesity are a complex interplay between physical, social, environmental, and economic factors all impacting on a person’s ability to manage their weight (AIHW, 2017). Social inequity compounds dietary issues. High-quality food is often more expensive or harder to access, while energy-dense food is often relatively cheap and readily available. Many communities have seen a reduction in opportunistic energy expenditure as the physical demands of paid and domestic work have reduced, and leisure has seen an increased focus on sedentary screen- based activities (Department of Health, 2015; WHO, 2018). In the language of our profession, a person’s weight is influenced by who they are as an occupational being – their context and their occupations.

People living in larger bodies report that one of the most significant sources of discriminatory behaviour is health services (Lawrence et al., 2021). This can manifest as difficulty accessing services due to a lack of bariatric equipment, which compounds feelings of shame (Sikorski et al, 2013). Health professionals also reinforce negative stereotypes such as a assuming a correlation between having obesity and being lazy or unmotivated, even linking characteristics not related to weight such as assuming the overweight person is dishonest or lacking intelligence (Brewis, 2014). A significant number of people with obesity receive inappropriate comments about their weight from health professionals (Puhl & Heuer, 2009). The consequence of this entrenched discrimination is that people may be reluctant to seek essential care due to the fear that every health concern will be linked back to their weight.

The social narrative around obesity is that it is problem of epidemic proportions. There is an assumption that health-service based obesity prevention means that during every health encounter, larger bodied people should be told about the risks of excess weight and given clear advice on what to do to avoid being obese. A ‘choice and responsibility’ paradigm reinforces the idea that it is then up to them to do something about their own weight or be prepared be held accountable for the consequences. This approach has not been shown to work as the determinants of someone’s behaviour are not primarily about choice, so it is simply not appropriate to attribute responsibility in this way (Dawson, 2011). Furthermore, it has been shown that framing of obesity as a matter of choice prevents health services from playing an effective role in the prevention of the health consequences of obesity (Pearce et al, 2021).

People with obesity know that they are overweight because they will inevitably have been on the receiving end of stigma and discrimination because of the way they look. Health is so often judged by body size with slim being seen as ‘normal and healthy’. Consequently, people in larger bodies are judged as not taking care of their health, regardless of their health status. Focusing on weight loss as a solution reinforces the idea that all overweight people are a burden on society (Bacon & Aphramor, 2011). Occupational therapists work with individuals and communities, supporting them to do the things they want and need to do. We must be mindful that we do not project onto our clients what we think they need to do.

My proposal therefore is this: occupational therapists should not be focusing on weight and certainly not on weight loss because in doing so, we are overlooking the complexity of gaining and losing weight and reinforcing the framing of obesity as a negative state, a problem to be fixed. Focusing on weight loss reinforces the myth that all overweight people are a burden on society based on an arbitrary measurement such as body mass index. Instead, we should strive to maintain a focus on occupational participation, defined as “having access to, initiating, and sustaining valued occupations within meaningful relationships and contexts” (Egan & Restall, 2020). In doing so, we can support people to identify what life looks like for them, regardless of their weight. More importantly, collectively as a profession, we should strive to challenge the obesity discourse which frames obesity within a dichotomy of good (thin) or bad (fat) and speak out against and work to combat the bias and stigma that ultimately inhibits peoples’ occupational participation.

About the author:

Claire is an Assistant Professor in Occupational Therapy at the University of Canberra. She has extensive clinical experience in adult acute and rehabilitation services in Australia and the UK, has worked as a multidisciplinary team manager and has undertaken health service evaluation, development and project policy roles.

Claire was awarded a PhD from the University of Sydney in 2020. Her thesis entitled The Obesity Paradigm and the Role of Health Services in Obesity Prevention: a systems views utilised a systems thinking approach to explore the link between stigma and the concept of choice. Claire’s area of research interest is in the implementation of research into healthcare settings using a systems approach, with a particular focus on workforce development.

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