Amid 'war on obesity,' skeptics warn of stigma

The images are striking: Overweight boys and girls staring somberly from billboards and online videos, real-life embodiments of the blunt messages alongside.

"Chubby kids may not outlive their parents," for example. Or: "Big bones didn't make me this way. Big meals did."

The ads - part of a new "Stop Child Obesity" campaign in Georgia - won some enthusiastic praise for their attention-grabbing tactics. But they also have outraged parents, activists and academics who feel the result is more stigma for an already beleaguered and bullied group of children.

"Billboards depicting fat kids are extraordinarily harmful to the very kids they are supposedly trying to help," said the National Association to Advance Fat Acceptance, which called for the billboards' removal.

The Georgia Children's Health Alliance, which created the ads, said they were necessary to jar parents of obese kids out of a state of denial that their children had a problem.

The furor reflects a broader nationwide phenomenon as states, cities and the White House itself - led by first lady Michelle Obama - expand efforts to curb obesity. For all the public support of these efforts, there's also a vocal and passionate corps of skeptics and critics worried that widespread discrimination toward the overweight and obese will only increase.

"Stigma is not an effective motivator," said Rebecca Puhl, a Yale University psychologist who is a leading expert on weight discrimination. "Whether children or adults, if they are teased or stigmatized, they're much more likely to engage in unhealthy eating and avoidance of physical activity."

Research by Puhl and her colleagues at Yale's Rudd Center for Food Policy and Obesity suggests that weight discrimination is pervasive - at schools, in the workplace, in the media, among health care providers. Yet efforts to combat it frequently founder: Only one state, Michigan, outlaws weight discrimination, and the anti-bullying policies proliferating in schools often lack specific content related to teasing of overweight children.

The spotlight on obesity intensified last year when Michelle Obama unveiled her national public awareness campaign, "Let's Move." Its goal, she said, was to eliminate childhood obesity within a generation by helping parents make better food choices, serving healthier food in schools, and encouraging children to exercise more.

Many aspects of "Let's Move" won near-universal praise. But activists in the fat-acceptance movement and experts who espouse a "health at every size" approach were upset that the campaign encouraged the monitoring of children's body mass index, or BMI, and thus might contribute to stigmatization of heavier kids.

"The idea of a BMI report card is horrible," said Paul Ernsberger a professor in the nutrition department at Case Western Reserve University's School of Medicine in Cleveland.

"To declare we're going to eliminate childhood obesity - that's actually a very stigmatizing thing to say," Ernsberger said. "The overweight child hears that and thinks, 'They wish I wasn't here.'"

Linda Bacon, a nutrition professor at City College of San Francisco, is the author of "Health At Every Size" - a manifesto for a movement stressing a healthy lifestyle rather than weight control. She said the focus by "Let's Move" on BMI was of dubious medical value and posed potential problems for kids at all weight levels.

"It's done much more damage than good," Bacon said. "The larger kids feel bad about themselves, and the thinner kids feel it doesn't matter whether they exercise or eat well."

Deb Lemire, president of the Association for Size Diversity and Health, credited Michelle Obama with good intentions and commended various nutrition-related aspects of "Let's Move." But she said the emphasis on weight risked worsening the problems of teasing and bullying.

"The message that gets to the kids is, 'There really is something wrong with me,'" said Lemire, of Cuyahoga Falls, Ohio. "We're saying we love you, we want you to have wonderful lives and be successful, but right now you're just not good enough."

The first lady's press office declined to respond in detail to the criticism, but defended "Let's Move."

"There will always be critics, but our approach is comprehensive, nurturing and working, with success already seen across the country," the office said in an e-mail.

There's no question that "Let's Move" has broad, high-powered backing, from groups such as the American Academy of Pediatrics. Its supporters note that one in three American children are overweight or obese, putting them at higher risk of serious health problems while billions of dollars are spent yearly treating obesity-related conditions.

Dr. Sandra Hassink, who chairs the pediatrics academy's obesity work group, said she witnesses the toll of weight-based bullying on a daily basis at her clinic at the A.I. duPont Hospital for Children in Wilmington, Del.

However, she defended the use of BMI as a screening mechanism.

"We know that elevated BMI places you at elevated risk of health problems," she said. "It's a screening tool to start a conversation with a child and family about health behavior that will reduce that risk."

Weight loss doesn't necessarily need to be the overriding goal in every case, she suggested, but it can be a vital part of countering diabetes, liver disease, sleep apnea and other obesity-related problems.

Critics of "Let's Move" say it could have struck a more positive tone about the diversity of body sizes and the possibility of being both large and healthy simultaneously.

"Regardless of her intentions, the first lady is making things worse," said San Francisco attorney Sondra Solovay, who teaches and writes about weight-based discrimination.

"I invite her to talk to fat adults who have experienced the hatred and discrimination firsthand," Solovay said, "and ask them how this program would have impacted them as kids."

Several local and state anti-obesity initiatives also have drawn fire from weight-discrimination watchdogs - notably Arizona Gov. Jan Brewer's recent proposal to levy a $50 fee on state Medicaid recipients who are obese and don't follow a doctor-supervised slimming regimen.

"This proposal does nothing to improve public health, and only perpetuates further stigma toward thousands of individuals whose quality of life is already reduced because of prejudice," Puhl wrote in her blog on Medscape.com.

One form of such prejudice is harassment at school. Peggy Howell, spokeswoman for the National Association to Advance Fat Acceptance, protested when members of Congress recently introduced a bill that addressed bullying based on race, ethnicity, gender, disability, sexual orientation and religion, but made no mention of body size.

"Why are weight and height missing?" Howell asked. "Multiple studies indicate that fat children are the group being most bullied."

Puhl says too little attention is paid to such bullying.

"Youth who are obese cannot conceal their weight - their stigma is very visible," she said. "And yet their voices are not being heard. They are so vulnerable to victimization, with such devastating consequences."

Indeed, weight-related bullying is being cited by family members as a possible factor in the decision of two 14-year-old Minnesota girls to commit suicide together on April 16.

Puhl, who has studied weight discrimination for more than a decade, was lead author of a 2007 study of overweight children that concluded their quality of life, due to stigmatization by peers, was comparable to that of people with cancer.

She also has examined how obese people are portrayed in ads, news reports, movies and TV shows. Too often, says Puhl, they are depicted in needlessly negative ways - slouching on a sofa, eating junk food.

"We need to be sure we are fighting obesity, not obese people," she says.

Among other initiatives, the Rudd Center has compiled a gallery of photographs portraying obese individuals "in ways that are positive and non-stereotypical" - strolling outdoors, shopping for fresh produce.

Puhl says her research indicates Americans would support legislation to prohibit weight discrimination, particularly in the workplace. Yet only Michigan and a handful of cities, including San Francisco and Santa Cruz, Calif., have such laws in place.

There's been little serious discussion in Congress or most legislatures about following Michigan's example by outlawing weight discrimination at the federal or state level. A bill introduced several times in Massachusetts has failed to advance; a similar proposal died in Nevada's legislature this year after employers objected.

Michigan's law, enacted in 1976, has resulted in only a handful of weight-related complaints each year, according to Michigan State University human resources professor Mark Roehling. He says many overweight workers may be hesitant to pursue legal remedies even if they do feel discriminated against.

One of the few high-profile lawsuits in Michigan involves two former waitresses who claim Hooters fired them in 2009 because they weren't sufficiently slim. Hooters officials say the state law shouldn't apply because the appearance of their waitresses was a legitimate concern. The case remains unresolved.

Meanwhile, fat-acceptance activists continue to struggle against what they perceive as bias - on matters such as airline seating and seatbelt standards that don't account for extra-large people.

Marilyn Wann, San Francisco-based author of the book "FAT!SO?," says she's proud to call herself fat, and objects to the terms "overweight" and "obese."

She became an activist partly because she was unable to buy affordable health insurance, and is grateful that the Obama-backed health care overhaul now enables her to get coverage. But she wishes the White House would do more to counter weight bias.

"I had a painful childhood, and it would be worse now because weight stigma has increased," she said. "It would be amazing if federal government took a stand against weight discrimination."

Hassink, the Delaware pediatrician, said obesity and weight discrimination should both be combatted firmly and compassionately.

"The environment is pretty tough for people struggling with their weight," Hassink said. "But we need to have the conversation. We're all in this together."