Building Bridges: Interview with Rebecca Puhl (Part 1)

by Health At Every Size® Blog

by Jenny Copeland, PsyD

From the ASDAH Blog Committee: The Health At Every Size® Blog is stepping outside of our HAES® files “comfort zone” this week to present the first in a series of interviews which will explore the impact and influence on the Health At Every Size model of work being done by professionals who are not HAES-identified.

These “Building Bridges” posts are anticipated to appear periodically and will likely stir up mixed reactions and controversy among you, our readers. We are very aware that some of you may not agree with our choice of interviewees, and may experience them as highly controversial figures with viewpoints that are at odds with the genuine promotion of size-acceptance and/or the Health At Every Size principles. While the ASDAH Blog Committee acknowledges that these individuals do not fully embody the HAES paradigm, we firmly believe that some aspect of their work is valuable to HAES proponents as we attempt to address issues such as weight stigma, intersectionality, health-care access, research, policy development, and politics, among others. We encourage readers to respectfully ask questions, agree, challenge, and/or share your own ideas on the content of these interviews. Our overarching goal is to engage in meaningful dialogue around differences, in the hope of increasing our overall understanding and effectiveness in moving the HAES approach forward.

We thank Dr. Jenny Copeland for writing this first entry in the Building Bridges series. Due to its length, the second part of this interview will appear in August.

I will admit I’m a sucker for cheese. No, not the delicious and sometimes moldy protein. I mean inspiration: watching a television show or movie with touching music building to a crescendo or the pivotal epiphany in the quiet stillness. The Blind Side, The Newsroom, Up. I invest a small amount of time with potentially poor acting in exchange for knowing, if even for just one minute, that I can change the world. It gets me every time. These are the moments which keep me fighting through discouragement and burn out, the moments I call to mind when it’s time to take a risk.

As a member of ASDAH’s Leadership Team, I have the honor of helping build relationships with those who share a passion for eradicating weight stigma. When the opportunity came to interview Dr. Rebecca Puhl, Director of Research at the Yale Rudd Center for Food Policy & Obesity and leader of their weight bias initiatives, I needed the right inspiration to move forward. I knew that in the size acceptance community there are disagreements with the Rudd Center’s philosophy and hesitation to working with them. So I drew on the wisdom of Erin Gruwell* (1999), mentor of the Freedom Writers who taught her students not to fight but to live with integrity to enact change:

It would be easy to become a victim of our circumstances and continue feeling sad, scared or angry; or instead, we could choose to deal with injustice humanely and break the chains of negative thoughts and energies, and not let ourselves sink into it.

But really, one of my favorite moments happened on Grey’s Anatomy. The entire series built toward two characters (Meredith and Derek) committing to being together. They suffered through cheating, death of loved ones, lack of trust, and baggage from their family of origin. In the end they achieved a medical miracle together. At this point they finally get it: they realize they are more amazing together than they could ever be apart. Meredith rants at Derek before exclaiming: “I’m still mad at you, and I don’t know if I trust you. I wanna trust you, but I don’t know if I do, so I’m just gonna try, I’m gonna try and trust you because I believe we can be extraordinary together rather than ordinary apart.” That was it – a beautiful leap of faith with the hope for something great.

The following post is an interview with Dr. Puhl, meant to provide some insight into her understanding of weight stigma and her ideas of how we can work together for monumental change. I ask you, the Health At Every Size community, to take a ‘leap of faith’ and use this as an opportunity to consider her point of view in the interest of achieving weightier change in size perceptions – the potential for something greater.

Jenny Copeland, PsyD: How did you get interested in researching weight stigma?

Rebecca Puhl, Ph.D.: I went to graduate school at Yale to earn my PhD in clinical psychology. Initially, my focus of research was on the prevention of eating disorders. However, in my second year as a graduate student, I was given the opportunity by my mentor (Kelly Brownell) to write a research paper on the topic of weight stigma. The objective was to conduct a comprehensive review of the published research on weight stigma, to identify what was known and what was not known about the topic. At the time (this was almost 15 years ago) there had been some work published on weight stigma, but not much. It was not a topic that I knew very much about either. But, through the course of reviewing the literature and writing the manuscript, I became immersed in the subject and quickly realized what a significant social problem weight stigma is. It was also clear that many research questions needed to be answered to help bring attention to weight stigma, its devastating consequences for those who are affected, and the importance of finding ways to effectively reduce stigma.

Around the same time that I finished that paper, I was also beginning my clinical training and treating patients who were struggling with eating disorders, including binge eating. It quickly became apparent how much of a barrier weight stigma posed for these patients in their ability to recover and adaptively cope with their symptoms. Being the target of weight stigma not only reduced their self-esteem and increased their anxiety and feelings of shame and depression, but it often became a trigger for their disordered eating symptoms and maladaptive coping strategies, such as binge-eating. I was also saddened to see how often patients were being stigmatized about their weight from friends and family members, which was particularly damaging and had long-lasting effects on their emotional well-being.

So, it was the combination of these research and clinical experiences that led me to change the direction of my own research to focus 100% on weight stigma. I started with my dissertation, which tested and compared different methods of reducing stigmatizing attitudes about weight. And I never really looked back. It’s a topic that I’m very passionate about, and I’m grateful that I’ve had the opportunity to continue to pursue this important issue in my career as a scientist.

JC: It seems that “fighting a war on obesity” by definition contributes to weight stigma – can you help us understand how one can truly fight weight stigma and simultaneously fight obesity?

RP: From the Rudd Center’s perspective, our war is not best described a war on obesity, but rather our war is against the unhealthy food environment in our society, which impairs the health of all Americans, regardless of their body size. We want to create an environment that makes it easy for people to engage in healthy eating and physical activity behaviors, whether their BMI places them in the “obese” range or not. We believe that improving the food environment and reducing weight bias are compatible objectives, and there are many examples in public health and medicine that address both a health issue and the stigma it produces. As one example, great strides were made in the treatment and prevention of AIDS once stigma was recognized as a legitimate barrier and problem. The aim was not to eradicate or punish people with AIDS – quite the contrary – compassion and defense of basic human rights were essential.

In the case of obesity, we can’t ignore the evidence that there are many children and adults in our country who consume a poor diet, are physically inactive, and are obese. While these three variables are not always correlated, the research clearly indicates that obesity is statistically associated with unhealthy behaviors. In our research, we focus on diet, activity, and weight, because all three of these are associated with health. At the same time, we do not make assumptions about people’s behaviors based on their body size. We have seen individuals whose BMI places them in the obese range who are fit and eat a healthy diet, and we have seen individuals with a low BMI who are unfit and eat an unhealthy diet. However, obesity remains a fairly reliable marker for certain health behaviors, so when prevalence rates of obesity began to double and triple in the population during the last few decades, this observation led to concerns that there is something about our environment that is contributing to poor health.

Our view is that everyone deserves to live in a healthy environment that supports the behaviors that keep our bodies healthy. At the same time, we feel that individuals who are experiencing poor health associated with excess weight and who want to lose weight, deserve support, respect, and access to effective treatment – not shame, blame, and stigma. This is where the message often emerges that we need to fight the condition, not the person, because so often weight stigma creates significant barriers and obstacles for these individuals in their ability to obtain the support that they want and deserve. This is also one of the reasons that I have recently started studying the stigmatizing content that is sometimes present in “anti-obesity” campaigns or media messages that aim to encourage healthy eating or exercise behaviors. You may recall the anti-obesity campaign by the Georgia Children’s Healthcare Alliance in Atlanta, which received national criticism for promoting negative messages and stigmatizing children. This kind of campaign reinforces stigma and bias and is problematic on numerous levels. In our research, we specifically set out to examine how the public reacts to different obesity-related media campaigns. Not surprisingly, stigmatizing campaigns were rated poorly and were not motivating to people in their efforts to improve their health (regardless of their body size). Instead, our findings showed that the kinds of media campaigns that increased motivation to improve healthy behaviors were campaigns that focused on specific health behaviors (such as replacing soda with water, or eating more fruits and vegetables) and didn’t even mention obesity (or body weight) at all. This tells us that the message should really be about supporting and empowering people, regardless of body size, in their efforts to engage in healthy behaviors.

JC: ASDAH is committed to erasing weight stigma from our cultural landscape.  What role might an organization like ASDAH play in helping to eliminate weight stigma?

RP: Certainly, it’s important for organizations like ASDAH to speak out against instances of weight stigma and to bring attention to this issue as a social injustice. The more voices that we have that can speak about weight stigma, the more influence we can have in fostering change. But, more importantly, we need organizations like ASDAH to offer strategies, solutions, and support to help replace stigmatizing actions with better alternatives. Calling out instances of weight stigma that we see in our culture is a first step, but it’s not enough to reduce stigma. We need to be part of the solution.

As an example, we’ve spent considerable time at the Rudd Center developing evidence-informed resources that we can quickly and easily disseminate to different groups to help reduce weight bias. We’ve created an image gallery containing hundreds of positive, non-stigmatizing images of adults and children to replace the “headless stomachs” and other denigrating images that so often appear in media reports. We’ve created policy briefs and resources about weight bias for policy makers who are interested in legislation to address weight discrimination. We’ve created toolkits, courses, and educational videos for health providers to increase their awareness of weight bias in the health care setting. In each of these cases, we have made our resources free and accessible to anyone who wants them. We’ve experienced great results with these resources. Our images have appeared in national news and media outlets, our courses have been taken by thousands of providers, our videos have become required training in a number of medical facilities, and our policy briefs have been read by state senators who are considering legislation. And in our experience so far, people have been very receptive to resources, and are grateful that they don’t have to figure out how to address the problem on their own.

So, in my opinion, the role that we need organizations like ASDAH to play is to create, offer, and disseminate resources and strategies to address this problem. There are so many domains of our society where bias is present, which means there are many groups to target in stigma-reduction efforts. Schools, the workplace, and health care facilities are a few examples of settings where resources and support are needed. On a broader level, we need to engage the media and policy makers on the issue of weight bias, and ASDAH could be valuable in working with the media to change their portrayals of body weight or offering advocacy support to policy makers in their efforts to push policies forward to address weight bias and discrimination.

Stay tuned for Dr. Copeland’s next post in which Dr. Puhl answers questions about workplace wellness programs, how to eradicate weight bias (and the potential barriers that may get in our way), and working in a biased environment.

 

*Gruwell, E. (1999). The freedom writers diary: How a teacher and 150 teens used writing to change themselves and the world around them. Crown Publishing Group.

14 Responses to “Building Bridges: Interview with Rebecca Puhl (Part 1)”

  1. I love the idea of building bridges and I’d particularly like to hear the meaningful dialogue about differences that is suggested in the opening. But the dialogue about differences didn’t happen in this article; can you make sure it’s addressed in part two or these comments? Jennie posed the important question about differences, noting her concern “that “fighting a war on obesity” by definition contributes to weight stigma.” She asked, “can you help us understand how one can truly fight weight stigma and simultaneously fight obesity? Rebecca’s response didn’t help me understand the Rudd Center’s position: “From the Rudd Center’s perspective, our war is not best described a war on obesity, but rather our war is against the unhealthy food environment in our society, which impairs the health of all Americans, regardless of their body size.” I don’t get this, Rebecca. The Rudd center explicitly states that it’s goal is to “prevent obesity” – and its fight against the unhealthy food environment takes place within this context. How can you simultaneously say you want to prevent obesity without promoting weight stigma? I’m thinking about a teenage girl who commented on the obesity prevention posters in her school and said to me, “Can you imagine what it’s like walking down the hall and seeing this blaring sign saying they don’t want anyone to look like me?” So if your goal is to change the food environment? why bring weight into the picture? Your arguments about the associations between health and weight seem to me to be irrelevant to the essential question; from my perspective, if we want to improve health, we can best do this by addressing health directly – any time our message is about preventing obesity we introduce stigma and will be less effective – and worse, causing harm. Response?

  2. Rebecca, I appreciate your willingness to engage in a conversation, but I find myself confused by your response. You state clearly that there are fat and “healthy” people, and also thin and “unhealthy” ones. You state clearly that the “unhealthy food environment” effects “everyone, regardless of their body size”. You are very careful in several of your statements to note that “obesity” is “associated” with health problems, I’m assuming because you know that there is no causal link.

    And then there is this statement: “At the same time, we feel that individuals who are experiencing poor health associated with excess weight and who want to lose weight, deserve ……access to effective treatment ….”

    I don’t understand why you insist on keep the focus on weight when by your own statements you understand that weight is not a good indicator of health status on the individual level. I am curious about what you think “effective treatment” for “obesity” is, since the data is crystal clear that calorie restriction (aka dieting) does not work for the overwhelming majority of people over time. Peoples’ desire to lose weight is part of a social construct that is not the same as a desire to be healthy. By keeping the focus on weight, you are feeding into the very problematic social construct you seem to want to help improve.

    I hope part 2 of this conversation will address some of this, and I am glad ASDAH is having these conversations!

  3. This interview is full of contradictions. What a headache!

  4. So far so good can’t wait to hear about workplace

  5. Jenny, frustrating as aspects of it may be, it’s an important conversation. Good for you in pursuing it.

  6. I think the discussion is good but agree with the other comments that the focus is still too much on weight and too little on health.

  7. I am hoping that Rebecca Puhl will be actively involved in answering the questions and concerns raised in the comment section of this blog post. The metaphor of a bridge, in my paradigm, is a structure that goes two ways which means a dialogue is imperative in order to come to some kind of an understanding. Thanks to Jenny Copeland for opening up a sensitive subject and one that impacts all of us fighting the war against the war on fat people. Warmly, Dr. Deah

  8. I want to address my comments directly to Rebecca:

    I so appreciate the research you’ve done on weight stigma – Ellen Frankel and I are in the process of updating our book Beyond a Shadow of a Diet, and we’ve incorporated some of your findings. I also saw you present at BEDA a couple of years ago and really enjoyed it.

    I echo the concerns stated above regarding mixed messages. I want to focus some questions specifically on the following statement in the interview:

    “At the same time, we feel that individuals who are experiencing poor health associated with excess weight and who want to lose weight, deserve support, respect, and access to effective treatment”

    1)What type of treatment have you found to be effective for people who want to lose weight, given the standard of maintaining weight loss for a two-five year period to be considered effective?

    2)Is there anything you would recommend that people at higher weights do to take care of their health that would not be equally applicable to people at lower weights?

    3)How do you feel about the concept of weight neutrality, i.e. helping people to engage in healthful, sustainable behaviors, without a focus on whether or not any weight is lost?

    4)Given the understanding you have of the harmful effects of weight stigma, do your own beliefs about focusing on weight loss/preventing obesity differ at all from stated mission of the organization at which you work?

    Thanks again for engaging in this conversation, and thanks to ASDAH for making this happen!

  9. And this is the moment where I walk away from HAES. Build new ones for people like Puhl and the Rudd Centre to continue to treat us as though we are diseased/defective?

    I thought HAES was all about creating a new paradigm, not giving the dominant one a new platform.

    BURN THE BRIDGES.

  10. Thank you, HAES® community, for your engaging and thought provoking comments. I will ensure Dr. Puhl is aware of your questions and thoughts, and will share any responses I receive from her. I appreciate the willingness to challenge ourselves to grow that these comments display. I look forward to more of these discussions as our movement continues to advance.

    Dr. Jenny Copeland

  11. The community that built and uses the HAES model is a grassroots community, and because it is diverse and not policed by any central authority, there are people who will come down on a spectrum of positions with regard to bridge building vs. bridge burning.

    But I think it is fair to say that a central tenet of the model is that weight diversity is not pathological, fatness is not a disease, and that diseases are diseases and should be the focus of intervention rather than weight. I don’t know how optimistic I can be, Dr.Copeland, when Dr. Puhl draws an analogy between fatness and AIDS, sidesteps the Rudd Center’s financial and strategic interest in justifying environmental and nutritional change by pathologizing and trying to preventing fatness, and reduces the work of four decades of activism to “calling out stigma but not offering alternatives.” Really???

    Nothing that Dr. Puhl is saying diminishes the value of her research, which has been exceedingly helpful in demonstrating in scientific language what fat people have been reporting about their lived experience all along. But it is as if the only part of our stories that gets written up is the part that serves the Rudd Center’s agenda to make our lives so seemingly unbearable that we shouldn’t be allowed to exist (“Won’t someone think of the children?”). It’s one thing to document abuse in order to allow a people to breathe and flourish, it’s another to document abuse in order to paint a people as a cautionary tale for your campaign to justify environments that will eliminate us. Those environments are just as bad for the thin people as the fat people, so what’s the point of invoking weight at all? And by the way – fat people have been a natural part of almost every human environment in history. You’re stuck with us, Rudd Center!

    The most confounding thing to me about Dr. Puhl’s work is how she seems to overlook the source of fat people’s distress as weight stigma itself, even though that is what she studies. It is as if she can’t quite seem to believe that weight stigma, on top of every other structural inequality that disproportionately impacts people the higher one’s weight, is really THE problem, rather than some mysterious property of fatness itself. Her laudable wish to help fat people with “effective treatments” would seem to point to eradicating stigma rather than eradicating fatness, right? Isn’t that answer right there in her data?

  12. Trying to make friends with those who would just as soon annihilate you isn’t “peace” – it is surrender.

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