Fat Stigma, Disordered Eating, and Ozempic
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There is no question that fat stigma is real. Nearly 20 years ago, I joined a commercial weight loss program and managed to lose 80 lbs in a period of ten months, which represented a drop in body mass index (BMI) from an “obese” 31 to my current “healthy” 19. The psychologist in me was curious to see how this change would affect the way I was treated, and the results of my unofficial case study were dramatic.
Not only did my student evaluations improve, but students were more likely to hold a door open for thin me or wave me across at a crosswalk (yes, I did count). On my way to a conference, an airplane seatmate confided that he was “relieved” that I was the one assigned the seat next to him rather than some of the other people he noticed in the waiting area.
Why do people stigmatize bodies? Am I not the same person at both weights? Among the roots of fat shaming is the religious concept of gluttony, or the excessive, sensation-seeking, and intemperate consumption of food. Gluttony, one of the cardinal sins in Christianity, was associated with selfishness and lack of will. This moral theme remains highly influential today.
Other influences on body image might be even older. Evolutionary psychologists have proposed that “ideal” female shapes, characterized by small waist circumference, small waist-to-hip ratio, and lower BMI, might reflect improved health and fertility. This relationship between body type and fertility is unlikely, however, and possibly even counterproductive in the subsistence lifestyle that characterized our species for most of its history.
More recently, media, and social media in particular, shape cultural ideals for appearance. Coupled with social media’s culture of mob-enforced conformity, the results can be brutal. Meg Bellamy, who played a young Princess of Wales on the television show “The Crown” related that online trolls complained that she was “too fat” for her role.
Regardless of their sources, cultural ideals for female body shape in wealthy countries are extreme. Playboy models, beauty contestants, and female actors average a BMI of 18.5, compared to the 29.6 BMI of the average adult American woman. When people perceive a discrepancy between how they look and how they want to look, negative outcomes are likely. In milder situations, self-esteem and confidence can be negatively impacted. In more challenging situations, true body dissatisfaction can lead to body dysmorphia, or the obsession with perceived physical flaws, or to diagnoses of disordered eating, including anorexia nervosa, bulimia nervosa, and binge eating disorder.
What is Body Positivity?
Countering stigmatization is the concept of body positivity, or the valuing of all bodies, regardless of appearance or ability. This movement has a long history but has gained prominence in more recent years.
Beginning in the 1960s, people began to push back against the idea that people’s worth was summed up by their appearance, an idea consistent with the Civil Rights movements of the day. The National Association to Advance Fat Acceptance (NAAFA) was formed in 1969 with the goal of ending discrimination based on weight.
The 1990s saw a precipitous increase in the weight of the American public. Data from the Centers for Disease Control in 1988 showed that no state reported more than 15 percent of its adult population as obese. Beginning in the early 1990s, however, rates began to skyrocket. By 2020, no state reported fewer than 20 percent of the adult population as obese, and many states reported rates of obesity between 40 percent and 45 percent.
Perhaps not surprisingly, the 1990s became the decade of “diet culture,” with one fad diet following another. People became obsessed with a thinness that seemed increasingly difficult to achieve. Eating disorders, including anorexia nervosa and bulimia nervosa, plagued many. To counter these trends, body positivity movements and mental health professionals encouraged people to take a more realistic, balanced view, bolstered by support groups found on the emerging internet.
The advent of social media both promoted fat stigma and supported efforts to reduce it. Exposure to “perfection” in the media has always contributed to body dissatisfaction, and social media’s reach and influence dwarfs anything preceding it. In particular, the graphic format of Instagram seems to make the platform a particularly powerful disseminator of cultural ideals. At the same time, social media influencers engage with large communities to promote body positivity. Brands have taken notice, leading to partnerships with influencers and using diverse models in advertising and campaigns.
Enter the GLP-1 Agonists
Dieting does work, as many members of the National Weight Loss Registry and I can personally attest, but success requires a level of attention and commitment that many people are simply not willing to invest. Given the numbers of overweight and obese adults, finding alternate weight loss solutions that work has been a holy grail, guaranteeing developers untold wealth.
Despite significant investment, the medical and pharmaceutical industries appeared stumped for years. Medical solutions were either ineffective or carried significant risks or side effects. Medications produced minor weight loss in the 10 lb. per year range. Bariatric surgery could produce dramatic effects but remains an invasive and expensive procedure. Plus, many patients eventually return to their pre-surgery weight.
A quiet revolution emerged when GLP-1 receptor agonists, marketed as Ozempic, Wegovy, Mounjaro, and others, were developed to treat Type 2 diabetes, especially in individuals with cardiovascular disease and obesity. These drugs, usually taken as weekly injections, mimic the action of a natural metabolic hormone that is released in the gut after a meal. The drugs slow the emptying of the stomach and stimulate the production of insulin, resulting in reduced appetite and lower blood sugar.
Patients using the GLP-1 receptor agonists met their blood sugar targets and experienced significant weight loss of around 15 and 20 percent of their starting weight. Side effects of the GLP-1 drugs were typically mild, although more severe problems such as pancreatitis can emerge in rare cases.
Physicians began prescribing the drugs for people without diabetes, again with remarkable results. I subscribe to several medical newsfeeds, and the responses from the physicians to the GLP-1 agonists can only be described as “giddy.” Doctors spoke of their joy at “finally” having something that could help their patients lose weight.
Probably the largest downside to these drugs is their enormous cost, often in excess of $1,000 per month. Many insurance companies adhere to short-term views of the current bottom line, rather than a long-term view which logically sees the reduction in obesity as a way to avoid even larger costs down the road in the form of bypass surgeries and other expensive procedures. People unable to obtain insurance coverage may resort to unregulated formularies offering DIY alternatives. We have yet to see the full extent of the fallout from these practices.
In the meantime, the cost issue has the potential to exacerbate existing health disparities. We may see a world where wealthy people can maintain a slimness that less fortunate people cannot achieve, making slimness the new socioeconomic status symbol.
Despite the success of these drugs, we don’t want to consider them as a “magic bullet.” The drugs are designed as adjuncts to sensible health habits, not a replacement for them. One of the advantages of traditional, healthy dieting is that you learn how to eat appropriately. All the GLP-1 drugs do is teach you what it feels like when you should stop eating. That’s an important lesson, but it doesn’t ensure you understand how to balance your intake of nutrients. If you eat ice cream until the GLP-1 drug tells you to stop, you’ll lose weight, but you won’t necessarily be healthy. Some patients already require assistance with protein deficiencies and other basic nutrient shortfalls.
Most patients will also need to continue the drugs indefinitely, possibly for life, to avoid gaining back their weight. To be fair, maintenance has always been a neglected and understudied aspect of weight loss. We get plenty of advice on losing weight, but nobody talks about how to keep it off. The average person simply reverts to their old habits that produced the problem in the first place.
I’ve experienced as much as a 20 lb. swing (thank you, Covid-19) since my initial loss and have had to experiment with habits that keep me on the lower side of that for good. First on my list is a daily greeting from my friendly bathroom scale. It’s much easier to fix one or two pounds than ten. That works for me, but other people might need different solutions. We need evidence-based practices that will help patients maintain their weight loss while weaning themselves off the drugs.
The Psychology of Weight Loss
My own experience with weight loss has been unequivocally positive. Being fat is simply uncomfortable, both physically and psychologically. My dislike of how I felt while fat is one of the key things that motivates me not to go back. But people who are convinced that losing weight will solve all of their problems are in for a nasty surprise. You’re still you. Having unrealistic expectations of a totally new life can lead to negative emotions and even depression.
We are probably too close to the GLP-1 phenomenon to truly understand the complex outcomes people experience. Some are unexpected or counterintuitive. One influencer who lost 45 lb. on a GLP-1 agonist was happy with his appearance and felt great, yet he expressed a sense of loss. Food was no longer comforting for him. While that is probably a good thing overall, the need for comfort is real. We need to explore healthy alternatives to fill this vacuum on an individual basis.
Another unexpected outcome can come in the form of the reaction of one’s social circle. We might expect our friends and loved ones to celebrate our weight loss with us, but it doesn’t always work that way. When I lost weight, my friends who were also heavy distanced themselves from me almost immediately. I don’t think they were doing this consciously but rather seemed to think I didn’t “belong” anymore. Research has shown that having an obese friend is associated with becoming obese, probably as a result of social comparisons. If all my friends look this way, too, I must be okay. In addition, seeing one of your own lose weight reminds us that we don’t have to be heavy, which can bring up feelings of guilt.
A serious concern in need of immediate research and clinical attention is the impact of GLP-1 agonists on people who already have eating disorders. I hope that it’s unlikely that a physician will prescribe the drugs in these cases, but the formularies are already hard at work expanding their markets. The concept of these drugs in the hands of a person with anorexia nervosa is truly frightening.
GLP-1 Agonists and Body Positivity
It seems fair to predict that the advent of GLP-1 agonists will profoundly affect body positivity. Before our eyes, celebrities and influencers who have espoused “all bodies are beautiful” for years are shrinking noticeably. Ozempic face, or sagging, wrinkling skin due to rapid weight loss, is an epidemic in Hollywood. Fashion brands such as Victoria’s Secret appear to be questioning the value of plus-sized models. If it’s relatively easy to be thin, more people might make that choice, and we might find ourselves back in those pre-1990s numbers. This could further stigmatize those who remain heavy, as they would be part of a shrinking minority.
The body positivity movements are currently in a defense mode. Body positivity influencers sharing their own journeys with weight loss are receiving support from some followers but also hostility from others who feel betrayed.
Perhaps the ideal solution is to aim for what some call “body neutrality,” where we treat people as people without reference to physical characteristics. This is a lofty goal, but if achieved, it could solve many problems.
Laura Freberg, PhD
Writer & Contributing ExpertLaura Freberg serves as professor of psychology at Cal Poly, San Luis Obispo, where she teaches introductory psychology and behavioral neuroscience.
Dr. Freberg is the author or co-author of several textbooks, including Discovering Psychology: The Science of Mind, Discovering Behavioral Neuroscience, Applied Behavioral Neuroscience, and Research Methods in Psychological Science. She served as President of the Western Psychological Association (WPA) in 2018-2019.