**5. The role of personal narratives**

who believe that lack of exercise plays a larger role in obesity than diet are more likely to

At the other end of the extreme, there are a variety of lay theories about the causes of obesity that blame factors outside of a person's control by highlighting a "toxic food environment" or "corporate manipulation" as culprits in the obesity crisis. Many participants in Barry et al.'s study [10] endorsed these narratives as capturing important causes of the obesity epidemic, and this judgment was correlated with support for more protective policy interventions. However, an experiment designed to test whether reading such narratives would increase support for the protective policy interventions failed to find support for a critical prediction: people who read a narrative that minimized the blame attributed to obese individuals for being overweight were no more likely to support societal-level policy interventions that would address causes of obesity outside a person's control [17]. Below, we discuss a popular alternative causal model of obesity—that it is a "disease"—which may be better suited to eliciting

In recent years, doctors and public health officials have sought to reduce the stigma of obesity and increase support for obesity-related research and policy interventions by officially classifying obesity as a "disease" [34–36]. Like narratives that highlight the role of environmental factors in obesity (e.g., "toxic food environment," "corporate manipulation"), describing obesity as a "disease" seems to reduce the personal responsibility associated with the condition. However, rather than appealing to external factors—the social and physical environments in which people live—thinking of obesity as a "disease" makes the condition less blameworthy by appealing to underlying physiological factors as the primary causes of

Recent research suggests that this biomedical view of obesity has gone from a minority viewpoint just three decades ago to perhaps *the* dominant perspective today [37] (but see [11]). This shift represents an important achievement for public health communications. At a high level, the increased public recognition of obesity as a "disease" in recent years suggests that the way health officials talk about obesity has significant downstream effects on how the general public thinks about the condition. At a more practical level, one of the specific goals of the messaging campaign seems to have been achieved, as a majority of the US population recently reported that thinking of obesity as a disease would facilitate treatment of the

However, researchers have also identified drawbacks to the disease model of obesity. The belief that weight is somewhat fixed by biological factors may negatively impact dieting goals and exercise intentions, especially among people who are overweight [15, 38]. In other words, reducing the blameworthiness of being obese is a double-edged sword: it not only mitigates the stigma associated with being overweight but also fosters an entity theory of obesity, reducing an important source of motivation for maintaining healthy habits that can help people

consume more food and be overweight [11].

28 Adiposity - Epidemiology and Treatment Modalities

such support.

**4. Disease theories**

weight gain [36].

condition [37].

So far, we have discussed the nature and consequences of several prominent lay theories of obesity. For years, the dominant way of thinking about obesity was that it resulted from poor lifestyle decisions—that it was the result of "sinful behavior." This model represents a challenge to public health officials because it fails to recognize the causes of obesity that are outside a person's control. Alternative lay theories—that highlight "environmental" contributions to obesity or appeal to a person's underlying physiology by classifying the condition as a "disease"—seem to reduce the stigma associated with obesity. However, there are important drawbacks to both. Namely, simply highlighting environmental contributions to obesity does not seem to increase support for important interventions that would reduce the prevalence of obesity (although evidence suggests that reading about the negative consequences of childhood obesity might; see [43]), and simply describing obesity as a disease can make weight gain feel inevitable and weight loss feel impossible.

Recent research suggests that reading personal testimonials about successful weight loss may help people construct a more positive mental model of obesity [41, 43–46]. Stories about individuals struggling (and succeeding or failing) to lose weight are ubiquitous, engaging, and provide a structured framework for thinking about the causes of and solutions to obesity [16, 17, 47]. Consider, for example, the popular reality television program "The Biggest Loser," in which morbidly obese contestants compete, through hard work and dedication, to lose the most weight over the course of the season. Although the show has been criticized for a variety of reasons—for promoting an unhealthy and unrealistic approach to weight loss [48] and because contestants have been found to regain lost weight after the show ends [18]—there is some evidence that it increases viewers' sense that they have control over their weight [49]. This suggests that exposing people to personal testimonials in which a protagonist succeeds at achieving a weight-loss goal—through healthy and realistic diet and exercise—may foster an incremental theory of the condition, making them more optimistic about obesity treatment in general [50].

In other words, it may be more effective to adopt a "bottom-up," rather than "top-down," approach to changing the way people think about obesity. Describing the underlying causes and consequences of obesity at a high level—by classifying the condition as the product of one's "environment" or the result of an underlying "disease"—represents a "top-down" strategy: seeking to change the stigma associated with obesity and increase support for public policy interventions by situating the condition in a particular causal framework (e.g., [51–53]). The drawback of this approach, as noted in the previous section, is that the candidate causal structures seem to encourage some inferences that are at odds with the goals of public health officials.

An alternative "bottom-up" approach would describe specific instances of people successfully losing weight, which could provide the foundation for people to induce the "right" lay theory of obesity: one that acknowledges causes of obesity that are within *and* outside a person's control, which motivates individuals to maintain a healthy lifestyle *and* promotes support for interventions that would address the social and environmental context that has given rise to the current public health crisis.

One specific feature of personal testimonials is that they provide the reader an opportunity to feel empathy for an individual struggling to lose weight [54]. In this context, empathy reflects the process of identifying with someone else's struggle with obesity—taking their perspective and sympathizing with their condition [55]. A natural byproduct of such a feeling is an increased awareness of factors that cause obesity that are outside a person's control [41, 42, 56]. Thus, exposing people to personal narratives that describe successful weight loss may be particularly effective tools for public health officials. Such testimonials may lead people to support policy interventions that would address the social and environmental contexts that have given rise to obesity without completely mitigating the sense of personal responsibility that is needed to maintain healthy habits.

A recent series of studies have tested and found support for this possibility [41, 42]. In one experiment, participants read a personal narrative about a protagonist who had successfully lost weight (or not) and who attributed this outcome to their own personal motivation or to environmental reforms that enabled healthier eating and exercise [42]. One critical finding was that reading about successful weight loss elicited significant empathy from participants—both in the case of a protagonist who attributed successful weight loss to their own motivation and in the case of a protagonist who attributed successful weight loss to environmental reforms. These feelings of empathy were, in turn, highly predictive of support for obesity-related policy interventions.

This line of work suggests that personal testimonials about obesity may facilitate a more responsible and productive mental model of obesity. By describing a specific individual who works hard to lose weight, a personal narrative highlights the role of healthy self-regulation to prevent and reduce obesity. Such a description also seems to elicit empathy from readers, which leads them to recognize causes of obesity that are outside a person's control—and, in turn, to support important policy interventions. In other words, personal narratives seem to achieve the goals that have motivated recent work in the field of public health communications (e.g., by classifying obesity as a disease), and may have fewer or less serious unintended consequences (e.g., such an approach does not seem to undermine the importance of healthy eating and exercise).
