**6. Body positivity**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

Western societies, particularly those with affluence in the twenty-first century, have generally associated thinness with happiness, success, youthfulness, and social acceptance [56]. Most citizens of the Western world view fatness as a negative that is to be avoided. There has been a cultural prejudice and stigma toward those with overweight or obesity [60]. However, weight stigmatization has itself become a public health concern due to the associated psychological and physical health consequences to OW/obese individuals. The psychological and social stigmata associated with being OW/obese often makes this population vulnerable to discrimination in their personal and work lives [5]. Often blamed for their weight, the OW/obese are labeled as lazy, weak-willed, out of control, and lacking motivation [2, 56, 60]. The prevailing message in the media is that the cause and cure for obesity lies within the individual [60]. In a study examining obesity perception among policymakers from over 10 developed countries, over 90% saw lack of personal motivation as having a

Nevertheless, weight stigmatization has been a long-standing approach to reducing obesity. However, it has not proven to be a motivator for weight loss [60]. There are studies that show stigmatizing weight is counterproductive. Individuals who experience weight stigma or perceived weight discrimination are at increased risk for anxiety, depression, bulimia, body dissatisfaction, low self-esteem and other psychological disorders [24]. Other findings have shown that even after controlling for key covariates such as BMI, age, and sex, these psychological outcomes remain, indicating that overweight perception rather than obesity is associated

Weight stigma perpetuates unhealthy behaviors, including increased eating, reduced self-regulation, and avoidance of exercise [64]. Further, chronic stress resulting from weight stigma contributes to the development and/or pathophysiology of obesity, independent of adiposity [64]. Stress has been found to induce high levels of cortisol (an obesogenic hormone), leading to increased activity of the sympathetic nervous system (SNS) and release of corticotrophin-releasing hormone. Chronically elevated SNS activity could deregulate hypothalamic-pituitary-adrenal

Reducing obesity rates has become a target for public health action, due to the link between obesity and a range of chronic diseases and premature mortality. However, critics of this view suggest that obesity has been primarily framed within a medical narrative, thus generating greater social anxiety and fears of "fatness" [66]. Some argue that dominant medical narratives are responsible for the discourse circulating around the idea of fatness as a pathology and a moral failing [66], further asserting that all the statistics on fat people being unhealthy are baseless due to the failure of society to delineate between fat and fat stigma [67]. The supposed bias of physicians has increasingly come under scrutiny. Physicians are said to notoriously view fat patients as noncompliant, or unwilling to follow their directions [67]. Some medical and allied health professionals have been overtly labeled "fat phobic" and showing weight bias. Weight bias is defined as having a widespread stereotypical and prejudicial attitude, assumption, belief, or judgment toward fat people [68, 69]. Studies show widespread weight bias among medical professionals [70], medical students and physician assistants [71], and exercise and nutrition professionals [72], with no

axis activity, thus further contributing to the etiology of obesity [65].

**5. Weight stigmatization**

**5.1 The role of culture and society**

"strong" or "very strong" impact on obesity [23].

with psychological distress [63].

**5.2 Weight bias in clinical settings**

**86**

There has been a growing awareness of the psychosocial harms of weight stigmatization and fat shaming. Our culture is moving more toward body positivity, self-empowerment, inclusivity, and encouraging individuals to take pride in and accept their bodies, despite having BMI's that classify them as clinically OW/obese. Popularized through Instagram, with over 11 million posts tagged with #bodypositive, 4 million for #bodypositivity, and more than 1 million for #bopo [73]. Indeed, an internet search of body positivity will yield more than 112 million results [73]. Body positivity aims to challenge dominant body image ideals, promote acceptance and respect of all bodies, irrespective of shape, size, and features, focusing more on appreciating the functionality and health of the body rather than only its appearance [73] (**Figure 4**).

Positive body image is indeed a key factor in determining one's ability to reach weight loss goals. However, setting positive weight loss goals is an assumption in traditional approaches to weight loss [74]. Other assumptions include 1) the notion that adiposity increases risk of morbidity and mortality, 2) maintaining weight loss can be achieved through proper diet and exercise, which will prolong life, 3) obese individuals can improve health only through weight loss, 4) and finally, the high

#### **Figure 4.**

*A group of women at a fitness facility stretch to hold a child's pose with their hands all reaching in to form a circle. Body positivity promotes strength and fitness coming in many forms, no matter the body shape or size (photo by: Sarah Pflug. Available from: https://burst.shopify.com/photos/ladies-stretch-circle?c=yoga [Accessed: 13 August 2020]).*

economic burden on the health care system incurred by obesity-related costs can be mitigated by obesity treatment and prevention [74].

Many people who pursue weight-loss programs are seemingly motivated to lose weight to be normal, wear smaller clothes, and avoid weight stigmatization and discrimination rather than by the dangers of obesity or its associated health risks [54]. OW/obese individuals are now being more positively represented in the media, movies, and even in arenas where they have historically been absent or ignored, such as in the fitness and fashion industries, or as role models in music and entertainment. However, visual normalization of larger bodies, that is, more habitual visual exposure to people with excess weight, may further contribute to the higher prevalence of overweight and obesity, particularly among those with lower levels of education and income [75].

#### **7. Fat acceptance and health at every size movements**

#### **7.1 Fat acceptance**

Established in 1969, the National Association to Advance Fat Acceptance (NAAFA) is a fat-rights organization congealed out of early protests of fat activists (**Figure 5**). Established as a support movement, the organization protests discrimination in the workplace and lack of fat acceptance in society [76]. The organization is dedicated to protecting the rights and improving the quality of life for fat people [77].

Fat acceptance and body positivity have become synonymous terms of late. Arguing that the former term is rooted in the latter term, some claim that fat acceptance is threatening to destroy the body positive movement. They contend that those originally intended to benefit from body positivity were individuals like cancer survivors who have suffered physical disfigurement, people with physical disabilities, and members of underrepresented racial/ethnic groups frequently ignored by the media. These individuals have no control over primarily physical factors that have set them apart.

Parallels have been drawn between fatness and smoking (i.e. an unhealthy and deadly condition brought on by behaviors, but difficult to change once the behavior is set in motion) [78]. It follows that those with no apparent medical reason for OW/obesity (e.g., medications, Cushing's syndrome, polycystic ovary syndrome), on some level, choose to be OW/obese. Conversely, there are those that believe the idea that fat is permanently changeable to be a myth, citing studies that report participants gaining more weight than originally lost within three years of ending a diet [67].

Culture, society, (social) media, and reality TV have all influenced obesity perception, outpacing influential and well-established clinical definitions and medical advice warning of the cardiometabolic risks of obesity. For example, the terms "fat," "curvy," "plus-sized," and "full-figured" are more frequently used among plus-size fashion bloggers, reclaiming the use of the word "fat," and lessening the weight stigma around obesity [79]. OW/obese people can now be found on the glossy covers of magazines and amassing followers on social media outlets such as blog sites, Instagram, YouTube, TikTok, Tumblr, Twitter, and other online spaces. Under the guise of glamor and glitz, OW/obese social media and reality TV influencers advertise "fit, fabulous, and fat" lifestyles, which only serve to contradict public health messaging discouraging unhealthy lifestyles. While fat activists and the fat acceptance movement are working to reduce weight stigmatization, their influence on the public, particularly those with central adiposity, can potentially undermine the recognition of being overweight and its health consequences [75].

**89**

MUO [25, 33].

*Obesity Acceptance: Body Positivity and Clinical Risk Factors*

Civil lawmakers are also shifting the narrative to more acceptance and inclusivity as it relates to OW/obese perception. Antidiscrimination law theorizes unfairness based on government classifications of a group of people who are singled out and burdened without sufficiently good reason or in employment decisions based on protected traits outlined in Title VII of the 1964 Civil Rights Act. Fat advocates have become familiar with the difficulty of seeking legal arguments for fat rights protection under Title VII while also arguing that obesity is a medicalized impair-

*The National Association to Advance Fat Acceptance (NAAFA) is an all-volunteer, multigenerational fat-rights organization seeking to change the narrative around fatness, fight for fat-rights, and increase respect for all people, regardless of body type or size. Available from: https://naafa.org/ [Accessed: 13 August 2020].*

Like the fat acceptance movement, HAES® is a weight-neutral approach that advocates the idea that health can be achieved and sustained, independent of weight status. The HAES® approach advocates intuitive eating, which involves listening to and acting on internal hunger and satiety cues and preferences. A HAES® approach attempts to addresses weight bias and stigma in individuals living with obesity, and is touted as a promising public health approach instead of focusing on weight status as an ultimate health outcome [74]. Proponents of HAES® assert that the long-term sustainability of traditional medical or behaviorally based interventions (e.g., pharmacological, surgical, and behavioral) for obesity has been disappointing. HAES® is emerging as standard practice in the eating disorders field [80] whose principles are professed by an array of civil rights groups and international professional organizations dedicated to promoting fat

There is evidence supporting the notion of fit at every size. Higher fitness levels among the MHO are associated with fewer metabolic complications and lower prevalence of MetS at any age and across different weight status groups [31]. However, as previously mentioned, MHO has been shown to be a transient state to

It is important to emphasize that health is a continuum on which every person lies, with one end of the spectrum representing morbidity/mortality and the other

*DOI: http://dx.doi.org/10.5772/intechopen.93540*

ment and disability [78].

**Figure 5.**

**7.2 Health at every size**

acceptance and fighting weight discrimination [80].


#### **Figure 5.**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

economic burden on the health care system incurred by obesity-related costs can be

Many people who pursue weight-loss programs are seemingly motivated to lose weight to be normal, wear smaller clothes, and avoid weight stigmatization and discrimination rather than by the dangers of obesity or its associated health risks [54]. OW/obese individuals are now being more positively represented in the media, movies, and even in arenas where they have historically been absent or ignored, such as in the fitness and fashion industries, or as role models in music and entertainment. However, visual normalization of larger bodies, that is, more habitual visual exposure to people with excess weight, may further contribute to the higher prevalence of overweight and obesity, particularly among those with lower

Established in 1969, the National Association to Advance Fat Acceptance (NAAFA) is a fat-rights organization congealed out of early protests of fat activists (**Figure 5**). Established as a support movement, the organization protests discrimination in the workplace and lack of fat acceptance in society [76]. The organization is dedicated to protecting the rights and improving the quality of life for fat people [77]. Fat acceptance and body positivity have become synonymous terms of late. Arguing that the former term is rooted in the latter term, some claim that fat acceptance is threatening to destroy the body positive movement. They contend that those originally intended to benefit from body positivity were individuals like cancer survivors who have suffered physical disfigurement, people with physical disabilities, and members of underrepresented racial/ethnic groups frequently ignored by the media. These individuals have no control over primarily physical

Parallels have been drawn between fatness and smoking (i.e. an unhealthy and deadly condition brought on by behaviors, but difficult to change once the behavior is set in motion) [78]. It follows that those with no apparent medical reason for OW/obesity (e.g., medications, Cushing's syndrome, polycystic ovary syndrome), on some level, choose to be OW/obese. Conversely, there are those that believe the idea that fat is permanently changeable to be a myth, citing studies that report participants gaining more weight than originally lost within three years of ending a

Culture, society, (social) media, and reality TV have all influenced obesity perception, outpacing influential and well-established clinical definitions and medical advice warning of the cardiometabolic risks of obesity. For example, the terms "fat," "curvy," "plus-sized," and "full-figured" are more frequently used among plus-size fashion bloggers, reclaiming the use of the word "fat," and lessening the weight stigma around obesity [79]. OW/obese people can now be found on the glossy covers of magazines and amassing followers on social media outlets such as blog sites, Instagram, YouTube, TikTok, Tumblr, Twitter, and other online spaces. Under the guise of glamor and glitz, OW/obese social media and reality TV influencers advertise "fit, fabulous, and fat" lifestyles, which only serve to contradict public health messaging discouraging unhealthy lifestyles. While fat activists and the fat acceptance movement are working to reduce weight stigmatization, their influence on the public, particularly those with central adiposity, can potentially undermine

the recognition of being overweight and its health consequences [75].

mitigated by obesity treatment and prevention [74].

**7. Fat acceptance and health at every size movements**

levels of education and income [75].

factors that have set them apart.

**7.1 Fat acceptance**

**88**

diet [67].

*The National Association to Advance Fat Acceptance (NAAFA) is an all-volunteer, multigenerational fat-rights organization seeking to change the narrative around fatness, fight for fat-rights, and increase respect for all people, regardless of body type or size. Available from: https://naafa.org/ [Accessed: 13 August 2020].*

Civil lawmakers are also shifting the narrative to more acceptance and inclusivity as it relates to OW/obese perception. Antidiscrimination law theorizes unfairness based on government classifications of a group of people who are singled out and burdened without sufficiently good reason or in employment decisions based on protected traits outlined in Title VII of the 1964 Civil Rights Act. Fat advocates have become familiar with the difficulty of seeking legal arguments for fat rights protection under Title VII while also arguing that obesity is a medicalized impairment and disability [78].

#### **7.2 Health at every size**

Like the fat acceptance movement, HAES® is a weight-neutral approach that advocates the idea that health can be achieved and sustained, independent of weight status. The HAES® approach advocates intuitive eating, which involves listening to and acting on internal hunger and satiety cues and preferences. A HAES® approach attempts to addresses weight bias and stigma in individuals living with obesity, and is touted as a promising public health approach instead of focusing on weight status as an ultimate health outcome [74]. Proponents of HAES® assert that the long-term sustainability of traditional medical or behaviorally based interventions (e.g., pharmacological, surgical, and behavioral) for obesity has been disappointing. HAES® is emerging as standard practice in the eating disorders field [80] whose principles are professed by an array of civil rights groups and international professional organizations dedicated to promoting fat acceptance and fighting weight discrimination [80].

There is evidence supporting the notion of fit at every size. Higher fitness levels among the MHO are associated with fewer metabolic complications and lower prevalence of MetS at any age and across different weight status groups [31]. However, as previously mentioned, MHO has been shown to be a transient state to MUO [25, 33].

It is important to emphasize that health is a continuum on which every person lies, with one end of the spectrum representing morbidity/mortality and the other health and vitality. There is a size threshold, albeit non-discrete, over which a person crosses over into a state of increased risk of, or overt illness. Established comorbidities and sequelae frequently accompany sustained obesity, despite practicing intuitive eating, that reduce quality of life, not the least of which include increased risk of musculoskeletal pathology [81], arthritis/joint pain, respiratory conditions/ diseases (e.g., sleep apnea, asthma), depression/anxiety, inability to participate in certain activities, and physical disability [1]. Additionally, the association between intuitive eating and diet quality remains unclear in epidemiologic literature. Nevertheless, HAES® holds value in its deemphasis on restrictive dieting, which has been associated with increased psychological stress, increased cortisol levels, and subsequent weight gain [65].

Despite years of empirical medical and comprehensive epidemiological research, many fat activists take pride in maintaining higher BMI and embracing their size, all while holding in contempt any efforts to increase health and wellness. Permeating through activism, academia, fashion, and even sports, the HAES® approach appears to promote not only acceptance, but pride in the esthetic of the fat body. Members of this movement seek to bring people of larger size back from the margins of society, fiercely labeling those who oppose their ideas as "body-shamers" and "fat phobic" perpetuators of societal norms.

While the OW/obese may find intuitive eating and HAES® approaches successful, there still remains a tremendous (mental) health care cost of obesity-related illnesses. These costs are a real economic impact to society. Years of medical and scientific research has provided irrefutable evidence of the deadly cost of condoning preventable OW/obesity and unhealthy lifestyles of over 650 million OW/obese worldwide. Simultaneously, the medical and public health community must not use the campaign to reduce fat as justification for prejudice and oppression. OW/ obese individuals have a right to make their own choices; but health literacy and knowledge of the correct information and use of that information to make informed health decisions is of utmost public health concern.
