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Promoting Prejudice: Ableism, Weight Stigma and Just Really Bad Science

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March 17th marked the opening of the 12th International Congress on Obesity in Kuala Lumpur, Malaysia. To get the conference off to a good start, the organisers - The World Obesity Federation - decided to put their money where their mouth was and turn off the escalators in the conference centre. If only they'd put their brains there instead.

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Image credit: Steve Pratt
[Sign at bottom of tall escalator says 'Dear Guests, In conjunction with the 12th International Congress on Obesity, the escalators will not be operational from 09:30 to 16:00 hrs]

First, let me tell you why they thought this was a good idea. There is definitely evidence that encouraging people to use the stairs, for example by putting a sign next to the lifts or escalators saying 'Why not use the stairs?' or making the stairwells more attractive, does actually increase the number of people who take the more physical route. This is no doubt a good thing - physical inactivity is independently associated with poorer long-term health outcomes, and these interventions remind people who are so inclined and able to do so that this is a relatively simple opportunity to be more active.

But therein lies the rub: 'inclined and able to do so'.

I'll start with 'inclined'. I'd be very interested to see the evidence base to suggest that coerced exercise promotes increased physical activity overall. I did look. I found one study in rats. Compared with a sedentary group and one that was allowed to voluntarily run on a wheel, the forced exercisers gained the most weight and had by far the highest mortality. But anyway. Let's get back to humans and move on to 'able'.

In addition to the people who physically cannot climb a flight of stairs, for whatever reason, what about the people who can do a little, who might have taken the escalator but tried to also climb a bit on the way up - now they no longer have that option. It's take the whole flight of stairs or nothing - this approach is actually reducing movement opportunities for some people. And what about people who approach the escalator and realise that they can't get up that way and have to look around desperately for the lifts? Apparently, lifts were available, although this was not printed on the self-satisfied signage at the bottom of the escalators. How does this make them feel? Guilty? Embarrassed? If they don't have an obvious physical disability there is the concern that other people are looking, wondering why they're not taking the stairs, and making all kinds of negative assumptions about them. And heaven forbid they are fat too. People are fat for all sorts of reasons (yes, they are, concern trolls - read the literature), but this situation is bound to have people judging them and finding them wanting - too lazy and greedy to move yourself? No wonder you're fat! Stereotype threat - the fear that your actions will confirm others' negative beliefs about you - is associated with poorer overall health and reduced engagement in health behaviours - so if the intended purpose was to encourage fat people to exercise, this is likely to backfire.

By producing this momentary shame, this jolt out of a comfortable world environment into one a little more hostile, this intervention is a form of microagression. Microagressions were first defined in the racial discrimination literature, and described as "brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people." But microagressions are not restricted to racial minorities. Nor are they benign. They are far more commonplace than overt discrimination but create a hostile world environment. Like the one at this conference. If having your body size described as a disease were not sufficient. This intervention promotes shame, stigma and prejudice against fat people. Yes, people of all sizes may choose to take the lift, but it is the heavy ones who will be judged most harshly. And people involved in health promotion efforts would do well to familiarise themselves with the increasingly well documented detrimental effects of weight stigma. Chronic actual or perceivedstigma of any kind exacerbates health inequalities and is also directly harmful for health. Stigma is a stressor, and is met with the body's biological response to stress. Physically, stress hormones promote the development of visceral adiposity - the kind of fat that is known to be harmful for health. The kind that increases the risk of diabetes, hypertension and heart disease. It is also associated with higher rates of depression and other negative psychological outcomes. It's worth noting that in cultures where fatness is valued, the relationship between higher weight and poor health is much weaker or non-existent. Exposure to weight stigma also increases binge eating and reduces motivation to exercise. Also, it's not nice.

And finally, there is that other group of people who really simply have no desire to climb a huge flight of stairs at this time or any other? Nobody is obliged to do so, although some may feel pressured by this approach.

So we have all these people who either can't or won't take the stairs. But lifts are available, say the organisers. Approximately one per escalator, according to the floor plan of the Kuala Lumpur Convention Centre. Now think how many people can go up a moving escalator in a given time. And think how many people could be transported in a lift in that same time. Now think about the people who would have needed the lift anyway, those in wheelchairs for example. Who are suddenly finding it much harder to get where they want to go because the lifts are clogged up with people who can't or don't want to take the stairs. I mean, look at those stairs! Many people of all shapes and sizes might struggle with those - especially if travelling up several levels, for example between the exhibition hall and the lecture theatres. These people will now be forced to use the lifts. Also, think about people with physical limitations who might not have needed to take the lift, who could have taken the escalators while holding on to the rail, but who might now have to stand around unsupported while waiting for a lift to become free. Or people with knee problems - maybe from jogging - who may have been able to go up the stairs, but for whom going down might be mechanically difficult and painful. Also now forced to take the lifts. Did the organisers give any thought to the consequences of reducing availability for disabled participants? It doesn't seem so. This is a blatantly ableist conceit, in which forethought and consideration are conspicuous by their absence.

Responses to these photos on twitter that alerted the organisers to the possible problem with their 'intervention' were not taken very seriously. They failed to grasp the point. They tweeted: "We wanted the escalators to be turned off to promote healthy lifestyles for EVERYONE."
But there is a difference between 'promoting' a healthy lifestyles and forcing it down people's throats. Big Brother-style interventions are likely to have a paradoxical effect, making people resentful and resistant. Particularly those who feel singled out. And, 'for everyone'? Maybe that would seem more believable if they had put up signs saying "ICO want to help promote healthy lifestyles for all. Why not think about taking the stairs?" But this ostensible global 'public health intervention' is a thinly veiled dig at fat people, whether intended or otherwise. "Obesity conference. Take the stairs." How in any way is that not conflating obesity with sloth? Perpetuating the myth that fat people don't exercise. Many fat people are both active and fit (yes, they really are, and if you're not familiar with the extensive high quality research in this area, you perhaps might want to become so before commenting here) and many thin people are not. That some commentators at the conference cannot see that this sign is simply promoting prejudice shows just how deeply ingrained weight stigma is among health professionals who research and treat higher weight people.

Before the health and fitness people jump all over this post and claim I'm against exercise, I'm not. I think it's wonderful. It's good for pretty much every aspect of health and wellbeing we have (although not so much for weight loss). I would certainly agree that people of all sizes may benefit from increasing their physical activity levels if it is appropriate for them to do so and within their abilities. But that is not what this sign is saying, and it is not what this ham-fisted attempt at 'environmental re-engineering' is achieving. This is an ill-thought out exercise in fat shaming, with no basis in scientific evidence, dressed up in a veneer of condescending benevolence. Not good enough.