Weight Bias Is Rooted in Racism and Hurting Us All

"Sometimes I feel like the world just don't love me back," pop star Lizzo said through tears on Instagram Live in August 2021 after the release of her single "Rumors." Despite the success of the hit, her mood was being dragged down by "fat-phobic, racist and hurtful" commentary, which she attributed to "internalized self-hatred."

"Whatever happens to the song is God's will. But what I won't accept is y'all doing this to Black women over and over and over again, especially us big Black girls," said Lizzo, an unapologetic icon of "body normativity," as she told ​Vogue​. "When we don't fit into the box that you want to put us in, you just unleash hatred on us. It's not cool. I'm doing this shit for the big Black girls in the future who don't want to be scrutinized or put into boxes."

Those boxes are constructed at the intersection of anti-fat bias and anti-Black racism. "Lizzo is representative of what happens to fat Black women on the internet all the time," Phoenix-based Tigress Osborn, chair of the National Association to Advance Fat Acceptance (NAAFA), tells LIVESTRONG.com. (NAAFA, a fat-rights organization, uses the word fat to describe people in large bodies in order to neutralize its historic stigma.)

"The racists will come out to tell you all the things about yourself and your skin color. The fat-phobes will come out to tell you all the things about your body. And it is a double-whammy."

Sometimes the commentary comes from a place of internalized bias, says Osborn, who is Black. "All of the horrible comments about Lizzo didn't come from thin, white people."

Yet Lizzo has a pop star's resources and support to help her deal with the worst effects of racism and weight bias, Osborn says. "I saw Cardi B come out and say, 'That's my girl. Don't attack my girl.' How do we universalize that so that all the fat, Black women get that kind of standing up to bullying from people who are more privileged?"

An important first step is a more widespread understanding of just how ingrained and intertwined racism and size bias are in Western society. Their junction is as old as schemes to divide human beings into races in the first place, according to some scholars.

Historically throughout Western culture, thin was not "in." Just look at the voluptuous figures in a Rubens painting or other European masterpieces created in the 17th and 18th centuries.

But by the 18th century with the growth of the slave trade, that was starting to change. "By the middle of the 18th century, a lot of French philosophers in particular were arguing that, 'You know what? When we're in the colonies, we're noticing that Africans are sensuous. They love sex, and they love food. And for this reason, they tend to be too fat. Europeans, we have rational self-control. This is what makes us the premier race of the world. So in terms of body size, we should be slender, and we should watch what we eat,'" University of California, Irvine sociologist Sabrina Strings, PhD told NPR in July 2020.

By the turn of the 20th century, race-based eugenics — the belief that so-called desirable traits could be bred into the dominant European-descended population — had taken hold of scientific discourse and public policy. A Nordic/Aryan ideal arose: blond-haired, blue-eyed and thin, a counter to the growing numbers of immigrants from Southern and Eastern Europe who were perceived to be shorter and "fleshy," as Strings writes in her book, ​Fearing the Black Body: The Racial Origins of Fat Phobia.​

The association between self-control and body type has lingered into the 21st century, along with the drive to distinguish a white elite through thinness, Strings explains in her book.

"How we evaluate overweight and obesity in this country is based upon criteria that don't fit the population that we're studying."

With the pressure to be thin comes "a discourse of shame" around bodies, particularly for women, and particularly in the American South, Brie Scrivner, PhD, a medical sociologist at the University of Alabama at Birmingham who studies anti-fat bias, tells LIVESTRONG.com.

"If you can control yourself then you're doing it 'the right way.' And that doesn't just mean controlling your eating, it also means controlling your emotions, your sexual habits or proclivities, how you dress yourself — you always have to be handling it, and so being in a larger body signals that you are not in control," says Scrivner, who is white.

Black American culture has been able to resist the extremes of this European American body ideal — but only up to a point, Osborn says. "We also uphold beauty standards that include expectations of certain body shapes. Even as we embrace curves, it's still, 'Little in the middle, but she got much back,' right? That's a different narrative than: 'It's OK to be whatever size you are, in whatever way.' We still lob 'fat' against people as an insult, even as we allow for fatness in a different way than the mainstream culture."

More recently, the medical establishment has helped to reinforce the European ideal through weight standards that fail to account for the diversity of healthy body shapes and sizes, Strings writes in ​Fearing the Black Body​.

The World Health Organization (WHO) defines overweight and obesity as conditions with "abnormal or excessive fat accumulation that presents a risk to health," and which are linked to heart disease, stroke, diabetes, some cancers, osteoarthritis and a number of other chronic diseases. These associations led the American Medical Association to categorize obesity as a disease in 2013 and urge health insurance to cover evaluation and management.

The medical standard typically used to define whether a body is "normal" or not is the body mass index or BMI, which is calculated by dividing a person's weight in kilograms by the square of their height in meters. According to the Centers for Disease Control and Prevention (CDC), the BMI categories are:

• ​Underweight:​ less than 18.5
• ​Healthy:​ 18.5 to 24.9
• ​Overweight:​ 25 to 29.9
• ​Obesity:​ 30 and above

"The BMI measure was developed in the 1940s based upon Metropolitan Life Insurance tables, which did not include Black individuals, as they weren't insuring our lives," explains Fatima Cody Stanford, MD, MPH, an obesity medicine doctor at Massachusetts General Hospital in Boston. "So how we evaluate overweight and obesity in this country and around the world is based upon BMI criteria that don't fit the population that we're studying."

Under current standards, nearly three-quarters of all people in the U.S. over age 20 have overweight or obesity, according to the CDC. Black adults have the highest obesity rates compared to all other racial and ethnic groups in the U.S., at just under 50 percent, per the CDC. But people who descend from different areas of the world tend to carry fat on their bodies differently, with differing effects on their health, Dr. Stanford says.

"It's not a competition to see who is the most oppressed. It should be a commitment to see how all of us who are marginalized work together toward liberation."

For instance, Black people tend to carry more body fat right beneath the skin surface. This is called subcutaneous fat, and it's mostly concentrated in the hip, buttock and thigh regions. White individuals often carry more body fat around the organs, which is called visceral fat. "Now, if you were looking at which one is more deleterious to our health, it would be that visceral tissue," Dr. Stanford says.

Further, some studies have found that Black people have less body fat and more lean muscle mass than white people at the same BMI, which might mean they have a lower risk of developing obesity-linked diseases at the same BMI, according to the Harvard T.H. Chan School of Public Health. Meanwhile, Asian people have more body fat and a higher risk of weight-related health concerns than people of European descent at the same BMI.

Recognizing these differences and knowing that the whole point of measuring BMI is to help indicate a person's risk of disease and death (not to police how they look), Dr. Stanford developed an adjusted chart that accounts for metabolic health outcomes across sex assigned at birth, race and ethnicity. Her findings were published in February 2019 in ​Mayo Clinic Proceedings​.

Her adjustments move the obesity cut-off up to 31 for Black women, down to 29 for Hispanic women and down to 27 for white women. The obesity threshold moves down to 28 for Black and Hispanic men and down to 29 for white men. (The terms we've used to describe sex, race and ethnicity reflect the language used by Dr. Stanford's research and other studies on the topic.)

In other words, obesity is overestimated in Black women and underestimated in other groups. "They're not significant shifts, but it does show you that just assuming that everyone's the same is probably problematic," Dr. Stanford says.

Assumptions like these can lead to clinical, financial and psychological repercussions. For example, relying on BMI leads Black people to be disproportionately misclassified as having obesity and a higher risk of death, according to a July 2015 American Heart Association scientific statement in ​Circulation​.

Meanwhile, it leads Asian people to be disproportionately misclassified as not having obesity and more likely to have their risk of metabolic and heart diseases overlooked.

Even if obesity cut-offs accurately predict your health risks, a doctor's perception of your weight can affect the kind of care you get, Dr. Stanford says.

She recalls a patient who was denied hip surgery by an orthopedic specialist due to obesity and told to lose weight. After Dr. Stanford helped her lose enough to be considered to have a "normal" weight, doctors discovered a tumor in her hip.

"The fact that this patient had a delayed diagnosis for significant cancer, because she had hip pain associated with what was presumably her weight — that's horrible," Dr. Stanford says.

In a November 2012 ​PLOS One​ study of more than 2,000 doctors, researchers concluded "that strong implicit and explicit anti-fat bias is as pervasive among MDs as it is among the general public." The study authors called for additional research into how these biases may affect patients' experiences.

As many as 4 in 10 people who have obesity report having experienced discrimination relating to their size, whether at home, work, school or in a health care setting, according to a March 2020 consensus statement in ​Nature Medicine​ from several major endocrinology, diabetes and obesity organizations. Black women report the highest levels of weight discrimination compared to other groups, followed by Black men, according to an older but frequently cited June 2008 ​International Journal of Obesity​ study.

The harm can turn inward, too: 40 to 50 percent of U.S. adults with overweight or obesity internalize weight stigma, according to a January 2018 study in ​Obesity​. In other words, they apply society's negative stereotypes about larger bodies to themselves and blame themselves for their size.

Despite being more likely to express acceptance of larger body sizes, Black women aren't immune to this internalized stigma, Osborn says. In a January 2016 ​Ethnicity and Disease​ study, women categorized as African American and non-Hispanic white both shared implicit anti-fat bias. But the less Black women identified with being Black and the more white women identified with being white, the greater the implicit anti-fat bias they experienced.

Anti-fat bias also can affect Black people in a different way, according to Da'Shaun Harrison, a community organizer and author of ​Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness​​. "​Anti-Blackness creates the conditions by which one is able to be murdered as a fat person and there's no other way around it."

Large stature has been used to justify the deaths of unarmed Black men at the hands of police, because Black men are seen as both threatening and/or unhealthy enough to contribute to their own death, Harrison writes.

Mike Brown was described as "Hulk Hogan" by the Ferguson, Missouri police officer who fatally shot him in 2014. George Floyd, while thin, was kneeled on by multiple Minneapolis officers due to his towering stature. "The only reason that Eric Garner was murdered, the only reason why they felt that so many officers were needed for him to be taken down is because he was fat," Harrison says. "And the very reason that his death has been justified is because of his size."

Research backs up how ingrained this bias is: Non-Black people overestimate the size of young Black men, perceiving them to be "taller, heavier, stronger, more muscular and more capable of causing physical harm" than white men of the same age and size, according to a series of March 2017 studies in the ​Journal of Personality and Social Psychology​. This research also found Black men are seen as requiring more aggressive measures to control when suspected of a crime compared to white men of the same size.

Just as Black people bear the brunt of anti-fat racism, they have been among the leaders of fat liberation and body-positivity movements in the 21st century.

Osborn explains that the foundational work for body positivity was done "by Black women and femmes, and other LGBTQ folks and disabled folks and people who live in the most marginalized bodies." By contrast, "body positivity as we see it show up today is only a little off-center of mainstream." She hopes that the movement against weight bias will re-center around the communities who need it most.

"People often use the phrase, 'Fat is the last acceptable form of prejudice,'" Osborn says. "Racism exists. Sexism exists. Genderism exists. Ableism exists. And all these things are still thriving. It's not a competition to see who is the most oppressed. It should be a commitment to see how all of us who are marginalized work together toward liberation."