Weight stigma interventions as future avenues for stigma resistance: comment on Dubreucq et al.

Dubreucq et al. (2022) highlight the role stigma resistance in people with serious mental illness might play in people's trajectories of personal recovery. They found that participants with elevated resistance to internalized mental health stigma – around half of their sample – were more likely to be in advanced stages of personal recovery. They also found correlations supporting that stigma resistance to mental health stigma was related to other positive outcomes such as wellbeing and life satisfaction. In their insightful conclusions, the authors propose interventions through which stigma resistance toward mental health stigma can be improved and its benefits reaped toward better recovery outcomes in serious mental illness.

Dubreucq et al.'s (2022) line of work opens productive avenues through which we can improve outcomes for people with serious mental illnesses. One of these potential avenues is using stigma resistance interventions in dealing with weight stigma in people with serious mental illness. People with schizophrenia and other serious mental illnesses have higher weights and rates of obesity than the general population (Afzal et al., 2021). This has been associated with a higher risk of developing metabolic syndrome and years of life lost (De Hert, Schreurs, Vancampfort, & Van Winkel, 2009) as well as a decline in quality of life (Allison, Mackell, & McDonnell, 2003). Fortunately, these physical health issues have come to the forefront for researchers and clinicians and considerable efforts have been made to ameliorate the physical health outcomes of people with schizophrenia. However, as we turn our attention to interventions aimed at weight management and metabolic health, we must keep in mind how weight gain and obesity affect domains that go beyond those of physical health. Given the stigma associated with bigger bodies and weight gain, we need to consider how our clients and participants are seeing their lives altered in their relationships to themselves, peers and families, clinicians, and institutions, as they experience weight gain. These considerations will allow us to design and provide the best and most comprehensive intervention and prevention strategies when helping people with schizophrenia and other serious mental illnesses navigate weight stigma.

Facing weight stigma has been connected to decreased wellbeing and mental health in the general population (Emmer, Bosnjak, & Mata, 2020). People with schizophrenia already face the burden of dealing with stigma and discrimination based on their mental health, which has been connected to decreases in wellbeing (Morgades-Bamba, Fuster-Ruizdeapodaca, & Molero, 2019). The double burden of weight stigma in people with schizophrenia has been understudied but existing research points at potential further distress and reductions in self-esteem when dealing with both forms of stigma (Mizock, 2012). In line with the work of Dubreucq et al. (2022), internalized stigma seems to play an important role in wellbeing. The literature that does exist on this topic suggests that higher levels of internalized weight stigma is associated with decreases in wellbeing and self-esteem in people with schizophrenia, even beyond the effects of other types of weight stigma (Barber, Palmese, Reutenauer, Grilo, & Tek, 2011). Additionally, recent weight gain in people with schizophrenia has been related to lower self-esteem regarding their bodies and poorer psychosocial functioning (De Hert et al., 2006), hinting at how changes in weight can erode people with schizophrenia's relationships to themselves and others. Internalized weight stigma in people with schizophrenia poses the threat of a doubled burden in a population that is already highly subject to self-stigmatization. Dubreucq et al. (2022) point out how mental health stigma resistance might ameliorate some of the effects stigma has on recovery; this can also be the case for weight stigma in people with schizophrenia leading to better outcomes and course of illness.

Beyond the internalized forms of stigma that people with schizophrenia face regarding their weight, there are additional systemic forms of discrimination and mistreatment. There's evidence for people facing less job offers, lower wages, and less socioeconomic status based on weight discrimination (Friedman et al., 2005). This mirrors some of the difficulties faced by people with schizophrenia facing workplace discrimination (Hampson, Watt, & Hicks, 2020), making it so people are facing potentially compounding effects. This double injury is also possible when accessing healthcare resources; as weight stigma is also prevalent in healthcare professionals (Lawrence et al., 2021). This could add an additional burden to people with schizophrenia who already face being overlooked and undertreated due to mental health stigma (Thornicroft, Rose, & Kassam, 2007), even within mental health clinicians (Valery & Prouteau, 2020). Mechanisms like diagnostic overshadowing could be potentiated due to both stigmas. Further research is needed on how these forms of discrimination based on weight and mental health interact with each other when it comes to people with schizophrenia facing both.

In addition to the consideration of stigma in weight interventions, we need to consider how psychiatric disorders and other maladaptive behaviors can affect weight. Historically, as mental health professionals, we have focused narrowly on presenting mental health symptoms and overlooked relevant psychiatric co-morbidities. To avoid similar pitfalls, when creating weight management, weight gain prevention, or metabolic health plans with patients, it is important to take mental health into consideration in the form of comorbid eating disorders. Notably, people with schizophrenia have higher rates of binge eating disorder than the general population (approximately 10%, compared to 0.7–4.3% in community sample) (Kouidrat, Amad, Lalau, & Loas, 2014). Anorexia nervosa seems to occur at similar rates than in the general population (between 1% and 4%) but with a far greater number of men having this comorbidity than in community samples (0.81% compared to 0.1–0.3%) (Gorrell & Murray, 2019; Kouidrat et al., 2014). Beyond comorbidities, abnormal eating behaviors that do not meet criteria for an eating disorder – such as food craving, food addiction, or night eating were also found to be highly prevalent in people with schizophrenia – 2.5 to 4 times higher than in the general population (Sankaranarayanan et al., 2021). Any plan to prevent weight gain, promote weight loss, or install new health behaviors more generally in people with schizophrenia needs to consider that it will be dealing with a population where eating and weight-related beliefs and behaviors are more likely to be altered. Screening patients with a schizophrenia diagnosis for potential eating disorders should be incorporated as part of designing a treatment plan for weight management or metabolic health.

Accounting for the prevalence of eating disorders in people with schizophrenia can also highlight shared mechanisms that would illuminate avenues for potential future interventions and treatments. Some present examples in this line include some evidence for shared genetic risk between binge eating disorder and schizophrenia (Solmi, Mascarell, Zammit, Kirkbride, & Lewis, 2019) and increased rates of binge eating disorder in people with schizophrenia using olanzapine or clozapine (de Beaurepaire, 2021). Dietary and exercise counseling, including psychoeducational and behavioral modification programs, are central in safe and consistent weight management in people with schizophrenia (Faulkner, Soundy, & Lloyd, 2003). These interventions could also benefit from a more informed approach toward comorbid eating disorders and disordered eating patterns. Taking an integrated approach toward weight management in people with schizophrenia allows for rich opportunities in the research of interactions between mental health disorders. Additionally, interventions aimed at reducing weight stigma could benefit people with schizophrenia as suggested by Dubreucq et al. (2022).

As we focus on helping our patients better their metabolic health, we need to consider the challenges that come with living in a bigger body in a society where weight is stigmatized. Having this in mind will help us understand the level of stress our patients face and aid us in supporting them and championing them if they do face stigma because of their size. Challenging our own weight stigma as mental health clinicians and the discriminatory practices in our workplaces will also benefit our standards of care by lowering barriers for people that face discrimination based on their mental health and weight. As we broaden our perspective of what providing healthcare means for people with schizophrenia into one encompasses the whole person, we can do so in an integrated manner; where the mental health and wellbeing considerations of weight management and metabolic health are integrated into our treatment and prevention plans.