As it stands weight bias and stigma exist in a variety of realms in our society, and have led to detrimental outcomes for the healthcare industry (Fruh et al., 2021). The stigmatization of individuals who are overweight or obese occurs in multiple sectors including: healthcare, educational settings, the workplace and interpersonal relationships, and is associated with adverse physical and psychological health outcomes (Lacroix et al., 2017). To fully grasp the significance of the issue one must understand that the terms “weight bias” and “weight stigma” are utilized “interchangeably to refer to negative attitudes and discrimination toward individuals based on their body weight” (Lacroix et al., 2017). Addressing weight stigma is essential to obesity management as it causes inequalities in healthcare and impacts the outcomes of health (Goff, Lee, & Tham, 2023).
Weight bias developed over many centuries not just from one source, but from different cultural driving factors and parts of the world. Despite these influences being vastly different from one another, a negative connotation towards heavier weights was produced and unknowingly incorporated into the culture of healthcare. Weight stigma is the devaluation and discrimination of individuals based on their body size and weight (Tomiyama et al., 2018; Tylka et al., 2014). Using the term “obesity” is itself stigmatizing, as it labels those with bigger bodies as othered and diseased (Meadows & Daníelsdóttir, 2016). The negative attitudes and beliefs associated with enacted stigma are explicit and implicit (Phelan et al., 2015). Explicit attitudes are the conscious reflection of a person's opinion, whereas implicit attitudes are automatic and occur outside of awareness and contrast explicit beliefs (Phelan et al., 2015).
Primary care providers, medical trainees, nurses and other healthcare professionals hold explicit and implicit negative opinions about people with obesity (Phelan et al., 2015). The pervasiveness of explicit and implicit weight stigma results in the unfair treatment of those with larger body sizes, negatively impacting physical health, mental health, self-esteem, and well-being (Fruh et al., 2021). This has important implications for communication in the clinical interview, because the experiences of discrimination and awareness of stigmatized social status can cause patients to experience stress and have other acute reactions (Phelan et al., 2015). Providers frequently attribute unrelated medical issues to fatness, causing fat people to receive inadequate care and feel dismissed by their providers (Sabin et al., 2012). As a result, people are more likely to avoid seeking preventative and regular medical care because they anticipate bias (Sabin et al., 2012). Thus, potentially reducing the quality of the encounter, regardless of their provider's attitudes and behavior (Phelan et al., 2015). Rather than resulting in better treatment of patients with higher weights, the “obesity” label has caused more stigma (Meadows & Daníelsdóttir, 2016).
In 2013, the American Medical Association (AMA) classified obesity as a disease with the claim that it would improve support for treatment (Kyle et al., 2016). Since then, this disease has expanded into an epidemic with the World Obesity Federation estimating that 15% of adults (i.e. nearly 800 million people) were living with obesity globally in 2020 (Goff, Lee, & Tham, 2023). This number is expected to rise to more than 1 billion adults, affecting one in five women and one in seven men worldwide by 2030 (Goff, Lee, & Tham, 2023). Experiencing anti-fat bias and weight stigma is an independent risk factor for poor health outcomes. Weight stigma negatively impacts healthcare quality and hinders public health goals as it creates health disparities and hampers public health efforts (Talumaa et al., 2022). Physiological, psychological, and maladaptive behavioral responses are elicited by the stress of stigmatization in addition with perceived suspicion and anticipation (Talumaa et al., 2022). Weight stigma harms one’s health through the biological stress response that causes inflammation and metabolic dysregulation and through the psychological consequences of anxiety and depression (Tomiyama et al., 2018; Tylka et al., 2014). The long-term and immediate effects of weight stigma potentiates high levels of stress which contribute to impaired cognitive function (Phelan et al., 2015). Prolonged exposure to stress increases allostatic load and can contribute to several long-term physiological health effects including: heart disease, stroke, depression and anxiety disorder; diseases that disproportionately affect obese individuals and have been empirically linked to perceived discrimination (Phelan et al., 2015). Additionally, weight stigma can potentially undermine successful treatment outcomes, including those for obesity due to direct effects of provider attitudes on patient-centered care that reduce the quality of the patient encounter, harming patient outcomes and reducing patient satisfaction (Goff, Lee, & Tham, 2023; Phelan et al., 2015). When healthcare providers assign weight-related stereotypes to their patients, the quality of care provided to those patients decreases (Tomiyama et al., 2018; Tylka et al., 2014). Weight stigma and a relation of weight with certain conditions may result in worse care for smaller patients as well, since symptoms indicative of diseases more commonly associated with higher weights such as sleep apnea or type II diabetes may go undiagnosed in smaller patients (Tomiyama, Carr, et al., 2018; Tylka et al., 2014).
One study found that 21% of patients with overweight and obese BMIs feel judged by their provider (Puhl & Heuer, 2010; Sole-Smith, 2020; Tomiyama et al., 2018). This can impact the likelihood of higher weight patients seeking care when they need it. In one study, 68% of high-weight women reported that they had delayed seeking healthcare because of their weight, even though more than 90% of study participants had health insurance (Puhl & Heuer, 2010). Feelings of stigma not only keep patients from seeking healthcare, but also decrease adherence to treatment (Puhl & Heuer, 2010; Sole-Smith, 2020; Tomiyama et al., 2018). Therefore, interventions to identify and reduce weight bias and weight stigma in healthcare professionals are important to improving healthcare provision, the health and well‐being of patients with obesity, helping patients better cope with and reduce the effects of stigma (Goff, Lee, & Tham, 2023; Talumaa et al., 2022).
Healthcare providers (HCPs) are called to utilize a weight-inclusive approach rather than weight-normative. A weight-inclusive approach focuses on health as a multifaceted concept while attempting to increase access for all and reduce forms of stigma that impair care delivery, while the weight-normative approach focuses on weight and weight-loss related to health status and consequently creates stigma toward bigger bodies (Tylka et al., 2014; Alberga et al., 2016). Awareness is one part of the solution, the issue necessitates that challenging and changing widespread, deep-rooted beliefs, longstanding preconceptions, and prevailing mindsets requires a new public narrative of obesity that is coherent with modern scientific knowledge (Rubino et al., 2020). The failure to address stigma among current and future HCPs upholds bias formation (Talumaa et al., 2022). Being heralds of healthcare, HCPs must advocate for education in their workplace or university related to weight stigma and implementation of weight-inclusive care and legal protections against weight-based discrimination, as well as understanding the complex factors regulating body weight and address weight stigma, its prevalence, origins and impact (Talumaa et al., 2022).
Weight stigma and discrimination are pervasive and cause significant harm to affected individuals (Rubino et al., 2020). HCPs must recognize that all patients, regardless of body size, deserve respect and freedom from discrimination when seeking care. HCPs are also called to reflect on their own attitudes and biases toward fat people to ensure that even heavier weight patients are provided the best quality of care rather than experiencing discrimination. Discussions of health promotion activities with patients can proceed without focusing on weight. Heavier weight patients’ healthcare experiences must also be acknowledged and validated, allowing for any negative experiences that come up to be addressed.