Weight bias and stigma in health care

This page has been written by the Boden Collaboration on Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney; and reviewed by Professor Andrew Hill, Professor of Medical Psychology, University of Leeds.

What is weight bias and stigma?

Weight stigma refers to social stereotypes and misconceptions about people with obesity, while weight bias refers to negative attitudes toward and beliefs about others because of their weight. Weight bias or weight-based discrimination occurs when individuals are treated differently or unfairly because of their weight or size. Internalised weight bias is holding negative beliefs about oneself due to weight or size.¹

Weight stigma has been categorised into (a) public, (b) provider-based and (c) structural stigma. There are cognitive (ideas, beliefs), affective (feelings) and discriminatory (behavioural) aspects of stigma across these three domains. A key idea is that of 'attribution' – i.e. apportioning responsibility for overweight or obesity to the individual, often in a pejorative way (it’s their own fault, laziness, gluttony etc.).²³

Prevalence of weight bias and stigma

Weight bias is pervasive in our society. It is pervasive in mass media, including news, movies and television, as well as social media. The increasing average weight of the population has meant that larger body sizes are now more common, but a number of studies have identified that weight bias has increased alongside the rising obesity rates. Individuals with obesity experience bias from educators, employers, health professionals, the media and even from friends and family. Studies examining the prevalence of weight bias in Australia are limited but European data suggest that one in five people with obesity experienced some form of bias, with nearly double this for people with severe obesity.⁴ Work by the Rudd Centre for Food Policy and Obesity in the US found that over half of adults with obesity experienced stigma in their workplace.⁵ Children with obesity from primary school age onwards are more likely to feel bullied by their peers. Similarly, adults with obesity report experiencing weight bias from health care professionals. A range of Australian and international studies have found high levels of both explicit and implicit weight bias among doctors, nurses, exercise scientists, physiotherapists, dietitians and psychologists. More than half of all health professionals exhibit some form of weight bias towards people with obesity.⁶

Where and how does weight bias and stigma occur?

We use a range of traits to categorise people at first meeting. These are often based on a person’s appearance and may include gender, class, race, age, body size and weight – or a combination of these factors. How a person is categorised by each observer influences his or her status in society and how they are treated. When we meet a person with obesity and perceive the person's large body size, one or more forms of bias tend to become activated, whether or not we are aware of it.

As a health professional trying to help a person with obesity, you may need to focus on the health implications of weight during a consultation. It is also important to consider the psychosocial health and well-being of patients and consider the past experiences a person may have had with weight bias and stigma in your interactions with them.

Consequences of weight bias and stigma

This recurring confrontation with weight bias in daily life can lead to negative self-perception and what is termed 'internalised weight bias'. See the Obesity Action Coalition resource, Understanding Obesity Stigma. This can have significant social (reduced interaction), emotional (feelings of shame, self-blame and vulnerability), behavioural (unhealthy coping mechanisms) and even physiological (chronic stress) consequences which have negative impacts on long-term health and well-being.⁷⁸ The impacts of weight bias on personal well-being and health include increased risk of depression, anxiety, low self-esteem, poor body image, substance abuse, suicidal thoughts and behaviours and binge eating behaviours.

In addition, weight bias and stigma can affect health and well-being by its impact on:

• Quality of medical care: Research shows that health professionals will interact differently with patients with obesity.
• Health policy: Weight bias impacts health system policies, limiting access to evidence-based obesity management and supports and reducing the resolve around prevention programs. There is currently a lack of comprehensive obesity management and support systems within Australia. This denial of treatment may be seen as unfair and unethical.
• Interpersonal and social relationships: Some people with obesity experience weight bias and criticism from their family and relatives.
• Education: Young people with obesity face higher risk of being bullied in school. Teachers may have lower expectations from children with obesity, which may impact a child’s opportunities for higher education.
• Employment: Adults with obesity report being stigmatised in the workplace and face barriers in hiring and promotional practices. Their earnings are less than those of healthy weight.

Bias and stigmatisation in the health care setting

As noted above, several studies have observed weight bias in health care settings.^{9 8}

• BY WHOM: Weight bias has been identified in members of the general public and in all groups of health professionals including among obesity specialists.
• WHY: Often, health care professionals believe that patients with obesity are responsible for their own weight. They may also internalise social stereotypes about obesity and regard patients with obesity as lazy, non-compliant, unintelligent and lacking motivation and willpower. This has implications for the therapeutic relationship between health care professionals and patients across the health care continuum.
• HOW: Health care professionals can use hurtful words and display negative attitudes and behaviours. They may also give simplistic advice (eat less, move more) and spend less time in consultation with patients living with obesity. They may also perform less medically necessary screening and diagnostic tests, which can have serious consequences for individuals' health and well-being.

In addition, the physical environment that healthcare settings provided to people living with obesity may itself contribute to stigma. Providing inappropriate equipment such as seats, beds or toilets that are not wide or sturdy enough for people with obesity to be comfortable; insensitive signage to clinics; and even having to weigh people at loading docks all produce or contribute to stigma.

How can health care systems address bias and stigmatisation?

It is important for health professionals to develop a respectful therapeutic relationship with patients and support patients in improving their overall health and well-being and not obsess on weight outcomes.

Although there has been limited work in this area, some studies have shown success in decreasing stigma through the following actions at a policy level.¹⁰⁸

• Having an up-to-date understanding of obesity as a long-term health condition.
• Educating GPs and all health care professionals about the uncontrollable factors of obesity.
• Giving a key message that weight status and obesity are not under exclusive personal control.
• Promoting a guided, patient-centred, non-judgmental and respectful counselling approach.
• Utilising adapted materials, such as appropriate large-size cuffs to measure blood pressure, wide chairs without armrests in the waiting room, appropriate scales (up to 200 kg), etc.
• Educating health care professionals to be empathic when they welcome the patient; they should ask the patient for permission to weigh them and should measure them in a discrete room.
• Reminding GPs/health professionals that 5% to 10% weight loss is sufficient to have substantial benefits for physical health (decreasing co-morbidities). They should also work to improve patients' psychological well-being, improving body image, increasing self-esteem, self-confidence, self-affirmation and quality of life.

What can health care professionals do about weight stigma and bias?

It is important for health care professionals to know that beyond its effects on overall health and well-being, obesity also affects people's overall social well-being due to the pervasive social stigma associated with it.

Weight bias and stigma should not be tolerated in health care, education or public policy sectors. Health professionals can improve their practice to help their patients in the face of weight bias and obesity stigma.¹¹⁸

Be aware of your personal attitudes and beliefs about body weight, size and obesity and reflect on how this is influencing your behaviour and practice.

• Be careful to meet your patient in a respectful way.
• Use non-stigmatising language in communications around weight issues as words are very important.
• As a first step, use person-first language in describing people having and living with obesity.
• Be respectful in documenting patient’s issues around weight within clinical records.
• Role model behaviour to colleagues, staff and trainees that is supportive and non-biased toward individuals and families with obesity.‍
• Create a welcoming and non-stigmatising clinic that accommodates people of diverse body shapes and sizes.
• Be aware of the effect that stigma may have had on your patient, including social effects of weight bias and internalised bias. Ask your patient about these issues if it is appropriate.
• Help to build your patient’s self-confidence.
• Identify other professionals you can refer your patient to for help with the non-medical effects of stigma.
• Advocate for improved understanding and acceptance of weight stigma issues among colleagues, families and community institutions.

User and patient organisations

Recently, a national support organisation was established for people living with and affected by overweight or obesity (see Weight Issues Network). There may also be local patient groups in your area or region. These organisations can provide support for your patient in the form of shared and lived experience, information and contacts. You can be ready to refer your patient to such groups by making informational brochures and internet links available.

The Weight Issues Network is also active in promoting improved health care policies in the area of obesity and weight stigma and collaborates with other healthcare support groups.

Other help for your patient

Psychosocial factors, such as interpersonal relationships, income or employment, housing or other factors, may be concrete obstacles to effective obesity treatment or management. Organisations that offer help may span social services, psychological therapy, churches or other non-profit organisations.

Find out what help is available and be ready to refer your patient. If possible, seek opportunities for active collaboration.

Trust the patient and give support

Only the patient can do the job. But s/he needs your trust, highlighting the importance of respecting the patient's decisions and providing support.

Acknowledgement: This page has been based on an original report by Durrer et al, 2017.¹²