Addressing Weight Bias in Healthcare

Experts define weight bias (or stigma) as a “widespread form of prejudice that leads to the stigmatization of individuals who are perceived to have excess weight.”¹ As the fourth most common form of discrimination in the United States, these negative attitudes are often considered socially acceptable.² Over the past decade, the prevalence of individuals’ weight bias increased by 66% in the United States.³  

Anti-fat attitudes also appear in healthcare professionals,⁴ from physicians, to researchers, and to medical students. Studies suggest that healthcare professionals and medical students may harbor both implicit and explicit weight bias. ⁷ A 2014 study of a medical school cohort found that existing weight bias in that cohort was stronger than racial, sexual, and socioeconomic bias.⁶ 

Unfortunately, fat stigma can carry over into clinical practice.⁴ Healthcare providers may see fat patients as non-compliant patients.^5,8 Studies suggest that fat patients typically receive less time from doctors, as well as fewer preventative and diagnostic tests.^4,5,8 Providers may even explicitly blame patients for their weight.³ Other areas of the healthcare system create barriers for fat patients. Most insurance providers, for example, charge higher premiums if the person has a body mass index (BMI) above 30.⁹ In addition, inadequate equipment, furniture, and spatial layouts make many healthcare environments inaccessible to fat people.¹ 

Weight bias impedes access to healthcare services for fat patients.^3,9 These patients often delay or avoid healthcare services,¹⁰ and when they do access it, they are less likely to receive evidence-based and bias-free healthcare.⁹  For instance, fat cisgender women are less likely to receive cervical cancer screening,¹¹ breast cancer screening,¹² and colorectal cancer screening¹³ than non-fat cisgender women. These biases can hinder provider-client communication, potentially leading to reduced quality of care, non-adherence, and poorer treatment outcomes.¹⁴  

Importantly, research links weight bias to many health consequences independent of BMI and sociodemographic risk factors. Stigma adversely affects weight-related health via stress,¹⁵ increased eating,¹⁶ and reduced exercise motivation.¹⁷ Studies causally link weight bias with increased caloric consumption and lower dietary self-control.¹⁶  Perhaps counterintuitively, these attitudes actually undermine weight loss goals and increases the risk of weight gain, regardless of BMI.  

Further, weight bias negatively impacts mental health; decades of research link it to depression, anxiety, binge eating, low self-esteem, and body dissatisfaction.²  Collectively, research associates weight bias with disease burden, multiple chronic conditions, and mortality. Of note, weight stigma actually predicts mortality more strongly than other stigmas do.¹⁸ Current public and personal health recommendations rarely consider weight stigma an obstacle to health and health behaviors.⁵⁸ Evidence suggests that a focus on weight does not promote health.¹⁹ 

Experts propose various solutions to address weight bias in healthcare and its adverse effects on patients’ health. Many call for a paradigm shift in the way the field defines “health”.¹ For example, The Health at Every Size movement encourages a more holistic approach to health that focuses on weight-neutral outcomes, such as physiological measures, health behaviors, and psychosocial outcomes. Bias education and reduction training in healthcare professionals and adequate and inclusive healthcare equipment are also important measures.³⁰ To further advance these efforts, experts recently published a joint international statement against weight stigma.²⁰  

References 

1. Pearl, R. L. Weight Bias and Stigma: Public Health Implications and Structural Solutions. Soc. Issues Policy Rev. 12, 146–182 (2018). https://doi.org/10.1111/sipr.12043

2. Puhl, R. M., Andreyeva, T. & Brownell, K. D. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int. J. Obes. 32, 992–1000 (2008). https://doi.org/10.1038/ijo.2008.22.

3. Puhl, R. M. & Heuer, C. A. The Stigma of Obesity: A Review and Update. Obesity 17, 941–964 (2009). 

4. Lee, J. A. & Pausé, C. J. Stigma in Practice: Barriers to Health for Fat Women. Front. Psychol. 7, (2016). 

5. Persky, S. & Eccleston, C. P. Medical Student Bias and Care Recommendations for an Obese versus Non-Obese Virtual Patient. Int. J. Obes. 2005 35, 728–735 (2011). 

6. Phelan, S. M. et al. Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity 22, 1201–1208 (2014). 

7. FitzGerald, C. & Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med. Ethics 18, 19 (2017). 

8. Foster, G. D. et al. Primary care physicians’ attitudes about obesity and its treatment. Obes. Res. 11, 1168–1177 (2003). 

9. Drury, C., Aramburu, A. & Louis, M. Exploring the Association Between Body Weight, Stigma of Obesity, and Health Care Avoidance. J. Am. Acad. Nurse Pract. 14, 554–561 (2002). 

10. Alberga, A. S., Edache, I. Y., Forhan, M. & Russell-Mayhew, S. Weight bias and health care utilization: a scoping review. Prim. Health Care Res. Dev. 20, (2019). 

11. Adams, C. H., Smith, N. J., Wilbur, D. C. & Grady, K. E. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 20, 45–57 (1993). 

12. Wee, C. C., McCarthy, E. P., Davis, R. B. & Phillips, R. S. Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Ann. Intern. Med. 132, 697–704 (2000). 

13. Ferrante, J. M. et al. Colorectal cancer screening among obese versus non-obese patients in primary care practices. Cancer Detect. Prev. 30, 459–465 (2006). 

14. Papadopoulos, S. & Brennan, L. Correlates of weight stigma in adults with overweight and obesity: A systematic literature review. Obesity 23, 1743–1760 (2015). 

15. Jackson, S. E., Beeken, R. J. & Wardle, J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obes. Silver Spring Md 22, 2485–2488 (2014). 

16. Vartanian, L. R. & Porter, A. M. Weight stigma and eating behavior: A review of the literature. Appetite 102, 3–14 (2016). 

17. Vartanian, L. R. & Novak, S. A. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obes. Silver Spring Md 19, 757–762 (2011). 

18. Sutin, A. R., Stephan, Y. & Terracciano, A. Weight Discrimination and Risk of Mortality. Psychol. Sci. 26, 1803–1811 (2015). 

19. Tylka, T. L. et al. The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. J. Obes. 2014, e983495 (2014). 

20. Rubino, F. et al. Joint international consensus statement for ending stigma of obesity. Nat. Med. 26, 485–497 (2020).