Overcoming Stigma and Bias in Obesity Management

Excerpt

The World Health Organization (WHO) defines obesity as "abnormal or excessive fat accumulation that may impair health." The prevalence of obesity has risen exponentially over the last 50 years, and the WHO estimates that more than 650 million adults globally were living with obesity in 2016. There is no international consensus on whether obesity should be categorized as a medical condition. In June 2013, the American Medical Association voted to recognize obesity as a disease requiring treatment and prevention, but not all countries agreed. Proponents argue that classifying obesity as a disease leads to more effective management and fewer complications. Labeling obesity as a chronic condition, such as asthma or hypertension, promotes a holistic approach that reduces the stigma and discrimination experienced by affected individuals and improves education for healthcare professionals, policymakers, and the general public. Critics argue that labeling obesity as a medical condition may lead to unnecessary interventions and contribute to further stigmatization by reinforcing negative stereotypes and promoting a narrow focus on individual responsibility rather than addressing the complex underlying socio-economic and environmental factors.

Weight bias and stigma are well-documented areas of concern in healthcare settings. Bias refers to attitudes, beliefs, or assumptions—whether conscious or unconscious—that influence how individuals perceive and interact with others. Overt bias is intentional and includes negative attitudes such as blaming patients for their weight. Implicit bias, by contrast, is more subtle and often goes unrecognized; for example, assuming that individuals with obesity are noncompliant with medical recommendations. Weight stigma is the process by which individuals are devalued, marginalized, or discriminated against based on body size; it is often the consequence of bias, reflecting how biased beliefs manifest through behaviors, institutional practices, and social norms. Weight stigma can lead patients to feel judged, avoid seeking care, and experience poorer health outcomes.

In clinical settings, bias and stigma can contribute to discrimination, reduced access to care, and compromised patient outcomes. Members of interprofessional healthcare teams may not always recognize the presence or impact of either explicit or implicit bias. As a result, stigma may prompt individuals to delay or avoid necessary medical care due to fear of judgment or discrimination, ultimately delaying diagnosis and treatment. Weight stigma can also erode the clinician–patient relationship, hinder effective communication, and reduce treatment adherence, all of which may lead to suboptimal health outcomes.

Obesity is often associated with stigma due to prevailing societal attitudes linking body weight to personal character flaws and a lack of self-discipline. Obesity discrimination rivals that based on race and age, but lacks comparable legal safeguards. In the United States, no federal legislation prohibits discrimination based on weight. Clinicians often view obesity solely as the result of individual choices, such as poor diet and lack of exercise, rather than acknowledging the multifactorial etiology. Similar to stigma, stereotypes, negative assumptions, and bias about individuals with obesity can lead to discriminatory attitudes, creating an environment where patients feel judged or blamed, which can hinder the quality of medical care and affect patient-clinician relationships. Recognizing and challenging these biases is crucial for clinicians to provide compassionate, patient-centered care that addresses the multifaceted nature of obesity and supports individuals in achieving their health goals.

People who are overweight or obese report experiencing discrimination from an early age in education, at work, and in healthcare, stemming from the stigma associated with the condition. This stigmatization occurs at younger ages than in the past as the prevalence of childhood obesity increases. Children with obesity are more likely to be bullied than their healthy-weight peers. Commonly held societal beliefs that individuals with obesity are lazy, overindulgent, and lacking in self-control are inaccurate and negatively impact patients.

Results from a 2005 study conducted in France showed that most clinicians knew that being overweight and obese pose health risks, and 79% agreed that weight issues fell under their scope of practice; however, 30% of respondents expressed negative attitudes towards obese patients. In another study of patients in weight management programs in 6 Western countries, results revealed that more than two-thirds reported experiencing weight stigma from their doctors. A 2022 Israeli study's results reported that more than half of patients with a body mass index greater than 25 kg/m² noted "insensitive and judgmental comments" from their clinicians.

Results from several Australian, British, and Israeli studies have demonstrated similar beliefs. Australian clinicians reported feeling frustrated when treating patients with obesity who they believed lacked self-motivation and compliance. In a British qualitative survey, many primary care clinicians held the view that obesity is caused by unhealthy eating and lack of exercise, solely blaming the patient. In Israel, results from another study showed that 31% of family medicine clinicians judged overweight people as lazier than those of average weight. Surveys have also noted that "difficult" patients, perceived as those with behaviors harming their health, may elicit strong negative emotions. Primary care clinicians may even spend less time with patients with obesity and hold the mistaken belief that labeling them as "obese" will motivate them to lose weight.