Continuing Education Activity

Weight bias and stigma are prevalent and well-documented issues in healthcare settings that negatively impact patient care and health outcomes. Bias refers to preconceived attitudes, beliefs, or assumptions—conscious or unconscious—that influence patient interactions. Overt bias may manifest as blaming individuals for their weight, while implicit bias is more subtle, such as assuming nonadherence to medical advice based on body size. Weight stigma results when these biases translate into marginalization, devaluation, or discriminatory behavior. Stigmatizing experiences may discourage individuals from seeking medical care, delay diagnosis and treatment, and contribute to poorer physical and mental health outcomes. In clinical environments, these dynamics can compromise the clinician–patient relationship, reduce communication effectiveness, and impair treatment adherence, ultimately reinforcing health inequities.

This continuing education activity provides clinicians with evidence-based strategies to recognize and address weight bias and stigma in healthcare. Participants learn to identify explicit and implicit biases within themselves and their clinical environments, implement stigma-reducing communication strategies, and advocate for equitable care practices. Emphasis is placed on collaborative, interprofessional approaches—engaging clinicians, nurses, dietitians, mental health professionals, and administrative staff—to create inclusive care environments. Improved recognition of weight stigma and coordinated team-based interventions support more respectful, patient-centered care, enhance treatment adherence, and improve long-term health outcomes for individuals affected by weight-based discrimination.

Objectives:

• Identify overt and implicit weight stigma and bias in healthcare within patient encounters.
• Assess how weight stigma and bias negatively affect healthcare outcomes by hindering treatment adherence for patients with obesity.
• Apply strategies to identify, address, and reduce stigmatizing behaviors in healthcare settings and design weight-friendly clinical environments. 
• Implement strategies within the interprofessional team to prioritize well-being, recognizing the multifaceted nature of obesity and its impact on health.

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Introduction

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.[1][2]

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.[3] 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.[4] Commonly held societal beliefs that individuals with obesity are lazy, overindulgent, and lacking in self-control are inaccurate and negatively impact patients.[5][6][7] 

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.[8] 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.[9] 

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.[10][11][12][13][14]

Issues of Concern

Stigma and bias can lead to suboptimal care, and clinicians must be aware of the potentially profound impact of their words and actions, both deliberate and unintentional. An example of overt bias towards patients with obesity is a clinician making derogatory comments or using offensive language about a patient's weight during or after a medical consultation. Inappropriate language includes stigmatizing terms like "fat," joking inappropriately, or expressing negative stereotypes to colleagues about people with obesity. An instance of unintentional bias is a clinician assuming that a patient's health issues are solely attributed to their weight without thoroughly investigating other potential causes, such as attributing joint pain to obesity without considering other musculoskeletal conditions or assuming a lack of adherence to treatment plans based on body weight alone. This bias is often more subtle and rooted in unconscious societal stereotypes. By addressing these issues, clinicians can foster a more supportive and inclusive approach to patients with obesity, ultimately improving health outcomes. 

Bias can result in inadequate medical care, as individuals may hesitate to seek further help due to a fear of being judged or stigmatized, resulting in delayed diagnoses and a worsening of other chronic health issues. Weight stigma has even been shown to affect eating habits, leading to increased calorie consumption.[15] Results from a small observational study of Irish patients with obesity in 2021 noted that prior experiences of weight bias led to missed or canceled follow-up appointments, as well as an escalation of harmful behaviors related to food and physical inactivity as a response to being subjected to stigmatization.

Another example cited was binge or comfort overeating after medical consultations. Clinicians may inadvertently perpetuate stereotypes, such as making assumptions about a patient's lifestyle, likely compliance with treatment, or overall health behaviors. They may attribute all medical issues to obesity and focus solely on weight reduction rather than addressing patients' comprehensive healthcare needs. An example is when clinicians prescribe less pain medication for patients with orthopedic conditions who are instructed to lose weight first. Clinicians may neglect to discuss preventive care unrelated to weight, assuming patients with obesity are less likely to follow their recommendations. A 2024 review of observational studies between 1993 and 2023 noted fewer pelvic examinations and screening tests for cancer and less frequent intensification of diabetes management in patients with obesity.[16]

During the COVID-19 pandemic, obesity emerged as a risk factor for hospitalization, intensive care, and increased mortality. While clinicians may recommend prompt evaluation and treatment, those efforts succeed only if patients seek treatment. Weight stigma is recognized as a barrier to equitable healthcare, and patients with obesity are less likely to access the care they need. During the pandemic, The Lancet reported that many people with both obesity and COVID-19 in the United Kingdom (UK) expressed a sense of shame, a perception that they were less of a priority than others, and a reluctance to seek medical assistance. During the COVID-19 lockdowns, the term "quarantine-15" gained popularity as a description of weight gain associated with the pandemic. In the UK, a public health campaign from the National Health Service (NHS) in 2020 included the statement that "Tackling obesity would reduce pressure on doctors and nurses in the NHS, and free up their time to treat other sick and vulnerable patients," suggesting that those with obesity were burdening the health care system and putting lives at risk. This message only served to reinforce the stigma surrounding obesity and may have resulted in individuals avoiding much-needed medical care.[17][18][19]

Weight stigma is associated with adverse psychological and physiologic consequences. Patients with obesity may internalize the biases they experience, leading to decreased self-esteem and a reluctance to engage further with the healthcare system. This emotional toll can contribute to mental health challenges and poorer health behaviors, such as binge eating, increased overall food consumption, and decreased physical activity, as well as a physiologic stress response with elevated levels of cortisol and inflammatory markers. These effects are in addition to the already-known chronic health complications of obesity.[20][21] 

Many strategies exist to reduce weight stigmatization and bias in healthcare. The first step is recognizing that being overweight is a sensitive topic, and clinicians must address overall health and well-being, not just the body mass index. One participant in the previously mentioned patient-perspective Irish study said, "I wish my doctor would see me as a person first who has feelings." A good clinician-patient relationship positively impacts treatment compliance and reduces the likelihood of adverse health outcomes associated with weight bias. Clinicians who use motivational interviewing can promote positive behavior change through a collaborative, nonconfrontational approach. This approach uses reflective listening and open-ended questions to support patients as they develop intrinsic motivation to achieve healthier habits.[22]  

The healthcare team must establish a zero-tolerance policy against stereotypical language, images, or humor that inaccurately depict patients who are overweight or obese as lazy or lacking in self-discipline. A 2024 cross-sectional study of physicians in training in Turkey reported that nearly half had heard derogatory comments or jokes about patients with obesity during their medical education, and almost a quarter had witnessed a patient with obesity being subjected to discriminatory treatment while hospitalized. Leaders in medical education must challenge these widespread and longstanding biases about obesity and promote a narrative consistent with scientific knowledge. 

In 2020, a multidisciplinary group of international experts, including representatives from academic and scientific organizations, issued a joint consensus statement to end the stigma associated with obesity. They recognized that people who are overweight or obese face social stigma, and their statement condemned the use of language, attitudes, and policies that stigmatize weight and pledged to support initiatives to prevent discrimination in the workplace, education, and healthcare. They advocated for governmental and institutional policies and validated tools, such as the "Antifat Attitudes Test" (AFAT), to assess clinical attitudes towards people with obesity.[23] 

One potential strategy to reduce the stigmatization of obesity is increasing clinician empathy through perspective-taking exercises. Obesity simulation suits (OSS) have been used in multiple clinical settings as a teaching tool during simulated patient encounters. Standardized "mock" patients at a German medical school were asked to wear an OSS during a teaching encounter. Investigators later questioned the students, teachers, and mock patients about their experiences. The study concluded that the use of OSS to simulate obesity was convincing. The AFAT was administered after the session and showed that the students demonstrated more bias than the instructors or mock patients.

In simulated settings, tools such as the OSS enable learners to discuss sensitive topics, like weight, in a safe environment. In another study, a group of nurses and physiotherapists wore an OSS for 2 hours in a public setting. Following the experience, follow-up surveys revealed more empathetic and less judgmental attitudes towards individuals with obesity than before the study. In a similar study, nurses reported more positive attitudes about obesity after wearing an OSS. Another tactic in medical education utilizes dramatic readings rather than standard lectures about the medical management of obesity. One study's results showed that the medical students who participated in the former group exhibited lower levels of explicit bias when questioned afterward.[24][25][26][27] 

What makes a clinical setting "weight-friendly?" First, the staff must model practices and attitudes that promote inclusivity, respect, and personalized care for individuals of all body sizes and shapes. A nonjudgmental approach fosters open communication and trust, while using neutral language helps avoid stigmatizing terms related to body weight. Using "patient-first" language, such as "patient with overweight or obesity," is preferred over "obese patient." Patients prefer "healthy weight, overweight, and body mass index" rather than "morbidly obese, fat, and big." 

Using motivational interviewing and asking for permission to discuss the patient's weight before providing unsolicited advice promotes patient-centered communication and is less threatening for people who feel vulnerable. When primary care clinicians and staff believe they are treating patients with obesity with respect and compassion, their clinics may lack the appropriate equipment and furnishings to create a "weight-friendly" environment. Chairs in the waiting area and examination rooms must be sturdy and accommodate higher body weights. Chairs and sofas without armrests may be more comfortable for larger patients. Accessible, appropriately sized examination tables with steps or stools are necessary. Patients feel less self-conscious when weighed privately on scales designed for weights above 180 kg (400 lb). Other clinical supplies that can help create a body-positive space include extra-large patient gowns, large blood pressure cuffs, longer needles for phlebotomy, and vaginal specula in larger sizes.[28] 

Clinical Significance

The disease model views obesity as a complex and chronic medical condition rather than solely the result of personal choices and behaviors. Diet and physical activity play a significant role, influenced by genetic, environmental, and physiological factors. Obesity is associated with alterations in metabolic and hormonal regulation, which can challenge sustained weight loss. The disease model promotes a medical approach to managing obesity, including lifestyle modifications, medications, and, in some cases, bariatric surgery.

In the disease model, obesity is considered a chronic condition that requires ongoing medical intervention, rather than blaming the patient for unhealthy habits. Recognizing obesity as a chronic disease like hypertension, diabetes, or asthma enables clinicians to care for patients more effectively. The acceptance of this model by the medical community has influenced approaches to treatment, public health strategies, and research.[29] 

Obesity-related stigma creates barriers to care and increases the likelihood of poor health outcomes. Addressing stigma allows reframing obesity from personal failure to a treatable medical condition. Clinicians and patients can focus on preventing and treating known complications. Obesity increases the risk of cardiovascular diseases, including hypertension, dyslipidemia, stroke, and coronary artery disease, as well as metabolic disorders such as type 2 diabetes and insulin resistance. Obesity predisposes patients to osteoarthritis, back pain, sleep apnea, obesity hypoventilation syndrome, gout, and an elevated risk of certain cancers, particularly breast, colorectal, and endometrial. Clinicians who address the contributing role of obesity in these conditions mitigate the associated health risks and contribute to patients' well-being and quality of life.[30]

Discussing the conditions associated with being overweight and obese is often a more useful approach during an appointment than focusing solely on a patient's weight. An elevated body mass index and central adiposity increase the risk of developing type 2 diabetes. Furthermore, a prolonged period of high body weight is an independent risk factor for type 2 diabetes. Planning to screen for type 2 diabetes at a future visit is more productive than merely scheduling a follow-up visit for weight management, and is less likely to result in patients feeling they have failed if their weight remains unchanged.

Recommending guideline-directed screening for obesity-related cancers offers another opportunity to mention excess weight in a nonjudgmental manner. Meaningful conversations between clinicians and patients about these conditions ultimately address weight without it being the main topic of the discussion. While patients may focus on the cosmetic aspects of weight loss, clinicians should emphasize the health benefits of a lower body mass index. As little as 5% weight loss is significant, leading to reductions in chronic diseases, all-cause mortality, and improved quality of life metrics. A weight-friendly clinic helps patients feel comfortable and welcome, encouraging them to return for follow-up visits.[31][32]

Addressing weight-related stigma and biases dismantles barriers and fosters a supportive healthcare environment that can impact the trajectory of obesity-related health issues. Stigma can lead to suboptimal care, delayed diagnoses, unhealthy behaviors, and exacerbate chronic health conditions. Clinicians can reduce stigma by adopting patient-centered communication, motivational interviewing, and zero-tolerance policies against discriminatory practices. By creating inclusive spaces that foster open dialogue and promote individual autonomy, clinicians can proactively empower patients to manage their health concerns. Patient engagement is fundamental in mitigating the severity and progression of the medical complications linked to obesity. Accepting the disease model of obesity and addressing weight-related stigma ultimately improves clinical outcomes for patients with obesity.[33]

Enhancing Healthcare Team Outcomes

Interprofessional healthcare teams can improve outcomes by destigmatizing obesity and enhancing patient engagement. Recognizing obesity as a chronic disease is essential. Nurses and support staff should ensure that a weight-friendly environment is maintained. Clinicians can employ motivational interviewing techniques. Comprehensive treatment plans may involve lifestyle modifications, medications, and consultations with dieticians, mental health clinicians, surgeons, and other medical specialists. The team can support zero-tolerance policies against derogatory language and practices. Ultimately, healthcare professionals can take a proactive stance and advocate for public policies that denounce weight-based discrimination.[34]This approach optimizes patient care, promoting positive health outcomes for patients with obesity and related conditions.

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Disclosure: Sharon Daley declares no relevant financial relationships with ineligible companies.

Disclosure: Brittney Ginsburg declares no relevant financial relationships with ineligible companies.

Disclosure: Amy Sheer declares no relevant financial relationships with ineligible companies.