The Impact of Novel Medications for Obesity on Weight Stigma and Societal Attitudes: A Narrative Review

Abstract

Purpose of Review

This narrative review examines the potential implications of the expanded use of novel medications for obesity, particularly the GLP-1 receptor agonists, on weight stigma and societal attitudes towards pharmacologically induced weight loss. It analyses how these medications may potentially contribute to both reducing and exacerbating stigma and discusses strategies to reduce weight bias.

Recent Findings

The introduction of GLP-1 receptor agonists has demonstrated effectiveness in reducing weight and lead to improved health outcomes for individuals living with obesity. However, while these medications may reduce stigma by framing obesity as a medical issue rather than a personal failure, disparities in access and use related to high costs may inflate existing biases against those who cannot afford treatment. Also, a few studies indicate that users of these medications may feel stigmatised for taking what is perceived as an “easy way out” to lose weight, mirroring historical attitudes towards bariatric surgery.

Summary

The new medications for obesity may have the potential to reduce obesity stigma by reframing it as a medical condition rather than a moral failing. However, taking legal actions to build a more inclusive society including ensuring equitable access to these medications will be essential in mitigating stigma and help fostering a supportive environment for those living with obesity. Lessons from reducing stigma surrounding other medical conditions suggest that supportive health care and educational campaigns that promote the understanding of obesity as a complex health issue are needed to reshape negative perceptions towards individuals with obesity.

Introduction

While obesity is associated with various health risks, there is a widespread conception that it results mainly from personal failings, such as hedonism, lack of willpower or laziness, rather than from a complex interplay of genetic, biological, environmental, societal and psychological factors. This (mis)understanding often leads to the opinion that individuals with obesity are unhealthy by choice [1].

Consequently, those living with obesity may be blamed for their condition and subjected to moral judgments about their character and lifestyle. Furthermore, societal beauty standards, intensified by media and cultural narratives, often idealise thinness, equating it with attractiveness, success, and self-discipline further contributing to stigmatising attitudes towards people with obesity. Additionally, obesity is perceived to contribute to higher healthcare costs and reduced productivity, and individuals with obesity may be seen as a financial burden on society and face penalties in both medical care and employment [2]. Documentation of the stigma associated with obesity has been extensively reviewed elsewhere, hence the objective for this narrative review is to discuss weight stigma related to use of the newer and effective weight loss medication and strategies for tackling these stigmata (Fig. 1).

Fig. 1.

Mitigating Strategies for Addressing Stigma Related to Obesity. The figure highlights various types of stigma associated with obesity, including internalised and externalised stigma, and presents strategies to mitigate these through education, equitable access to treatment, legal actions, and training. Internalised stigma: Stigma individuals impose on themselves, influenced by societal norms and perceptions. Externalised stigma: Stigma imposed by external groups, such as media, healthcare, and peers. Mitigating strategies: Interventions like promoting education, training healthcare professionals, and ensuring equitable access to treatment to reduce stigma. I invented and created both myself - so no permission needed

Externalised Stigmatisation

Externalised stigmatisation refers to the negative attitudes, discrimination, and prejudices that individuals living with obesity face from others in the society. This form of stigmatisation can be explicit or overt shaming patients for their weight and using judgemental language. More implicit forms of external stigmatisation include believing that obesity is moral failure and all about personal responsibility, and that weight control is simple. Externalised stigmatisation is prevalent in various contexts, including healthcare settings. Despite the proportion of people with overweight and obesity has, and still is increasing in almost all countries, and obesity is becoming more common, there is no indication that attitudes towards people with obesity is changing in a positive direction [3]. Some studies suggest that men more that women and younger more than older people view weight as an individual responsibility [4].

Externalised Stigmatisation – in Health Care Settings

Several studies have documented that many health professionals assume individuals with obesity have unhealthy lifestyles and judge them as lacking self-motivation, compliance, and discipline [5–8]. Such assumptions can lead to dismissing the symptoms of individuals with obesity as a mere consequences of poor self-control, resulting in delayed or inadequate treatment compared to the management of other non-communicable diseases like type 2 diabetes or cardiovascular diseases [9]. A review from 2008 based on 32 studies showed lower rates of cancer screening with increasing body size [10], findings that were confirmed by a 2024 review demonstrating clear evidence that both men and women living with obesity were stigmatised in cancer screening situations, with excess weight serving as a barrier to accessing these services [11].

A recent review also documented fewer examinations and less frequent intensification of diabetes management in patients with obesity [12]. Moreover, patients with obesity generally do not benefit equally from various forms of healthcare cost exemptions; for instance, obesity therapy is not available free of charge in many countries [2]. Additionally, healthcare practitioners may deny patients effective weight loss medications, viewing these drugs as a quick fix that should be replaced by necessary lifestyle modifications [2].

Recently, a qualitative review [13] aimed to identify healthcare professionals’ perceptions towards obesity management and therapy across 15 previous studies. The findings showed that healthcare professionals had a broad range of perceptions and experiences when managing patients with obesity. Many found it challenging to discuss weight for fear of offending patients, which sometimes hindered therapy. However, results were mixed and while some healthcare professionals did not acknowledge the therapeutic relationship, others understood that this patient group experiences stigma within society and did not want to contribute further to it. A recent study examined weight stigma and the lived experience of weight stigma among 402 practicing dietitians in the United Kingdom, examining stigma both towards themselves and towards others. Interestingly, while dieticians expressed weight bias towards people living with obesity, many dieticians also had personal experiences with weight stigma prior to and post registration, which impacted on their career-related decisions and not least their perception of own ability to perform as dietitians [14].

Externalised Stigmatisation – in Employment and Education and from Media

People living with obesity also face discrimination in employment and education. In the workplace, individuals with obesity might be overlooked for promotions or excluded from team activities based on stereotypes about their abilities, including assumptions that they lack discipline, organisation, and initiative or should not have contact with customers [15]. A Swedish field experiment sent job applications matched on credentials but featuring photos of individuals with either obesity or normal weight to real job vacancies. The study could document significant labour market discrimination against individuals with obesity [16]. Furthermore, a recent review found penalties in wage levels and labour market attachment for people with obesity even if obesity was lost before adulthood [17].

In educational settings, studies indicate that both peers and teachers hold lower expectations and provide less support to students with obesity [18]. Stigma and weight bias are also prevalent among family members and negative weight attitudes among children often reflect those of their parents [19]. Physical bullying and ostracism based on weight are common, especially among children and adolescents [20].

International findings from 34 countries suggests that stigma related to ethnicity, skin colour, age, sexuality, disability, and gender decreased between 2009 and 2019. Despite this, there has been no reduction in weight-based stigma [21], rather the results showed that unconscious bias towards obesity increased over the period, where people in the survey increasingly, unconsciously, and automatically associated people with obesity with something negative.

This is also reflected in media reports and in social media, not least documented by a number of reports describing that people using the new medication are considered to take the easy-way-out [23–26].

Internalised Stigmatisation

Internalised stigmatisation occurs when individuals accept and integrate negative stereotypes and societal attitudes into their self-concept leading to self-blame and anxiety. This can lead to various negative outcomes, including low self-esteem, feelings of shame and worthlessness, beliefs that obesity management is a personal responsibility and a negative self-image. Internalised stigmatisation is frequent. Studies in the United States show it occurs among 40–50% of people living with obesity and is most common among those trying to lose weight [27]. Another US-based survey showed that more than half reported having experienced stigmatisation from colleagues and over 40% from employers [28].

In healthcare settings, internalised stigma can lead to reduced treatment engagement and to decreased willingness to seek medical help, potentially worsening health outcomes [29]. Additionally, individuals may feel hopeless about losing weight or improving their health, creating a vicious cycle of stigma and poor health. Building robust support systems for those living with obesity, including psychological support and counselling may help mitigate internalised stigma.

Stigmatisation from family and peers can lead individuals with obesity to avoid social events due to feelings of inferiority and fear of judgment based on their appearance [30].

Individual responses to obesity-related stigma vary depending on factors like age, gender, race, socioeconomic status and cultural context, making it challenging to determine who experiences the most social marginalisation. Some reviews suggest that girls and women are affected most [31] facing significant consequences like wage penalties and employment barriers, in particular for those women with both obesity and higher socioeconomic status [32].

Stigmatisation Related to use of Effective Medication for Obesity

The introduction of new the effective glucagon-like peptide-1 (GLP-1) receptor agonists weight loss medication like Wegovy in 2021 and Tirzepatide in 2023, has significantly impacted successful treatment for obesity [33]. These drugs have demonstrated great effectiveness in reducing obesity by increasing feelings of fullness and reducing cravings. They effectively help individuals achieve significant weight loss that was previously difficult to attain with medication or with diet and/or activity alone. Clinical trials have shown that these medications can result in average weight losses of 15–20% of body weight [34], which is a considerable improvement over older treatments. This level of weight loss can lead to marked improvements in health outcomes, including reductions in the risk of type 2 diabetes, hypertension, cardiovascular diseases, and other obesity-related conditions [35].

The success of these medications can contribute to a broader public education about the complex nature of obesity, that may lead to greater empathy and understanding to potentially reduce the external stigma and blame associated with it. This shift can challenge myths about obesity as a lack of will power and help individuals who achieve weight loss using these medications feel more confident and/or reduce the impact of negative comments and enhance overall life satisfaction. For physicians in general internal medicine, this offers an opportunity to treat obesity equitably by prioritising education for trainees and up-skilling practicing doctors on obesity’s pathophysiology, psychosocial impacts, and effective treatments [36]. Physicians are encouraged to create compassionate, patient-centered clinical environments, advocate for equitable access to comprehensive treatments, and implement coordinated care models to address both the social drivers and health impacts of obesity.

Important organisations such as the European Commission, the American Medical Association (AMA) and the World Obesity Federation advocate that severe obesity (defined as BMI < 30 kg/m²) should be classified as a chronic disease, arguing that labelling obesity as a disease may effectively reduce stigma, as highlighting the genetic and biological factors behind obesity would shift the perception of weight from being a moral issue and potentially alleviating the guilt and shame that individuals with obesity often experience. However, this argument has also been challenged arguing that classifying obesity as a disease may also lead to unnecessary interventions and contribute to further stigmatization, by reinforcing negative stereotypes and promoting a too narrow focus on individual responsibility, ignoring the complex underlying socio-economic and environmental factors [37].

The availability of effective weight loss medications also may change some healthcare professionals’ perceptions, moving from blaming individuals for their weight to acknowledging it as a treatable medical condition. This may prompt a need for more training and education for healthcare professionals about the biological and medical aspects of obesity. Indeed, a recent commentary noted that more effective nutrition training in medical education is needed, arguing that the currently inadequate education leaves physicians unprepared for counselling on nutrition, places undue focus on weight and body mass index, and can exacerbate anti-obesity bias [38].

A few years ago, a pledge was put forward by the Brazilian Association for the Study of Obesity and Metabolic Syndrome and the Brazilian Society of Endocrinology and Metabolism [39] to stop using terms like “weight loss drugs” arguing that it may contribute to stigma as such terminology implies that anyone seeking weight loss can use these medications for short-term results, only. Instead, using terms like “medications to treat obesity” or “anti-obesity medications” to clarify that treatment targets the disease rather than merely addressing symptoms were advocated for. Recently also the use of the term anti-obesity medication has been criticised arguing that the word “anti” is oppositional by definition and may lead to internalised weight bias and negative emotional responses. It was argued that instead, the language used around these medications should be supportive like “medications for obesity” [40].

Disparities in Access to the Novel Medication for Obesity

Significant challenges remain concerning equal access to and affordability of the new medications for obesity, which must benefit all individuals with obesity—not just those who can afford them.

When the medications are expensive, and access is limited by high costs and inconsistent insurance coverage, only certain groups of the population can benefit. This is likely to widen disparities in obesity treatment, especially as not all health insurance plans cover them, further limiting access for many people [41].

For individuals who cannot afford the medication stigma may intensify, as they may be perceived as unwilling or unmotivated to manage their obesity, even though the barriers they face are structural rather than personal. In this regard a recent publication argues that public health policymakers in the US need to ensure equal and continuous access to the new effective obesity therapeutics and improve patient-clinician trust [42]. The inequal access to effective medication can potentially create a two-tiered system where individuals who can afford the medications may experience reduced stigma, while those without access continue to face heightened blame and social judgment. Achieving equitable access to medication is therefore essential for maximising a positive impact. In agreement, a recent qualitative study involving 21 women with severe obesity identified stigma from healthcare providers, as well as cost and insurance coverage issues, as major barriers to accessing medication and appropriate care [43]. Another study investigated the effects of an insurance policy change that discontinued coverage for the obesity medications among 22 female patients who held the same state employee insurance carrier and participated in the same medical weight management program. Using semi-structured interviews, the study found significant emotional and psychological impacts stemming from this policy change, where “patients perceived the discontinuation of the obesity medication coverage as stigmatising and unjust, leading to feelings of hopelessness and fear” [44].

On the other hand, as medication for obesity in the future may become more commonly used and/or prices will likely be reduced, individuals with obesity may feel an increased pressure to use them to conform to societal standards of body weight. This pressure could lead to heightened internal stress and self-blame if the medication is not effective for them. Additionally, those who choose not to or cannot use the medications may face greater judgment and criticism. Therefore, ensuring that weight loss treatment is affordable and accessible to everyone is crucial. Implementing policies and programmes that lower costs and increase the availability of these medications can further help prevent new forms of inequality and stigma [41].

Stigma with Weight Regain

Another significant challenge for many individuals experiencing weight loss is that the weight lost during treatment is often regained [45] if the medications are discontinued [46], making these treatments potentially life-long drugs. Society often perceives weight regain as a sign of a lack of willpower or discipline, which can increase the external stigma. Additionally, medication discontinuation and subsequent weight regain may lead to repeated cycles of weight loss and regain, with potential consequences such as loss of medical insurance [2]. This weight regain can also trigger a return of internalised stigma, as individuals may feel renewed failure and shame over their inability to maintain weight loss without ongoing medication. As discussed recently in an editorial in Science [47], the re-emergence of so-called “food noise”—the persistent thoughts and urges related to eating—may contribute to feelings of frustration and helplessness, further enhancing negative self-perceptions.

Method

Papers cited in this narrative review were sourced from PubMed and PsychINFO. Search terms included keyword combinations related to the new effective weight loss drugs such as GLP-1 receptor agonists, and weight stigma to identify reviews that examined stigma in relation to the use of these new drugs for weight loss.The search string was: ([weight stigma]) OR [weight bias] OR [obesity stigma] OR [moral]) AND ([GLP-1] OR [ozempic] OR [wegovy] OR [tirzepatide] OR [semaglutide] OR [mazindol] OR [liraglutide] OR [pioglitazone] OR [sodium-glucose cotransporter-2 inhibitor] OR [anti-obesity medication] OR [AOM]). The search included studies published until November 3rd, 2024.

Results

The search resulted in 310 publications but only two of the publications were empirical studies that addressed stigma related to weight management using the new medications. One study was a randomised controlled intervention [22] the other a qualitative study [48].

The intervention study examined how potential negative public perceptions about individuals who use the new weight-loss medication for obesity operated [22]. The study randomised 357 US adults to read case stories that targeted negative evaluations and egocentric impressions about a subject (a women) with obesity who lost 15% body weight either with diet/exercise or with a GLP-1 agonist. Inventories included questions about, among others, negative weight-related stereotypes toward the woman, beliefs that she took a shortcut to lose weight, and that bio-genetic factors caused her baseline weight. The results showed that a woman losing weight using obesity medication was more negatively evaluated and judged to have taken a “shortcut” to achieve weight loss.

The qualitative study [48] used ethnographic methods that included direct observations and in-depth interviews with 3 general practitioners and 11 nurses or dieticians and examined how Wegovy was specifically managed and negotiated in general practice. The findings revealed that some health care professionals questioned whether obesity is a disease and its role in clinical care. Additionally, the health care professionals presented the new medication with a clear moral undertone, questioning patients’ motivations for wanting the drug and emphasising individual responsibility for lifestyle changes.

Discussion

Our literature search identified only two empirical studies - one RCT [22] and one qualitative study [48] - that explored stigmatisation related to weight loss from the new GLP-1 receptor agonists. Both studies found that negative attitudes persist, with the public and healthcare professionals alike viewing the medication as a ‘shortcut’ and questioning its legitimacy. More studies are clearly needed to confirm these findings.

The two identified studies did not examine methods for reducing stigma, but useful lessons might be learnt from research that examined patient experiences with stigma before and after bariatric surgery, or from fields that have successfully reduced other forms of stigma.

Lessons Learned from Patient Experiences with Bariatric Surgery

Numerous studies have examined stigma related to weight loss following bariatric surgery. These studies consistently show that stigma towards individuals with obesity is deeply rooted in societal attitudes. Even after achieving normal weights, individuals who undergo bariatric surgery often continue to face various forms of stigma, and weight loss through surgery is frequently viewed with scepticism compared to traditional methods like diet and exercise. For example, several experimental studies found that people who lost weight through bariatric surgery were evaluated more negatively than those who lost weight through behavioural methods [49–51]. In the largest of these studies, 138 women and 137 men from Australia were recruited via Amazon Mechanical Turk. Participants were shown a photograph of a woman with obesity, followed by a 1-year follow-up image after she had lost 95 pounds (45 kg) [49]. Subsequently participants were then randomly assigned information about how she lost the weight—either through strict dieting, regular exercise, gastric bypass surgery, or surgery plus regular exercise. Those informed that the woman had lost weight through surgery rated her more negatively than those who believed she had used diet and/or exercise alone. The participants who learned she had used surgery plus exercise rated her in-between. By contrast, the woman who lost weight solely through diet and exercise was rated as least lazy, least sloppy, and most competent and responsible for her weight loss. Mediation analyses showed that differences in ratings of laziness and competence were largely due to perceptions of personal responsibility for the weight loss.

Other studies similarly demonstrate that weight loss through surgery can have consequences for hiring and employment. For instance, a US-based study examined the stigma associated with surgical weight loss and found it led to significant social repercussions, including discrimination in hiring practices [52]. The study revealed that individuals who learned about a person’s past obesity and subsequent weight loss through surgery rated that person less favourably in terms of employability and personality traits compared to persons who lost weight through diet and exercise, hightlighting strong external stigma. These results underscore that even after significant weight loss, individuals may still face negative judgments based on their past weight status and the methods used to lose weight. While effective obesity medications may theoretically help challenge misconceptions and reduce stigma, it cannot be assumed that external stigmatisation will decrease nor that individuals who achieve significant weight loss will automatically experience improvements in self-esteem or body image.

Several qualitative studies and reviews have examined the motives, expectations, and perspectives of patients prior to bariatric surgery. For instance, Cohn et al. [53] reviewed 28 qualitative studies focusing on patients’ motives and expectations before bariatric surgery. They reported that patients generally expected post-surgery weight loss to have positive psychosocial benefits that would strengthen their personal identities, relationships, and improve engagement in public and professional life [53]. However, while patients often anticipated improved psychosocial well-being after surgery, findings from other reviews examining post-surgery experiences challenge these expectations [54, 55]. Coulman et al. [54] systematically reviewed 33 qualitative studies focusing on perspectives related to psychological health, sexual life, body image, and social relations among patients living with the outcomes of bariatric surgery. They found that patients sought a sense of control and normality, though their experiences were mixed. Initially, patients felt more in control of their weight and eating habits, but this sense often declined over time - particularly with some weight regain - leading to negative psychological experiences. Issues such as the need for plastic surgery to remove excess skin after bariatric surgery were highlighted as contributing factors to the negative psychological experiences. A recent study found that the psychological issues remained unresolved even after plastic surgery, suggesting that physical appearance was not the sole factor contributing to a negative self-image [56].

A recent qualitative study interviewed 18 individuals several years after bariatric surgery [57] focusing on coping strategies for stigma, self-esteem, and body dissatisfaction. It suggested that ten years post-surgery, many individuals continued to experience body dissatisfaction and viewed their bodies as deviant from social norms, often due to excess skin. This aligns well with the research showing that body image remains significantly worse in post-bariatric surgery patients compared to the general population [54, 58]. Furthermore, a qualitative study by Dimitrov Ulian et al. [59] additionally found that women who had undergone bariatric surgery continued to experience weight stigma regardless of the size of their weight loss, and felt judged for taking what was perceived as an ‘easy way out’ to lose weight.

Most recently, a scoping review by Garcia et al. [60] explored the experiences and consequences of bariatric surgery stigma among patients across 28 studies. They found that patients often internalised stigma and reported feeling shame for choosing surgery. Many continued to face negative comments and judgment when disclosing their decision to undergo, or revealing they had undergone, surgery. Consequently, many chose not to disclose their decision to others. This stigma also impacted their decision-making process leading some to delay their choice for surgery, some to seek it abroad, and some to opt out entirely.

The persistence of stigma even after significant weight loss following bariatric surgery suggests that individuals using the novel obesity medication may also continue to face stigma despite achieving their weight loss goals. Just as with bariatric surgery, society may perceive the use of medication for weight loss as a shortcut, reinforcing that weight control should be achieved solely through willpower. Indeed, in agreement with the results from the recent randomised study evaluating weight-related stereotypes toward a woman using a GLP-1 agonist for weight loss [22], several recent media reports indicate that people using new obesity medications are judged for ‘cheating,’ leading some to choose not to disclose their decision to use these drugs [23–26, 47].

Previous literature indicates that cultural perceptions of body image can influence societal acceptance of bariatric surgery. In some regions, this may reduce external stigma, while in others it may heighten it, as documented in a study examining the varying experiences of stigma related to bariatric surgery across different countries [61]. Likewise, cultural differences in the experience, acceptance, and use of the new medications could potentially influence the degree and the nature of stigma. A more nuanced understanding of how different groups experience stigma could potentially provide relevant insights for reducing stigma associated with new obesity medications. Proactively addressing these stigma-related challenges seems essential as the effective medications for obesity become more prevalent in obesity management.

Lessons learned from studies addressing educational efforts to reduce weight stigma.

A recent review of 25 interventional studies aimed to identify strategies to reduce weight bias among healthcare trainees and students. They identified five strategies for reducing weight stigma: (i) increased education, (ii) providing information about causes and controllability, (iii) fostering empathy, (iv) promoting a weight-inclusive approach, or a combination of these [62], and concluded that it is essential to address weight stigma early and continuously in healthcare education, and focus on genetic and socioenvironmental factors. They also concluded that a shift from a weight-centric to a health-focused, weight-inclusive approach is necessary.

Other studies have investigated whether viewing obesity as a disease rather than a personal responsibility could help reduce weight stigma. For example, an experimental study randomised 309 participants to read one of three texts that either presented obesity as a disease; did not present it as a disease; or a text that did not address obesity [63]. Participants who read the text framing obesity as a disease subsequently had more positive attitudes toward individuals with obesity than those who read the other texts. In another experiment, 365 healthcare professionals were divided into two groups: one group was instructed to view severe obesity as a disease, while the other group was not [64]. Both groups then reviewed a hypothetical medical profile of a patient with both obesity and migraines. Healthcare professionals (49% doctors, 31% nurses, and 20% physiotherapists, dieticians, and psychologists) who were asked to view obesity as a disease suggested more migraine-related treatments than those in the group where obesity was not considered a disease. Both these studies suggest that stigma towards obesity may decrease when people understand obesity as a disease caused by genetic and medical factors.

Lessons Learned from Campaigns to Reduce Stigma Associated with HIV/AIDS

The HIV/AIDS epidemic in the 1980s was accompanied by significant stigma and discrimination against those affected. The subsequent efforts made to reduce stigma surrounding both HIV/AIDS and substance abuse, although differing in various aspects such as etiology, transmission risk, treatment options, and the repercussions of non-treatment, there are similarities with obesity regarding negative societal attitudes, moral judgment, and blame. The introduction of effective treatments and the initial absence of anti-discrimination protections in comparable conditions may offer insights into mitigating weight stigma associated with pharmacologically induced weight loss through educational interventions.

In the early years after the first cases of AIDS gay societies and communities played an important role in reducing stigma and discrimination. Government response was slow and gay activists and organisations took matters into their own hands, creating support networks, public education campaigns, and activist movements, advocating for increased research funding, better access to treatment, policies to protect the rights of people with HIV/AIDS, and generally raising awareness about the disease. With the later introduction of antiviral treatments also public educational programs, that significantly contributed to improve societal attitudes toward individuals living with HIV were introduced, highlighting the importance of accurate information in challenging myths and advancing understanding [65]. Indeed, unlike obesity, where the stigma has only recently been addressed in joint international consensus statements [1, 9, 66], the United Nations General Assembly Special Session on HIV/AIDS in 2001, followed by the Joint United Nations Programme on HIV/AIDS in 2007, emphasised that stigma and discrimination were significant barriers to effective treatment and prevention efforts, leading to initiatives that focused on community engagement and education [67].

Campaigns and education efforts aimed to reduce discrimination and moral judgment against those with HIV/AIDS by specifically educating the public about HIV transmission, treatment possibilities, and the realities of living with the virus. This helped reduce moral judgments, but also emphasised that reducing stigma was important to improving health outcomes [68]. As a result, the narrative around HIV shifted, framing HIV as a medical condition that could affect anyone. This allowed patients to re-enter social life with fewer stigmas attached [68, 69]. Also, while initially medication use for HIV/AIDS was viewed by the public as a sign of weakness or an easy solution, and as antiretroviral therapy transformed HIV from a fatal disease into a manageable chronic condition, the visible signs of the disease diminished, and public perceptions shifted positively, recognising the importance of medical treatment rather than viewing it as a personal failing [70].

The evolution of stigma surrounding AIDS before and after the antiviral treatments, illustrates how societal attitudes towards medical conditions can change [65]. However, while obesity itself is not a death sentence, the societal adaptation to effective HIV treatments may still provide useful insights into how attitudes toward the new obesity medications could evolve as their effectiveness becomes more widely acknowledged. However, in the case of HIV/AIDS, despite the extensive public education campaigns, medical advancements, and legal efforts to address stigma, the condition still carries a significant level of stigma, albeit less than in earlier decades.

Also, anti-discrimination protections for people with HIV/AIDS emerged and were strengthened by the Americans with Disabilities Act (ADA) in 1990, providing legal support for those facing unfair treatment due to HIV/AIDS. These protections applied across the entire United States and this example provides important learnings of how legal frameworks can be used to combat stigma and protect vulnerable populations [71]. The US Affordable Care Act prohibits discrimination based on health status, but as noted by Pomeranz and Puhl, the law still does not explicitly list obesity as a protected disability [71]. The Act can provide some protections for people with obesity and there have been a few court decisions that have recognised severe obesity as a potential disability under certain circumstances, which has helped protect some people with obesity in relation to health insurance coverage. In the UK the disability laws require employers and employees to not discriminate or harass their colleagues with obesity and to provide reasonable adjustments in the workplace where discrimination is a possible outcome of behaviors or policy arrangements [72]. In EU, the European Court of Justice ruled in 2014 that while obesity itself is not a protected characteristic under EU anti-discrimination law, severe obesity can in some cases be considered a disability if it causes long-term physical, mental or psychological impairments [73].

Similar to protections under the ADA for HIV/AIDS, obesity should be listed as a protected characteristic within anti-discrimination laws in EU and other countries. For example, the European Court of Justice recognizes obesity as a disability and UK disability laws require employers to make reasonable accommodations for employees with obesity to prevent discrimination. Legislation could also require organisations, particularly in healthcare to implement training and policies aimed at reducing obesity stigma to protect against obesity-related stigma and promote fair treatment. In Denmark, a recent citizen proposal has initiated efforts to enforce legislative changes aimed at protecting individuals with diverse body sizes. This proposal suggests including ‘body size’ as an explicitly protected characteristic, on par with ‘disability,’ in Sect. 266 b of the Penal Code and the “Act on the Prohibition of Discrimination in the Labour Market.”

The case of HIV demonstrates the deep-rooted resilience of stigma. In HIV/AIDS, stigma is not solely linked to the disease but also to cultural, social, and historical factors - such as sexuality, drug use, and fear of contagion - which are challenging to eradicate through awareness alone. Obesity faces similar issues. It is not just a shift in medical understanding that is required but also a change in entrenched cultural attitudes regarding personal discipline and moral judgement. Like with HIV/AIDS, public education campaigns targeting obesity stigma are essential, but they must extend beyond the biological and medical aspects to address the complex social, moral, and psychological factors contributing to this stigma.”

Substance use disorders are another group of diseases with significant stigma and negative societal values around personal responsibility, self-control, and health morality, regardless of the availability of treatment. Obesity is similarly viewed by many as a dependency disease. Lessons may therefore also be learned from studies addressing how the introduction of treatments like disulfiram (Antabuse) has influenced societal stigma towards alcoholism or how nicotine replacement therapies have influenced stigma towards smoking. However, while studies have examined changes in perception of smoking and alcoholism over time, few studies have specifically investigated how views on alcohol or smoking addiction may have changed before and after the introduction of Antabuse and nicotine replacements [74]. Thus, research on whether the introduction of methadone has contributed to positive changes in societal attitudes towards drug addiction and treatment remains limited. Individuals receiving methadone continue to face discrimination, including in healthcare settings, where they may be perceived as lacking motivation or compliance [75]. A recent opinion paper described how governments, institutions, and educational bodies increasingly recognise that substance use treatment, policies, and language need to evolve to provide better societal understanding of and support for affected individuals [76].

Religious and Moral Roots of Obesity Stigma

Most studies on obesity stigma were from Western societies, where stigma surrounding obesity may be linked to moral teachings and norms rooted in Christian, particularly Protestant, traditions. Research in psychology and theology supports this, showing that negative societal attitudes towards obesity are rooted in perceptions of immorality or uncleanliness [67]. In societies that follow these values, stigma can be reinforced by the strong emphasis on personal responsibility and moral judgment, viewing self-control, persistence, and dedication as essential for success, and suffering as a necessary part of personal growth [77].

Understanding the interplay between these moral teachings and societal perceptions may be of importance for addressing the stigma associated with obesity [67]. The notion that “the pure do not suffer” adds to the problem by implying that individuals with obesity have failed to maintain control over their bodies and.

lives, and need to show stamina, “pull themselves together” and lose weight through sheer willpower. When effective obesity medications are used, societal perceptions may label this as “cheating,” suggesting that true success can only be achieved through hard work such as diet and exercise. This stigma is furthermore founded by the belief that those who have experienced obesity cannot any more be considered “pure” or in control, as their past struggles are viewed as evidence of moral failure. Such biases may further make it difficult for those affected to seek help with weight loss.

Limitations and Future Directions

Although several media reports highlight substantial stigma associated with the use of the new obesity medications, the scientific literature—both qualitative and quantitative—remains limited, and the field is still in it’s infancy including studies examining strategies for how to mitigate stigma related to weight loss from the new obesity medications.

The differences by nature, between losing weight by bariatric surgery and by medication for obesity also restrict the generalisability of findings from one to the other. Bariatric surgery involves invasive procedures and significant physical transformations, making it difficult to fully compare weight loss stigma experienced by those who undergo surgery with that faced by individuals using medications. As a result, more research is needed to understand the specific dynamics of stigma related to these newer obesity medicine treatments. Also, the parallels between the stigma associated with obesity medications and that faced by individuals using medications for conditions like HIV/AIDS, while potentially informative, might still oversimplify the complexities associated obesity stigma and fail to take account for the unique social and moral connotations surrounding weight, body image, and personal responsibility. In addition, while it is recognised that there are clear disparities in access to the novel obesity medications, it is beyond the scope of the paper to fully address these structural inequalities comprehensively. Finally, this narrative review primarily draws from selected databases like PubMed and PsycINFO, potentially leading to overlooking of some relevant interdisciplinary insights from public health, sociology, and anthropology potentially affecting the depth of the analysis. In this regard, a recent paper by Hunt et al. [78] explored the evolutionary perspectives on addiction, framing obesity as a condition shaped by evolutionary factors rather than personal failings. The authors argue that modern environments overstimulate the brain’s reward system, leading to maladaptive behaviours like overeating. They suggest this understanding could help shift the narrative away from blaming individuals for their obesity, as GLP-1 agonists, help regulate this reward system, thus positioning obesity as a biological issue rather than a moral or behavioural one. The paper aligns with the broader view that our responses to food, similar to behavioural addictions like video games or social media, are deeply rooted in evolutionary history, and supports the idea that medicalisation and the development of effective treatments may reduce both internal and external stigma associated with obesity. The paper argues that by educating the public about the evolutionary and biological factors contributing to obesity, the narrative may shift from individual blame to recognising obesity as a complex medical condition, potentially fostering more supportive and less stigmatising environments in healthcare, workplaces, and social settings (Table 1).

Table 1.

Mitigating strategies to reduce stigma, discrimination and bias related to the new medication

Promote Education and Awareness: Promote education campaigns that explain obesity as a complex condition influenced by genetic, biological, environmental, and societal factors, and not a result of personal failings. Reduce discrimination in employment and education by challenging stereotypes and promoting inclusion.

Ensure Equitable Access to Treatments: Advocate for policies that make effective obesity medications accessible and affordable for all individuals, regardless of socioeconomic status. Implement policies that lower costs, provide insurance coverage, and eliminate barriers that may prevent people from accessing necessary medical interventions

Train Healthcare Professionals: Ensure healthcare professionals receive training on the complexities of obesity to avoid bias. Focus training on understanding obesity as a medical issue to improve patient interactions and reduce the stigma faced by individuals seeking treatment in healthcare settings. Enhance training for healthcare providers to recognise and address their own biases regarding obesity. Encourage patient-centered care that avoids moral judgments to provide timely and appropriate treatment and support without assuming lack of self-control or motivation. Take legal actions and build a more inclusive legal structure: Promote anti-stigma training and policies in both healthcare and employment. Explicitly include obesity as a protected characteristic within anti- discrimination laws Recognise obesity as a disease. Require employers to provide reasonable support for employees with obesity to prevent discrimination and promote an inclusive workplace.

Important steps have already been taken to inform healthcare professionals, policymakers, and the public about the stigma associated with obesity, and as discussed above, international multidisciplinary groups of experts and representatives from relevant scientific organisations have recently launched several joint consensus statements with recommendations to eliminate weight bias [1, 9, 59]. However, while it is believed, and advocated for, that educating people about the causes of obesity can reduce obesity stigma, evidence for such efforts remains limited [79]. Some of the recent suggestions have been that future stigma-reduction programmes should also include information about the significant effort that many people living with overweight and obesity invest into maintaining a healthy diet and exercise regime, even if those efforts do not always result in weight loss. This approach aims to challenge assumptions about the perceived lack of effort among individuals with obesity [49].

Conclusion

The introduction of effective weight loss medications, like the GLP-1 receptor agonists, in addition to providing a realistic method to manage weight has the potential to reduce both internalised and externalised stigmatisation of people living with obesity. However, as is evident from stigma related to weight loss with bariatric surgery it also carries the risk of new forms of pressure and judgment. This review highlights the clear need for more studies examining stigma and strategies to mitigate it in the context of weight loss medications. The extensive literature on stigma following bariatric surgery demonstrates that obesity stigma is deeply rooted in societal attitudes and fueled by misconceptions about its causes, often perceived as personal failure rather than a complex medical condition. These misconceptions are likely also present in relation to weight loss medications. Currently, most available information is anecdotal or derived from lay press articles, with limited scientific evidence linking the use of novel obesity medications to weight stigma and negative societal attitudes.

It is important to address the stigma-related challenges proactively as these new weight loss medications become more common in obesity management. Comprehensive strategies reducing stigma requires education, healthcare reform, policy initiatives, and ensuring equitable access to these treatments. Reshaping public and medical profession attitudes trough education informed by lessons learned from the stigma associated with HIV/AIDS, may guide how to help shift societal attitudes and ensure that individuals using these medications are not unfairly judged or stigmatised. Additionally, building a more inclusive legal structure to protect against obesity-related stigma and promote fair treatment is needed as is ensuring fair and equal access to the medical treatments, to avoid making existing inequalities and negative attitudes worse against those who cannot afford, tolerate or want the treatment.

Author Contributions

B.L.H had the idea for the article, performed the literature search and drafted, wrote and critically revised the work of the submitted and published versions.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Competing Interests

Berit L Heitmann is a Co-principal investigator of the LightCOM project that was financed by a grant to the University of Copenhagen and The greater Copenhagen Hospital Corporation from the Novo Nordic Foundation (NNF22SA0080921).