Ending Weight Stigma to Advance Health Equity

Approximately 42% of Americans have a body mass index (BMI) categorized as obesity (≥30kg/m²),¹ which represents almost a 40% increase in prevalence over the past decade. Obesity – caused by complex interactions among genes, biology, environment, and behaviors – is associated with the leading causes of preventable death in the U.S., including heart disease, diabetes, and certain cancers.² In the U.S., obesity and related conditions are prevalent across all racial and ethnic groups and disproportionately impact minoritized communities. Non-Hispanic Black adults have the highest obesity prevalence (50%), followed by Hispanic adults (46%),^1,2 and rates are particularly high among Black women. Obesity disproportionately affects other marginalized communities, such as American Indian, Alaska Native, Native Hawaiian, and Pacific Islander populations, sexual/gender minority groups, and individuals with disabilities.

Disparities in obesity and its related conditions may result in part from systemic inequities that could be addressed by targeting structural and social determinants. These factors include place-based environmental conditions that shape eating and physical activity patterns, healthcare access, stress, and behavioral opportunities to manage obesity effectively. Weight stigma is less commonly recognized as a social determinant of health, which contributes to health disparities while remaining largely unaddressed in public health.³

Weight Stigma

Negative attitudes toward individuals with obesity, high body weight, or larger bodies (i.e., weight bias) are pervasive worldwide, especially in Western cultures.⁴ Due to the widespread misconception that weight is entirely within an individual’s control, negative character traits (e.g., stereotypes), blame, and moral judgments are applied to people with high weight.³ These derogatory attitudes and beliefs contribute to the societal devaluation and mistreatment of individuals with a high weight, or weight stigma. Weight stigma includes social exclusion, derogation, discrimination, and overall unfair treatment due to weight or size.⁵ This stigma is often measured based on individual perceptions of mistreatment (e.g., perceived discrimination⁶). It can also be evaluated based on objective assessments of environmental conditions that promote stigma (e.g., discriminatory policies, media messages⁵) and actions of others (e.g., disrespectful language used by healthcare professionals⁷). Even without personally experiencing weight stigma from other people, individuals with a high weight often report distress in anticipation of negative judgment and mistreatment from others.⁵ They may also internalize stigma by absorbing societal weight stereotypes and scorn and applying these attitudes to themselves, leading to self-blame and self-devaluation.⁸

Exposure to weight bias and stigma occurs throughout the lifespan. Weight is one of the leading reasons for teasing and bullying among youth, yet few anti-bullying policies or interventions include protections related to weight.⁵ Similarly, few laws prohibit weight-based discrimination despite evidence of its impact on education, employment, and wages. Weight stigma is reported around the world, including in Asian, African, and other non-Western countries. Approximately 40% of U.S. adults report experiencing weight stigma, with higher rates among younger adults and those with the highest BMIs. Internalized weight stigma is estimated to affect the majority of adults with high body weight.⁸ Of note, individuals without objectively high weights can still experience and internalize weight stigma, due in part to unrealistic societal beauty standards and harsh judgment of bodies that do not conform to strict ideals (e.g., hourglass figure, muscularity, etc.). Individuals with very low body weight may also face bias and stigma. Still, there is a disproportionate impact of weight stigma on individuals with high weight or obesity.

The adverse effects of weight stigma on mental and physical health are robust. Prospective associations between weight teasing and future psychological distress and disordered eating suggest that early weight stigma experiences have lasting consequences in adulthood.⁹ Across the lifespan, weight stigma is associated with depression, anxiety, disordered eating, substance use, suicidality, and poor health-related quality of life. Considered a form of chronic stress, weight stigma elicits physiological and behavioral coping responses (e.g., unhealthy eating, physical activity avoidance) that undermine engagement in weight management and contribute to increased risk for chronic diseases.⁶ Moreover, weight-based discrimination affects determinants of health such as financial and social resources.

Weight stigma negatively affects healthcare access and quality of care through discriminatory structural and social factors. Structural factors include inadequately sized medical equipment (e.g., scales, gowns) and a historical lack of insurance coverage for evidence-based obesity treatments due in part to their classification as “cosmetic” (although the coverage landscape has been evolving). Social factors include healthcare professionals’ negative attitudes toward people in larger bodies.⁷ Patients report healthcare providers as a primary source of weight stigma, describing feelings of being judged, disrespected, and shamed because of their weight. Healthcare professionals report blame and negative assumptions about patients with high weight and use less patient-centered communication with these patients.⁷ Due to weight stigma, many patients report avoiding or delaying medical appointments, potentially increasing morbidity and mortality risk. Weight stigma may also hinder effective community and patient engagement in health-related research due to discriminatory policies (e.g., BMI cutoffs for eligibility) and negative attitudes that result in stigmatizing research.

Intersectionality

A critical step toward centering equity in weight stigma research is investigating how intersecting forms of structural oppression contribute to stigma experiences and the impact of weight stigma on health.¹⁰ Informed by a legacy of Black Feminist Thought and coined by legal scholar and activist Kimberlé Crenshaw,¹¹ intersectionality underscores how multiple forms of inequity including racism, colorism, sexism, colonialism, classism, ableism, heterosexism, and transphobia, compound to shape individuals’ and groups’ experiences of disadvantage and privilege, including experiences of stigma.¹²

Early work has shown differences in weight stigma based on individual social identities (e.g., gender, race), with studies tending to find higher levels of weight stigma in cisgender girls and women and lower levels in Black and Latine people relative to their majority group counterparts.^5,8,10 However, investigating weight stigma only in the context of one identity fails to capture the many social identities that intersect to influence lived experiences of stigma. Weight stigma is often experienced in tandem with racism, heterosexism, and other sources of discrimination in ways that can be difficult to disentangle^13,14 and that are not captured in dominant stigma paradigms. Experiencing weight stigma alongside other forms of oppression may compound stress and exacerbate the risk for adverse health outcomes.¹³

The paucity of research on weight stigma among minoritized populations in the U.S. and abroad necessitates immediate and robust new research. Understanding the impact of multiple intersecting forms of stigma will require studies with large, diverse samples. For example, statistical techniques such as latent class analysis or structural equation modeling can be used to examine interrelationships among different marginalized identities and the health consequences of experiencing or internalizing weight stigma.¹² Quantitative and qualitative approaches can also be used to research specific subgroup populations (e.g., young Asian women, Hispanic gay men, etc.) to provide richer information on the experiences of individuals with multiple marginalized identities.

With significant biases documented in health care,¹⁵ a notable gap remains in understanding how weight bias affects care delivery and health outcomes, particularly for culturally diverse patient populations. While some studies have explored cultural variations in perceptions of excess weight, few have examined the intersection of these cultural body ideals with healthcare providers’ perceptions and their impact on healthcare quality and outcomes. Health services research may benefit from including measures of patients’ cultural weight attitudes and perceived and internalized weight stigma to enhance patient-provider communication and inform culturally-sensitive obesity interventions.

In addition, current measures of weight stigma have not been adequately evaluated in racial, ethnic, gender, sexual, and other minority populations (e.g., immigrant, socioeconomically-disadvantaged, etc.). Overall, few weight stigma assessments address cultural differences, and gender diversity is limited in weight stigma research. Further measure development and testing are required to accurately capture weight stigma experiences and internalization in all groups.

Finally, future research would be strengthened by partnering with persons with lived experience and using community-engaged approaches. Recognizing heterogeneity within larger population groups is crucial; for example, identifying sociocultural contexts in which weight stigma is less pronounced can provide insights into how to address this problem. Engaging persons representing the diversity of marginalized populations will ensure that these distinctions receive attention, enhance the external validity of research findings, and aid in developing interventions that are more likely to resonate with priority populations.

BMI

A major source of weight stigma comes from unfair assumptions and restrictions based solely on BMI. BMI was developed as a population-level surrogate measure of adiposity based on data from 19^th-century Western European men.¹⁶ Its foundation limits its applicability to other populations. Indeed, differences in the relationship between BMI and health are observed across racial and ethnic groups. For example, BMI has a stronger relationship with type 2 diabetes risk (and at lower BMI values) in Asian versus white populations, while this relationship is weaker in Black versus white populations.¹⁷

BMI was not developed as a diagnostic tool for individual health, but it is often used as one. Applying BMI at the individual level can be stigmatizing – especially for racial and ethnic minority populations – given the variable relationship between BMI and health outcomes across demographic groups. When healthcare professionals focus predominantly on BMI without considering other health metrics (e.g., body composition, HbA1c), patients without weight-related concerns may be inappropriately counseled to lose weight; illness-induced weight loss may be mistakenly praised; and non-weight related causes of symptoms (e.g., cancers) may be overlooked. BMI is frequently used to deny access to medical treatments, including those that provide significant benefits for health and quality of life (e.g., orthopedic surgeries, organ transplants, and fertility treatments). These discriminatory policies and adverse outcomes disproportionally affect and may deepen disparities for minoritized populations with a higher prevalence of high BMI.²

Given these concerns, there have been calls for appropriate BMI cutoffs or eliminating the use of BMI. In June 2023, the American Medical Association adopted a policy recommending that BMI be used in conjunction with other measures when assessing patients’ health.¹⁸ This policy could improve healthcare for patients with obesity by expanding the focus of visits from solely BMI to include factors that more directly impact health and quality of life.

Combatting Weight Stigma While Promoting Health Equity

Weight stigma deleteriously affects physiological and psychological well-being and may exacerbate health disparities in marginalized groups. Efforts to directly intervene against weight stigma may improve health and health equity. Table 1 highlights research and clinical opportunities to advance efforts to prevent and reduce weight stigma and bolster health equity initiatives.

Table 1.

Research & clinical opportunities to address weight stigma & foster health equity

Research Opportunities
Include individuals with lived experience of obesity and weight stigma throughout the research process, including prioritization of research foci, study design and implementation, and analysis and dissemination of results
Evaluate the effectiveness of engagement methods to determine best practices for including those with lived experience in the research process and increasing community-led research
Include body weight and size in new and ongoing diversity, equity, and inclusion initiatives
Develop and test culturally-centered, multilevel interventions to address weight stigma across settings (e.g., healthcare, education) and populations (e.g., students, patients, providers)
Investigate efficacy of new laws and policies as they are enacted, e.g., the Massachusetts Act or New York City Human Rights Law prohibiting height and weight discrimination
Critically evaluate widely used weight stigma measures to ensure that they capture the full scope of the experience and internalization of weight stigma among people of color, LGBTQ+ people, and individuals from other marginalized communities
Develop and validate weight stigma measures for use across various groups
Encourage use of validated weight stigma measures in population-based studies and clinical research so that effects and correlates of weight stigma can be studied across the lifespan
Investigate the mechanisms by which weight stigma may affect cardiovascular health
Develop weight bias prevention interventions for medical students and healthcare providers (including education about causes of obesity) and test their effects on student/provider biases, quality of care (e.g., counseling skills), and patient outcomes/satisfaction
Identify key psychosocial variables (including internalized weight stigma) and provider weight biases that impact how patients navigate the healthcare system and quality of care provided
Test the effects of training individuals to recognize obesity stigma and advocate for themselves, and of training patient navigators to facilitate medical care of patients with obesity
Consider implications of blanket recruitment strategies that use BMI to identify eligible study participants and, when appropriate, include other health outcome measures beyond BMI alone
Consider the cultural appropriateness of weight bias/stigma recommendations, and recognize that weight bias/stigma and its internalization often differ by culture
Understand how social determinants of health (e.g., food insecurity, low socioeconomic status, etc.) may influence weight bias/stigma
Examine the intersectionality of multiple identities and forms of discrimination related to race/ethnicity, gender/sexual identity, social status, age, and weight/size by including diverse samples in weight stigma research and weight stigma measures in health equity research
Integrate systems approaches and methods (systems mapping, modeling) to better understand the external factors and multi-scale systems surrounding an individual that affect body weight
Clinical Opportunities
Recognize that individuals with obesity are likely to have experienced weight stigma, and other forms of stigma as well
Ask individuals about their experiences with the healthcare system as someone in a larger body, and validate/express empathy when they discuss stigmatizing experiences in healthcare
Train providers to counsel patients that obesity is caused by complex factors, not moral failure
Teach medical students, residents, and healthcare professionals about weight bias/stigma and how to provide care that is not stigmatizing, by including required patient-centered communication skills and weight bias/sensitivity training with patient stories and interactions
Assess body image and eating disorder symptoms as part of a comprehensive weight history
Consider and explore causes of change in weight since the last visit or over longer periods of time, rather than focusing on current weight without any context of weight history
With compassion and respect, use shared decision-making to determine care plans, supporting patients in the path they chose (including if they are not interested in weight-related treatment)
Document patient preferences for weight-related discussions so that they are not asked about weight at each visit if they do not wish to discuss it; similarly, chart patient preferences for being weighed (or not) and remember and respect these preferences
Pause during patient preparation, patient interactions, and documentation to check weight bias, e.g., by asking oneself a set of questions such as, what are other possible explanations for the patient’s problem? How would you understand the problem if the patient did not have obesity?
Shift patient-provider communications from weight-centric to weight-inclusive conversations
Revamp current public health messages on obesity prevention to include additional risk factors like environmental influences and hormonal changes due to stress. Highlight other benefits of physical activity and healthy eating beyond weight reduction, such as improvements in overall health, mood, concentration, and energy levels
Enhance clinical care by adopting a systems-oriented approach that goes beyond individual focus. Utilize systems maps and models to effectively guide and refine clinical practices

A meta-analysis of intervention studies found small to moderate effects in reducing weight bias among healthcare students and providers.¹⁹ However, many studies lacked diverse populations, had short timeframes, were unsustainable, and did not recruit community-dwelling adults. Given the prevalence of obesity among racial/ethnic and sexual/gender minority populations, persons with disabilities, and other overlooked groups, research is needed to inform the efficacy and effectiveness of weight bias-reducing interventions in diverse populations. Multilevel interventions implemented within healthcare systems – such as anti-discriminatory policies, training for providers and staff, and support for patients who experience or internalize weight stigma – will likely have more sustainable results than isolated, unidimensional interventions. An emphasis on patient-centered care and humanization can be a first step toward understanding the heterogenous experiences and needs of individuals with multiple marginalized identities.

Additionally, effective interventions for diverse groups may require population-specific designs. For example, research suggests that internalized stigma and coping strategies vary by race/ethnicity.¹⁰ These data reinforce the importance of engaging those with lived experience to identify effective strategies that reduce the impact of weight stigma and improve quality of life in diverse communities.

A key to combatting weight stigma is universal recognition that obesity is not the result of individual failures in self-discipline but, rather, of broken systems that contribute to a chronic disease with complex underlying biology. Increases in the prevalence of obesity are due to multi-dimensional and interdependent drivers related to the physical, social, and economic environments in which individuals live their lives, making healthy choices more challenging and less accessible or appealing. Considering this complexity, applying a systems lens in research (e.g., using network analysis) can illuminate the interrelated causes and consequences of high body weight and guide the design of interventions.

Recent efforts have been encouraging, with a focus on educating the public and practitioners about factors influencing body weight and detrimental health outcomes, particularly in marginalized groups. One example is the joint consensus statement developed by a multidisciplinary group of international experts to address the gap between weight stigma and scientific knowledge regarding the mechanisms of body-weight regulation.³ A causal loop model developed as part of a strategic plan for obesity prevention and treatment by the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions highlighted biased mental models, social norms, and stigma as critical factors that affect outcomes such as care-seeking behavior.²⁰ Greater use of a systems lens when considering interventions for obesity has the potential to address the root causes of health disparities while simultaneously challenging stigmatizing notions about the causes of disease.

Involving those with lived experience in discussions about mitigating weight stigma is vital for fostering effective engagement in research. Equally important is understanding each community’s sociocultural norms concerning body weight. For example, Black women who live in supportive communities more accepting of higher body weights may be protected from the negative consequences of weight discrimination.¹³ Opportunities exist to identify diverse community voices that can advocate and promote strategies to shift perceptions about weight.

Obesity and related conditions have a greater impact on marginalized groups, leading to further health disparities. Weight stigma exacerbates this marginalization. To promote health equity, it is crucial to raise awareness about weight stigma and integrate efforts to reduce weight stigma into all disease prevention and treatment interventions.