From education to patient care: the impact of weight stigma in healthcare

Abstract

This scoping review explored the literature about weight stigma in healthcare education and patient care and how it may impact individuals living in larger bodies. Two databases, MGH OneSearch and PubMed, were utilized, focusing on research published from 2013 to 2023 in English. A total of 18 articles were identified and used for this review. Evidence indicated that healthcare providers stigmatize patients living in larger bodies, both implicitly and explicitly. Studies found that medical students preferred thin patients and had strong anti-fat bias (P < 0.001). Weight bias in healthcare can lead to discrimination, impacting patients’ mental and physical well-being, including heightened stress, altered caloric intake, fluctuations in body size, and declining overall health. The impact of weight stigma in healthcare is recognized but understudied. This review suggests that believing weight is within patient control fosters blame and stigma. Learning about weight stigma and developing nonstigmatizing education for healthcare students and providers should be a priority. Understanding how weight stigma may delay healthcare and increase chronic illness risk could encourage more compassionate care for patients in larger bodies.

The prevailing social notion associates thinness with health, as fatness, assessed by body mass index (BMI), is automatically linked to medical conditions. Doctors are trained to use BMI readings to advise weight loss to improve their patients’ health. Although well intentioned, the history of the BMI itself and subsequent recommendations for weight loss are typically unsuccessful and can come with inadvertent consequences instead.^1–5 The phrases “people with higher weight” or “living in a larger body” are suggested by the National Association to Advance Fat Acceptance and National Eating Disorder Collaboration to replace “overweight” and “obesity.” These terms were selected for use in this paper following discussions and recommendations from communities of people who live in larger bodies and have lived experience with eating disorders, along with research conducted in this field.⁶

The BMI was developed by mathematician and statistician Adolphe Quetelet in the 1830s, who at the time referenced it as Quetelet’s index.⁷ Quetelet’s mission was to determine the “average man” (l’homme moyen) and was later used to justify eugenics.⁷ At the time, his sample population only included White Belgian individuals, inaccurately representing the community and public today. The BMI was adopted by life insurance companies in the early 20th century, as they compiled tables of height and weight to determine what to charge prospective policyholders, observing weight in relation to mortality.⁸ Early actuarial tables only represented a fraction of the total population at the time.⁹ Utilizing these tables, the Metropolitan Life Insurance Company developed the standard tables for what was termed “desirable” weight in 1959, which implemented the categories of the BMI cutoffs used up until the 21st century.⁸ In the early 1990s, the World Health Organization and International Obesity Task Force chose to align the BMI to international standards, reestablishing the cutoff for overweight at >25 kg/m².¹⁰ The BMI remains the primary method for evaluating weight and determining one’s health status. This was never the purpose of this tool.

The BMI provides a numerical value of an individual’s height and weight, limiting its use and accuracy for measuring health. The American Medical Association classified obesity as a disease in 2013 without sufficient research.¹¹ Given its history and limitations, the usage of BMI has been described as unethical, inaccurate, and an invalid tool to measure health status.^10,12–14

The healthcare system equates body size to health status and well-being, normalizing discrimination and bias toward people living in larger bodies.¹⁵ Weight stigma, also known as weight-based discrimination, weight bias, fatphobia, or fat stigma, consists of cultural stereotypes that individuals in larger bodies are lazy, incompetent, and noncompliant.¹⁶ Weight stigma directed toward larger-bodied individuals may put them more at risk for developing chronic disease^17,18 and negative health effects independent of BMI.^3,19 Weight bias has been normalized within healthcare education, potentially preventing optimal, ethical care for these patients. The purpose of this scoping review was to explore the literature about weight stigma present in current healthcare education and patient care and how it may impact individuals living in larger bodies.

METHODS

A search of the literature was conducted to explore the evidence of weight stigma present in healthcare education and patient care and how it impacts individuals living in larger bodies. Two databases were utilized for this search, including MGH OneSearch, the authors’ library’s implementation of EBSCO Discovery Service Health, and PubMed, yielding the most recent research publications for the years 2013 to 2023. The research was not limited to a specific country, but needed to be available in the English language. The following terms were included when utilizing both databases: healthcare, obes*, patient, provider. More specific terms were implemented in the search and can be found in Table 1. This search is reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) (Figure 1).

Table 1.

Search terms

Database	Search Terms
MGHOneSearch	Larger bodie* OR Obes* OR Overweight AND Weight stigma* OR Weight bias OR Weight prejudice OR Obesity stigma AND Primary care OR Primary health care OR Wellness exam OR Patient-centered care AND Medical education OR Healthcare education OR training NOT children NOT pediatrics NOT adolescents NOT weight loss or weight reduction or lose weight
PubMed	Larger bodie* OR Obes* OR Overweight AND Weight stigma* OR Weight bias OR Weight prejudice OR Obesity stigma AND Primary care OR Primary health care OR Wellness exam OR Patient-centered care AND Medical education OR Healthcare education OR training NOT children NOT pediatrics NOT adolescents NOT weight loss or weight reduction or lose weight

Figure 1.

Selection of studies using the PRISMA-P flowchart.²⁰

Prior to screening, articles that focused on weight loss without mentioning weight stigma were excluded. Focusing on the adult population, all reports that studied children and adolescents alone (individuals <18 years old) were also omitted. During the screening process, studies were excluded if there was no mention of weight stigma and if weight loss was the main outcome. When assessing for eligibility, other reports were excluded for studying weight stigma solely in the public setting, along with literature reviews assessing reports prior to the year 2013. A total of 18 articles were identified and used for this literature review.

RESULTS

Eighteen articles were screened and assessed for eligibility. The following reports were excluded in the final screening process: weight stigma toward nonpatient (n = 2), literature reviews for years prior to 2013 (n = 5), and weight stigma not as the main outcome (n = 4). Worldwide locations were included for this literature review, including countries and varying states in the USA, Canada, Australia, France, Germany, and the United Kingdom. Studies included both observational and experimental data. Studies assessed the impact of weight stigma from longitudinal large population data (n = 2) and a random group of participants (n = 2), while one assessed the impact of weight stigma through a narrative review. Impact included effects of health status and stress (n = 2) and other consequences related to the healthcare setting and patient care (n = 3). To assess weight bias from providers and students, observational data such as surveys were highly prevalent (n = 13). Surveys used included the Implicit Association Test (IAT) (n = 4), the Implicit Relational Assessment Procedure (IRAP) (n = 1), the Anti-Fat Attitudes scale (n = 1), and researcher-developed surveys (n = 3). All studies except one (Major et al., 2014) focused on the categories “overweight” (BMI > 25 kg/m²) and “obese” (BMI > 30 kg/m²). Academic institutions and programs included medical students (n = 5), medical students and residents (n = 1), and health profession education students (n = 1) (see Table 2). The studies included in this review were classified into one or more of the following themes: weight stigma in the healthcare setting, weight stigma in healthcare education, and the impact of weight stigma on larger bodied patients.

Table 2.

Summary of studies

Author(s), year	Country	Study design	Population	Sample size	Setting	Study aim/focus	Measurement tool(s)	Key findings
Miller et al, 2013	United States	Cross-sectional survey	Third-year medical students	310	Southeastern US medical school	Assess the prevalence of implicit and explicit weight bias among medical students and evaluate their awareness of their bias	Weight IAT; semantic differential item (explicit bias)	39% had significant implicit anti-fat bias; 33% reported significant explicit anti-fat bias; 67% of students with implicit anti-fat bias were unaware of it; male students were more likely to report explicit bias
Puhl et al, 2014	United States	Cross-sectional survey	Postgraduate health students (PA, clinical psychology, psychiatry)	107	Northeastern US medical school	Examine weight bias, perceptions of “obesity” causes, observations of weight bias	UMB-FAT scale: custom survey on perceived bias; attitudes toward patients	High exposure to weight bias; bias linked to frustration, negative treatment expectations; beliefs that “obesity” is behavioral mediated bias impact
Gudzune et al, 2014	United States	Cross-sectional internet survey	“Overweight” and “obese” adults engaged in primary care	600	National sample, United States	Assess relationship between perceived PCP weight judgment and weight loss attempts/success	Custom survey; self-reported weight and perceptions of PCP	Perceived judgment increased attempts but not successful weight loss; counseling without judgment linked to better outcomes
Jackson et al, 2014	United Kingdom	Longitudinal cohort study	Adults ≥50 years	2944	English Longitudinal Study of Aging (ELSA)	Assess associations between perceived weight discrimination and changes in weight, waist circumference, and weight status	Self-report discrimination survey; objective weight and waist circumference measurements	Weight discrimination linked to weight gain, waist gain, and increased odds of becoming “obese”
Major et al, 2014	United States	Experimental study	Female college students	93	Western US university	Test effects of weight-stigmatizing messages on eating behaviors, dietary control, and stigma concerns	Experimental exposure to stigmatizing/ control articles; food consumption; self-efficacy scale	Stigmatizing messages increased calorie intake and reduced control in diet among self-perceived “overweight” women
Richard et al, 2014	United States	Cross-sectional survey analysis	Adults aged 18–65 visiting primary care physicians	6628	National dataset (Medical Expenditure Panel Survey)	Examine differences in physician-patient communication by “obesity status”	Patient-reported communication composite (adapted from CAHPS survey)	“Obese” patients reported lower communication scores, less respect, less time spent by physicians
Tomiyama et al, 2014	United States	Narrative review and model development	Not a sample study; theoretical model based on existing literature	N/A	N/A	Propose and support the model linking weight stigma, stress, eating behaviors, cortisol, and weight gain	Review of empirical studies on stigma, stress, cortisol, and eating behavior	Weight stigma acts as a chronic stressor promoting eating, cortisol secretion, and subsequent weight gain; suggests a vicious cycle (COBWEBS model)
Tomiyama et al, 2014	United States	Cross-sectional comparison study	“Obesity” researchers, clinicians, and professionals	232	National US obesity conference	Compare explicit and implicit weight bias among professionals between 2001 and 2013	Written (pen-and-pencil) IAT; explicit bias ratings (general feelings, stereotypes)	Implicit anti-fat bias decreased, but explicit anti-fat bias (e.g., laziness) increased from 2001 to 2013
Phelan et al, 2015	United States	Narrative literature review	Patients with “obesity”; healthcare providers	N/A	Healthcare settings (primary care focus)	Review evidence on the impact of weight stigma on healthcare quality and outcomes	Literature review of empirical studies across health communication, psychology, healthcare	Weight stigma reduces quality of care, worsens provider-patient communication, increases care avoidance, and contributes to poorer health outcomes
Phelan et al, 2015	United States	Prospective cohort study	US medical students	1795	49 US medical schools	Assess changes in implicit and explicit weight bias over medical school and identify influencing school factors	Weight IAT; explicit bias thermometer; surveys on curriculum, contact, and role modeling	Implicit bias decreased, explicit bias increased; positive contact with patients reduced bias; negative faculty role modeling increased bias
Baker et al, 2017	United States	Cross-sectional and longitudinal assessment	First and third year medical students	325 assessments	Western US medical school	Assess implicit weight bias and examine changes across medical training	IRAP	Students showed pro-thin and pro-fat attitudes; bias decreased over time, driven by improved attitudes toward “overweight” and “obese” individuals
Pearl et al, 2017	United States	Cross-sectional experimental vignette study	Medical students and internal medicine residents	219	Northeastern US medical training institution	Examine effects of medical trainees’ weight-loss history on weight-biased attitudes and responses to patients	AFA questionnaire; patient vignettes; emotional and alliance rating scales	Trainees who lost/maintained weight showed more bias and blame toward patients struggling with weight loss; gender moderated some effects
Vadiveloo and Mattei, 2017	United States	Prospective cohort study	Adults aged 25–75	986	National US sample (MIDUS study)	Examine 10-year associations between perceived weight discrimination and allostatic load	Perceived discrimination survey; biomarker panels for allostatic load (7 systems)	Perceived weight discrimination doubled risk of high allostatic load; strongest associations with inflammation, glucose metabolism, and lipid/metabolic dysregulation
Geller et al, 2018	United States	Pre/post descriptive students of educational intervention	First-year medical students	∼110 students per year (6 cohorts)	Northeastern US medical school	Address weight bias in medical students through an ethics-focused session involving reflections and media analysis	Weight IAT; custom survey on beliefs about “obesity” causes; self-reported attitude changes	70% showed thin preference; 30% report attitude improvement after ethics session; video clips were most influential in shifting perceptions
Seymour et al, 2018	United States	Cross-sectional qualitative study	Healthcare professionals (primary nurses)	220	Midwestern US healthcare settings	Explore how weight bias among healthcare professionals affects quality of care using hypothetical patient scenarios	ATOP scale; open-ended responses to patient vignettes	High weight bias linked to more specific diet/exercise advice, quicker pharmaceutical intervention, more emphasis on weight loss, and less empathetic discourse toward patients with “obesity”
Gupta et al, 2020	Canada	Cross-sectional national survey analysis	Adults aged >18 years	16,340	National Canadian health survey	Examine association between body weight and self-reported discrimination in healthcare settings	Canadian Community Health Survey; logistic regression models	Adults with class II/III “obesity” had 52% higher odds of reporting healthcare discrimination compared to non-obese peers; weight stigma persists across Canadian healthcare
Phelan et al, 2021	United States	Cross-sectional observational study	Third- and fourth-year medical students	111	Midwestern US medical school	Assess how weight bias and faculty role-modeling influence students’ patient-centered communication with higher-weight standardized patients	IAT; explicit bias surveys (AFA, ATOP); patient-centeredness coding (RIAS); standardized patient encounters	Students perceiving more negative role-modeling and norms showed poorer patient-centered communication (lower friendliness, respectfulness, interactivity); implicit and explicit bias levels alone were not major predictors
Puhl et al, 2021	Australia, Canada, France, Germany, United Kingdom, United States	Cross-sectional multinational survey	Adults engaged in a weight management program	13,966	Online survey across six Western countries	Examine associations between experienced and internalized weight stigma and healthcare experiences across six countries	Modified Weight Bias Internalization Scale; custom healthcare experiences survey	Weight stigma and internalized weight bias were associated with healthcare avoidance, lower perceived quality of care, poor provider communication, and great perceived judgment across all countries

AFA indicates Anti-Fat Attitudes; ATOP, Attitudes Toward Obese Persons; CAHPS, Consumer Assessment of Healthcare Providers and Systems; IAT, Implicit Association Test; IRAP, Implicit Relational Assessment Procedure; PCP, primary care physician; RIAS, Roter Interaction Analysis System.

Weight stigma in the healthcare setting

Five studies addressed the possible and pervasive weight stigma occurring within the healthcare setting,^2,21–24 with one assessing the discrimination experienced both in the healthcare field and within everyday life.²⁵

Evidence from research indicates that healthcare providers stigmatize patients living in larger bodies, both implicitly and explicitly.^2,21–23 Implicit bias referred to stigmatization that was automatic and unintentional.²⁶ This contrasts with explicit bias, in which the individual is aware and intentional with the stigma.²⁵ Healthcare providers exhibited significant implicit and explicit anti-fat or pro-thin bias toward individuals living in larger bodies.² Over a 12-year period, Tomiyama et al (2014) found that healthcare providers who attended the Obesity Week Conference in 2001 and subsequently in 2013 developed an increase in explicit bias as their implicit bias decreased.²⁷

The relationship and trust between healthcare providers and their patients is impacted by weight stigma. Gudzune et al (2014) found that healthcare providers were more likely to judge patients living in larger bodies for their size.²¹ These authors found that patients who received this judgment were significantly more likely to attempt weight loss but with failed attempts.²¹ There were variations in how a provider treated individuals living in larger bodies when compared to thin people. Utilizing obesity as an independent variable, researchers found that patients received less respect from their providers, reduced explanation of treatment and interventions, decreased patient involvement and inclusion, poorer listening skills, and overall less time spent with the patient during their visit.^22,24 When they used the Attitudes Toward Obesity Persons (ATOP) tool, Seymour et al (2018) found that healthcare providers were more likely to show bias toward individuals living in larger bodies due to their weight, impacting the quality of care they provide.²³

Weight stigma is prevalent in Western culture.^24,25 Over 50% of individuals living in larger bodies have a history of experiencing weight stigma in the countries of Australia, Canada, France, Germany, the United Kingdom, and the United States. Two-thirds of study participants in each country reported weight-based discrimination from their healthcare providers.²⁴

These studies underscore the presence of weight stigma within the healthcare environment, specifically among healthcare providers treating individuals in larger bodies. Similar findings were also prevalent within healthcare education, specifically for students as they trained and worked toward becoming healthcare providers.^28–34

Weight stigma in healthcare education

Medical education contributes to weight stigma. Seven studies captured weight-based discrimination found in medical students^28,31–34 and students enrolled in health discipline training and residency,²⁹ with one study assessing the discrimination experienced both in medical students and the general public.³⁰

Out of the seven total studies, five captured medical students’ implicit and explicit bias specifically toward larger-bodied patients.^{28,30,31,33,34} Measurement tools used to capture implicit bias included the IAT^30,33,34 and the IRAP.³¹ Explicit bias was captured utilizing web-based surveys²⁸ and ‘feeling thermometers.’³⁰ Other tools to capture potential bias included Likert scales (Geller et al, 2018) and the AFA scale.³²

Two tools are commonly used to measure weight bias. There is discussion comparing the validity of IAT versus the IRAP when assessing implicit attitudes. The IAT has been critiqued as a simplistic tool that uncovers bias utilizing speed and accuracy, categorizing concepts such as race, size, gender, and age.³¹ The IRAP uncovers bias by assessing the relational connections between these same concepts using relational frame theory.³⁵ Unlike the IAT, the IRAP presents a combination of stimuli using categorical, evaluative terms. Baker et al (2017) utilized the IRAP for a deeper analysis of implicit attitudes (thin vs fat) and found that medical students were “pro-thin” and not necessarily “anti-fat.” They also found that the implicit bias of medical students lessens over time.³¹

Studies indicated that medical students preferred thin patients^30,31,33,34 and had strong anti-fat bias (P < 0.001).²⁸ This bias correlated with instances of discriminatory actions and adverse remarks by both faculty and residents toward patients living in larger bodies, occurring both implicitly (P = 0.02) and explicitly (P < 0.001).³⁰

Studies demonstrated how these biases impact medical students’ attitudes toward and beliefs about patients living in larger bodies^29,34 and how their perspectives changed if they themselves had succeeded in purposeful weight loss.³² These included observations of weight stigma by medical students and the potential repercussions it might entail for the quality of care they provide larger-bodied patients.^29,30 The normalization of negative attitudes toward higher-weight patients was significantly associated with poor patient-centered care (P = 0.002). Findings also highlighted weight-based discrimination present in their curriculum, capturing the amount of training related to health disparities, emotional regulation, interpersonal skills, dealing with difficult patients, and skill providing weight loss counseling.³⁰ Students also reported observations of their own preceptors toward patient care during training.^29,30 Medical students reported the belief that higher-weight patients lacked motivation to make changes along with overall noncompliance (69%). Students who reported bias toward patients with higher weight also reported feelings of frustration when engaging in patient care with these individuals.²⁹

Impact of weight stigma on larger-bodied patients

Five studies addressed and evaluated the impact of weight stigma toward individuals living in larger bodies.^17,36–39 Two studies retrieved data from large population-based samples^36,39 with support of other measurements such as questionnaires, interviews, and biomarker data.¹⁷ Only two studies focused specifically on weight stigma perceived by the patient in a healthcare setting,^36,38 while the remainder of studies captured weight stigma’s impact on food consumption,³⁶ stress,² changes in body size,³⁵ and health status.¹⁷

The bias toward individuals in larger bodies persisted in both the healthcare system and in everyday life.^17,37,38 The stigma associated with larger bodies contributed to high individual stress levels, also known as high allostatic load—a condition that increased significantly when individuals experienced weight stigma.^17,37,38 Individuals with high allostatic load were at a higher risk of experiencing comprehensive, long-term health effects, from anxiety and depression to heart disease and stroke. Evidence suggests that long-term weight discrimination is strongly associated with lipid and metabolic dysregulation, glucose metabolism, and inflammation.¹⁷

Experiencing this threat to identity or stereotype may lead to impaired communication with a patient’s physician and overall cognitive function.³⁸ In particular, women who perceived themselves as “overweight” were more likely to be concerned about experiencing weight discrimination (P < 0.001). Major et al (2014) found that individuals within the highest weight range exposed to weight-stigmatizing messages demonstrated a strong correlation between heightened stress levels and an increase in caloric intake (P = 0.02).³⁷

Perceived weight discrimination was also associated with changes in body size, including weight, waist circumference, and weight status.³⁶ Authors found significant associations between perceived weight stigma, also known as discrimination, and weight change over 4 years. When adjusting for BMI, sex, age, and wealth, individuals who experienced weight-based discrimination exhibited an increase in weight. Assessing the same factors, those who did not experience weight-based discrimination were found to have lost weight (P < 0.001). There was a significant association between weight discrimination and higher odds of becoming obese for participants who were not classified as obese at the start of the study (P = 0.004).³⁶

The mental and physical well-being of individuals is impacted when individuals in larger bodies experience weight stigma. Studies found that this included heightened stress levels,² altered caloric intake,³⁷ fluctuations in body size,³⁶ and a decline in overall health status.¹⁷ Patients experiencing this stigma exhibited mistrust toward their providers, delay in preventative testing, and overall avoidance of clinical care.^24,38

Weight stigma in society

The weight bias existing outside of healthcare further underscores the reality that everyone, including providers, students, and staff, is affected by societal beliefs. In Canada, 37% of individuals experienced weight-based discrimination in their daily lives, with approximately 6% reporting weight stigma in healthcare.²⁵ Phelan et al (2015) found that although implicit weight bias decreased over time within medical training, it increased in the general public.³⁰ Explicitly, weight bias increased during this time frame for medical students and remained stable in society. Vadiveloo and Mattei (2017) assessed nine different scenarios assessing individuals’ frequency (“sometimes,” “rarely,” or “never”) of weight-based discrimination in their daily lives. They found that individuals living in larger bodies who experienced weight stigma were put more at risk for developing chronic disease.¹⁷

DISCUSSION

In this literature review, 18 published articles were examined and analyzed to explore recent evidence of weight stigma present in healthcare education and patient care and how it impacts individuals living in larger bodies. Weight stigmatization is present in both healthcare and education, leaving patients living in larger bodies with harmful consequences.

Engaging in weight stigma does not improve the chances of weight loss³⁶ and negatively impacts the health status of patients.^2,36–38 Personal experience and knowledge from education typically shape the understanding of health and well-being as students enter the field as providers. Weight stigma remains widespread and often overlooked in healthcare settings, where it is frequently treated as socially acceptable despite its harmful effects.^16,40,41

Weight loss in the long term has yet to be proven successful^4,42,43 and often leads to negative effects independent of BMI.^2,19 Experiencing weight stigma from providers initiates a distressing cycle: stress sets off cortisol release, fostering reward sensitization, impairing executive function and eating habits, culminating in weight gain and heightened risk of further stigma for patients.² When patients return to providers with weight gain or lack of weight loss, they are then deemed “noncompliant.”¹⁶ The impact on patient care and well-being suffers when weight stigma is present, as it disrupts relationships with patients^21–24 and creates harm.^17,37,38

Limitations

The year range 2013 to 2023 was chosen to yield the most recent evidence of the existence and impact of weight stigma in healthcare and education. However, extending this range to prior years might capture longitudinal bias in both the healthcare setting and within training.

Sample size was a common limitation in studies assessing weight stigma in education. The sample of cohorts, number of students, and number of institutions varied across studies. One study assessed one cohort from a single medical school,³³ others assessed various cohorts in one institution.^29,32,34 Limited sample sizes along with the time period impacts generalizability. Studies assessing diverse cohorts across multiple institutions can discover the prevalence of weight stigma. Identifying factors of this bias could create opportunities for purposeful interventions for mitigation.

Implications

Through this research, important gaps emerged in three themes: weight stigma in healthcare, weight stigma in healthcare education, and the impact of weight stigma for patients living in larger bodies. Healthcare and healthcare education are connected, as medical education is mandatory in pursuing a career in the healthcare field worldwide. Following healthcare professions students throughout their education and into their careers as providers could yield essential data about changes in weight stigma over time. These data could be instrumental in implementing interventions to mitigate the effects of weight stigma. Surveys were the most common tools used for bias assessment for both healthcare providers and healthcare profession students. These included the IAT,^30,33,34 IRAP,³¹ Likert scales,³³ the AFA scale³² and the ATOP scale.²³ Other tools to assess bias included questionnaires such as web-based surveys²⁹ and ‘feeling thermometers.’³⁰ The IAT and web-based surveys showed greater validity, specifically with a greater sample size.³⁰

Further research and future implementation

Further research implementing interventions to prevent and/or dismantle weight stigma is needed in both healthcare institutions and health professions education. There are a variety of ways to confront weight bias in healthcare, with a larger opportunity to start in health professions education.

Future research should evaluate education for healthcare workers to ensure that they provide safe and ethical care for patients in all bodies and abilities. Like prejudices such as racism and sexism, weight discrimination should not be tolerated. Utilizing a weight-inclusive approach in all sectors of health profession education would allow students to assess and become aware of their own internalized biases and dismantle that bias when caring for patients living in larger bodies. As the next generation of providers complete this training, there is more of a possibility for that bias to cease as they become preceptors within the field. Ensuring that this approach is embedded in the curriculum will guide students to develop stronger rapport and communicate with their higher-weight patients, while also shifting the paradigm toward weight-inclusive care. Prioritizing this effort with an interdisciplinary approach could avoid the current health consequences of weight-centric treatment, the normalized shame toward individuals in larger bodies, and patient avoidance of care.

The IAT is described as the gold standard in measuring bias.⁴⁴ However, in a single study that chose the IRAP over the IAT, a preference for thin patients was evident but did not necessarily indicate anti-fat bias. The IRAP utilizes deeper analysis in understanding implicit bias; however, it has questionable validity. This contrasts with studies that utilized the IAT.³¹ Research shows that when under time pressure, participants typically tend to spontaneously frame opposing associations in a positive way.⁴⁵

The weight bias present in the general public and in medicine is inextricable as providers and medical students are part of the same larger societal context. Only three studies simultaneously evaluated the weight bias present in healthcare and in society.^17,25,30 This raises concern about how these two environments can synergistically contribute to the overall well-being of the community. Studies that aim to capture the perspectives of providers and students concurrently, with the insight of their patients, could highlight the rapport developed within the patient–provider relationship. This combination of perspectives is understudied. A search could highlight the weight stigma experienced by individuals living in larger bodies specifically, revealing possible themes relating to medical encounters, lived experience, patient care experiences, and rapport with providers, alongside quantitative data such as laboratory values and metabolic parameters. This yields an opportunity for utilizing qualitative data, or a mixed-methods approach. Phelan et al (2021) was the only study in this literature review that solely captured the healthcare experience of individuals living in larger bodies from a qualitative perspective. Fatphobia experienced in the healthcare setting impacts individuals who share the common trait of living in a larger body.³⁴ Weight stigma itself can be viewed as a phenomenon. Exploring this more could open the opportunity for further improvement and growth for health professionals and create safer spaces for individuals to receive optimal, less stigmatizing care.

Knowing of this disruption in care and overall health status of patients living in larger bodies calls for an increased awareness of how normalized discrimination can be in the healthcare and education settings. Even when evaluating weight stigma within medical education, Phelan et al (2015) presumed that patients in larger bodies were inherently more challenging, which could be characterized as weight stigma in and of itself.³⁰ The paradox in normalizing this discrimination is that it contradicts the intended goals providers set out to achieve for patients. For example, medical providers often advise patients in larger bodies to limit their caloric intake, which may inadvertently lead to an increase in stress and consumption of calories. Although many educational institutions visibly commit to ethical care, weight stigma is still widely accepted and even encouraged in disguise as interventions for “noncompliant” patients.

CONCLUSION

The impact of weight stigma within healthcare is recognized but remains understudied. Further research could highlight the significant impact of stigma on the lives of patients who are medically termed overweight or obese. This literature review showcased how the common belief that weight is something patients are able to control, even in healthcare, can lead to blame and stigma by care providers. Conducting further research in this area will highlight that current treatments and tools are outdated, ineffective, and often exacerbate weight gain. Learning the impact of weight stigma and developing nonstigmatizing education for healthcare students and providers should be a priority. Understanding how weight stigma may lead to a delay in healthcare and risk developing chronic illness in these patients will encourage healthcare workers to provide more compassionate care toward patients living in larger bodies.

DISCLOSURE STATEMENT

The authors report no funding or conflicts of interest.