The weight of society: a qualitative study on how social norms shape body size and weight ideals

Summary

Background

Weight bias and stigma have transformed body weight from a purely biological attribute into a complex social phenomenon. Social and health scientists continue to critically examine how weight stigmatising discourses and biased perceptions shape attitudes, beliefs and everyday experiences. Studies show that socially mediated subjectivities profoundly affect women's health-related behaviours and decision-making. This study seeks to explore, from the standpoint of patients attending a gynaecological clinic, how weight bias and stigma influence women's perceptions of their own weight and body size and the healthcare decisions they make.

Methods

This qualitative study was conducted in a Family Planning Outpatient Clinic in the southeastern region of Brazil. Interviews (n = 6) and focus groups (n = 2, six participants per group) with patients were conducted from February to November 2024. All participants identified as women, and the interviews and focus groups were analysed using a reflexive thematic analysis approach.

Findings

The rationality of weight bias and stigma influences how women perceive their weight and body shape. This turns biological functions, such as eating and exercising, into social actions that respond to imposed norms that shape common sense about what is considered a healthy and desirable weight.

Interpretation

Medical research and clinical practice often reduce health risk factors to poor personal choices or biological predispositions, while neglecting systemic drivers such as weight bias, stigma and fatphobic representations, medicalised discourses of weight, and neoliberal ideals equating thinness with moral virtue. The rationality behind the embodied realities of women navigating weight-based discrimination reveals how weight bias and stigma shape women's everyday life, social actions and healthcare decisions.

Funding

São Paulo Research Foundation (FAPESP).

Research in context.

Evidence before this study

We searched PubMed and BVS/BIREME for studies reporting women's weight bias and stigma experiences accessing gynaecological healthcare and exercising their sexual and reproductive rights. We used seven search strategies to identify relevant literature. The first strategy included the terms “reproductive rights,” “sexual rights,” “sexual reproductive rights,” “woman,” “women,” “weight bias,” and “weight stigma,” while excluding “obesity,” “fat,” and “fatness.” The second strategy was similar but included “women” instead of “woman.” The third strategy combined “reproductive rights,” “sexual rights,” “women,” “woman,” “anti-fatness,” “obesity bias,” “fat,” and “fatness,” and excluded “obesity.” The fourth strategy included “reproductive rights,” “sexual rights,” “women,” “woman,” “overweight,” “weight bias,” and “weight stigma,” excluding “obesity,” “fat,” and “fatness.” The fifth strategy used “sexual reproductive health rights,” “women,” “woman,” “weight bias stigma,” and “overweight,” while excluding “obesity,” “fatness,” and “fat.” The sixth strategy included “sexual reproductive health rights,” “anti-fatness,” “woman,” “women,” “fatness,” and “fat,” and excluded “obesity” and “overweight.” The seventh strategy combined “sexual reproductive health rights,” “obesity bias,” “woman,” “women,” “obesity,” and “overweight,” while excluding “fat” and “fatness."Our search was not limited to specific study types, included studies published through January 31, 2024, and was not restricted by language. We also included studies in the analysis stage between February 1, 2024, and March 31, 2025. Our search identified a review focused on best practice contraception care for women with obesity. However, it does not address any of the topics concerning our research. We decided to carry out internet searches (Google), searching for references in the authors' own knowledge papers.

Added value of this study

Analyse how weight intersects with other social factors, such as gender, sexism, and sexuality, across many settings in which women live and work. Health is linked to complex ideas about weight—such as judgements based on body shape or size—and to real-world health outcomes. Taking this broad, critical view is essential for reducing the harm caused by weight bias and stigma. Study participants faced weight bias and stigma in every part of their lives, which drove them to unsafe and non-evidence-based weight loss/not gain methods to meet the social demands for a specific body size, weight, aesthetic ideals, and a “healthy” look.

Implications of all the available evidence

This study shows that recognising weight as a social phenomenon and weight bias and stigma as a social determinant of health is essential for improving women's healthcare and everyday lives. It is also important to consider how women perceive and understand weight in order to reduce misconceptions about weight bias and stigma. In Latin America, this issue is particularly complex, and there is a need for a stronger focus on evidence-based approaches that challenge prevailing social and cultural views regarding body weight and body shape.

Introduction

Although the World Health Organization classified obesity as a chronic disease decades ago,¹ and more recently, the World Obesity Federation² and Rubino et al.³ reiterated its status as a chronic, progressive, and recurrent disease. At the societal level, obesity continues to be widely viewed and framed primarily as a risk factor for other diseases, rather than as a disease in itself. Because the clinical definition of obesity as a chronic disease has not been implemented in health systems and social structures, obesity continues to be mistakenly associated with and described as body size, which leads to the pathologisation and stigmatisation of larger bodies despite evidence that size alone does not equal disease.4, 5, 6, 7, 8, 9 Emerging evidence challenges the validity of Body Mass Index (BMI) as a diagnostic tool: a BMI ≥25 no longer reliably indicates overweight status, nor does a BMI ≥30 singularly define obesity.^5,8,9 The medicalised framing of obesity and weight over recent decades has led to the use of obesity and fatness as synonymous terms, conflating distinct concepts and perpetuating the pathologisation of fat bodies and non-hegemonic body weight.

For that reason, Rubino et al.³ classified obesity as a chronic, systemic disease caused by excess adiposity, moving beyond BMI to focus on impaired tissue and organ function. This definition recognises obesity as a biological disorder of adiposity regulation and helps address stigma while guiding more effective treatment. However, the framing of medical treatment as a matter of personal responsibility—including lifestyle factors— can be questioned, especially since the same committee notes that the predominant drivers are multifactorial.

Ignoring the broader context of obesity as a chronic disease—one that impacts overall health regardless of body weight or body size—contributes to the restriction of fundamental human rights such as education, employment, housing, and healthcare.¹⁰ This neglect also leads individuals with higher weight, or those who consider themselves overweight, to internalise negative beliefs about their bodies, weight and health. As a result, they often feel personally responsible for their weight, which can prevent them from accessing respectful and appropriate healthcare, while also compounding the everyday challenges they face.11, 12, 13, 14 Moreover, people with larger bodies experience direct harm from weight stigma, which affects both their access to care and the quality of care received.^7,15,16 This is especially true for women with higher weight or those who identify as fat or overweight, whose experiences are often dismissed by dominant medical narratives.17, 18, 19

In the Latin American context, Brazil stands out as the most prolific contributor to Eggerichs’ how weight bias and stigma (WBS),²⁰ although its research generally follows patterns observed in other regions, including such as weight-based bullying,21, 22, 23, 24 the psychosocial toll of dietary coercion on adolescents,25, 26, 27 self-reported discrimination among youth,²⁸ and links between mockery and body dissatisfaction.²⁹ Collectively, these studies establish a foundation for examining WBS in Brazil.

Research on lived experiences reveals the diverse mechanisms through which WBS are internalised,^4,30, 31, 32, 33 highlighting how stigma persists and adapts depending on context and the person's social positioning. Importantly, understanding WBS theoretically differs from experiencing it daily—a distinction often overlooked in clinical settings, where the focus on intervention outcomes dominates, thereby neglecting non-medicalised experiences before and after Metabolic and Bariatric Surgery (MBS).

Furthermore, these studies lack a critical sociological analysis of weight as a social phenomenon—one that gives symbolic meaning to body weight, transforms biological functions into social actions, and shapes how people relate to one another in everyday life. These epistemological limitations, rooted in the privileging of clinical metrics over lived experience, underscore the need for qualitative inquiry and sociological frameworks that examine weight as a socially constructed determinant of health and that prioritise lived experiences of stigma.

This article draws on a doctoral research study focused on how WBS impede women's exercise of sexual and reproductive rights. Focussing on women's lived experiences, the study explored how perceptions of body weight acquire social meaning through encounters with WBS. We sought to explore how WBS impact the sexual and reproductive rights of women with higher body weight, aiming to understand their personal perceptions of WBS and how it shapes their everyday experiences. Specifically, we examined how these women comprehend WBS, how social relationships in both public and private life perpetuate this stigma, and how this bias becomes internalised.

Methods

Study design and theoretical framework

We conducted a qualitative study grounded in phenomenological sociology,^34,35 drawing on the phenomenology of perception³⁶ and its critiques.^37,38 Data were analysed using Reflexive Thematic Analysis (reflexive TA),39, 40, 41 emphasising meaning construction through reflexive engagement and narrative coherence.

Setting and participants

The study was carried out at the “Family Planning Outpatient Clinic, Women's Hospital Prof. Dr. José Aristodemo Pinotti – CAISM” located in Campinas, São Paulo, Brazil. We chose this clinic for its specialisation in women's sexual and reproductive health and its active participation in clinical and research endeavours. Eligible participants were patients who self-identified as women aged 18–49 years with a BMI ≥25 kg/m², registered at the clinic, recruited through posters, online forms, and nurse-facilitated invitations, yielding eight interviews and two completed focus groups.

The study employed both interviews42, 43, 44, 45 and focus groups^46,47 based on methodological complementarity. Interviews provided private, in-depth individual narratives and revealed personal sense-making patterns, while focus groups leveraged group dynamics to uncover shared social norms, sense-making patterns and collective understandings through interactive discussion. Together, these methods offered a holistic view, contextualising individual experiences within broader social discourses and enriching and rationalising the findings.

We conducted the interviews and focus groups in Brazilian Portuguese, with all quotes translated into English.

Participant group-size justification

Rather than prespecifying a numeric target, we determined participant group adequacy using the information power model,⁴⁸ which ties the required participant group size to the depth and relevance of participants’ contributions to construct meaning through reflexive engagement in analytic categories.

Data generation process

We conducted interviews between 21 February and 17 April 2024, each lasting approximately 60 min. We convened two focus groups between 31 October and 28 November 2024; each session lasted approximately 90 min. All interviews and focus group discussions were audio-recorded, transcribed verbatim, and anonymised with numeric identifiers (e.g., “Interview 03-2024”). Interview guides and focus-group scripts were piloted to ensure clarity. Participants also completed a structured sociodemographic questionnaire capturing age, education, income, and other relevant characteristics (Tables 1 and 2).

Table 1.

General demographic profile.

Interviewees - age	Average 33.4 years (range: 21–49)
Interviewees - marital status	5 married/stable union, 1 single
Focus group 1 participants - age	Average 26.3 years (range: 23–33)
Focus group 1 participants - marital status	3 married, 3 singles
Focus group 2 participants - age	Average 30.2 years (range: 18–40)
Focus group 2 participants - marital status	2 married, 2 single, 2 divorced
Interviewees – race/ethnicity	Parda (3), White (2), Black (1)
Focus group 1 participants - ethnicity	Black (2), White (2), Yellowa/Asian (1), Parda (1)
Focus group 2 participants - ethnicity	Parda (2), White (2), Yellowa/Asian (1), Black (1)
Interviewees - level of education attained	Completed secondary school (4), Incomplete secondary school (2)
Focus group 1 participants -level of education attained	Completed secondary school (4), Completed higher education (2)
Focus group 2 participants -level of education attained	Completed secondary school (3), Incomplete secondary school (3)

^aYellow terminology was retained from participant self-identification and national classification categories.

Table 2.

Socioeconomic characteristics.

Interviewees income	Average R$ 4800.00 (range: R$ 2400.00-R$ 12,000.00) Average US$ 861.68a (range: US$ 430.84-US$ 2154.21a)
Focus group 1 income	Average R$ 5616.67 (range: R$ 1200.00-R$ 9000.00) Average US$ 1008.29a (range: US$ 215.42-US$ 1615.65a)
Focus group 2 income	Average R$ 4448.33 (range: R$ 1590.00-R$ 15,000.00) Average US$ 798.55a (range: US$ 285.43-US$ 2692.76a)
Dependants	Average 3–4 dependants per household; FG2: one participant said six people depend on an income of R$ 1800.00 (US$ 323.12a)
Number of interviewees who had at least one pregnancy that reached full term	Five of six
Number of FG1 participants who had at least one pregnancy that reached full term	Two of six
Number of FG2 participants who had at least one pregnancy that reached full term	Four of six
Number of abortions reported across all participants	One spontaneous abortion
Paid work	All participants reported having paid work
Mobility	Five participants were born/lived outside São Paulo State

^aBased on Morningstar exchange rate United States Dollar - US$1 – Real Brasileiro R$5.55 (10/06/2025).

Researcher positionality and reflexivity

MASC's expertise in gender-based violence and the lived experience of WBS provided a framework to understand domination and stigma. XRS's research on health-related WBS and embodied experience informed the analysis through a health equity lens. MJDO's lived experience and research on gender relations and women's sexual and reproductive rights highlighted the long-term impacts of stigma. The researchers' non-hegemonic body shapes supported insight into participants' experiences while requiring ongoing reflexivity about shared assumptions. Their perspectives strengthened the analysis through complementary theoretical and lived knowledge.

Recognising the impact of institutional power dynamics, the lead researcher and co-authors adopted a non-stigmatising recruitment language and emphasised participant agency to minimise medicalised stigma. Reflexivity was maintained throughout data generation and analysis, with ongoing critical engagement regarding gendered hierarchies, clinical authority, and researcher identity.⁴⁹ Scott's framework⁵⁰ and theoretical insights from Lamas,⁵¹ and Butler⁵² informed our understanding of gender as a constructed and agentic phenomenon.

Data analysis

Transcripts were imported into Quirkos v2.5.3 for inductive, open, reflexive thematic analysis coding. Analysis followed Mihas'⁵³ multi-phase memoing and the 6Cs framework (Causes, Contexts, Contingencies, Consequences, Conditions),⁵⁴ iteratively developing and refining themes via Braun and Clarke's six phases.⁴⁰ Guided by González Rey's social subjectivity⁵⁵ and a critical constructionist lens, we constructed a total of five overarching themes. In this paper, we elaborated on two themes: 1) “The Weight Itself — Gendered Body Norms and Internalised Stigma” and 2) “Eu me policio (I keep myself in check) — Internalised Stigma and the Moralisation of the Weight.” The themes explore two main aspects of understanding body weight as a social phenomenon. The first theme examines weight as a construct shaped by the medical regime of truth and its gendered expectations around the body and weight, particularly those imposed on women. The second theme addresses how beliefs and ideas about weight as social phenomena, become part of participants' everyday lives by turning biological functions into social actions. This happens because individuals feel motivated to control their weight—either avoiding gain or aiming for loss—reflecting the internalisation of WBS. For further information, consult the Supplementary Document. The remaining three themes address related but distinct aspects of the investigated phenomenon. Briefly, these themes include: 3) “Weight Bias and Stigma in Sexual Rights Exercise” and 4) “Weight Bias and Stigma in Reproductive Rights Exercise”, which condense participants' experiences of encountering and challenging WBS in their everyday sexual and reproductive lives. Theme five, “Everyday Life and Caring Work: Between Caring for Oneself and Caring for Others”, examines how standards of body weight conflict with women's everyday lives, particularly in light of the unpaid care work they perform and societal expectations regarding weight and body size. Due to space constraints and the need for comprehensive analytical exploration of each one, these themes will be addressed in subsequent manuscripts dedicated to these specific dimensions of the findings and will be included in the first author's doctoral thesis.

Rigour

We ensured methodological rigour by engaging in continuous reflexivity, discussing findings with co-authors, and making our coding decisions transparent. We also embraced the subjective nature of reflexive thematic analysis to centre and highlight participants’ lived experiences.⁴¹

Ethical considerations

The Research Ethics Committee (Comitê de Ética em Pesquisa, CEP) of State University of Campinas - UNICAMP approved the study under protocol CAAE: 73834423.6.0000.5404, in line with Brazil's National Health Council Resolutions 466/12 and 510/16. All participants provided written informed consent via the Free and Informed Consent Term (FICT). Participants received R$50.00 (US$9.00) for interviews and R$40.00 (US$7.20) for focus groups to offset expenses. No clinical care was contingent on participation. Data were securely stored in password-protected formats, and fully anonymised datasets were archived in UNICAMP's Research Data Repository (REDU). It is available here: https://doi.org/10.25824/redu/LZR2O1.

Role of funding source

The São Paulo Research Foundation funded the research and preparation of the article, but the funding source was not involved in the research or preparation of the article.

Results

The study involved 18 women from Campinas City and its metropolitan area, aged 18 to 49, recruited for their direct willingness to participate in the research. For the interviews, 8 participants agreed to participate, but only 6 interviews were analysed. Two interviews were not conducted due to the participants personal inabilities to continue in the study.

Participants took part in interviews (6) or focus groups (6 participants per group) and represented a wide range of economic backgrounds (household incomes ranged from the minimum salary to five times the minimum salary), employment statuses (16 participants were employed), education levels (11 had completed high school, 5 had not finished high school, and 2 held college degrees), and self-identified race/ethnicities (six Parda, six White, four Black, and two Yellow/Asian; (terminology retained from participant self-identification and national classification categories), ensuring the participants group reflected considerable social and economic diversity.

The use of stigmatising terminology is due to the words used by the participants and those that appear in the government documents or articles cited. Not using them as such would interfere with participants’ discourse, thereby altering the perceptions, connotations, and uses of the words. For this reason, we have used the exact words participants said or that appeared in government documents.

Theme 1 explored how participants’ weight perceptions and meanings are fundamentally conditioned by the internalisation of WBS, shaped by how weight is perceived across different spaces-times in everyday situations. Therefore, external stigmatisation shaped their self-perception.

In Brazil, society has long upheld a standardised weight and corporeal ideal that dictates prevailing aesthetic norms and aspirations. This hegemonic bodily model, however, is exclusionary: it erases the multiplicity of body weights and shapes. Within Brazil's patriarchal culture, this erasure disproportionately burdens women, shaping their self-perceptions and how others perceive them.56, 57, 58

“It is complicated because if you are too thin, there is that prejudice of people. Moreover, if you gain some weight, you also have people's prejudices; it is a bit complicated because I think nothing is good”

(001).

Repeated social interactions operated as mechanisms of moralisation, in which body weight became conflated with assumptions about discipline, responsibility, and health. Even in the absence of illness, participants described being positioned as unhealthy or failing subjects. Over time, these judgements were not merely resisted but absorbed, restructuring how participants came to perceive and classify themselves.

“People do not know what [the person] is doing, and yet they have a large body”

(003).

WBS functioned as a disciplinary force circulating across everyday contexts: familial, professional, commercial, and healthcare space-times. Participants described how bodies and weights were scrutinised, segmented, and evaluated, whether through generalisations about fat bodies or overweight, fixation on specific body parts, or moralising labels. These encounters sedimented weight as a visible marker of deviation requiring correction. Participants further highlighted that disciplinary norms were not only imposed externally but reproduced horizontally:

“Even among the same obese people, they stigmatise themselves”

(001).

Such statements illustrate how the stigmatising gaze becomes internalised and redistributed, transforming social surveillance into self-surveillance and peer surveillance. Participants who had always lived in larger bodies described relatively less explicit familial WBS, often interpreting teasing as benign. However, exposure to ridicule and judgement in public spaces remained persistent. These repeated encounters facilitated the early internalisation of shame and bodily self-consciousness, revealing how stigma operates through cumulative, normalised interactions rather than isolated incidents. Particularly salient were comments framed as concern or care:

“Wow, but what if you do something, […] because [you know] it's willpower”

(FG1).

Despite their ostensibly supportive tone, participants experienced these remarks as moral injunctions, reinforcing the expectation of weight self-management and implying personal failure.

“Mistreatment, humiliation, people think it's a normal comment, you know? […] I don't see it that way, I see it as humiliation in the form of a joke, it's horrible, the person hurts you and harms you and tries to attack you”

(FG1).

Through such interactions, participants described the gradual destabilisation of self-esteem. Weight and body size previously experienced as unproblematic became objects of scrutiny, correction, and dissatisfaction. Several participants reported that weight became distressing only after sustained exposure to judgement.

“I think that what affects us the most is what causes the most emotional effects that sometimes lead us down other paths that we don't even realise, even food, for example, and other much more serious problems, such as compulsion and depression”

(FG1).

Clothing emerged as a particularly potent site of embodied normativity. Ill-fitting garments did not merely cause discomfort but also symbolised failure to conform to normative body standards.

“Today, it is no longer me who chooses the clothes to wear; it is the clothes that choose me, you understand? So that causes some discomfort in me … shame, actually”

(002).

For participants, tight or no-longer-fitting clothing amplified self-consciousness, especially around the abdomen and hips, occasionally leading to social withdrawal and fixation on specific body areas. These embodied discomforts triggered fears of further weight gain and provoked hypervigilance, often in the form of compulsive exercise or restrictive dieting.

“I, for example, depending on the clothes, [when] I'm sitting, I'm doing something, I start thinking, what do these clothes look like, does [the fat] stick out or not? I wonder if [the clothes] fit well on me”

(FG2).

Weight was thus lived as a moralised and visibly regulated condition. Participants linked thinness with virtue-laden attributes — health, discipline, well-being — and with the pressure to conform to gendered demands, such as a standard body shape and weight, illustrating the internalisation of dominant biomedical and aesthetic discourses.

“For me, the ideal body would be [a thin body], because I already align it with health, well-being, diet, physical exercise, and other things as well”

(FG1).

Theme 1 demonstrates that participants' perceptions of weight are not formed in isolation but are fundamentally constructed through the internalisation of societal WBS. Rooted in patriarchal values that prescribe a narrow ideal for the woman's body, this internalisation is driven by repeated exposure to external stigmatisation—ranging from overt ridicule to ostensibly benevolent comments—which teaches individuals to view their weight as morally flawed and deviant. This stigma is acutely embodied in everyday struggles, such as with clothing, which serve as tangible proof of this perceived transgression. Consequently, the relentless external judgement erodes self-esteem, triggering profound shame, hypervigilance, and psychosocial harm as the internalised societal gaze supplants one's own perception. Ultimately, the internalisation of WBS functions as a powerful mechanism of social control, compelling women to conform to a hegemonic patriarchal ideal, often at the direct expense of their physical health and overall well-being.

Theme 2 focused on how participants enacted internalised WBS through persistent self-regulatory practices. “Eu me policio,” translated as “I keep myself in check,” denotes sustained, internalised self-monitoring and self-regulation. The English rendering captures the general sense but does not fully convey the culturally embedded emphasis on continuous discipline and behavioural correction carried by the original phrase. Participants described routinised strategies of bodily governance:

“I have started keeping myself in check … eating at the right times, having my first meal of the day, lunch at the appropriate hour, trying to eat dinner earlier, and including exercise in my routine”

(004).

These practices functioned as technologies of the self — deliberate efforts through which participants sought to regulate eating, movement, weight and bodily appearance in alignment with dominant norms. Dietary schedules, portion control, and exercise were framed as moral responsibilities rather than optional behaviours.

“I check myself (eu me policio) to be in good standing”

(003).

Participants’ statements reveal the strong imprint of healthism, the ideology that constructs body management as an ethical obligation and individualises health responsibility while obscuring structural constraints. Although health was invoked, narratives suggested that visual conformity and avoidance of social judgement were primary drivers. Failure to achieve weight loss was experienced not as biological variability but as personal inadequacy.

“I cannot understand why I do not lose weight despite everything I do […]. So, you look [yourself] and think … my God, what am I turning into? What's happening?”

(002).

In this context, participants extended their surveillance to others, especially family.

“I tell my daughters not to end up like me […] Beware that someday your metabolism will slow, you will gain weight and end up just like me […] I always teach them to have a different vision of life, so they do not follow in their mother's footsteps”

(002).

This dual monitoring reflects how fully participants had absorbed the logic of individualised responsibility, assuming accountability not only for their own bodies but also for preventing perceived bodily failure in others. Care became inseparable from discipline. For some participants, the imperative of weight correction culminated in bariatric surgery:

“But I really decided to do it for the sake of my health because I knew that when the time came, the problems would all come at once, and then I would be in pain because of the size of the patient, so I said no, I need to find a way to improve my life”

(005).

Here, surgery functioned as an intensified technology of the self, framed as a proactive moral decision to avoid future illness and social burden. Even post-surgery, participants described sustained vigilance driven by fear of weight regain:

“So, I eat less, […] I try to maintain my weight, so I don't gain weight, right? Because if I don't, I'll gain it all back. […] So, when I realise that I'm a little over what I expected, I cut back to stay healthier, you know? So, I try to maintain the weight I lost 15 years ago”

(008).

Participants also became acutely aware of differential social treatment following weight loss:

“Whether out of malice or not, people treat you differently”

(008).

Such narratives expose how WBS operates as a form of embodied legitimacy, revealing the conditional nature of social recognition. The post-surgery congratulations underscored the stark differential treatment afforded to thinner bodies, confirming that the disciplined efforts participants undertook were navigations of a pervasive system that grants dignity conditionally based on weight.

Theme 2 explores how the internalisation of WBS compels participants to adopt a rigorous regime of bodily discipline, transforming weight management into a moral obligation rather than a health pursuit. Driven by the logic of healthism—which individualises health responsibility and hides broader social structures—participants engage in dieting, exercise, and even surgery primarily to achieve visual acceptability and pre-empt societal judgement. This internalised compulsion fosters constant, often frustrating, self-surveillance over food and daily routines, a logic so pervasive that it extends to policing the habits of family members. The experience of bariatric surgery patients is particularly revealing; the subsequent congratulations and preferential treatment they receive starkly expose the deep societal bias against fatness and weight, validating the very disciplinary efforts undertaken to navigate a world that rewards thinness over fatness.

Discussion

Since much of medical research and clinical practice continue to frame weight as an individual health risk linked to personal choices or biology, systemic drivers—such as weight-biased representations, medicalised discourses, and neoliberal ideals equating thinness with moral virtue—remain insufficiently examined. Participants' accounts illuminate the consequences of this reduction: when weight is treated primarily as a biomedical variable, the social processes that render it harmful are hidden. The persistence of individualising frameworks in clinical practice despite evidence of their adverse effects^7,22, 23, 24 suggests that WBS is not merely a deficit in professional awareness but reflects deeper epistemological commitments within healthism.⁵⁹ These commitments include what might be termed clinical individualism —the assumption that health problems originate in and can be resolved at the level of individual bodies and behaviours. This epistemological stance renders systemic drivers invisible, not through neglect but through paradigm: within a biomedical frame, social processes are literally unseeable. Participants’ accounts thus do not simply add patient perspectives to existing knowledge; they also challenge the adequacy of the frame itself.

Building on the Pan American Health Organization's definition of social determinants of health (SDOH) as “the circumstances in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life”,⁶⁰ this study theorised weight as a social determinant of health and as a social phenomenon that defines and conditions individuals' everyday actions. This framing shifts analytic attention from weight as an intrinsic risk to the pathways through which its social meaning, mediated by discrimination, moralisation, and clinical encounters, produces harm. The distinction is critical: treating weight as a risk factor implies that the problem is weight itself; treating weight as a social phenomenon implies that the problem is how weight organises social life experience and the lifeworld.^34,35 The latter opens analytical space for interventions that do not require weight change to improve health and well-being. From a phenomenological sociology perspective,³⁴ social action is structured through shared values, beliefs, and symbols that generate taken-for-granted knowledge within the lifeworld.³⁵ In this light, WBS is not an abstract attitude but a structuring condition of lived experience—it shapes not only how others treat the stigmatised but how the stigmatised inhabit their own bodies and move through space-time.

Drawing on Merleau-Ponty's³⁶ premise and its critiques^37,38 that the body is inseparable from the world, we foreground perception as a mechanism through which WBS are internalised and reproduced. While prior research has extensively documented the prevalence and psychosocial consequences of WBS,^4,7,12,61 our findings specify how stigma becomes sedimented at the level of perception and in everyday life. WBS operate not only through explicit discrimination but through anticipatory self-regulation, in which individuals come to experience their own weight through the evaluative gaze they have internalised. In doing so, the study extends the sociological phenomenological approach by demonstrating that the reproduction of WBS is anchored in pre-reflective, perceived, and embodied processes rather than solely in articulated cognitive beliefs. This finding addresses critiques^37,38 that phenomenological sociology has neglected embodiment; by centring perception, we show that the lifeworld is not merely cognitive but gendered and corporeal, and that WBS is felt before it is thought.

The participants' accounts reveal how aesthetic and biomedical discourses reinforce each other. Health language legitimised aesthetic norms, while aesthetic judgements moralised interpretations of health. This dynamic shows that women were expected to seek thinness for health reasons, but at the same time, their motivations were based on demonstrating that they conformed to the moral canon that labels overweight and fatness as flaws. Such findings resonate with scholarship on the moralisation of women's bodies and gendered surveillance.^7,24,61, 62, 63, 64, 65, 66 However, they also extend this literature by demonstrating that surveillance increasingly operates through perception rather than direct lived experience. Participants regulated themselves not primarily because they were being watched, but because they had learnt to watch themselves. This shift from external to internal surveillance is a hallmark of neoliberal governance,^65,67,68 in which social control is achieved not through coercion but through the production of self-regulating subjects. Therefore, these findings reflect the influence of neoliberal discourses of healthism,^59,69 which position health as an individual responsibility.

The Brazilian context further underscores how hegemonic body ideals are embedded in classed and racialised histories, with the thin ideal intersecting with histories of colonialism and racialised beauty standards in ways that compound exclusion for women already marginalised along multiple axes.56, 57, 58 Although participants did not explicitly name these structures, their accounts reflected awareness of the social hierarchies underpinning aesthetic norms. Fatness was constructed as deviant and morally suspect, aligning with broader Western patterns yet inflected by local histories. The absence of explicit commentary on race and class in participants' narratives does not indicate that these dimensions are irrelevant; rather, it may reflect the naturalisation of middle-class, white aesthetic norms as simply beautiful or healthy rather than as socially located preferences. In this sense, the findings complement evidence from Latin America and the Caribbean on WBS^20,70 by situating these dynamics within socio-spatial and temporal contexts of everyday life, while also suggesting the need for future research that explicitly examines intersections with race and class.

BMI exemplifies how medical classifications acquire normative authority. Embedded within neoliberal rationality,^59,69 BMI translates bodily diversity into a measurable deviation, thereby individualising responsibility. Despite sustained critique of its evidentiary basis^5,8,9,71,72 and the Lancet Diabetes & Endocrinology Commission's characterisation of the concept as inherently flawed,⁷³ BMI remains globally entrenched.⁵ This persistence cannot be explained solely by scientific debate; rather, it reflects BMI's institutional embeddedness in public policies, surveillance systems, and professional training. Once a classification is built into the medical regime of truth, into the forms clinicians complete, into the algorithms that determine care, and into the epidemiological studies that shape policy, it becomes extraordinarily difficult to displace, regardless of scientific consensus.¹⁴ Our findings clarify how this institutional authority becomes personal: BMI categories are internalised not simply as diagnostic labels but as identity positions. As Poulain¹⁶ warned, the uncritical spread of BMI through public health campaigns risked transforming a medical tool into a social norm that would legitimise pseudoscientific claims and encourage the pursuit of thinness (p. 182). Participants' accounts demonstrate how this transformation unfolds through repeated social encounters that naturalise the normal/abnormal binary.^5,7, 8, 9^,16,74 When participants described themselves using terms such as obese or overweight, regardless of medical diagnosis, they revealed that BMI had become a technology of weight control. This standardisation treats higher weight as harmful for health and legitimises stigma through widespread BMI use.^20,71 This moralisation of weight^74,75 supports claims, such as Brazil's assertion that six in ten people are “overweight” or “obese” based only on BMI,^76,77 while ignoring clinical definitions of obesity beyond body measurements.^3,78

Importantly, participants’ self-regulatory practices were rarely driven by ignorance of health information. Although health rationales were invoked, appearance was frequently acknowledged as the more immediate motivator. Dietary control and structured routines functioned as disciplinary practices.⁶⁶ Here it is evident that the problem with weight moralisation is that it reinforces the belief that weight is an indicator of health and virtue.⁷⁴ In the participants' accounts, achieving or maintaining a specific body appearance or weight drives their actions, so suggesting that providing more information about health in general does not solve the problem; instead, it can exacerbate the perception of failure if it continues to be weight-centred. An effective intervention requires a commitment to changing the aesthetic and health-focused discourse that makes weight more important than well-being.

The intergenerational transmission of surveillance further complicates individualised accounts of responsibility. Mothers sought to protect daughters from anticipated WBS, yet in doing so, reproduced the norms that render weight vulnerable to judgement. This dynamic illustrates that WBS persist not because women uncritically accept them, but because they navigate constrained moral landscapes in which conformity appears protective.⁷⁹ The mother who warns her daughter not to end up like her is not simply endorsing dominant norms; she is trying to spare her daughter suffering. That her efforts may have the opposite effect, teaching the daughter that her weight and body size are a problem requiring vigilance, reveals the structure of reproduction under conditions of WBS. Such findings deepen existing discussions of gendered embodiment by highlighting how agency and reproduction of norms coexist within conditions of structural constraint.^7,64, 65, 66 Women are neither passive dupes of ideology nor free agents; they make choices, but they make them within contexts not of their own choosing.

These insights carry concrete implications for practice and policy. First, clinical training must move beyond weight-centred paradigms toward a social determinant of health framework. Education should critically examine weight-based stigma, the limitations of BMI,^5,8,9,78 and the documented harms of moral-responsibility narratives.^7,15, 16, 17 Competence should encompass the capacity to provide care that does not reproduce shame or surveillance. This entails distinguishing analytically and clinically between obesity, body weight, and fatness,^16,72 and recognising the gendered dimensions of monitoring practices.^7,17,61, 62, 63, 64, 65, 66, 67 Beyond adding content to curricula, this requires transforming how clinical competence is assessed. Currently, a clinician who knows the latest weight management guidelines is considered competent; a social determinants of health framework would equally value a clinician who can interact with patients of all sizes without perpetuating WBS. Shifting competence definitions shifts what is taught, how it is taught, and how it is evaluated.

Second, public health initiatives should reconsider messaging that frames weight loss as a moral obligation.^16,74 Weight-inclusive approaches can decentre body size while promoting health-supportive behaviours without presuming pathology. Such approaches exist—Health at Every Size® has demonstrated some efficacy⁸⁰—but remain marginal within public health infrastructures organised around weight reduction as the primary indicator of success. Mainstreaming weight-inclusive approaches requires not only evidence but political will to challenge weight-centred paradigms. The finding that surveillance is transmitted within families suggests that community-based interventions should create space-times for collective reflection on inherited norms, while avoiding blame directed at women who operate within restrictive social expectations,^50,66 without positioning women as solely responsible for norms they did not create.

Third, institutional reform is necessary. Anti-discrimination policies, guideline revisions acknowledging BMI's limitations,^5,8,9,72,78 and evaluation metrics prioritising well-being over weight reduction are critical steps. Models that focus on behaviours and outcomes rather than weight alone offer viable alternatives.⁸⁰ Yet implementing such models requires confronting the structural incentives that sustain weight-centred care. Health systems are organised around weight as a metric: quality indicators, reimbursement structures, and clinical guidelines all reinforce weight-centred practice. Changing practice without changing these underlying incentives is unlikely to succeed. Institutional reform must therefore address not only what clinicians do but the systems within which they do it.

Addressing WBS, therefore, demands coordinated shifts across clinical, community, and policy domains. Recognising weight as a social determinant of health⁶⁰ entails more than conceptual refinement; it requires reorienting approaches, measurement, communication, and care practices away from moralised weight and body size toward structural conditions shaping health. By foregrounding lived experience and situating it within broader epistemological and institutional contexts, this study underscores that mitigating WBS is not solely a matter of changing individual attitudes but of transforming the systems that tolerate, produce, and legitimise them. The participants whose narratives animate this study did not need better weight loss advice; they needed to live in a world where their body size and weight were not read as moral failings. That is the transformation our findings ultimately call for.

Limitations

While this study offers valuable insights into participants' perceptions, it is important to recognise that the research findings are contingent on local social norms regarding weight. Firstly, as is characteristic of reflexive TA, the themes developed reflect an interpretive process shaped by the researchers' theoretical positioning, assumptions, and subjectivities. Although reflexivity was maintained throughout the analytical process, the interpretation remains situated. Secondly, participants were recruited from a single urban gynaecological clinic in a Brazilian metropolis. This clinic serves women from diverse socioeconomic backgrounds and educational levels. Therefore, their experiences may differ from those in other geographical, cultural, or institutional contexts. Our objective was to deepen our understanding of weight bias and stigma in everyday life and of how they influence participants' social actions. Finally, our positionality, shaped by professional training and personal experiences, inevitably influenced how we understood and represented participants’ meanings and interpretations. Transparency about this influence is essential, but it also stresses the situated quality of qualitative knowledge.

Conclusion

Our findings reinforce and extend the growing evidence of weight bias and stigma in Latin America and the Caribbean^20,70 by illuminating the socio-spatial and temporal contexts in which body weight is experienced. We showed that weight is fundamentally a social phenomenon through in-depth qualitative inquiry. Everyday practices of nutrition and physical activity were transformed into social actions that both reflect and reproduce weight bias and stigma. Moreover, these processes are deeply gendered and internalised via socially specific rationalities, reproducing inequities observed in other settings.^7,19 To address weight bias and stigma effectively, interventions must move beyond individual behaviour change and instead target the underlying structural and relational dimensions.

Contributors

MASC: Conceptualisation, methodology, data generation, validation, data curation, writing–original draft, writing–reviewing & editing. XRS: Conceptualisation, writing–reviewing & editing, and final approval. SFB: Data generation, validation, and final approval. KSP: Data generation, validation, and final approval. MJMDO: Conceptualisation, writing–reviewing & editing, final approval, & supervision. Accessed and Verified the Data: MASC, XRS, and MJMDO.

Data sharing statement

Deidentified participant data—including interview recordings and verbatim focus group transcripts in Brazilian Portuguese—are available on REDU concurrently with publication. Related study documents (e.g., the free and informed consent form template) are also accessible. All users with REDU access may download the deposited data and documents directly; investigator support is available upon request but is not required. Any further access restrictions are those imposed by REDU.

Declaration of interests

XRS reports grants or contracts from Social Sciences and Humanities Research Council, consulting fees from the European Association for the Study of Obesity, The Obesity Society, Obesity Medicine Association, Obesity Action Coalition, Health Services Executive (Ireland), Royal College of Physicians of Ireland, International Federation for the Surgery and Other Therapies for Obesity, Eli Lilly Sweden, European Coalition for People Living with Obesity, Sociedad Mexicana de Nutrición y Endocrinología; and honoraria from Eli Lilly Sweden, The Obesity Society, and Obesity Canada; support for attending meetings from the European Association for the Study of Obesity, Leadership or fiduciary role from Bias180 and Other financial or non-financial interests from K&X Ramos AB and Replica Communications. All other authors declare no competing interests.