Time to end weight stigma in healthcare

Weight stigma and discrimination is experienced by people living with obesity (PLWO) on almost a daily basis, across many settings. Counterintuitively, given that healthcare settings should be a safe space that is free of judgement, empirical evidence has demonstrated that weight stigma in healthcare settings is pervasive, where PLWO are stigmatised, disrespected, and in some instances discriminated against through lack of equitable access to care [1]. The conscious and unconscious stigmatising attitudes held by healthcare professionals is a reflection of (1) exposure to consistent and widespread weight stigma, and (2) the lack of training and education for healthcare professionals about the complexity of obesity as well as how to avoid bias and stigmatising attitudes that may impact care for PLWO. It should be noted that weight stigma and discrimination is reported by healthcare professionals across many professions including clinicians specialising in obesity care [2].

Contrary to societal misconceptions, and often reflecting media content and portrayal of obesity, that weight stigma can be beneficial, substantial evidence informs that experiences of weight stigma are detrimental and are well-known to be associated with physical and mental health concerns such as depression, and increased cardio-metabolic risk factors [3,4]. These experiences can also lead to maladaptive responses including reduced physical activity, disordered eating behavior and reduced healthcare seeking behavior. When weight stigma is experienced in healthcare settings, this can lead to avoidance of future care, reduced adherence to services, and lower trust and communication with healthcare professionals, which may contribute to reduced quality of care and exacerbate health disparities.

In 2016, the World Health Organization (WHO) [5] called for the elimination of discrimination in healthcare settings, within which it was highlighted that “stigma and discrimination in health takes many forms—the denial of health care and unjust barriers to service provision, inferior quality of care and a lack of respect” – this has been evidenced in the case of obesity, and was included within a weight bias and obesity stigma statement in 2017 [6].

As such, there is a long overdue need to call for action to end weight stigma and discrimination in healthcare settings. The pervasiveness of weight stigma and discrimination that has been evidenced globally, requires structural changes given that it is evident in health policy, public health campaigns and healthcare training, including disparities in the framing of obesity compared to other health conditions [7]. Indeed, it has become so ingrained that healthcare professionals may unwittingly engage an inappropriate communication, stigma or discrimination.

Aligned to the WHO call for ‘zero discrimination in healthcare’ and based on empirical evidence of the pervasiveness of weight stigma and discrimination in healthcare, there is a need for:

• 1All patients, no matter their background, to be treated with respect and dignity, and included as part of their care. PLWO are disrespected, patronised and in some instance, treated with contempt, including verbal insults, inappropriate humour and insensitive comments about body size and weight [8]. Actively including patients in their care can improve experiences, the patient-practitioner relationship and outcomes. This includes weight-related terminology where healthcare professionals should invite patients to elicit the most preferred terms when discussing weight and use patient-centred communication strategies.
• 2Access to timely, quality healthcare. Even where services and care are available and of high quality, people are denied access due to discriminatory practices [5]. Irrespective of the reason for attending healthcare, everyone should have equal opportunity to access care in a timely fashion – an expectation we would all hope for when we seek care.
• 3Development of education resources about the complexity of obesity and the impact of weight stigma for current healthcare professionals and build into education of the next generation of healthcare professionals. Education and training are needed for healthcare professionals to raise awareness of weight stigma and discrimination in healthcare, and how to avoid conscious and unconscious bias impacting patient care.
• 4Participation of PLWO in the development of obesity-related policies and care. In line with the National Institute for Clinical Excellence's Patient and Public Involvement Policy principle “that lay people and organisations representing their needs in the development of guidance, advice and quality standards as well as their implementation” [9].
• 5Address the stigmatising framing of obesity policies and campaigns. Framing of policies relating to health conditions such as cancer encompass empathy, compassion, respect, social support and togetherness, and importantly hope and optimism which are known to support behavior change and healthcare engagement. Obesity policies however, encompass fear, frustration, pessimism and often individual blame which are oppositely known to be less effective in supporting behavior change and can reduce healthcare engagement.

In summary, the now substantial evidence demonstrating the widespread experiences and impact of weight stigma that is ultimately leading to inequitable healthcare, calls for concerted efforts to address weight stigma in healthcare settings. The overwhelming evidence that weight stigma in healthcare is detrimental warrants action.

Declaration of Competing Interest

Dr. Flint reports grants from Johnson & Johnson, grants from Novo Nordisk, personal fees from Novo Nordisk, outside the submitted work.