January 2018 Issue

The Health Impact of Weight Stigma
By Carrie Dennett, MPH, RDN, CD
Today's Dietitian
Vol. 20, No. 1, P. 24

It may be the main culprit of poor health outcomes in overweight and obese clients.

Are antiobesity attitudes contributing to obesity-related health problems?

It's no secret that weight bias is prevalent in American society. Weight bias, negative attitudes and beliefs about individuals because of their weight,1 leads to weight stigma, the labeling of people with stereotypes based on their weight.2 It's a common belief that weight stigma will motivate individuals who don't meet body size ideals to change their behaviors in order to avoid further stigma.3

However, what research overwhelmingly shows is that weight stigma doesn't encourage people to lose weight or improve their health. Instead, stigma leads to greater risk of depression, poor body image and self-esteem, increased stress, disordered eating behaviors, and avoidance of physical activity.4-7 This may lead to additional weight gain—and greater stigma—having serious consequences for physical and psychological health.8,9

How Prevalent Is Weight Stigma?
"In a series of national studies that my team has published over the last five years, we typically see that about 40% of the general population reports that it has experienced some type of weight stigma—whether it be weight-based teasing, unfair treatment, or discrimination," says Rebecca Puhl, PhD, deputy director of the Rudd Center for Food Policy & Obesity at the University of Connecticut in Hartford.10-12

Weight discrimination is one of the most common forms of discrimination reported by American adults, especially among women. Among youth who experience teasing, bullying, or other victimization at school, weight is one of the most common reasons.4,10 "Data show that, as obesity rates have risen over the past few decades, so have rates of weight-based discrimination," says Rebecca Pearl, PhD, an assistant professor of psychology at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.1

Experienced vs Internalized Stigma
Research suggests that internalized weight stigma—when individuals accept weight-based stereotypes to be true about themselves—has the greatest impact on physical and mental health.13,14 "Some people fear that if people feel too good about their bodies and themselves, they will not be motivated to engage in healthful eating behaviors and physical activity," Pearl says. "Studies show the exact opposite to be true: When people internalize weight stigma and feel bad about themselves because of their weight, they feel less confident in their ability to engage in healthful behaviors and are more prone to binge eating, avoiding physical activity, and other behaviors that contribute to weight gain."13,15-18

Failed weight loss attempts and overvaluation of weight and body shape may strengthen this internalized stigma,16,17 which occurs among individuals of all BMI categories.19 Among those with binge eating disorder, distress about binge episodes can increase individuals' expression of weight stigma toward themselves and others.17

One of the most common types of stigma is inappropriate comments from family members,20 which is significantly associated with unhealthful behaviors.8 However, there are many sources of stigma, including media, society, employers, educators, and health care providers.21 "All of these types of groups need to be targeted with stigma reduction," Puhl says. "Targeting just one won't be sufficient to change societal attitudes or stigma. It needs to happen on all levels."

Weight Stigma in Health Care
In one startling example of weight stigma in health care, in 2010 the British Public Health Minister urged health care providers to tell patients with an obese BMI that they're "fat," because telling them they're "obese" wasn't motivating enough.22 A 2006 study found that physicians were the top source of weight stigma for women and the second most frequent source for men, with 69% of patients experiencing weight bias by doctors—and 37% experiencing weight bias by dietitians.20

A 2015 systematic review found that dietitians tend to have less negative attitudes than the general public and other health care professionals. However, six of the eight studies found that dietitians were prejudiced to some degree against people with obese BMIs—either being explicitly "fat-phobic" or simply having a preference for thin patients—and four studies found that dietitians viewed people with obese BMIs as being personally responsible for their weight and associated health conditions.23

"As health care providers, it's our duty to first do no harm—so we need to educate ourselves about the impacts of weight stigma and work to stop perpetuating it," says New York-based dietitian Christy Harrison, MPH, RDN, CD, host of the Food Psych podcast.

When providers believe negative stereotypes about patients with an obese BMI, patients pick up on the resulting attitude shift and lose trust.24,25 Their reactions could be harmful to both emotional and physical health, including severe caloric restriction or other unhealthful eating patterns.22

Primary care guidelines recommend that health care practitioners automatically provide patients who have a BMI higher than 30 with weight loss interventions and nutrition advice even if they're being seen for something unrelated to body weight, such as strep throat.26 This is unfortunate because research has found that people's perception that they're overweight may lead to long-term weight gain, so awareness-raising conversations about body weight can do more harm than good.25

"I've had several larger-bodied clients who were counseled to lose weight by their physicians, despite the fact that these clients were in treatment for eating disorders that had been triggered by weight-loss efforts," Harrison says. "The majority of the clients I've treated for disordered eating cite bullying or shaming for their weight by parents, peers, coaches, or health care professionals as the initial trigger for their issues with food."  

Patients—especially women—who experience weight bias from providers may cancel or delay appointments and preventive health care screenings, especially if they've gained weight since the previous visit.23,24,27 Failure to get adequate preventive health care—whether due to weight stigma, lack of access to health care, or other factors—could be responsible for some of the negative health outcomes typically associated with obesity.23

Julie Duffy Dillon, MS, RD, LDN, CEDRD, a North Carolina-based dietitian and host of the Love, Food podcast, specializes in working with women with polycystic ovary syndrome (PCOS), a complex reproductive and metabolic disorder for which doctors often prescribe weight loss. "Because PCOS prevents a woman's body from metabolizing food like everyone else, weight loss rarely occurs unless it includes weight cycling. They're told they can't receive adequate medical care for infertility unless they successfully lose weight first," she says. "In the end, most women of size with PCOS avoid medical care all together. I don't blame them. They're protecting themselves from further discrimination and oppression."

Society, Media, and the 'War on Obesity'
Even though research suggests the public does consider the influence of genes, biological variables, the food environment, and socioeconomic factors on body weight, it places more significance on controllable internal factors.2 For example, even when people acknowledge that the food environment may contribute to weight gain, they tend to believe in individual control over that food environment (ie, willpower),2 and that people in larger bodies are choosing to not conform to societal norms. The result is moral judgment and stigma.28 This may be driven by media coverage, which often depicts people in larger bodies in a stigmatizing way,24 such as when they're photographed from unflattering angles and eating subjectively unhealthful foods with their heads cropped out of the image or film footage.29

Dillon says people of size with whom she speaks are particularly affected by these visuals. "This reinforces stereotypes that people of size are lazy, gluttonous, and choose their size," she says. "Media also tend to sensationalize or miscommunicate research to say that people of size can control their weight, should work harder, and cause harm on the rest of us."

Public health campaigns designed to prevent obesity (the "war on obesity") may paradoxically have the opposite effect, as many messages use stigmatizing language and imagery.8,30-33 Messages such as "Childhood obesity is child abuse" and "Chubby kids may not outlive their parents" are stigmatizing and not motivating, while universal weight-neutral messages such as "You have the strength to take control of your health" and "Learn the facts, eat healthfully, get active, take action" can be motivating.30,34

"The constant barrage of messages about the so-called obesity epidemic and the supposed perils of higher weights only adds more stigma and shame to anyone living in a larger body in a world that already discriminates against people on the basis of size in workplaces, schools, the health care system, the home, and public spaces," Harrison says.

Health Effects of Weight Stigma
The health risks of weight discrimination are consistent with the observed effects of racial discrimination.8,35 Being the target of weight stigma increases the risk of poor mental health outcomes,36 including depression, anxiety, poor self-esteem, suicidal thoughts and behaviors, and eating disorders. These associations happen regardless of BMI, so it's unlikely that body weight itself is a cause.8

There's growing evidence that weight stigma also is associated with increased disease and mortality risk,37-40 and internalized stigma appears to raise cardiometabolic risk the most.41-43 Weight stigma is correlated with higher levels of the stress hormone cortisol, greater oxidative stress, increased blood pressure, and higher levels of C-reactive protein and other proinflammatory cytokines that have been observed to be greater in people with obese BMIs.5,8,44,45 Cortisol can contribute to metabolic risk and further weight gain by triggering eating and visceral fat accumulation.46

"It's difficult to disentangle which health problems are due to stigma vs biological factors," Pearl says. "Obesity and weight-related health outcomes are complex issues with many different contributing factors. Stigma is one factor that contributes to or exacerbates obesity-related health problems."

Weight discrimination also contributes to high-risk health behaviors that have nothing to do with diet and exercise, including increased risk of cigarette smoking, driving while intoxicated, and risky sexual and drug use behaviors.47

Weight Stigma in Research
Many research studies frame weight stigma as a problem because it interferes with weight loss. For example, a 2016 study states that providers who are biased against individuals with obesity hinder the efforts to effectively fight the obesity epidemic.24 There are two ways to examine this idea.

"We have decades of irrefutable evidence that interventions aimed at lowering body weight are ineffective and lead to future weight gain in the vast majority of people," says Marci Evans, MS, RD, CEDRD-S, LDN, owner of Massachusetts-based Marci RD Nutrition. "Decreasing stigma is a vital goal but doing so in the service of weight loss reinforces the harmful notion that the goal of weight loss is not only possible but also something to strive for."48

On the other hand, Puhl says it's important to acknowledge that weight stigma is both a social injustice and a public health issue, including in published research. "One of the reasons it's important to highlight that stigma interferes with weight loss is that there tends to be a public perception that maybe stigma will provide incentive or motivation for people to lose weight," she says. "It's important to acknowledge this evidence to challenge misguided views that stigma is somehow OK and may help people lose weight."

Puhl says many studies on weight stigma and health conduct analyses to rule out the effect that body weight itself may have on various health outcomes.8 "What this research usually shows is that weight stigma contributes to adverse health outcomes over and above body weight."

However, the impact of weight stigma is rarely addressed in studies that look for associations between BMI and health, research that as Dillon points out, shows correlations, not cause. "This research skips many steps to understanding health and body size," she says. "Did the adipose tissue cause their high cholesterol or high blood pressure? Or did the weight bias cause it? Any research on higher-weight individuals needs to control for the effects of weight bias before suggesting size alone causes negative health outcomes."

Harrison says that failing to address weight stigma in studies that look at the associations between BMI and health outcomes may contribute to stigma. "Not accounting for weight stigma leads to more blame being placed on body size as the assumed cause of these health outcomes, which in turn further reinforces the already entrenched weight stigma in our society and health care model."

What Dietitians and Providers Can Do
To stop the perpetuation of weight stigma, RDs can look within themselves and begin to deal with any personal biases they may have. They can focus on health and not weight when educating clients and modify the ways in which they conduct counseling sessions.

"I think we start with ourselves. We start with our own personal assumptions about body weight, health, and appearance," Puhl says. "We challenge weight-based stereotypes. We think about the language that we use to talk about weight. We model sensitivity and compassion to people of diverse body sizes, especially in front of our children."

Dillon says dietitians need to understand their own biases, including bias toward people of size. "We need to appreciate that we have been trained since we were young to exclude fat individuals from participating in typical life experiences and blame them for that exclusion," she says. "We RDs can also make a pact to not participate in diet culture. Helping people to pursue weight loss just sets them up to weight cycle and further oppresses people of size. RDs pursuing weight loss also contribute to size oppression—if we don't accept our own bodies changing then we can't help others do that same work." Alternatives that RDs can explore for themselves—and their clients—include Health At Every Size and intuitive and mindful eating.26 Body image work also may be warranted, possibly with the assistance of a mental health professional.

"Health care professionals can educate themselves on facts about the complex etiology of obesity49 and the significant limitations of current behavioral weight loss treatments," Pearl says, noting that patients typically lose 5% to 10% of their body weight, and most patients regain some or all of their lost weight in the long term. "They can remember that weight is not entirely within an individual's control, and behavioral change can be very difficult. Weight is not a reflection of personal characteristics (eg, laziness), and there may be significant biological or environmental obstacles that prevent patients from being able to lose weight," she says.

Along these lines, Harrison says reducing stigma means focusing on health, not weight.26,50 "It means not telling clients that their weight puts them at risk of health problems, but instead offering them evidence-based interventions to manage their health that have nothing to do with weight." For example, physical activity, stress reduction, eating a balanced diet, and getting adequate sleep have demonstrated health benefits for people of all body sizes.

"We can help reduce the impact of weight stigma by setting up our practice environment to be accessible and friendly to people of size," Dillon says. She encourages RDs to be mindful of their word choices. For example, instead of "normal" for body size, refer to sizes as high weight or low weight. Dillon also likes to ask her clients which words they prefer she use in sessions to describe size.

Harrison says reducing weight stigma also means not weighing clients except in medically necessary cases where significant weight changes could be a symptom of worsening health status, such as restrictive eating disorders, renal issues, or congestive heart failure.

Bottom Line
"People deserve to be treated with dignity and respect, regardless of their body size, and this needs to be an expectation in patient care," Puhl says.

More research is needed to help determine whether weight stigma has a cause-and-effect relationship with "obesity-related" health outcomes.8 Meanwhile, Pearl says it's important that dietitians avoid making assumptions about clients' health or health behaviors based on their weight. "If patients are interested in improving their health behaviors, providers can play a significant role in helping their patients feel supported and confident in their ability to improve their health."

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutrition-related topics. She also provides nutrition counseling via the Menu for Change program in Seattle.

1. Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring). 2008;16(5):1129-1134.

2. Sikorski C, Luppa M, Kaiser M, et al. The stigma of obesity in the general public and its implications for public health — a systematic review. BMC Public Health. 2011;11:661.

3. Stuber J, Meyer I, Link B. Stigma, prejudice, discrimination and health. Soc Sci Med. 2008;67(3):351-357.

4. Puhl RM, Himmelstein MS, Gorin AA, Suh YJ. Missing the target: including perspectives of women with overweight and obesity to inform stigma-reduction strategies. Obes Sci Pract. 2017;3(1):25-35.

5. Muennig P. The body politic: the relationship between stigma and obesity-associated disease. BMC Public Health. 2008;8:128.

6. Jackson SE, Steptoe A. Association between perceived weight discrimination and physical activity: a population-based study among English middle-aged and older adults. BMJ Open. 2017;7(3):e014592.

7. Schmalz DL. 'I feel fat': weight-related stigma, body esteem, and BMI as predictors of perceived competence in physical activity. Obes Facts. 2010;3(1):15-21.

8. Papadopoulos S, Brennan L. Correlates of weight stigma in adults with overweight and obesity: a systematic literature review. Obesity. 2015;23:1743-1760.

9. Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity (Silver Spring). 2014;22(12):2485-2488.

10. Puhl RM, Latner JL, O'Brien K, Luedicke JL, Danielstottir S, Forhan M. A multinational examination of weight bias: predictors of anti-fat attitudes across four countries. Int J Obes (Lond). 2015;39:1166-1173.

11. Himmelstein MS, Puhl RM, Quinn DM. Intersectionality: an understudied framework for addressing weight-stigma. Am J Prev Med. 2017;53:421-431.

12. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J Obes (Lond). 2008;32(6):992-1000.

13. Pearl RL, White MA, Grilo CM. Weight bias internalization, depression, and self-reported health among overweight binge eating disorder patients. Obesity (Silver Spring). 2014;22(5):E142-148.

14. Pearl RL, Puhl RM. The distinct effects of internalizing weight bias: an experimental study. Body Image. 2016;17:38-42.

15. Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: implications for binge eating and emotional well-being. Obesity (Silver Spring). 2007;15(1):19-23.

16. Pearl RL, White MA, Grilo CM. Overvaluation of shape and weight as a mediator between self-esteem and weight bias internalization among patients with binge eating disorder. Eat Behav. 2014;15(2):259-261.

17. Puhl RM, Masheb RM, White MA, Grilo CM. Attitudes toward obesity in obese persons: a matched comparison of obese women with and without binge eating. Eat Weight Disord. 2010;15(3):e173-e179.

18. Jung F, Spahlholz J, Hilbert A, Riedel-Heller SG, Luck-Sikorski C. Impact of weight-related discrimination, body dissatisfaction and self-stigma on the desire to weigh less. Obes Facts. 2017;10(2):139-151.

19. Puhl RM, Himmelstein MS, Quinn DM. Internalizing weight stigma: prevalence and sociodemographic considerations in US adults [published online October 30, 2017]. Obesity (Silver Spring). doi: 10.1002/oby.22029..

20. Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring). 2006;14(10):1802-1815.

21. Puhl RM, King KM. Weight discrimination and bullying. Best Pract Res Clin Endocrinol Metab. 2013;27(2):117-127.

22. Puhl RM, Peterson JL, Luedicke J. Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. Int J Obes (Lond). 2013;37(4):612-619.

23. Jung FU, Luck-Sikorski C, Wiemers N, Riedel-Heller SG. Dietitians and nutritionists: stigma in the context of obesity. A systematic review. PLoS One. 2015;10(10):e0140276.

24. Fruh SM, Nadglowski J, Hall HR, Davis SL, Crook ED, Zlomke K. Obesity stigma and bias. J Nurse Pract. 2016;12(7):425-432.

25. Dollar E, Berman M, Adachi-Mejia AM. Do no harm: moving beyond weight loss to emphasize physical activity at every size. Prev Chronic Dis. 2017;14:E34.

26. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.

27. Lee JA, Pausé CJ. Stigma in practice: barriers to health for fat women. Front Psychol. 2016;7:2063.

28. Phelan JC, Link BG, Dovidio JF. Stigma and prejudice: one animal or two? Soc Sci Med. 2008;67(3):358-367.

29. Puhl RM, Peterson JL, DePierre JA, Luedicke J. Headless, hungry, and unhealthy: a video content analysis of obese persons portrayed in online news. J Health Commun. 2013;18(6):686-702.

30. Puhl RM, Peterson JL, J Luedicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages. Int J Obes (Lond). 2013;37(6):774-782.

31. Pearl RL, Dovidio JF, Puhl RM. Visual portrayals of obesity in health media: promoting exercise without perpetuating weight bias. Health Educ Res. 2015;30(4):580-590.

32. Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100(6):1019-1028.

33. Alberga AS, Russell-Mayhew S, von Ranson KM, McLaren L. Weight bias: a call to action. J Eat Disord. 2016;4:34.

34. Puhl R, Luedicke J, Peterson JL. Public reactions to obesity-related health campaigns: a randomized controlled trial. Am J Prev Med. 2013;45(1):36-48.

35. Udo T, Grilo CM. Cardiovascular disease and perceived weight, racial, and gender discrimination in U.S. adults. J Psychosom Res. 2017;100:83-88.

36. Sikorski C, Luppa M, Luck T, Riedel-Heller SG. Weight stigma "gets under the skin" — evidence for an adapted psychological mediation framework: a systematic review. Obesity (Silver Spring). 2015;23(2):266-276.

37. Jackson SE. Obesity, weight stigma and discrimination. J Obes Eat Disord. 2016;2:3.

38. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013;8(7):e70048.

39. Sutin AR, Stephan Y, Terracciano A. Weight discrimination and risk of mortality. Psychol Sci. 2015;26(11):1803-1811.

40. Vadiveloo M, Mattei J. Perceived weight discrimination and 10-year risk of allostatic load among US adults. Ann Behav Med. 2017;51(1):94-104.

41. Pearl RL, Wadden TA, Hopkins CM, et al. Association between weight bias internalization and metabolic syndrome among treatment-seeking individuals with obesity. Obesity (Silver Spring). 2017;25(2):317-322.

42. Kahan S, Puhl RM. The damaging effects of weight bias internalization. Obesity (Silver Spring). 2017;25(2):280-281.

43. Robinson E, Haynes A, Sutin AR, Daly M. Telling people they are overweight: helpful, harmful or beside the point? Int J Obes (Lond). 2017;41(8):1160-1161.

 44. Jackson SE, Kirschbaum C, Steptoe A. Perceived weight discrimination and chronic biochemical stress: a population-based study using cortisol in scalp hair. Obesity (Silver Spring). 2016;24(12):2515-2521.

45. Sutin AR, Stephan Y, Luchetti M, Terracciano A. Perceived weight discrimination and C-reactive protein. Obesity (Silver Spring). 2014;22(9):1959-1961.

46. Himmelstein MS, Incollingo Belsky AC, Tomiyama AJ. The weight of stigma: cortisol reactivity to manipulated weight stigma. Obesity (Silver Spring). 2015;23(2):368-374.

47. Sutin AR, Terracciano A. Perceived weight discrimination and high-risk health-related behaviors. Obesity (Silver Spring). 2017;25(7):1183-1186.

48. Ogden J, Clementi C. The experience of being obese and the many consequences of stigma. J Obes. 2010;2010:429098.

49. Hilbert A. Weight stigma reduction and genetic determinism. PLoS One. 2016;11(9):e0162993.

50. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105(6):929-936.