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Obesity, Stigma, and Discrimination

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Last Update: October 26, 2023.

Definition/Introduction

Obesity, a complex medical condition, has reached epidemic proportions in the United States (US). The National Health and Nutrition Examination Survey (NHANES) conducts height and weight assessments on a representative sample of Americans to gauge its prevalence. A study by Hales et al reported that between 2013 and 2016, the prevalence of obesity stood at 36.5% for men and 40.8% for women.[1] This prevalence has been on the rise since the 1970s, and it is projected that by 2030, nearly 48.9% of adults in the US will be obese.[2][3] Individuals with obesity face increased risks of morbidity and mortality due to health conditions such as diabetes, hypertension, hyperlipidemia, coronary artery disease, respiratory illness, and other comorbidities.[4][2] Obesity also significantly impacts healthcare expenditure, with direct medical costs for obese adults estimated at more than 200 billion USD annually in the United States.[5]

Diagnosing and Understanding Obesity

Body mass index method

Obesity is defined by the body mass index (BMI), which is calculated by dividing a patient's weight (in kilograms) by the square of a patient's height (in meters).[6] Based on an individual's BMI, obesity is classified in the table below.

Table Icon

Table

Table. Obesity Classification.

Waist circumference

Another method to define obesity is measuring waist circumference. In men, obesity is defined as having an abdominal waist circumference of ≥40 inches; in women, it's ≥35 inches.[7]

Percentage of body fat

Obesity can also be diagnosed based on the percentage of body fat. Generally, a body fat percentage of ≥30% in men and ≥35% in women is used as the cut-off value for diagnosing obesity.[8] However, it's important to note that there is a lack of consensus on these values. 

Other diagnostic methods

While various other methods exist to diagnose obesity, BMI remains the most widely used due to its accessibility, cost-effectiveness, and reasonable reproducibility.

Challenging Stereotypes and Bias

Unfortunately, the rising rates of obesity have led to the emergence of harmful stereotypes and biases targeting people who are obese.[9] Society has wrongly associated obesity with laziness, irresponsibility, and a lack of self-control. This perception persists despite the recognized influence of genetic, socioeconomic, and environmental factors in the development of obesity. These attitudes have fostered a damaging stigma, resulting in prejudice and discrimination against those affected. Addressing this issue requires dispelling misconceptions and creating an environment of empathy and support for individuals of all body sizes.[10][11]

Issues of Concern

Understanding Weight Stigma

Weight stigma refers to individuals' social devaluation and denigration due to their excess body weight, leading to negative attitudes, stereotypes, prejudice, and discrimination.[12] This issue has escalated, with a two-thirds increase over the past decade.[10] Remarkably, its prevalence now rivals discrimination based on race and age, yet it lacks comparable legal and social safeguards.[13] Addressing weight bias is crucial to establishing equitable protections and creating a more inclusive society that upholds the rights and dignity of individuals, regardless of their body size.

Despite the global prevalence of obesity, individuals with obesity often face discrimination and mistreatment in settings like schools, workplaces, and healthcare facilities. A study by Carr et al noted that those with a BMI of 35 or higher are more likely to experience institutional and employment discrimination.[14] Concerns about weight-based victimization in school children have also been raised.[15] Similarly, a large-scale study comprising 13,996 individuals across various countries found that at least 66% of those experiencing weight stigma also encountered it from healthcare providers.[16] Another study involving 1697 individuals with a BMI >25 reported suboptimal treatment in 48% of cases, with more than 50% noting insensitive and judgmental comments from various healthcare professionals.[17] Research has shown primary care providers spend less time during office visits with obese individuals as they view them as noncompliant patients.[18] A healthcare professional's weight bias impairs their ability to offer support and empathy to these patients, compromising their overall health care.[19] This discrimination in healthcare can deter patients with obesity from seeking healthcare services, affecting overall healthcare resource utilization, including preventive and screening care.[20]

Disease stigmas result from misconceptions and biases that exacerbate the suffering of individuals with these conditions, such as HIV and AIDS. The media highlights these attitudes by depicting thin actors as popular and kind, while overweight actors are often rude, aggressive, and unpopular.[21] The media, educators, and health professionals must be informed and properly educated about the harmful consequences of weight stigma to reduce weight discrimination. The stigma and prejudice towards obese persons significantly impact adverse physical and psychological outcomes.[22] It's crucial to recognize that despite substantial evidence linking obesity to genetic and environmental factors, it is still commonly perceived as an individual-level problem.

Clinical Significance

The current belief is that labeling an individual obese will motivate weight loss.[23] However, research has consistently shown that weight stigma has severe and lasting physical and psychological consequences for this group.[22][9][24][25][26] Individuals with obesity tend to internalize this stigma, reducing confidence in their ability to lose weight.[10] Children and young adults with obesity often face weight-based bullying and discrimination, making obesity the most common cause of youth experiencing such mistreatment in school.[22][27][28]

Weight stigma is also associated with an increased risk of depression, anxiety, suicidal thoughts, and low self-esteem.[29] Weight stigma negatively impacts individuals' eating patterns[30] with one study demonstrating that exposing overweight or obese individuals to weight stigma increased their calorie consumption.[25][26] These negative psychological and behavioral effects, including more frequent binge eating and reduced physical activity, put obese individuals at a higher risk for cardiovascular disease, diabetes, and stroke.[31] 

When obese patients experience weight bias in a medical setting, they are more likely to cancel appointments and avoid future preventative health care, ultimately increasing their medical risks and healthcare costs.[19][27] Weight-based discrimination and stigmatization are linked to lipid and metabolic dysregulation, glucose metabolism issues, and elevated markers of inflammation, leading to an elevated 10-year cardiometabolic risk and increased morbidity.[32] One study even suggests that weight-based discrimination might result in a 60% increase in mortality among individuals, although the exact mechanism is unclear.[33]

Weight stigma affects healthcare access and outcomes for obese individuals. Some studies have demonstrated elevated C-reactive protein levels (indicating systemic inflammation) in individuals with perceived weight stigmatization.[34] There has also been evidence suggesting obese women are less likely to be up to date regarding screening procedures such as Pap smears and mammography.[35] This is often due to embarrassment, perceived weight stigma during clinical visits, the lack of appropriately sized examination equipment, and poor patient-provider communication. These factors can lead to delayed cancer diagnoses, increasing morbidity and mortality.

Weight bias and stigma are troubling, influencing perceptions and resource allocation for crucial obesity-related research. This unfortunate reality has resulted in chronic underfunding, hindering the advancement of knowledge in this field.[36] As a result, there has been a rise in cardiovascular diseases, highlighting the consequences of allowing weight bias to persist.

Even interventions like weight loss surgeries are not immune to societal bias. One study revealed that individuals undergoing weight loss surgeries face more negative judgments compared to those who lose weight through diet and exercise alone.[37] This disparity in perception highlights a reluctance to provide universal coverage for surgical weight loss options.

Nursing, Allied Health, and Interprofessional Team Interventions

Addressing Weight Stigma in Healthcare Settings

In the healthcare sector, it's crucial for professionals to confront weight stigma and acquire a comprehensive understanding of obesity. When discussing the need for weight loss, healthcare providers should consider not only biological factors but also environmental influences.[27] An effective approach involves educating patients about adopting a healthy lifestyle, emphasizing components like a balanced diet, regular exercise, sufficient sleep, and stress reduction.[10] Moreover, healthcare professionals should enhance the physical and social environment to facilitate better patient care. This involves effective communication and creating clinical settings that accommodate patients.[38]

Healthcare providers must also be mindful of the language they use when interacting with patients. Research indicates that terms like obese, fat, and morbidly obese can have negative outcomes, whereas referring to patients as individuals with obesity or specifying the grade of obesity can yield more positive results.[39] Another essential aspect to focus on is overall health and behaviors rather than just weight. To further improve interpersonal interactions and avoid embarrassment for obese patients, clinicians should ensure their physical environment includes office chairs that are armless and large enough to seat overweight patients and provide large gowns and medical equipment such as larger blood pressure cuffs and scales.[38]

Utilizing the 5 As Method

In primary care settings, the 5 As method (ask, assess, advise, agree, and assist) offers a nonjudgmental framework for obesity counseling. This approach involves asking patients for permission to discuss weight, assessing their readiness for change, evaluating key metrics like BMI, waist circumference, and obesity stage, providing advice on associated health risks, shifting the focus toward behavior rather than just weight, setting realistic weight-loss expectations and treatment plans, and assisting patients in identifying and addressing barriers. It's essential to recognize obesity as a chronic, relapsing disease throughout this process.[40]

Advocating for Public Policy

In addition to generating awareness, a pivotal strategy for combating weight bias involves advocating for the implementation of robust public policies.[41] These policies should unequivocally denounce weight-based discrimination and take a proactive stance against bullying and cyber harassment targeting individuals with obesity. These policies should span various domains, including education, employment, healthcare, and public spaces, ensuring protection against unjust treatment for individuals with obesity. Engaging in open dialogues is vital to garner support, dispel misconceptions, and highlight the detrimental impact of weight bias on individuals' mental and physical well-being.

Nursing, Allied Health, and Interprofessional Team Monitoring

To bring about meaningful change, we must take a 2-pronged approach: first, we need to increase awareness to reshape how society perceives obesity, and second, we must push for legislative reforms that provide concrete protections. By adopting this approach, we can work towards creating a fairer and more inclusive society where individuals with obesity are treated with respect, receive support, and are empowered to succeed without the burden of unfair bias or discrimination.

Review Questions

References

1.
Hales CM, Fryar CD, Carroll MD, Freedman DS, Aoki Y, Ogden CL. Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016. JAMA. 2018 Jun 19;319(23):2419-2429. [PMC free article: PMC6583043] [PubMed: 29922829]
2.
Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, Long MW, Gortmaker SL. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019 Dec 19;381(25):2440-2450. [PubMed: 31851800]
3.
Li M, Gong W, Wang S, Li Z. Trends in body mass index, overweight and obesity among adults in the USA, the NHANES from 2003 to 2018: a repeat cross-sectional survey. BMJ Open. 2022 Dec 16;12(12):e065425. [PMC free article: PMC9764609] [PubMed: 36526312]
4.
Apovian CM. Obesity: definition, comorbidities, causes, and burden. Am J Manag Care. 2016 Jun;22(7 Suppl):s176-85. [PubMed: 27356115]
5.
Cawley J, Biener A, Meyerhoefer C, Ding Y, Zvenyach T, Smolarz BG, Ramasamy A. Direct medical costs of obesity in the United States and the most populous states. J Manag Care Spec Pharm. 2021 Mar;27(3):354-366. [PMC free article: PMC10394178] [PubMed: 33470881]
6.
Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutr Today. 2015 May;50(3):117-128. [PMC free article: PMC4890841] [PubMed: 27340299]
7.
Ross R, Neeland IJ, Yamashita S, Shai I, Seidell J, Magni P, Santos RD, Arsenault B, Cuevas A, Hu FB, Griffin BA, Zambon A, Barter P, Fruchart JC, Eckel RH, Matsuzawa Y, Després JP. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol. 2020 Mar;16(3):177-189. [PMC free article: PMC7027970] [PubMed: 32020062]
8.
Okorodudu DO, Jumean MF, Montori VM, Romero-Corral A, Somers VK, Erwin PJ, Lopez-Jimenez F. Diagnostic performance of body mass index to identify obesity as defined by body adiposity: a systematic review and meta-analysis. Int J Obes (Lond). 2010 May;34(5):791-9. [PubMed: 20125098]
9.
Brewis AA. Stigma and the perpetuation of obesity. Soc Sci Med. 2014 Oct;118:152-8. [PubMed: 25124079]
10.
Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010 Jun;100(6):1019-28. [PMC free article: PMC2866597] [PubMed: 20075322]
11.
Luck-Sikorski C, Riedel-Heller SG, Phelan JC. Changing attitudes towards obesity - results from a survey experiment. BMC Public Health. 2017 May 02;17(1):373. [PMC free article: PMC5414181] [PubMed: 28464915]
12.
Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan DH, Mechanick JI, Nadglowski J, Ramos Salas X, Schauer PR, Twenefour D, Apovian CM, Aronne LJ, Batterham RL, Berthoud HR, Boza C, Busetto L, Dicker D, De Groot M, Eisenberg D, Flint SW, Huang TT, Kaplan LM, Kirwan JP, Korner J, Kyle TK, Laferrère B, le Roux CW, McIver L, Mingrone G, Nece P, Reid TJ, Rogers AM, Rosenbaum M, Seeley RJ, Torres AJ, Dixon JB. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020 Apr;26(4):485-497. [PMC free article: PMC7154011] [PubMed: 32127716]
13.
Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring). 2008 May;16(5):1129-34. [PubMed: 18356847]
14.
Carr D, Friedman MA. Is obesity stigmatizing? Body weight, perceived discrimination, and psychological well-being in the United States. J Health Soc Behav. 2005 Sep;46(3):244-59. [PubMed: 16259147]
15.
Puhl RM, Luedicke J, Depierre JA. Parental concerns about weight-based victimization in youth. Child Obes. 2013 Dec;9(6):540-8. [PMC free article: PMC3868270] [PubMed: 24147818]
16.
Puhl RM, Lessard LM, Himmelstein MS, Foster GD. The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLoS One. 2021;16(6):e0251566. [PMC free article: PMC8168902] [PubMed: 34061867]
17.
Sagi-Dain L, Echar M, Paska-Davis N. Experiences of weight stigmatization in the Israeli healthcare system among overweight and obese individuals. Isr J Health Policy Res. 2022 Jan 31;11(1):5. [PMC free article: PMC8802507] [PubMed: 35101130]
18.
Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015 Apr;16(4):319-26. [PMC free article: PMC4381543] [PubMed: 25752756]
19.
Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003 Sep;11(9):1033-9. [PubMed: 12972672]
20.
Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review. Prim Health Care Res Dev. 2019 Jul 22;20:e116. [PMC free article: PMC6650789] [PubMed: 32800008]
21.
Makara-Studzińska M, Podstawka D, Goclon K. [Factors influencing self-perception of overweight people]. Pol Merkur Lekarski. 2013 Nov;35(209):313-5. [PubMed: 24575656]
22.
Puhl RM, King KM. Weight discrimination and bullying. Best Pract Res Clin Endocrinol Metab. 2013 Apr;27(2):117-27. [PubMed: 23731874]
23.
Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res. 2008 Apr;23(2):347-58. [PubMed: 17884836]
24.
Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009 May;17(5):941-64. [PubMed: 19165161]
25.
O'Brien KS, Latner JD, Puhl RM, Vartanian LR, Giles C, Griva K, Carter A. The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress. Appetite. 2016 Jul 01;102:70-6. [PubMed: 26898319]
26.
Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity (Silver Spring). 2007 Jan;15(1):19-23. [PubMed: 17228027]
27.
Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001 Dec;9(12):788-805. [PubMed: 11743063]
28.
van Geel M, Vedder P, Tanilon J. Are overweight and obese youths more often bullied by their peers? A meta-analysis on the correlation between weight status and bullying. Int J Obes (Lond). 2014 Oct;38(10):1263-7. [PubMed: 25002148]
29.
Vartanian LR, Porter AM. Weight stigma and eating behavior: A review of the literature. Appetite. 2016 Jul 01;102:3-14. [PubMed: 26829371]
30.
Schvey NA, Puhl RM, Brownell KD. The impact of weight stigma on caloric consumption. Obesity (Silver Spring). 2011 Oct;19(10):1957-62. [PubMed: 21760636]
31.
Walsh K, Grech C, Hill K. Health advice and education given to overweight patients by primary care doctors and nurses: A scoping literature review. Prev Med Rep. 2019 Jun;14:100812. [PMC free article: PMC6374522] [PubMed: 30805277]
32.
Vadiveloo M, Mattei J. Perceived Weight Discrimination and 10-Year Risk of Allostatic Load Among US Adults. Ann Behav Med. 2017 Feb;51(1):94-104. [PMC free article: PMC5253095] [PubMed: 27553775]
33.
Sutin AR, Stephan Y, Terracciano A. Weight Discrimination and Risk of Mortality. Psychol Sci. 2015 Nov;26(11):1803-11. [PMC free article: PMC4636946] [PubMed: 26420442]
34.
Sutin AR, Stephan Y, Luchetti M, Terracciano A. Perceived weight discrimination and C-reactive protein. Obesity (Silver Spring). 2014 Sep;22(9):1959-61. [PubMed: 24828961]
35.
Aldrich T, Hackley B. The impact of obesity on gynecologic cancer screening: an integrative literature review. J Midwifery Womens Health. 2010 Jul-Aug;55(4):344-56. [PubMed: 20630361]
36.
O'Keeffe M, Flint SW, Watts K, Rubino F. Knowledge gaps and weight stigma shape attitudes toward obesity. Lancet Diabetes Endocrinol. 2020 May;8(5):363-365. [PubMed: 32142624]
37.
Vartanian LR, Fardouly J. The stigma of obesity surgery: negative evaluations based on weight loss history. Obes Surg. 2013 Oct;23(10):1545-50. [PubMed: 23519633]
38.
Friedman KE, Ashmore JA, Applegate KL. Recent experiences of weight-based stigmatization in a weight loss surgery population: psychological and behavioral correlates. Obesity (Silver Spring). 2008 Nov;16 Suppl 2:S69-74. [PubMed: 18978766]
39.
Puhl RM, Phelan SM, Nadglowski J, Kyle TK. Overcoming Weight Bias in the Management of Patients With Diabetes and Obesity. Clin Diabetes. 2016 Jan;34(1):44-50. [PMC free article: PMC4714720] [PubMed: 26807008]
40.
Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013 Jan;59(1):27-31. [PMC free article: PMC3555649] [PubMed: 23341653]
41.
Puhl RM. Weight stigma, policy initiatives, and harnessing social media to elevate activism. Body Image. 2022 Mar;40:131-137. [PubMed: 34953387]

Disclosure: Melody Fulton declares no relevant financial relationships with ineligible companies.

Disclosure: Sriharsha Dadana declares no relevant financial relationships with ineligible companies.

Disclosure: Vijay Srinivasan declares no relevant financial relationships with ineligible companies.

Copyright © 2024, StatPearls Publishing LLC.

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Bookshelf ID: NBK554571PMID: 32119458

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