How does weight stigma affect healthcare?

How common is weight bias in healthcare?

Weight bias is common across almost every healthcare profession. A systematic review and meta-analysis of 41 studies found weight bias among doctors, nurses, dietitians, psychologists, physiotherapists and other professionals. Most of this bias is implicit: people are not aware of it, and many sincerely want to give good care.

Patients notice it too. In a survey of almost 14,000 adults in a weight management programme in Australia, Canada, France, Germany, the UK and the US, between 56% and 61% said they had experienced weight stigma. In every country, about two in three of them said this had happened with a doctor.

Bias does not only come from people. Many clinics are not designed for larger bodies, with chairs that have narrow arms, blood pressure cuffs that are too small, examination tables that feel unsafe, and gowns that do not fit. This sends a message that some patients are not expected. You can read more about the wider problem on our page on weight stigma.

What are the consequences for patients?

Weight stigma can lead to worse care and worse health, even when professionals mean well. A review of research from several disciplines found that negative attitudes can shape how professionals see patients, how they talk with them and the decisions they make. Patients who expect to be judged may feel stressed, trust their doctor less and avoid appointments.

• Delayed care. People who have felt judged before often wait longer before seeking help, so problems may be found at a later stage.
• Avoiding screening. In a US study of almost 500 women with a higher weight, those with the highest body mass index were less likely to have had a recent cervical screening test. They named disrespectful treatment, embarrassment about being weighed, unwanted advice to lose weight and equipment that was too small as barriers.
• Missed diagnoses. When every symptom is blamed on weight, other causes can be missed. This is called diagnostic overshadowing. Clinical guidelines, such as the Canadian adult obesity guideline, ask professionals to look for the root causes of health problems instead of attributing every symptom to weight.
• Internalised stigma. Over time, some people start to believe the negative messages about themselves. In the six-country survey, people with more internalised weight bias avoided healthcare more often.

Stigma can also affect mental health and eating behaviour. Our page on sleep, stress and mental health explains these links.

What does good, stigma-free care look like?

Good care treats obesity as a chronic disease, starts with permission and respect, and looks at your whole health, not only at the number on the scale. Several clinical guidelines describe this approach.

The 5As approach

Obesity Canada developed the 5As of Obesity Management to help professionals start a respectful conversation. It is now used in guidelines in other countries as well.

Other signs of good care

• Asking permission each time before talking about weight or taking measurements. The Canadian adult obesity guideline recommends this as the first step of every conversation.
• Treating the complaint you came in with, and not waiting for weight loss before treating other conditions.
• Suitable equipment: chairs without narrow arms, large blood pressure cuffs, scales and tables for higher weights, and gowns in all sizes.
• Weighing in a private place, explaining why the weight is needed, and not commenting on the number.
• Neutral, person-first language, such as weight and body mass index, instead of words that blame.
• Offering all evidence-based options, including psychological support, medication and surgery, where they fit your situation.

What can you do as a patient?

You have the right to be treated with respect and to take part in decisions about your own care. These steps can help you feel more in control.

• Prepare. Write down your symptoms, questions and goals before the visit. Our doctor visit checklist can help.
• Bring someone. A friend or family member can listen, take notes and support you.
• Ask about weighing. You can ask why your weight is needed today, ask to be weighed in private, or ask not to be told the number. Sometimes the weight is needed for safety, for example to calculate a medicine dose or before an anaesthetic.
• Bring the focus back. If your complaint is brushed aside, you can say: I understand weight may play a role. What else could be causing this, and what tests would you do for someone with a lower weight?
• Ask for equipment. It is reasonable to ask for a larger blood pressure cuff or a chair without arms.
• Get a second opinion. In most healthcare systems you can ask to see another professional if you do not feel heard.
• Give feedback or complain. Most practices and hospitals have a complaints procedure. Many countries also have a patient advocate, ombudsman or health service regulator. The rules differ by country.

Never let a bad experience stop you from getting urgent care. If you have chest pain, sudden shortness of breath or other serious symptoms, call your local emergency number.

What can healthcare professionals and organisations do?

Professionals and organisations can reduce weight bias with training, better equipment and clear standards of respectful care. The international consensus statement on ending weight stigma calls for teaching on the causes and treatment of obesity in all training programmes, and for stigma-free practice skills for professionals who work in obesity care.

• Learn about your own implicit bias and about the biology of obesity. Our page on genetics and biology is a starting point.
• Check that waiting rooms, examination rooms and equipment work for people of all sizes.
• Use the 5As or a similar structured, permission-based approach.
• Ask patients what words they prefer when talking about weight.
• Look for other causes of symptoms before attributing them to weight.