'Be Their Cheerleader': Docs Should Try to Reduce Weight Stigma

Marlene Busko

June 14, 2021

Among adults in a weight management program in six countries who replied to a survey, more than half reported experiencing weight-related stigma — being teased or treated unfairly or being discriminated against by others because of weight.

Moreover, in each country they were commonly stigmatized by family members, starting at a young age, and by doctors, shows the research.

People with overweight/obesity who experienced weight stigma and developed internalized weight bias — that is, they applied negative weight stereotypes to themselves — were more likely to avoid going to see doctors or to have frustrating interactions with doctors (for example, feel that their concerns were not heard).  

These findings, by Rebecca M. Puhl, PhD, are based on survey replies from close to 14,000 members of WW (formerly Weight Watchers) in Australia, Canada, France, Germany, the United Kingdom, and the United States.

The study results were published online June 1 in articles in PLoS One and the International Journal of Obesity.

There were "more [between]-country similarities than differences in weight stigma," report Puhl, deputy director for the Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, and colleagues.

"We must prioritize efforts to establish a healthcare culture free of weight stigma and work collaboratively to develop supportive interventions to help people who experience this stigma," they urge.

Invited to comment, Amy E. Rothberg, MD, PhD, an endocrinologist and professor, University of Michigan, Ann Arbor, who was not involved in the research, said it provides new insights into weight stigma in several countries — with the caveat that fewer than 5% of people invited to participate replied to the surveys, so it may not be representative of all people in weight management programs.

Nevertheless, the study "lays out nicely how weight bias is even more marked in childhood, although by no means disappearing in adulthood," she said. "It shows we need to be very sensitive with the language we use and the actions we model with our children," she noted in an email.

Similarly, Ruhl said that "the fact that family members are such common sources of weight stigma across these countries indicates a collective need" to "help families engage in more supportive communication with their loved ones."

"For many people, these experiences begin in youth from parents and close family members, and they can last for many years and have long-term negative consequences," she observed in a statement from her university.

Two Thirds of People Had Experienced Weight Stigma From Doctors

Roughly two thirds of the people who had experienced weight stigma said that they had been unfairly treated or discriminated against by doctors — which provides "a compelling reason to step up international efforts to reduce weight biases held by medical professionals," said Ruhr.

"We must prioritize efforts to establish a healthcare culture free of weight stigma, and we also need to work collaboratively to develop supportive interventions to help people when they do experience this stigma," she urged.

"Weight bias is steeped in misconceptions about obesity including a lack of understanding of the biology and that it is a serious health problem, not an issue of will or lifestyle choice," Rothberg pointed out.

She noted that the results of the ACTION study by Kaplan and colleagues on the perceptions of barriers to effective obesity care, published in Obesity in 2018, elaborates on this.

Asked what clinicians can do, she replied: "Practitioners need to understand that many individuals with higher weight are exposed to stigma in many facets of their life and are bombarded with images of what they should look like or be like."

"We have to provide an environment that is friendly and sensitive starting with our waiting rooms (having culturally sensitive materials), adequate equipment and clothing (gowns, chairs, scales, etc)."

"We should greet our patients warmly, when appropriate ask permission to talk about weight after establishing a rapport, allow them to talk about their concerns openly and uncensored (as we should do with all of our patients), talk with them about what they hope to achieve, and help them formulate a plan that works for them."

"Be their cheerleader," she concluded. "Help them to understand that the provider knows how very challenging weight loss and weight maintenance can be (if they want to lose weight). Establish follow-up. Address their own negative attitudes that they may have about themselves."

Looking Into Weight Stigma in Different Countries

An international consensus statement in 2020 that Ruhl coauthored called for the elimination of weight stigma, but it is not clear how weight stigma may differ across countries, the researchers write.

For the new work, they invited adults living in the six countries enrolled in the WW weight management program to participate in an online survey about body weight and health in May to July 2020.

A total of 23,415 members replied (3.8% to 5.9% of those invited).

The study sample was comprised of 13,996 members who were eligible for the study and completed the survey (1245 members in Australia and roughly 2500 members in each of the other countries).

Most participants were women (range, 94% to 97%) and White (91% to 97%). They were a mean age of 52 (18 to 89) years, had a body mass index ranging from 29.3 to 31.1 kg/m2, and had been a WW member for roughly 1 to 4 years.

More Than Half Had Experienced Weight Stigma

The article published in the International Journal of Obesity reported on weight-related stigma prevalence, type, and sources, which were similar across countries.

More than half (56% to 61%) of the respondents replied "yes" to the question: "Have you ever been teased or treated unfairly or discriminated against because of your weight?"

Among the respondents with weight-related stigma, 51% to 58% had been teased by family members, 34% to 43% had been unfairly treated because of their weight, and 25% to 35% had been discriminated against because of weight.

The participants had most often experienced weight stigma from family members (76%-88%), followed by classmates (72%-81%), doctors (63%-74%), coworkers (54%-62%), and friends (49%-66%).

Those with a higher BMI were more likely to report experiencing weight-related stigma.

Weight-related stigma most often began in childhood or adolescence, when it was most frequent and most distressing, and the incidence declined with increasing age.

Impact on Healthcare Experience

The article in PLoS One reported how weight stigma affected healthcare.

Across all six countries, weight stigma from any source was associated with internalized weight bias, which in turn was associated with poorer healthcare experiences.

Compared with other survey respondents, and independent of BMI and demographics, individuals who had higher internalized weight bias had less frequent check-ups (as they did not like to be examined), and were more likely to perceive that their doctor judged them based on their weight, or did not listen to them carefully, or did not respect what they had to say.

The study was funded by a grant from WW International (formerly Weight Watchers) to the University of Connecticut. Puhl has reported receiving funding through an award from the National Heart, Lung and Blood Institute/National Institutes of Health. Senior author Gary D. Foster is an employee (chief scientific officer) and shareholder of WW. The other authors and Rothberg have reported no relevant financial relationships.

Int J Obes. Published online June 1, 2021. Abstract

PLoS One. Published online June 1, 2021. Full Text

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