Reducing Weight Bias in Obesity Management, Practice and Policy

Canadian Adult Obesity Clinical Practice Guidelines 1

KEY MESSAGES FOR HEALTHCARE

POLICY MAKERS

• Policy makers developing obesity policies should

assessandreectontheirownattitudesandbeliefs

relatedtoobesity.

• Publichealthpolicymakersshouldavoid using stig-

matizing language and images. It is well established

that shaming does not change behaviours. In fact, shaming

can increase the likelihood of individuals pursuing unhealthy

behaviours and has no place in an evidence-based approach

to obesity management.

6,9

• Avoidmakingassumptionsinpopulationhealthpol-

iciesthathealthybehaviourswillorshouldresultin

weight change. Weight is not a behaviour and should

not be a target for behaviour change. Avoid evaluating

healthy eating and physical activity policies, programs and

campaigns in terms of population-level weight or BMI out-

comes. Instead, emphasize health and quality of life for

people of all sizes. Because weight bias contributes to

Reducing Weight

Bias in Obesity

Management, Practice

and Policy

Sara FL. Kirk PhD

, Ximena Ramos Salas PhD

, Angela S.

Alberga PhD

iii

, Shelly Russell-Mayhew PhD, R.Psych

i) School of Health and Human Performance, Dalhousie

University

ii) Obesity Canada

iii) Department of Health, Kinesiology and Applied Physiology, Concordia University

iv) Werklund School of Education, University of Calgary

CitethisChapter

Kirk, SFL, Ramos Salas X, Alberga AS, Russell-Mayhew

S. Canadian Adult Obesity Clinical Practice Guidelines:

Reducing Weight Bias, Stigma and Discrimination in

Obesity Management, Practice and Policy. Available

from: https://obesitycanada.ca/guidelines/weightbias.

Accessed [date].

UpdateHistory

Version 1, August 4, 2020. The Canadian Adult Obesity

Clinical Practice Guidelines are a living document, with

only the latest chapters posted at

obesitycanada.ca/guidelines.

Introduction

People living with obesity frequently experience weight bias, stigma

and discrimination. The role that these play in obesity management

has, until recently, been poorly understood. This chapter provides

an overview of these constructs, using the best available evidence

to illustrate how they inﬂuence obesity development, diagnosis,

management and prevention. This is the ﬁrst time that weight

bias, stigma and discrimination have been included in Canadian

clinical practice guidelines for obesity, in recognition of emerging

and compelling evidence that they represent a signiﬁcant chal-

lenge to practice and policy. For questions related to lived experi-

ence of obesity and experiences of clinical care, qualitative meth-

ods are the appropriate research approach. While we recognize

that there is a relative paucity of high-quality evidence on weight

bias, stigma and discrimination in this area, the patients and clinicians

working on these guidelines feel it is important to highlight. It is

our hope that work in this area will continue and richer information

will be available for future guidelines.

To support standard practice within chronic disease management,

we use people-ﬁrst language throughout this chapter. For fur-

ther information, refer to https://obesitycanada.ca/resources/peo-

ple-ﬁrst-language.

Given the limited evidence in the published literature, this chapter

includes recommendations where sufﬁcient evidence is available,

alongside key messages for health professionals, policy makers

and patients where evidence is limited.

Canadian Adult Obesity Clinical Practice Guidelines 2

RECOMMENDATIONS

1. Healthcare providers should assess their own attitudes and

beliefs regarding obesity and consider how their attitudes

and beliefs may inﬂuence care delivery (Level 1a; Grade A).

2. Healthcare providers should recognize that internalized

weight bias (bias towards oneself) in people living with

obesity can affect behavioural and health outcomes (Level

2a; Grade B).

2–5

3. Healthcare providers should avoid using judgmental words,

(level 1A, grade A),

images (Level 2b, Grade B)

and practices

(Level 2a, Grade B)

when working with patients living with

obesity.

4. We recommend that healthcare providers avoid making

assumptions that an ailment or complaint a patient presents

with is related to their body weight (Level 3, Grade C).

7,8

KEY MESSAGES FOR PEOPLE

LIVING WITH OBESITY

• Weightbiasmayaffectqualityofhealthcareforindi-

vidualswithobesity. For example, weight bias may neg-

atively affect health professionals’ attitudes and behaviours

toward individuals living with obesity.

7,14

• Experiencesofweightbiascanharmyourhealthand

well-being. Experiencing unequal treatment because of

your size or weight, for example, is not acceptable. Talk

to your healthcare provider about your experiences with

weight bias. Speak up and support action to stop weight-

based discrimination.

15–17

• Talktoyourhealthcareprovideraboutaddressingin-

ternalizedweightbias. Bias can impact your behaviours

and your health. Self-stigma and self-blame can be addressed

through behavioural interventions, consistent with the prin-

ciples of cognitive behaviour therapy and acceptance and

commitment therapy.

2,18–22

(See the Effective Psychological

and Behavioural Interventions for People Living with Obesity

chapter for more information on these therapies.)

• Tryfocusingonimprovinghealthyhabitsandquality

ofliferatherthanweightloss. Weight is not a behaviour

and should not be a target for behaviour change.

23,24

health and social inequalities, advocate for and support peo-

ple living with obesity. This includes supporting policy action

to prevent weight bias and weight-based discrimination.

6,9–14

• Policy makers should know that most people living

withobesityhaveexperiencedweightbiasorsome

formofweight-baseddiscrimination.Public health policy

makers should consider weight bias and obesity stigma as

added burdens on population health outcomes and develop

interventions to address them. To avoid compounding the

problem, we encourage policy makers to do no harm, and

to develop people-centred policies that move beyond per-

sonal responsibility, recognize the complexity of obesity and

promote health, dignity and respect, regardless of body

weight or shape.

• Healthcareproviders should ensure their clinical envi-

ronmentisaccessible,safeandrespectfultoallpatients

regardlessoftheirweightorsize. Make efforts to improve

health and quality of life rather than solely focusing on obesity

management. Ask permission before weighing someone,

and never weigh people in front of others; instead, place

weighing scales in private areas. Healthcare providers should

consider how their ofﬁce’s physical space accommodates

people of all sizes and ensure they have properly sized

equipment (e.g., blood pressure cuffs, gowns, chairs, beds)

ready in clinical rooms prior to patients arriving. Because

weight bias impacts morbidity and mortality, advocate for

and support people living with obesity. This includes action

to create supportive healthcare environments and policies

for people of all sizes.

Canadian Adult Obesity Clinical Practice Guidelines 3

Whatdowemeanbythetermsweightbias,

stigmaanddiscrimination?

The terms weight bias, stigma and discrimination are often used

interchangeably, but more accurately reﬂect a continuum, with

weight bias describing the negative weight-related attitudes, beliefs,

assumptions and judgments in society that are held about people

living in large bodies. Weight bias can be expressed as explicit, implicit

and internalized forms. Explicit weight bias is deﬁned as having overtly

negative attitudes toward people with obesity. Examples of explic-

it weight bias include assumptions that people living with obesity

are lazy, unmotivated, lacking self-discipline or willpower, and non-

compliant with medical treatment. Implicit weight bias is concep-

tualized as having unconscious negative attitudes toward people

in large bodies. That is, implicit weight-biased attitudes are not ac-

knowledged by those holding them but can nevertheless shape the

way that people view and treat individuals living with obesity.

Internalized weight bias, or self-directed bias, is the extent to which

individuals living with obesity endorse negative weight-biased be-

liefs about themselves. Internalized weight bias is already prevalent

within the general population (44%), however individuals living

with obesity are more likely to endorse such beliefs (52%).

People

who have high weight bias internalization tend to believe that they

deserve the negative attitudes or negative treatment they receive.

This is exempliﬁed by strongly supporting statements such as, “I am

less attractive than most other people because of my weight,” or “I

feel anxious about being overweight because of what people might

think of me.” Few studies have explored the relationship between

obesity management and weight bias; in recent years, research has

shown strong associations between internalized weight bias and

mental health outcomes.

26–29

Internalized weight bias has been

shown to have a negative impact on outcomes that have convention-

ally been associated with the management of obesity. For example,

weight bias internalization has been associated with exercise avoid-

ance and binge eating.

4,20,30–40

Weight or obesity

stigma (we use the term weight stigma here, but

the term obesity stigma is also often used in the literature) represents

the manifestation of weight bias through harmful social stereotypes

that are associated with people living with obesity. An example of

weight or obesity stigma in the healthcare system is if health pro-

fessionals believe that individuals with obesity are non-compliant

with medical advice or treatment, and hence assume that obesity

management strategies will not work. The existence of weight bias

and stigma can, in turn, lead to weight discrimination, which is the

unjust treatment of individuals because of their weight.

Examples

of unjust and inequitable treatment include but are not limited to

health professionals spending less time, having more insensitive or

rushed communications or establishing less emotional rapport with

patients living with obesity. In extreme cases, weight-based discrim-

ination can lead to patients being denied treatment or avoiding

seeking help from the healthcare system.

42–46

Howprevalentareweightbias,stigmaand

discrimination?

Weight bias and stigma are pervasive in our society. Approximately

40% of adults report a history of experiencing some form of weight

bias or stigma.

Weight bias has been documented among parents

and families,

pre-adolescents and adolescent peers,

teachers,

employers and human resource professionals,

healthcare profes-

sionals

and even among individuals with obesity themselves.

Speciﬁcally, weight bias is prevalent among the general population,

and has been found to be signiﬁcantly greater than two other tar-

gets of bias that are common in modern society: homosexuality and

Muslim faith.

There is extensive literature documenting weight

bias and stigma across a range of health professionals, including

physicians, nurses, dietitians, psychologists and healthcare train-

ees.

Weight bias has also been investigated among pre-service

health promotion students.

Weight discrimination manifests across multiple settings as noted

above, the consequences of which are far reaching, as explained in

the following section.

Weight/height discrimination has been found to have signiﬁcantly

increased between 1995–1996 and 2004–2006, from 7% to 12%.

The prevalence of weight discrimination has increased by 66% over

the past decade, and is comparable to rates of racial discrimination,

especially among women.

10,13

The prevalence of perceived weight

discrimination across life domains, such as employment, schools,

healthcare and interpersonal relationships, ranges from 19.2%

among individuals with Class I obesity (BMI 30–35 Kg/m

) to 41.8%

among individuals with severe obesity (BMI > 35 Kg/m

Whataretheconsequencesofweightbias,

stigmaanddiscrimination?

Weight bias, stigma and discrimination can have several physi-

cal, psychological and psychosocial consequences. For example, a

systematic review of 23 studies showed that there are many bio-

psychosocial consequences of weight or obesity stigma in treat-

ment-seeking adults with overweight and obesity.

The following

sections will describe how weight bias, stigma and discrimination

can affect a person’s physical and mental health, lead to avoidance

of preventive healthcare, hinder obesity management efforts and

increase overall morbidity and mortality.

Physicalhealthconsequences

Like other forms of discrimination, including racism, weight dis-

crimination is associated with increased risk for morbidity. There are

physiological mechanisms that may contribute to this increased risk

to physical health, such as increased chronic stress, which can in-

crease cortisol levels, and oxidative stress independent of adiposity

level.

16,56

A systematic review of 33 studies found that weight or

obesity stigma was positively associated with obesity, diabetes risk,

cortisol level, oxidative stress level, C-reactive protein level, eating

Canadian Adult Obesity Clinical Practice Guidelines 4

disturbances, depression, anxiety, and body image dissatisfaction.

One longitudinal study has also shown that perceiving weight dis-

crimination is associated with a 60% increase in mortality risk.

Indeed, the effect of weight-based discrimination was comparable

to other established risk factors, such as smoking history and disease

burden. It is not clear how weight discrimination contributes to mor-

tality. Some theories link experiences of weight discrimination to

behavioural risk factors such as sedentary lifestyles and increased

food consumption as coping mechanisms.

Distress over obesity is

heightened when people perceive themselves to have poorer health

because of obesity-related conditions, such as chronic pain, osteo-

arthritis, and cardiovascular disease.

There is some evidence that internalized weight bias mediates the

relationship between weight or obesity stigma experiences and

negative psychological outcomes.

Weight bias internalization may

be associated with even poorer mental health outcomes than the

perceived experience of weight bias.

In other words, believing one-

self to be deserving of weight or obesity stigma may lead to worse

psychological outcomes than the actual stigmatizing encounter

itself.

Furthermore, adults who internalize weight bias are more

likely to binge eat. Coping mechanisms for individuals who experi-

ence weight discrimination are to engage in unhealthy behaviours.

Weight discrimination also increases risk for obesity.

Mentalhealthconsequences

It is well established that being a target for weight bias, stigma and

discrimination is associated with negative mental health outcomes.

Individuals living with obesity may face negative mental health im-

pacts because of their weight status across multiple levels of their

environment.

Global measures of mental health indicate that ex-

periences of weight bias are associated with psychological distress

in both treatment-seeking and community samples.

Psychosocial

correlates of weight bias include medication non-adherence, anx-

iety, perceived stress, antisocial behaviour, substance use, coping

strategies and social support.

Weight bias is also associated with

greater body image disturbance.

In treatment-seeking adults

with obesity, more internalized weight bias was associated with a

stronger negative impact on body image.

Experiencing weight or obesity stigma is associated with poorer

psychological functioning in a sample of individuals seeking treat-

ment for obesity.

Experiences of stigma also signiﬁcantly and in-

dependently predict psychological concerns in obesity-treatment

seeking individuals after controlling for BMI. Stigmatizing experi-

ences, not only body weight, contribute to adverse mental health

consequences in people living with obesity. In one study, the harmful

effects of stigma experiences extended beyond psychological distress

and morbidity of obesity to include an increased risk in all-cause

mortality.

In another study, individuals who perceived they had

experienced weight stigma were almost 2.5 times more likely to

experience mood or anxiety disorders than those who did not, even

when accounting for standard risk factors for mental illness and

measured BMI.

Depression is associated with weight gain and individuals with

obesity are at greater risk of depression, particularly those cate-

gorized with Class II and III obesity.

Emerging evidence suggests

that perceived weight discrimination may be an explanation for this

relationship, with particular evidence for middle-aged and older

adults.

54,63,64

In a treatment-seeking sample of 255 individuals with

binge eating disorder, weight bias internalization was associated

with poorer overall mental health scores, and depressive symptoms

mediated this relationship.

Stigma and discrimination are also seen as chronic stress conditions

attributed to the additional stress that individuals from stigmatized

groups are exposed to daily as a result of their position in society.

Chronic stress has a signiﬁcant impact on mental health and dis-

crimination-speciﬁc stressors should be considered in intervention

approaches.

One study showed that overvaluation of shape and

weight mediated the relationship between self-esteem and weight

bias internalization in a sample of individuals with overweight/obesity

and diagnosed binge eating disorder.

Populationandpublichealthconsequences

Weight bias can have social and economic consequences for in-

dividuals living with obesity, such as inequities in interpersonal

relationships and fewer opportunities for education and employ-

ment.

14,58,67–69

A fundamental driver of weight bias is a lack of public

understanding of the complex and multi-faceted nature of obesity.

When the science about the complexity of obesity is not communi-

cated to the public, it can lead to an oversimpliﬁcation of obesity.

For example, public health strategies that focus on obesity as an

issue of unhealthy eating and physical inactivity, and ignore biologi-

cal, genetic, environmental and societal contributors of obesity, can

contribute to the oversimpliﬁcation of the disease and to a lack of

public understanding of the disease.

This can lead to inaccurate social narratives that obesity is a self-in-

ﬂicted choice and that it is only up to individuals with obesity to

address their own obesity. This lack of understanding, in turn, can

lead to people experiencing weight bias and stigma. Public health

research has identiﬁed a need to:

• Changethepublichealthobesitynarrativetoalignwithcurrent

scientiﬁc and medical understanding of obesity as a chronic

disease; and

• Develop comprehensive obesity strategies that reect patient

experiences may prevent further stigmatization of obesity.

Furthermore, stigma has an independent impact on population

health inequalities.

As such, weight bias and obesity stigma should

be considered as key social determinants of health.

14,71

Studies have also explored how weight bias may reveal itself through

public health campaigns.

Public health strategies that emphasize

the duty and responsibility of individuals to make healthy choices

can end up blaming or punishing those who make unhealthy or

Canadian Adult Obesity Clinical Practice Guidelines 5

contested choices.

Individuals with obesity perceive obesity public

health messages as overly simplistic, disempowering and stigma-

tizing.

6,73

Public health campaigns that promote negative attitudes

and stereotypes toward people with obesity, stigmatize youth with

obesity or blame parents of children with overweight are not only

ineffective in motivating behaviour change but also end up labelling

and stigmatizing individuals further.

Two recent critical analyses of Canadian obesity prevention poli-

cies highlight how a focus on individual behaviours, rather than a

population approach that addresses social determinants of health,

can contribute to weight bias and stigma. The ﬁrst, by Ramos Salas

et al., identiﬁed ﬁve prevailing narratives that may contribute to

weight bias:

1) Childhood obesity threatens the health of future generations

and must be prevented;

2) Obesity can be prevented solely through healthy eating and

physical activity;

3) Obesity is an individual behaviour problem;

4) Achieving a healthy body weight should be a population health

target; and

5) Obesity is risk factor for other chronic diseases not a disease in

itself.

The second analysis, by Alberga et al., also noted that a Canadian

federal report on obesity used aggressive framing and disrespect-

ful terminology with a strong focus on individual behaviours.

The authors stated that this may be contributing to weight stigma

and recommended that future Canadian policies, reports and cam-

paigns address fundamental social determinants of health.

70,74

Consequencestoengagementinprimary

healthcare

Weight bias in healthcare settings can reduce the quality of care

for patients living with obesity.

It is established through consistent

evidence across a number of studies that healthcare professionals

endorse weight bias and stigma about patients living with obe-

sity.

37,48,53

There is also strong evidence that patients with obesity

perceive biased treatment in healthcare and that these perceptions

may inﬂuence patient engagement in primary healthcare services.

Patients have reported patronizing and disrespectful treatment

from their primary care providers, as well as poor communication

and blaming most health issues on excess weight.

Furthermore, there is substantial documented data that weight bias

may negatively affect healthcare professionals’ obesity manage-

ment practices.

This evidence suggests that patients with obesity

are vulnerable to weight bias in healthcare settings, which may im-

pact morbidity and mortality. For example, existing evidence suggests

that healthcare professionals may be spending inadequate time

with patients with obesity.

76,77

Patients who experience weight bias

in healthcare settings may delay or forgo essential preventive care,

like breast, cervical and colorectal cancer screening, for fear of re-

ceiving disrespectful treatment and negative attitudes from provid-

ers.

5,11,14,42,46,78

They may also engage in “doctor shopping” to ﬁnd

a more respectful healthcare provider.

18,79,80

Patients report being

embarrassed about being weighed,

78,81

receiving unsolicited advice

to lose weight and a lack of equipment (e.g. gowns and exam ta-

bles too small to be functional).

78,82–84

Importantly, and contrary to

popular belief, weight bias, stigma and discrimination do not en-

courage positive behaviour change, as noted in the above sections

on the physical and mental health consequences of these issues.

Howdowereduceweightbias,stigmaand

discriminationinhealthcaresettings?

International organizations such as the American Academy of Pe-

diatrics and the British Psychological Society (British Psychological

Association, 2019) have published policy statements with recom-

mendations for healthcare professionals to reduce weight stigma

in clinical practice.

Obesity Canada is also working with many

national health professional associations to recognize that weight

bias, stigma and discrimination should be addressed seriously by all

health professionals.

Key to reducing weight bias, stigma and discrimination in health-

care settings is for health professionals to be aware of their own

attitudes and behaviours toward individuals living with obesity. As

noted above, health professionals providing support for obesity

management should acknowledge that weight bias is prevalent

among health professionals, and that they are not immune to it

themselves. They should be willing to reﬂect on if/how weight bias

affects their own attitudes and behaviours toward patients who are

living with obesity. This can be achieved by completing a self-assess-

ment tool such as the Implicit Association Test, for weight bias.

Given that weight bias is established early, usually before health

professionals start their professional training, there is a need for

systematic education on weight bias and stigma in all health profes-

sional training programs. All professional health disciplines should

therefore include weight bias sensitivity training in their curricula.

Because internalized weight bias can have negative impacts on

health-related outcomes, it is also important that health profession-

als assess their patients for internalized weight bias. This can be

accomplished through sensitive questioning/dialogue (e.g., “Can

you share with me if or how your weight affects your perception of

yourself?/motivational interviewing).

Coping strategies to address

internalized weight bias should be incorporated into behavioural in-

terventions, consistent with the principles of cognitive behavioural

therapy and acceptance and commitment therapy. (See the Effec-

tive Psychological Behavioural Interventions for People Living with

Obesity chapter for more information on these therapies).

Reviews of weight bias reduction interventions have shown that

one approach is not sufﬁcient to reduce weight bias among health

Canadian Adult Obesity Clinical Practice Guidelines 6

professionals.

1,67,87

These reviews highlight the importance of mov-

ing beyond awareness and information provision to raising skills and

competencies in health professionals and advocating change in social

norms and ideologies about body weight. A systematic review of 17

weight bias reduction interventions among health student trainees and

practicing health professionals identiﬁed four key components to help

decrease weight bias among health professionals:

• Presentfactsaboutuncontrollableandnon-modiablecausesof

obesity (i.e. genetics, biology, environment, socio-cultural inﬂu-

ences, and social determinants of health);

• Providepositivecontactwithpatientslivingwithobesitytoevoke

empathy (i.e. include the patient voice);

• Include empathic obesity experts as peer-modelling health

professionals; and

• Repeat exposure with patients living with obesity over the

long-term.

Promising strategies to reduce stigma in the healthcare setting include:

• Improvingproviderattitudesaboutpatientswithobesityand/or

reducing the likelihood that negative attitudes inﬂuence provider

behaviour;

• Alteringtheclinicenvironmentorprocedurestocreateasetting

where patients with obesity feel accepted and less threatened;

and

• Empoweringpatientstocopewithstigmatizingsituationsand

attain high-quality healthcare.

Gapsinourknowledge:questionsforfuture

research

Because of the evidence about the negative physical, psychological

and social consequences of weight bias noted in this chapter, in-

ternalized weight bias is an important consideration for weight

bias reduction strategies in healthcare. For example, individuals

with higher internalized weight bias report less weight loss, lower

physical activity levels, higher caloric intake, greater disordered

eating behaviours

and even greater cardiometabolic risk.

There

is therefore a need for more research to better understand, and

more effectively assess and reduce, internalized weight bias.

This is perhaps because behaviour change interventions may not be

maximizing their potential beneﬁts by ignoring internalized weight

bias. Health professionals are advised to address internalized weight

bias within any obesity management strategy (i.e., self-compassion as

a resource;

inducing empathy and inﬂuencing controllability attribu-

tions;1 and careful and considered use of language and terminology).

Finally, a great deal more research is needed to understand the im-

pact of weight bias, stigma and discrimination on care for people

with obesity. There is a need for more research, beyond convenience

or treatment-seeking groups, towards replication with more gen-

eralizable populations. The development and testing of novel in-

terventions are also needed to reduce weight bias, or its impact on

behaviour, in medical trainees, practicing physicians, other health

professionals, and other staff members of health organizations.

Correspondence:

[email protected]

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