Content uploaded by Stuart W Flint
Author content
All content in this area was uploaded by Stuart W Flint on May 19, 2015
Content may be subject to copyright.
14 British Journal of Obesity Volume 1 No 1 2015
Article
Obesity stigma: Prevalence and impact
in healthcare
Stuart William Flint
Citation: Flint SW (2015)
Obesity stigma: Prevalence and
impact in healthcare. British
Journal of Obesity 1: 14–18
Article points
1. Healthcare providers have
been repor ted to have negative
attitudes towards obese
people, perceiving them to
be lazy, non-compliant with
treatment and unintelligent.
2. These stereotypes are not
supported by evidence and can
lead to suboptimal healthcare
care provision from the
practitioner and dissatisfaction,
embarrassment and reduced
motivation to seek medical
help and make diet and
lifestyle changes in patients.
3. Obesity stigma is reinforced
early in a medical student’s
education, and it is at this
stage that interventions to
reduce stigma have been
found to be successful.
Key words
- Obesity
- Stigma
Author
Stuart Flint is a Research
Fellow in Exercise Psychology,
Shefeld Hallam University.
Obesity stigma is reported across population groups, impacting the wellbeing of obese
people. Perhaps counterintuitively, healthcare professionals have stigmatising attitudes
and, in some cases, fail to provide advice and treatment to obese patients. The reports
summarised in this review suggest that intervention is required to improve treatment
and to reduce adverse patient behaviours such as avoiding appointments and not
reporting concerns to healthcare providers.
Obesity has emerged as a public health
concern across the world. Over time,
there has been a substantial increase in
the prevalence of obesity and its associated health
complications, such as diabetes and coronary
heart disease (James, 2008). Obese children and
adults often become withdrawn from society
through experiences of rejection, stigma or
stereotyping, which may have additional impacts
on health and psychological wellbeing (Puhl and
Brownell, 2006). The impacts of obesity stigma
on the individual include depression, anxiety, low
self-esteem, body image concerns, binge eating,
avoidance of physical activity, self-harm and
suicide (Faith et al, 2002; Puhl and Brownell,
2006; Vartanian and Shaprow, 2008; Puhl and
Heuer, 2009).
A plethora of studies (e.g. Tillman et al,
2007; Puhl and Heuer, 2009) indicates that
overweight and obese people are perceived
negatively by others, which can result in a
number of harmful psychological responses,
such as lowered self-esteem and confidence.
Rejection and stigmatisation are purported to
be more likely in childhood and adolescence, the
years of development in which socially adaptive
relationships are formed more frequently (Pearce
et al, 2002). Obesity stigmatisation is reported in
various populations; for instance, in jurors in their
decisions of guilt and responsibility (Schvey et al,
2013) and obesity researchers (Flint and Reale,
2014), as well as settings including the home and
school (Puhl and Latner, 2007), the workplace
(Flint and Snooke, 2014) and exercise facilities
(Robertson and Vohora, 2008).
Previous research examining obesity stigma
has shown that obese people are stereotyped
as lazy, gluttonous, unattractive, intellectually
slow, socially inept and lacking in self-esteem
(Crandall, 1994). These stereotypes are often
without evidence but they are informed by a
variety of sources, including the media and
education. The foundations for stigmatising obese
people is suggested to be a result of attributing
the condition to controllable causes (i.e. energy
intake vs. energy expenditure), and this is a
constant message in a society that is bombarded
with information suggesting that body fatness
can be modified relatively easily, which has led to
increased awareness of body shape and size. It has
also been reported that healthcare professionals
report a belief that obesity is controllable, which
is linked to obesity stigma (Swift et al, 2013a). In
fact, Latner et al (2008) suggest that obesity stigma
Obesity stigma: Prevalence and impact in healthcare
British Journal of Obesity Volume 1 No 1 2015 15
is likely to be stronger than other forms of stigma,
and that this may be due to the differences in
perceptions of personal responsibility.
It would be reasonable to expect healthcare
professionals to be an inf luential source when
forming perceptions about health conditions.
However, an area of increasing interest is the
potential impact of obesity stigma on medical
treatment. Counterintuitively, obesity stigmatisation
has been reported in healthcare professionals,
including physicians, nurses, psychologists and
dietitians. Healthcare professionals have a critical
role in the management of obesity. Thus, assessing
current practice and examining opportunities to
improve healthcare provision is of high importance.
When evaluating obesity stigma, it has been
proposed that measuring implicit attitudes (i.e.
those that occur without conscious awareness
and are formed involuntarily) is superior to
measuring explicit attitudes (i.e. those that occur
consciously and are deliberately formed), as this
negates demand characteristics and response
biases (Rudman, 2004). Demand characteristics
occur when participants form an interpretation
of the research aims and subsequently modify
their behaviour. Response bias refers to inaccurate
responses due to, for instance, the wording of a
question, and this is commonly associated with
survey research.
Whilst measurement of implicit attitudes can
be employed using, for instance, the Implicit
Association Test (Greenwald et al, 1998),
which has occasionally been used to examine
obesity stigma (Flint et al, 2013), research on
the phenomenon in healthcare professionals has
primarily involved measures such as the Attitudes
Toward Obese Persons scale and the Beliefs About
Obese Persons scale (Allison et al, 1991), or the
F-Scale (Bacon et al, 2001). Notwithstanding
these weaknesses, the research to date indicates
the presence of stigmatising attitudes in healthcare
professionals.
Teachman and Brownell (2001) report that
healthcare professionals have negative attitudes
towards both obesity as a condition and people
who are obese. Healthcare providers perceive
obese people to be lazy, non-compliant, poorly
self-controlled, weak-willed, sloppy, dishonest,
unsuccessful and unintelligent (Price et al, 1987;
Hebl and Xu, 2001; Foster et al, 2003; Ferrante et
al, 2009; Puhl and Heuer, 2009; Huizinga et al,
2009).
Stigma among specific healthcare
practitioners
Physicians
A cluster of studies have reported that physicians
view obese patients as less self-disciplined,
less compliant and more annoying than non-
obese ones and that, as patients’ BMI increases,
physicians are likely to have less patience and desire
to help them (Hebl and Xu, 2001; Huizinga et
al, 2009). Additionally, physicians have reported
that seeing obese people was a waste of their time
and that they had less respect for these patients.
For example, Kristeller and Hoerr (1997) sampled
more than 1200 physicians, examining attitudes,
intervention approaches and referral procedures for
obesity. The physicians’ responses were indicative
of poor management. Despite an awareness of the
associative health risks and despite acknowledging
that many patients were overweight or obese, the
physicians failed to intervene to the extent they
should have in their role, appeared ambivalent in
relation to the management of patients, and were
unlikely to refer patients to weight management
programmes. Moreover, the authors reported
that only 18% of physicians would discuss weight
management with overweight patients, while 42%
would do so with mildly obese patients. Similarly,
Price et al (1987) reported that 23% of physicians
did not recommend treatment to obese patients,
with 47% reporting that weight management
counselling was inconvenient.
Nurses
Physicians are not the only healthcare providers
who have been found to hold anti-fat attitudes and
perceptions. Both registered and student nurses
stereotype obese patients (Foster et al, 2003; Poon
and Tarrant, 2009). For example, nurses were
reported to view these patients as lazy, lacking
in self-control and non-compliant to treatment
(Ogden and Hoppe, 1998). Reports that nurses
have stigmatising attitudes are concerning given
that a concomitant increase in obesity-related
clinical practice has been observed in line with
the increased prevalence of the condition across
Page points
1. While many studies into
obesity stigma are limited by
their use of measurements of
explicit attitudes, there is a lot
of evidence that healthcare
professionals hold negative
stereotypes of both obesity as
a condition and obese people.
2. Physicians have been found
to have less patience and
respect for obese patients,
and less desire to help them.
3. Despite knowing the associated
health risks, less than half of
physicians report discussing
weight management with
obese patients, feeling that
it is a waste of their time.
Obesity stigma: Prevalence and impact in healthcare
16 British Journal of Obesity Volume 1 No 1 2015
the world. For example, Brown et al (2007)
reported that UK practice nurses often provide
lifestyle advice and engage in other obesity-related
activities. Nurses’ anti-fat attitudes are particularly
alarming given the potential implications on
patients’ quality of life (Kolotkin et al, 2001) and
experiences of healthcare (Puhl and Brownell,
20 01).
Healthcare students
A number of studies have evaluated the attitudes of
students in training for a range of obesity-related
occupations, including doctors, nurses, dietitians,
psychologists and nutritionists. This research has
demonstrated stereotypical attitudes towards obese
patients, including beliefs that they have poor self-
control and no willpower, and that they are sloppy,
less likely to adhere to treatment, unsuccessful
and responsible for their symptoms (Keane,
1991; Wigton and McGaghie, 2001; Persky and
Eccleston, 2011; Swift et al, 2013a). It has also
been reported that medical students’ derogatory
and cynical humour is directed at obese patients
(Wear et al, 2006). Swift et al (2013a) examined
weight bias in 1130 healthcare students in the
UK. They demonstrated that the majority of the
sample, and in particular those who were training
to become nurses, reported fat stigmatisation
and strong beliefs that obesity is controllable.
Controllability beliefs are particularly important,
as it is suggested that there is a positive correlation
between beliefs that obesity is controllable and
stigmatising attitudes towards obese people
(Allison et al, 1991).
Patient impact
The importance of studying healthcare
professionals’ attitudes is also highlighted by the
impact of stigmatising experiences on patients.
Patients report feelings of disrespect, criticism
and being dismissed by healthcare professionals,
which has led to the perception that their weight-
related concerns are not taken seriously and that
professionals are reluctant to address them (Brown
et al, 2006). For example, Brown et al (2007)
report that obese patients are reluctant and, in
some instances, ambivalent about raising concerns
about their weight due to their experiences with
the GP or practice nurse. This breakdown in
communication further exacerbates the poor
patient–practitioner relationship, potentially
leading to increased feelings of shame and
embarrassment in reporting health concerns.
Furthermore, these perceptions are suggested
to lead to patients avoiding and cancelling
appointments. There are also reports that parents
of obese children believe they are criticised by
healthcare professionals, which impacts the
patient–practitioner relationship (Anderson
and Wadden, 2004; Bertakis and Azari, 2005).
Tackling obesity stigma in healthcare to avoid this
detrimental impact on patients is warranted. Puhl
and Heuer (2010) suggest that obesity stigma is a
health threat, may cause health inequalities and
can hinder efforts to intervene with obesity.
Terminology used by healthcare
professionals
Beyond the attitudes of healthcare professionals,
consideration of the language used in consultation
has drawn some attention. Various terms are used
to refer to overweight and obese people (Smith
et al, 2007), and the impact of these terms has
been highlighted over the last decade. Schwartz
and Brownell (2004) suggest that the language
used may have a number of implications that are
particularly important in healthcare settings. The
interchangeable terminology used to describe
excess fatness and the impact of inappropriate
language employed by healthcare professionals
suggest that guidelines are warranted. Previous
research has highlighted the detrimental impacts
of inappropriate language on the patient–
practitioner relationship (Tailor and Ogden, 2009;
Dutton et al, 2010; Jochemsen-van der Leeuw
et al, 2011).
Certain language used by healthcare professionals
has been reported to stigmatise and impact
motivation by giving the impression of blaming
patients for their weight. Communicating effectively
by not stigmatising patients, emphasising health
improvement with change and identifying
achievable behavioural goals rather than weight
targets is recommended and may increase the
effectiveness of healthcare provision. Terms such
as fat, morbidly obese and chubby are reported
to be the most stigmatising and least motivating,
whilst other terms that should be used are weight,
Page points
1. Stigma in healthcare
professionals can be traced as
far back as medical school,
with the majority of healthcare
students reporting stigmatising
attitudes and the belief that
obesity is controllable.
2. The effects of this stigma on
patients include reluctance
to raise concerns about their
weight to their practitioner and
avoiding contact with them.
3. In addition to healthcare
providers’ at titudes, their
choice of language can affect
the relationship with patients
and can cause feelings of
stigma and demotivation.
Obesity stigma: Prevalence and impact in healthcare
British Journal of Obesity Volume 1 No 1 2015 17
unhealthy weight and overweight. Patients’ reactions
to stigmatising language include feeling upset and
embarrassed, seeking new healthcare support,
not talking to healthcare professionals about their
obesity and experiences, and avoiding subsequent
medical appointments (Amy et al, 2006; Tailor and
Ogden, 2009; Puhl et al, 2011; 2013).
Interventions to reduce obesity
stigmatisation
Anti-fat attitudes are reported to be robust
and resilient to change, and there have been
a number of unsuccessful intervention efforts
(e.g. Flint et al, 2013). Interventions that have
shown promise in studies of healthcare students
are those that attempt to address beliefs about
the controllability of obesity (O’Brien et al,
2010; Swift et al, 2013b). These interventions
can reduce obesity stigma through education
about the uncontrollable causes of obesity.
This is in line with suggestions that the more
controllable obesity is believed to be, the more
likely a healthcare provider is to have stigmatising
attitudes towards obese people.
Of the interventions for obesity stigmatisation,
educational interventions appear to be the
most successful (Daníelsdóttir et al, 2010). For
example, Poustchi et al (2013) reported that a
brief intervention in which medical students
were exposed to a 17-minute video titled Weight
Bias in Health Care, in addition to discussions
about their experiences with obese patients, was
effective in reducing obesity stereotypes and
increasing their belief that uncontrollable factors
such as genetics are a contributing cause of obesity.
Likewise, Kuschner et al (2014) reported that an
educational intervention consisting of interactions
with an overweight or obese patient, targeted
reading and a facilitated discussion was effective
in reducing stereotyping and increasing empathy
and confidence in counselling skills in a sample
of first-year undergraduate medical students.
However, despite the promising short-term
findings in reducing such stereotypes, follow-up
analysis 1 year later revealed that the reduction
in stereotyping had reverted to baseline levels.
Furthermore, to date, no evidence to demonstrate
the long-term effectiveness of interventions to
reduce obesity stigma has been published.
Conclusion
Given that the role of healthcare is preventive and
curative, reports that healthcare professionals
stigmatise obese patients and, in some cases, are
not performing their job by providing advice and
treatment are both concerning and unacceptable.
Stigmatising attitudes and behaviours of healthcare
professionals threaten efforts to address the
prevalence of obesity. The extent and impact of
stigmatising attitudes noted in extant literature
suggests that intervention is warranted. Stigmatising
attitudes towards obese people are reported in
medical students, and it is at this stage of training
where intervention appears to be most appropriate.
Reports that healthcare professionals and
students stigmatise obesity would suggest that
current training fails to address this issue. Recent
reports demonstrate that educational interventions
to modify beliefs about the controllability of
obesity is effective in reducing obesity stigma
during training; however, long-term interventions
are warranted. n
Allison DB, Basile VC, Yuker HE (1991) The measurement of
attitudes toward and beliefs about obese p ersons. Int J Eat Disord
10: 599 –607
Amy NK, Aalborg A, Lyons P, Keranen L (2006) Barriers to routine
gynecological cancer screening for white and African-American
obese women. Int J Obes (Lond) 30: 147–55
Anderson DA, Wadden TA (2004) Bariatric surgery patients’ views
of their physicians’ weight-related at titudes and practices. Obes
Res 12: 1587–95
Bacon JG, Scheltema KE, Robinson BE (2001) Fat phobia scale
revisited: the shor t form. Int J Obes Relat Metab Disord 25: 252–7
Bertakis KD, Azari R (2005) The impac t of obesity on primary care
visits. Obes Res 13: 1615–2 3
Brown I, Thompson J, Tod A, Jones G (200 6) Primary care support
for tackling obesit y: a qualitative study of the perceptions of
obese patients. Br J Gen Pract 56: 666 –72
Brown I, Stride C, Psarou A et al (2007) Management of obe sity in
primary care: nurses’ practice s, beliefs and attitudes. J Adv Nurs
59: 329 –41
Crandall CS (1994) Prejudice against fat people: ide ology and self-
interest. J Pers Soc Psychol 66: 882–94
Daníelsdóttir S, O’Brien KS, Ciao A (2010) Anti-fat prejudice
reduction: a review of published studies. Obes Facts 3: 47–58
Dutton GR, Tan F, Perri MG et al (2010) What words should we use
when discussing excess weight? J A m Board Fam Med 23: 60 6–13
Faith MS, Leone MA, Ayers TS et al (2002) Weight criticism during
physical activity, coping skills, and reported physical ac tivity in
children. Pediatrics 110 : e23
Ferrante JM, Piasecki AK, Ohman-Strickland PA, Crabtr ee BF (2009)
Family physicians’ practices and attitudes regarding care of
extremely obese patient s. Obesity (Silver Spring) 17: 17 10 –6
Page points
1. Educational interventions that
inform practitioners about the
uncontrollable causes of obesity
and allow discussion with obese
people about their experiences
have been shown to reduce
stigma and stereotyping.
2. These interventions are most
effective when delivered
to healthcare student s.
3. However, there is no
evidence that these ef fects
persist over the long term.
Obesity stigma: Prevalence and impact in healthcare
18 British Journal of Obesity Volume 1 No 1 2015
Flint SW, Reale S (2014) Obesity stigmatisation from obesity
researchers. Lancet 384: 1925 – 6
Flint SW, Snooke J (2014) Obesity and discrimination: the next “big
issue”? International Journal of Discriminatio n and the Law 14:
183 –9 3.
Flint SW, Hudson J, Lavallee D (2013) Counter-conditioning as
an intervention to modify anti- fat attitudes. Health Psychology
Research 1: 122–5.
Foster GD, Wadden TA, Makris AP et al (2003) Primary care
physicians’ attitudes about obesity and its treatment. O bes Res
11: 11 68 –7 7
Greenwald AG, McGhee DE, Schwartz JL (1998) Measuring
individual differences in implicit cognition: the implicit
association test. J Pers Soc Psychol 74 : 14 64 –80
Hebl MR, Xu J (2001) Weighing the care: physicians’ reactions to
the size of a patient. Int J Obes Relat Metab D isord 25: 1246–52
Huizinga MM, Cooper LA, Bleich SN et al (2009) Physician respect
for patients wit h obesity. J Gen Intern Med 24: 123 6–9
James WP (2008) WHO recognition of the global obesity epidemic.
Int J Obes (Lond) 32(Suppl 7): 120– 6
Jochemsen-van der Leeuw HG, van Dijk N, Wieringa-de Waard M
(2011) Attitude s towards obesity t reatment in GP training pract ices:
a focus group study. Fam Pract 28: 422–9
Keane M (1991) Acceptance vs. rejection: nursing students’ attitudes
about mental illness. Perspect Psychiatr Care 27: 13 – 8
Kolotkin RL, Mete r K, Williams GR (2001) Quality of life and ob esity.
Obes Rev 2: 219–29
Kristeller JL, Hoerr RA (1997) Physician attitudes toward managing
obesity: dif ferences among six specialty groups. Prev Med 26:
542–9
Kushner RF, Zeiss DM, Feinglass JM, Yelen M (2014) An obesity
educational inter vention for medical students addressing weight
bias and communication skills using standardized patient s. BMC
Med Educ 14: 53
Latner JD, O’Brien KS, Durso LE et al (2008) Weighing obesity
stigma: the relative strength of different forms of bias. Int J Obes
(Lond) 32: 1145–52
O’Brien KS, Puhl RM , Latner JD et al (2010) Reducing anti-fat
prejudice in preser vice health students: a randomized trial.
Obesity (Silver Spring) 18: 213 8 – 44
Ogden J, Hoppe R (1998) Changing practice nurses’ management of
ob es ity. J Hum Nutr Diet 11: 24 9– 56
Pearce MJ, Boergers J, Prinstein MJ (2002) Adolescent obesity, overt
and relational peer vic timization, and romantic relationships.
Obes Res 10: 386 –93
Persky S, Eccleston CP (2011) Impact of genetic causal information
on medical students’ clinical encounter s with an obese virtual
patient: health promotion and so cial stigma. Ann Behav Med 41:
363–72
Poon MY, Tarrant M (2009) Obesity: attitudes of undergraduate
student nurses and registered nurses. J Clin Nurs 18: 2355– 65
Poustchi Y, Saks NS, Piasecki AK e t al (2013) Brief intervention
effective in reducing weight bias in medical students. Fam Med
45: 345– 8
Price JH, Desmond SM, Krol RA et al (1987) Family practice
physicians’ beliefs, attitudes, and practices regarding obesity.
Am J Prev Med 3: 339 –45
Puhl R, Brownell KD (2001) Bias, discrimination, and obe sity. Obes
Res 9: 788 –8 05
Puhl RM, Brownell KD (2006) Confronting and coping with weight
stigma: an investigation of overweight and obese adults. Obesity
(Silver Spring) 14: 180 2–15
Puhl RM, Heuer C A (2009) The stigma of obesity: a review and
update. Obesity (Silver Spring) 17: 941– 64
Puhl RM, Heuer C A (2010) Obesit y stigma: important consid erations
for public health. Am J Public Health 100 : 10 19 –28
Puhl RM, Latne r JD (2007) Stigma, ob esity, and the health of the
nation’s children. Psychol Bull 133: 557– 80
Puhl RM, Peter son JL, Luedicke J (2011) Parental perceptions of
weight terminology t hat providers use with youth. Pediatrics 128:
e786–93
Puhl R, Peterson JL, Luedicke J (2013) Motivating or stigmatizing?
Public perceptions of weight-related language used by health
providers. Int J Ob es (Lond) 37: 612– 9
Robertson N, Vohora R (2008) Fitness vs. fatness: implicit bias
towards obesity among tness professionals and regular
exercisers. Psychol Sport Exerc 9: 547– 57
Rudman LA (2004) Sources of implicit attitudes. Curr Dir Psychol
Sci 13: 79– 82
Schvey NA, Puhl RM, Levandoski KA, Brownell KD (2013) The
inuence of a defendant’s body weight on perceptions of guilt.
Int J Obes (Lond) 37: 1275– 81
Schwartz MB, Brownell KD (2004) Obesity and body image. Body
Image 1: 43–56
Smith CA, Schmoll K, Konik J, Oberlander S (2007) Carrying weight
for the world: inuence of weight descriptors on judgments of
large-sized women. J Appl Soc Psychol 37: 989–1006
Swift JA, Hanlon S, El-Redy L et al (2013a) Weight bias among UK
trainee dietitians, doctors, nur ses and nutritionists. J Hum Nutr
Diet 26: 395 –4 02
Swift JA, Tischler V, Markham S et al (2013b) Are anti-stigma lms a
useful strate gy for reducing weight bias among trainee healthcare
professionals? Results of a pilot randomized control trial.
Obes Facts 6: 91–102
Tailor A, Ogden J (2009) Avoiding the term “obesity”: an
experimental study of the impact of doctors’ language on
patients’ belief s. Patient Educ Couns 76 : 260 –4
Teachman BA, Brownell KD (2001) Implicit anti-fat bias among
health professionals: is anyone immune? Int J Obes Relat Metab
Disord 25: 1525 –31
Tillman T, Kehle TJ, Bray MA et al (2007) Elementar y school students’
perceptions o f overweight peers. Can J School Psychol 22: 68– 80
Vartanian LR, Shaprow JG (20 08) Effec ts of weight stigma on
exercise motivation and b ehavior: a preliminary investigation
among college-age d females. J Health Psychol 13: 131– 8
Wear D, Aultman JM, Varley JD, Zarconi J (2006) Making fun of
patients: medic al students’ perceptions and use of derogatory
and cynical humor in clinical set tings. Acad Med 81: 454 –62
Wigton RS, McGaghie WC (2001) The effect of obesity on medical
students’ approach to patients with abdominal pain. J Gen Intern
Med 16: 262–5
“Given that the
role of healthcare is
preventive and curative,
reports that healthcare
professionals stigmatise
obese patients and, in
some cases, are not
performing their job
by providing advice
and treatment are
both concerning and
unacceptable.”
