“Eat less and exercise more.” “Change your behavior and you’ll lose weight.” “It’s all in your head.” “It’s your lack of willpower.” “You’re selfish and lazy.” This is what people with obesity often hear from the media, friends, family and strangers.
Sadly, it’s what many hear from their doctors, too. More than half of patients with obesity reported experiencing weight stigma and of those, 66% experienced this stigma from physicians, according to a 2021 study conducted in six Western countries. That included perceived judgment from doctors about their weight. The result was patients with higher internalized weight bias avoiding healthcare visits more frequently than those without internalized bias.
Over 70% of U.S. adults struggle with obesity or being overweight. Why are we stigmatizing the majority of our population? While any obesity stigma is bad, it’s particularly discouraging that much of it comes from the healthcare industry. People with clinical obesity have a higher incidence of associated chronic diseases such as diabetes, hypertension and certain cancers, and treating obesity lowers the impact and prevalence of these and other medical conditions. The impact of stigma on treatment is acute for this population.
Americans are slowly starting to realize that obesity is a medical disease, rather than a moral condition. The American Medical Association recognized it as a disease in 2013, but the idea is still controversial in some circles. For the public, the tide is turning somewhat, due to GLP-1s, which raised awareness of the causes of obesity and its treatment into the spotlight.
As we know, the causes of obesity are not binary. While behavior is a factor in the development of obesity, there are also genetic and cultural contributions such as a meteoric rise in processed foods in the past few decades, which affect caloric intake and absorption.
Stigma Results in Worse Health Outcomes
Stigma can lead to self-blame, mental stress, additional weight gain and worse health outcomes. It can also hold people back from getting medical treatment, especially underserved populations such as Black and Hispanic Americans, making it less likely they will access treatment.
Framing obesity as a moral issue leads to more stigma. While some physicians may think of medication or bariatric surgery as “taking the easy way out,” arguing that patients should be able to lose the weight on their own, the “eat less, exercise more” approach does not work for most in this population. Fewer than 1% of obese people will obtain a normal body weight long-term. Continuing to stigmatize obesity is not only misguided, it’s futile.
How to Tackle the Stigma
Tackling stigma is not easy or quick, but there are ways to approach it. Acknowledging obesity as a disease, with treatment covered in company benefits, is an important step. The approval of GLP-1 medications for weight loss has many excited about the possibilities for improving healthcare status and outcomes in people with obesity, but there are obvious concerns about the cost. About 46% of large employers are covering these drugs for weight loss in 2024, according to a Business Group on Health survey, and 45% of employers pay for bariatric surgery.
Understandably, these benefits are expensive and employers are struggling to provide these needed and wanted healthcare benefits while containing the costs. Some are turning to third parties to provide weight loss program management. Others are considering the longer-term lower mortality and morbidity rates that decreasing weight can provide, along with employees valuing these treatments, and determining that the treatment costs are a worthwhile investment.
It’s important, though, that this stigma is also addressed with providers–first recognizing that it exists. Then we need to understand that obesity is a complex disease, much like hypertension or an autoimmune disorder. Research shows that patients are more likely to be open to treatment if doctors discuss it as a medical condition with multiple treatment options. When addressed as a chronic but treatable medical condition, patients and providers improved their relationship, reducing the patient’s internalized weight bias.
Recognizing the biases in how we treat obesity is the first step towards reassessing clinical decisions, including reviewing referral patterns for specialized obesity care, like anti-obesity medications and bariatric surgery. In ensuring we offer patients personalized care that considers the full complement of options, we help overcome treatment biases.
Lastly, we need doctors to get more education about obesity, both in medical school and through continuing education. Medical schools are selectively adding education about obesity and its comorbidities, but it needs to be done across the board. Fellowships in obesity care are on the rise, but most people with obesity are seen by primary care physicians without specialized training. These doctors want the best for their patients but may not be trained to say the right thing to patients or know the optimal resources to offer.
Understanding obesity as a treatable medical condition and chronic disease is the first step to reducing stigma. Obesity is not a personal failing. While lifestyle interventions may contribute to weight loss, these are not the only options and promoting them exclusively further reinforces the stigma.
As the spotlight is starting to shine on obesity care, we have an opportunity to make inroads. We can help reduce comorbidities through medications and bariatric surgery, so our patients can lead healthier and happier lives.
That is the goal, and reducing the stigma around obesity is a crucial step in that direction.
Dr. Raj Aggarwal and Dr. Tzvi Doron, twenty30 health.
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