Weight Bias and Obesity Discrimination

Every nurse knows they must give equal care to their patients, regardless of the patients’ status or situation. They also know they must regularly examine their own attitudes to recognize negative opinions and perceptions regarding certain types of patients. If discrimination is present—whether intentional or not--it can significantly impact the quality of care.

Discrimination is defined as the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age, or sexual orientation. One area of discrimination that’s important—and not always included in the definition--is obesity and its cousin, weight bias.

Adult BMI Chart: World Health Organization, 2019

Obesity discrimination in healthcare is the unequal treatment when people with obesity do not receive the same optimal care as people with normal BMI. Weight bias is seen in the negative attitudes, beliefs, assumptions, and stereotypes toward people with overweight or obesity.

Obesity discrimination and weight bias: Common in healthcare

People who are living with overweight (a body mass index [BMI] of 25 or greater) or obesity (a BMI of 30 or greater) are often treated differently by healthcare professionals. Research has consistently shown that many providers have harmful beliefs about these patients, including:

• Overweight people are always unhealthy
• If they cared about their health, they would lose weight
• Obese people lack self-control or discipline
• They are less likely to be compliant with treatment
• Overweight people are untidy and unhygienic
• They are less intelligent than people with normal BMI

An article in the American Medical Association Journal of Ethics cited papers showing that the incidence of weight bias has increased 66% since the period of 1995-2005; it now exceeds the level of racial, ethnic, physical disability, and sexual orientation biases. Women tend to face the most discrimination.

The article notes that in a survey of people with overweight or obesity, over half reported “inappropriate” comments from their healthcare providers regarding their weight. Rudd Center for Food Policy and Obesity notes that 69% of adults with obesity feel stigmatized by their healthcare professionals.

About 40% of healthcare professionals admit to having a negative response to patients with obesity. Another survey found that 24% of nurses felt “repulsed” by patients with obesity and 12% did not want to touch these patients. A third study revealed that 31% to 42% of nurses did not want to care for patients with obesity.

Patients with overweight or obesity tend to receive a lower quality of care than their peers without these conditions for several reasons:

1. Healthcare professionals spend less time with patients that they perceive to be non-compliant.
2. Primary care providers report having less respect for patients with obesity, so their communication and willingness to provide information are decreased.
3. One study showed that patients with overweight or obesity received 28% less time from healthcare professionals than patients with normal BMI.

One of the most troubling outcomes of weight bias is that healthcare professionals—including nurses—tend to downplay symptoms reported by patients with overweight or obesity. They focus on the patient’s weight, attributing complaints to obesity, even when symptoms indicate simple conditions like the flu or a cold. Providers make comments such as “If you’d lose weight, you wouldn’t have this problem.”

In a separate aspect, healthcare settings frequently don’t prepare for their patients with overweight or obesity. They may not provide proper equipment, such as extra-large blood pressure cuffs. Appropriately sized gowns are not available. Scales may not weigh above 350 pounds, or patients are weighed in a public area. Waiting rooms and examination rooms may not have chairs without arms. All of these send signals to people with overweight and obesity: “We don’t acknowledge or respect you.”

The stigma of not having a slender body

The result of these attitudes and beliefs is the stigma experienced by patients with overweight or obesity. Stigma is being seen in a damaging way because of a socially-degrading characteristic that’s considered to be a negative stereotype. Stigma leads to discrimination.

Some of the harmful effects of being subjected to stigma can include:

• Reluctance to seek medical help
• Lack of understanding by family, friends, co-workers or the public
• Fewer opportunities for work and school
• Hesitancy to participate in social activities
• Trouble finding appropriate housing
• Bullying, physical violence or harassment
• Belief of never succeeding or improving a situation

When a person with overweight or obesity experiences stigma or discrimination, they often eat more calories. About 80% of both genders reported using food as a coping strategy following an episode of “fat-shaming.” And 75% defiantly decide they will simply refuse to reduce their food intake. So, the healthcare professionals, who should be providing care and support, essentially provoke their patients to continue maladaptive responses to their condition.

Mental health problems are also associated with having overweight or obesity. People with these conditions experience depression, as well as feelings of guilt, rejection, and shame. They may be self-isolate and avoid social situations where they feel judged.

Make no mistake, too much weight is not healthy

Obesity has more than tripled since the 1960s. It is now more widespread than the opioid crisis. The World Health Organization considers it a global epidemic.

The National Institutes of Health recognized obesity as a disease in 1998. In 2013, the American Medical Association (AMA) declared obesity (BMI greater than 30) a chronic disease. The AMA states, “…it is a disease state with multiple functional changes that require a range of treatment and prevention options.”

According to the Centers for Disease Control and Prevention (CDC), the obesity prevalence in the United States is 42%. Between 1999-2000, the rate increased from 30.5% to 41.9%, with severe obesity increasing from 4.7% to 9.2%.

Part of the issue that healthcare professionals struggle with is that they know having overweight or obesity contributes to many serious medical conditions of the patients they care for. The National Institute of Health lists the health risks of carrying too much weight:

• Type 2 diabetes
• Hypertension
• Heart disease
• Respiratory disease
• Stroke
• Sleep apnea
• Metabolic syndrome
• Fatty liver disease
• Osteoarthritis
• Gallbladder disease
• Some cancers
• Kidney disease
• Pregnancy complications
• Premature death

It’s challenging for healthcare professionals who devote their careers to providing care for all who need it, to admit they find themselves conflicted regarding patients with overweight and obesity. Because treatment of these patients is not simple and straightforward, healthcare professionals can feel as frustrated as their patients, and revert to relying on stereotypes when planning or delivering care.

What can nurses do to address weight bias and obesity discrimination?

Provision 1 of the Code of Ethics for Nurses states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” Provision 3 continues: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.”

The first thing to do is to be aware of your own attitudes and beliefs about having overweight or obesity. It’s a good idea to do this for all potential areas of discrimination—everyone carries some type of bias. Our willingness to consider our own biases can lead to changes in our behavior.

When we don’t even know we have a bias, it’s called “implicit bias,” “unconscious bias,” or “hidden bias,” because we automatically arrive at our decisions and actions in an automatic way, without awareness, often based on stereotypes. Implicit or unconscious bias can be both positive and negative; unfortunately, with weight bias and obesity discrimination, the bias tends to be negative.

“Explicit bias” occurs when someone consciously and intentionally expresses their opinions, attitudes, or beliefs.

The Joint Commission has focused on implicit bias, because of its impact on equality in healthcare. Stereotypes result in resistance, and ultimately, discrimination. Here is what the Joint Commission says: “There is extensive evidence and research that finds unconscious biases can lead to differential treatment of patients by race, gender, weight, age, language, income and insurance status.”

Ideally, every person is entitled to equal holistic health care. No one should be—or feel—disadvantaged for any reason. This is where nurses can step up and change the conversation.

As members of the most honest and ethical profession, nurses are in an excellent position to combat weight bias and obesity discrimination.

Here are some important points:

• Remember that obesity is a chronic disease, NOT a personality trait.
• Weight control is complicated, much more than just cutting back on calories and moving around more. It’s an interaction between a person’s genetic background, their own medical history, their environment, and their personal situation.
• Saying “Some of my best friends are_______” does not change a belief; it reinforces implicit bias.
• As an advocate for all patients, a nurse should intervene when they detect weight bias or obesity discrimination.
• Ask patients if their questions have been answered or if they have the information they need to understand and comply with their condition and treatment.
• Use “person-first” language, as with any other disease. Do not say, “I’m caring for an obese patient.” Instead, say, “I am caring for a patient with obesity.”
• Do not use the term “morbidly obese,” and correct others who do. No other disease includes “morbid.” The proper term is “severe obesity.”

Weight-Neutral Terms for Healthcare Professionals

Educate yourself as you would with any disease

Overweight and obesity are permanent conditions around the world, the same as any other disease or disorder. Unfortunately, they are not included in most nursing or medical school curriculums. It’s up to all healthcare professionals to learn as much as possible about them in order to provide compassionate and effective care.

Here are some useful resources:

Harvard Implicit Association Test for Weight: This short test takes about 10 minutes. It assesses your beliefs, attitudes, and opinions about overweight and obesity. You will be asked to give basic demographic information, then will take a rapid test with drawings and words associated with weight. Results are given after you complete the test.
Obesity Fact Sheet: The Preventive Cardiovascular Nurses Association offers a concise fact sheet to use for patient education. It is meant for support and treatment management.

Nurses Obesity Network: Join this diverse group of nursing organizations working together to change the way nurses “view, treat, and advance care for people living with obesity.”

The Obesity Society: A scientific organization, the website has a tab for Healthcare Providers and Patients, with free articles and handouts.

Centers for Disease Control and Prevention: The CDC is always a good place to check for any type of health information. The Resources Library for Obesity includes fact sheets, statistics, and published research.

Department of Health and Human Services: As part of the Healthy People 2030 Initiative, HHS has an extensive list of evidence-based resources that can be used to establish programs and education efforts.

About the Author

Winona Suzanne Ball

Nursing Adviser, RN | MHS, Governors State University, IL
Full member of the American Nurses Association. Learn more