Fat Stigma in Women’s Health, led by the authors of this article, will be the focus of an Oct. 15 breakout session at the 24th Annual NPWH Premier Women’s Healthcare Conference, being held virtually from Oct. 13-16. Register here.

Fat stigma is a pervasive prejudice based on body size. It can be found in all aspects of society, with especially deleterious effects in healthcare. Strategies to decrease fat stigmatization include identification of implicit biases, advocacy of evidence-based interventions, and promotion of weight-inclusive practice.

Key words: fat stigma, weight inclusive, weight normative

Fat stigma is the phenomenon in which people living in larger bodies experience status loss and discrimination based on their body size. This is a widespread phenomenon that often affects individuals in every facet of their lives. In healthcare, and women’s health specifically, fat stigma is often related to negative health outcomes and barriers to care that systemically affect patients in larger bodies.¹ This phenomenon has started to gain the attention of healthcare providers and systems alike. Despite growing awareness, however, there remains a lack of understanding of how to specifically address the problem on individual provider and system levels to allow patients to feel a decreased impact of fat stigma. This article examines the impact of fat stigma on patients, identifies strategies to decrease stigmatization, and discusses the role of nurse practitioners in decreasing the experience of fat stigma. 

Impact of fat stigma on health

When addressing the issue of fat stigma and the impact it has on patients, it is important to consider the context of this phenomenon within the healthcare system. Body size, weight, and body mass index (BMI) are considered primary indicators of health and disease for many providers. Many symptoms and comorbidities are often quickly and directly blamed on body size, leading to limited evaluation or dismissive management plans. Additionally, an elevated BMI may be used as evidence of a “noncompliant patient” or one who does not care about their health.¹

Although some research shows correlation between certain comorbidities and body size, only a scant number of studies have found causation between the two. Rather than understanding this as an association, many in the healthcare field have attributed negative health outcomes solely to body size. Alternatively, evidence supports the idea that fat stigma can often have an unintended consequence and cause negative health outcomes.² Fat stigma can result in both negative patient experiences and outcomes. Experiences of fat stigma in a clinical setting can lead to avoidance behaviors, poor communication, decreased adherence, and a decrease in self-care behaviors.² Additionally, experiencing perceived discrimination has been linked to an increase in stress hormones, which can result in depression, anxiety, and heart disease.² Further, the experience of fat stigma is associated with decreased self-esteem and body image, and an increase in eating disturbances.¹ Connections have been established between fat stigma and a decreased motivation toward exercise and wellness behaviors.³ This then works to reinforce internal and social stereotypes that those living in larger bodies are inherently unmotivated toward wellness behaviors.³

Fat stigma is increased by blaming these negative outcomes solely on body size.³ If BMI is not a primary indicator of health, then weight loss is not an appropriate, quick fix to the variety of health problems for which it is often prescribed. The focus on body size and weight reduction perpetuate stigma and can act as a barrier and deterrent to care for many patients.²

Addressing implicit bias

Given the pervasiveness of fat stigma in society, a foundational first step in addressing the issue is an awareness of one’s own implicit biases regarding weight. All individuals have biases. These biases influence how one perceives and interacts with others. Bias on a conscious level is categorized as known or explicit bias, while bias that exists on a subconscious level is termed unconscious or implicit bias. Explicit bias in the context of fat stigma may present as a direct address of weight in a negative manner or connotation or jokes that reinforce stereotypes. Implicit bias may manifest as microaggressions (ie, verbal, behavioral, environmental) in interactions with others, resulting in negative encounters.^4,5 Examples of microaggression related to weight include waiting room or exam room furniture that does not accommodate higher-weight individuals, routine weight checks for all visits, and weight checks conducted in public areas.^3,6 Becoming aware of such biases allows the conscious work needed to resolve them. Several validated measures for self-assessment of weight bias are available through the UConn Rudd Center for Food Policy and Obesity website.⁷

An important part of exploring individual bias is understanding the concept of intersectionality in both the perpetuation and experience of stigma. Intersectionality is the concept that attempts to address the interactions between multiple social categories that an individual or population may experience.⁸ Social categories that interact include race, gender, sexual orientation, and socioeconomic status. Intersections between these categories may result in an increase in advantages or disadvantages when considered together.⁸ For example, a lesbian woman may experience increased discrimination due to the cumulative effect of her identity as a sexual minority along with her identity as a woman. These two identities may have cumulative disadvantages that are different and possibly potentiated when compared to the sum of her labels as “lesbian” and “female.”⁸

It is common for an individual who experiences fat stigma to experience stigma and discrimination as an intersection of other social categories.⁸ Elevated BMI is associated with sexual minority women and women of some racial minorities including African American and Hispanic populations.⁸ Further, different populations may vary in perception and internalization of fat stigma in a way that is relevant in how to implement fat stigma-reducing interventions.⁸

An example of intersection between weight and race can be seen in the following study. The US Department of Health and Human Services conducted a study evaluating the impact of body size and race on patient–provider communication.⁹ Their results showed no difference in quality of provider time and communication between lower and higher BMI groups of White participants. They did find, however, that Black participants with higher BMI reported decreased quality of provider communication in relation to time spent during the encounter as well as decreased quality of explanation in ways the patient could understand. Further, the Black participants with normal BMI reported higher quality in patient–provider communication and quality of provider time.⁹ This example illustrates the intersection between body size and race in individual experience in the healthcare system. When considering multiple social groups, the patient-reported experience changes. It is important when reflecting on one’s biases to do so with attention to intersectionality. Further, an intense emphasis on BMI may mask bias and discrimination against any marginalized population, as elevated BMI can be associated with social groups including African American, Hispanic, and sexual minority women, as listed previously.⁹

Using a weight-inclusive approach to care

After addressing personal bias, the next crucial step in addressing fat stigma is adopting a weight-inclusive approach to care. The weight-inclusive approach is an alternative to the weight-normative approach. The weight-normative approach utilizes BMI as a primary indicator of health and often leads to the recommendations of weight loss to treat complex illness. The weight-normative approach relates health and weight in a linear manner, resulting in assumptions that patients with higher BMI must be less healthy.³ It often relies on the concept that “healthy” weight is a direct result of a healthy lifestyle, with the implication being that people who have a high BMI are not doing enough, or working hard enough, to achieve optimal health. Despite the prevalence of this approach in the healthcare field, research connecting BMI and health do not establish causality or a linear relationship between the two.³ As mentioned earlier, the connection between BMI and health can in many ways be illustrated as a connection between experience of fat stigma and negative health outcomes.²

The weight-inclusive approach does not use BMI and body size as focal points in determining health status or management of illness. This approach recognizes that every patient has the potential to achieve wellness independent of weight when care is readily accessible and provided with dignity. The weight-inclusive approach can be seen as a key component of the Health at Every Size (HAES) movement to support people of all sizes in addressing health directly by adopting healthy behaviors.¹⁰ The weight-inclusive approach, specifically the HAES version, is evidence based, with research illustrating improvements in measures including physiologic measures, health practices, and psychological measures.³

Principles of the weight-inclusive approach can be used in daily clinical practice to deconstruct the weight-normative approach and decrease the amount of fat stigma experienced by patients. Box 1 summarizes weight-inclusive approach principles.³ Patient care using this approach is often multidisciplinary including mental health professionals and dieticians. Nurse practitioners (NPs) can lead the way on these multidisciplinary teams through patient advocacy for institutional changes.^3,11 

An essential step is to communicate the need for a weight-inclusive approach with all healthcare team members. To effectively incorporate the skills of each team member for sustained change, there must be a commitment to reducing and counteracting fat stigma experienced by patients.³

All team members should be willing to critically appraise the research that exists about obesity and health. It is important to be critical of assumptions made in the research, including BMI as a primary indicator of health. Does the research show causation? Is BMI a sole cause, a risk factor, or an associated finding?

Finally, prior to instituting direct interventions into patient care, the NP must deconstruct any underlying assumptions they may have due to prior use of the weight-normative approach. This includes understanding that people come in all shapes and sizes. Body size is not a direct reflection of one’s health, lifestyle, or character.³ Further, one’s relationship to their body, to food, and to a “healthy” lifestyle is often complex and should be considered with empathy when considering lifestyle recommendations appropriate to provide. Many people have been exposed to fat stigma, and its impact, within the healthcare system and in other facets of their lives. Being mindful of these considerations can help prepare a clinician for patient-centered, intersectional, and empathy-driven approaches to addressing fat stigma in their clinical settings and with their patients.^3,8,10

Role of NP in decreasing fat stigma

A weight-inclusive approach includes strategies that may be used to decrease fat stigma. NPs can help patients address internalized stigma and body shame and challenge any internalized expectations of weight loss. When patients ask about weight loss strategies, ask why they are interested in losing weight. Is the motivation wellness oriented or due to the expectation that they should have a smaller body? Provide feedback that counteracts the negative messages received in every facet of their lives. Let them know that weight loss is not a solution to all health problems, and that together as a team you can work to achieve their identified wellness goal.^3,11 Box 2 provides examples of strategies that can be used in short encounters to support patients and counteract fat stigma.^3,10

After years of experiencing fat stigma and body shame, many people have become disconnected from their own body. Often, there is a feeling that they are working against their body to lose weight. One may feel that it is their body preventing them from attaining the wellness they desire. NPs can help patients explore ways that their body is working as a partner with them. That partnership may be the ability to attain a physical feat, but it may also be as simple as their body allows them to connect with their loved ones. Researchers have reported increased body shame decreases engagement in self-care behaviors.³ These self-care behaviors are crucial to attaining wellness. By discussing the body as a partner in wellness rather than an obstacle, body shame can be gradually reduced. With a reduction in body shame, engagement in self-care activities may increase and the appreciation of one’s body can sustain motivation toward wellness longer than body shame does.³

If a patient is hoping to lose weight to improve wellness, this is an opportunity to change the focus from weight and body size reduction to a focus on holistic wellness. This includes interventions including intuitive eating and exercise one is interested in or feels physically good doing. Encouraging a patient to be aware of and true to hunger cues can help increase the sense of partnership with one’s body and decrease body shame. Research also shows that an emphasis on intuitive eating over time does not change body size but does improve the relationship to food, allowing for sustainable changes that may improve health.¹⁰

Encouraging joyful movement that makes the body feel good increases the likelihood of sustainability over time. Weight loss does not have the cure-all effect that is often attributed to it, but exercise as a self-care behavior can be important in physical and mental health. Exercise has been demonstrated to have positive effects on cardiovascular disease independent of weight and to improve mood and wellbeing through natural beta endorphins.¹² Beta endorphins are physiologic peptides produced by the central nervous system that have an impact on pain and stress.¹³ By participating in even short amounts of high-intensity exercise, the level of beta endorphins in the brain has been shown to increase and cause a positive mood shift.¹³ This suggests that exercise independent of weight has positive benefits on mood states and stress levels. By separating exercise and food intake from body size and weight loss, overall wellness can be improved. Personal empowerment can be increased by connecting and being in partnership with one’s body.¹⁰

NPs can also serve as advocates within their institutions to address implicit and explicit fat stigmatization that impacts healthcare and health outcomes. Further, NPs can engage with communities to ensure access to nutrient-dense foods, safe physical activity resources, and support services that emphasize a weight-inclusive approach.

Box 3 provides resources for healthcare providers and patient education and support in reducing fat stigma and implementing a weight-inclusive approach.

Conclusion

Practicing within the weight-inclusive approach contributes to the simultaneous attainment of patient-centered care and equity in healthcare settings. Patients have different care requirements depending on diverse factors in each of their lives. Fat stigma must be considered through an intersectional lens to best understand each individual’s perspective and experienced discrimination.

Initial change occurs on the individual NP level with self-awareness of one’s own biases and motivation for positive change. When the NP refuses to actively engage in or passively condone stigmatization based on body size, the necessary paradigm shift for positive change will occur. NPs have an opportunity to lead the way in providing evidence-based, patient-centered care that will result in a return of the foundational respect fat stigma has stripped from patient care. Ongoing research is needed to improve understanding of the impact of fat stigma, contributing factors, and interventions that will be effective in improving the patient experience and health outcomes in the short and long term. =

References

1. Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: a systematic review. J Adv Nurs. 2018;74(5):1030-1042.
2. Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326.
3. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;1-18.
4. The Ohio State University. Kirwan Institute for the Study of Race and Ethnicity. Understanding implicit bias. 2015. http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/.
5. Tyner AR. Unconscious bias, implicit bias, and microaggressions: what can we do about them? American Bar Association. GPSolo. July/August 2019;36(4).
6. Munro L. Everyday indignities: using the microaggressions framework to understand weight stigma. J Law Med Ethics. 2017;45(4):502–509.
7. UConn Rudd Center for Food Policy and Obesity. Weight bias and stigma > Tools for researchers, 2019. http://www.uconnruddcenter.org/weight-bias-stigma-tools-for-researchers.
8. Himmelstein MS, Puhl R, Quinn D. Intersectionality: an understudied framework for addressing weight stigma. Am J Prev Med. 2017;53(4):421-431.
9. Wong MS, Gudzune KA, Bleich SN. Provider communication quality: influence of patients’ weight and race. Patient Educ Couns. 2015;98(4):492-498.
10. Bombak A. Obesity, health at every size, and public health policy. Am J Public Health. 2014;104(2):e60-e67.
11. Puhl RM, Phelan SM, Nadglowski J, Kyle TK. Overcoming weight bias in the management of patients with diabetes and obesity. Clin Diabetes. 2016;34(1):44-50.
12. Miller KR, McClave SA, Jampolis MB, et al. The health benefits of exercise and physical activity. Curr Nutr Rep. 2016;5:204-212.
13. Basso JC, Suzuki, WA. The effects of acute exercise on mood, cognition, neurophysiology, and neurochemical pathways: A review. Brain Plasticity. 2016;2:127-152.

Web resources

npwh.org/courses/home/details/1555

uconnruddcenter.org/

sizediversityandhealth.org/

haescommunity.com/

benourished.org/

intuitiveeating.org/