WEIGHT AND WEIGHT BIAS 101

What are we talking about when we talk about weight and weight bias? 

Weight bias: Weight bias refers to discriminatory attitudes or behaviors towards people based on their body, habitus, or weight. Weight bias can occur in many settings, including in health care (Diedrichs, 2011).

Body positivity: Body positivity is a social movement aimed at promoting the acceptance and appreciation of all bodies. This movement challenges conventional beauty standards and emphasizes the importance of self-love (Cohen, 2020).   

Thin privilege: Thin privilege refers to the advantages that people with smaller bodies accrue due to their body size (Puhl & Heuer, 2010).

Weight-neutral approach: A weight-neutral approach is an approach to patient care that focuses on improving overall health and health behaviors, and does not focus on a person’s weight or body size (Association for Size Diversity and Health).

Why do weight and weight bias matter in healthcare?

Being aware of weight bias in healthcare is incredibly important: weight bias can both decrease the quality of care and hurt the patient-provider relationship (Phelan et al., 2015). Research demonstrates that healthcare providers often have negative beliefs and attitudes towards patients with higher body weights. Providers may spend less time with patients who are obese, offer them less counseling on health behaviors, and exhibit less empathy toward them (Gudzune et al., 2013). 

This weight bias can decrease patient satisfaction and increase health disparities. According to a narrative literature review, patients who are subject to weight bias are less likely to seek care and adhere to recommendations, and are more likely to have poor health outcomes (Phelan et al., 2015a). The damage that weight bias causes to the patient-provider relationship can decrease trust and lead to poor communication. 

What do we know about weight and weight bias in medical and health professions education?

Studies have shown that medical students’ education plays a role in determining their attitudes towards weight and weight bias. A 2013 study showed that the majority of first-year medical students exhibited both implicit and explicit weight bias (Phelan et al., 2013). And, over time, another study found an increase in both implicit and explicit weight bias among medical students exposed to faculty who modeled discriminatory behavior toward patients with obesity (Phelan et al., 2015b). 

Medical schools and other education programs can reduce the weight bias of many future health professionals. By modeling respectful encounters with patients with obesity, educating students about genetic and environmental causes of obesity, and increasing opportunities for positive contact between students and patients with obesity, faculty can reduce weight bias among medical students (Phelan et al., 2015b; Phelan et al. 2013). Addressing weight bias in medical education is an important step toward improving health care experiences and outcomes for patients. 

How does the Bias Checklist address weight and weight bias in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of weight and weight bias?”

If you answer no, you will be prompted to consider whether your content should mention weight and weight bias.

The Bias Checklist asks the following questions about weight-related content:

  • Does the content include any mention of weight or body mass index?

  • Does the content assume or imply a linear or straightforward relationship between weight (or body mass index) and health?

  • Does the content emphasize personal responsibility in discussions of obesity?

  • Does the content discuss genetic, epigenetic, social and structural risk factors related to obesity?

Below are some examples of common ways in which bias, shame, stereotype, and stigma toward weight can manifest in health professions education content:

  • Describing overweight and obese patients as "noncompliant"

  • Assuming that all overweight and obese are unhealthy, when it is much more complicated biologically

  • Any comment about this subject that is meant to elicit laughter

Last, the Checklist asks: 

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: An image of an overweight Mona Lisa is widely used in diabetes education. In this context, its intent is likely to use the weight of the subject as a source of humor. In addition, it reinforces the idea of a linear relationship between fatness and health. Less biased content could remove this image. Click here to view the image.

  • Example: Examples of weight bias submitted to the Bias Checklist sometimes emphasize personal responsibility in discussions of obesity, as opposed to genetic, epigenetic, social, and structural factors that contribute to obesity. Vignettes should avoid using language that blames a patient when a lifestyle change does not lead to weight loss.

  • Example: One test question describes an examination of an “obese man with no other abnormalities.” First, the AMA recommends the use of person-first language in discussing people with obesity (see more information here: https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-H-440.821.xml). In addition, the use of the phrase “no other abnormalities” stigmatizes obesity. This question might be better phrased to describe an “unremarkable man with obesity.”

Where can I go to learn more? 

I learn best by…

Reading

  • "The Body Is Not an Apology: The Power of Radical Self-Love" by Sonya Renee Taylor

  • "Health at Every Size: The Surprising Truth About Your Weight" by Lindo Bacon

  • "Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand About Weight" by Lindo Bacon and Lucy Aphramor

Watching

  • "The Weight of the Nation": a four-part documentary series exploring obesity in the United States

  • "Fat Chance": a TED Talk by writer and researcher Dr. Lindo Bacon on the health benefits of embracing body diversity

  • "Weight Bias in Medicine: A Growing Concern": a webinar hosted by the Obesity Society discussing the impact of weight bias on healthcare

Listening

  •  "The Body Love Project": a podcast dedicated to promoting body positivity and inclusiveness

  • "Food Psych": a podcast that explores the psychology of eating, body image, and relationships with food

Need a consultation?

The following people have identified themselves as experts in weight bias and are willing to be contacted with questions regarding your content.

  • Rebecca Garden, PhD, Associate Professor of Public Health and Preventive Medicine, SUNY Upstate Medical University (email: gardenr@upstate.edu)

  • Karen Teelin, MD, MSEd, Associate Professor of Pediatrics, SUNY Upstate Medical University (email: teelink@upstate.edu)

Have something to add? 

Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Weight and Weight Bias 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Weight and Weight Bias 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Weight and Weight Bias 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Weight and Weight Bias 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Weight and Weight Bias 101 - Consultant”

References

  1. Cohen, Rachel, et al. (2020). The case for body positivity on social media. Journal of Health Psychology, 26(13). https://doi.org/10.1177/1359105320912450

  2. Diedrichs, Phillippa C. (2011). How to lose weight bias fast! British Journal of Health Psychology, 16(4), 846-861. https://doi.org/10.1111/j.2044-8287.2011.02022

  3. Puhl, R. M., & Heuer, C. A. (2010). Obesity Stigma: Important Considerations for Public Health. American Journal of Public Health, 100(6), 1019-1028. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2009.159491

  4. The health at every size® (HAES) principles. (2023, March 9). ASDAH. Retrieved March 30, 2023, from https://www.sizediversityandhealth.org/health-at-every-size-haes-approach/ 

  5. Phelan, S.M., et al. (2015a). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev., 16(4), 319-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381543/

  6. Gudzune, K. A., et al. (2013). Physicians build less rapport with obese patients. Obesity, 21(10), 2146-2152. https://onlinelibrary.wiley.com/doi/full/10.1002/oby.20384

  7. Phelan, S. M., et al. (2015b). The mixed impact of medical school on medical students’ implicit and explicit weight bias. Medical education, 49(10), 983-992. https://onlinelibrary.wiley.com/doi/abs/10.1111/medu.12770

  8. Phelan, S. M., et al. (2013). Implicit and explicit weight bias in a national sample of 4,732 medical students. Obesity, 22(4), 1201-1208. https://onlinelibrary.wiley.com/doi/abs/10.1002/oby.20687

contributing writer(s)

Sophie Pollack-Milgate, BA

Jacqueline Hogan, MD Candidate

last updated October 4, 2023