Beyond the Scale: Addressing Weight Stigma to Improve the Care of Patients with Serious Illness

Mary, a 60-year-old female, was referred for a psychological evaluation due to feelings of anger and depression. During that visit, she shared that for months she had reported abdominal discomfort to her primary care provider, only to be told that dietary changes would help. As someone with a larger body, Mary had a long history of feeling dismissed in medical settings. When she finally pushed for further evaluation, she was diagnosed with ovarian cancer.

Understandably, Mary felt betrayed and angry. She couldn’t stop wondering whether things might have been different if her concerns had been taken seriously. Her diagnosis shook her trust in the health care system and made it difficult to engage with her oncology team—adding emotional pain to an already devastating experience.

Mary’s experience is not unique.

As clinicians caring for people with serious illness, we often see patients living with excess body weight. More than two out of five adults in the U.S. have obesity (defined as a BMI > 30), and one-third of cancer survivors over age 20 fall into this category. With numbers like these, it’s not a question of if you’ll care for a seriously ill patient with excess body weight, but when—and how well.

Many patients with excess body weight have experienced discrimination in the health care system due to their size. Known as weight stigma, this form of discrimination can compromise clinical decision-making, delay diagnoses, and erode trust between patients and providers.

This blog offers an overview of weight stigma—what it is, how it affects people with serious illness, and seven practical ways clinicians can recognize and address it in their daily practice to provide more compassionate, person-centered care.

Weight stigma is the “social devaluation and denigration of individuals because of their excess body weight, [which] can lead to negative attitudes, stereotypes, prejudice, and discrimination,” as defined in the Joint International Consensus Statement for Ending Stigma of Obesity. It is pervasive and persistent, it’s reinforced in relationships with family and friends, workplaces, the media, and even doctors' offices.

Despite being untrue, the messages perpetuated by weight stigma are deeply harmful. People often internalize these beliefs, which can shape their self-perception, daily lives, and relationships—including those with their health care providers.

Over the years, we’ve heard countless patients describe how their weight negatively influenced the care they received. Some shared that their symptoms were dismissed or attributed solely to their weight. They were told they would feel better if they simply lost weight—only to later be diagnosed with a serious medical condition, like our patient, Mary. Others have described shaming experiences, such as being told, “It’s hard to complete your physical exam because of your size,” or overhearing a clinician say, “Their entire pantry is probably an example of what not to eat,” outside of the exam room.

Experiences like these erode trust between patients and clinicians and may lead people to delay or avoid seeking care—even from clinicians who are committed to providing compassionate, high-quality care.

The bottom line is that weight stigma may compromise the quality of care for people with serious illness. Here are just a few examples:

• Patients with obesity are more likely to be undertreated for pain.
• Clinicians report reluctance to perform pelvic exams on patients with obesity. Without proper pelvic exams, the diagnosis of several serious conditions is delayed or missed.
• Clinicians report providing less health education to patients with obesity. This could be detrimental when caring for people with serious health conditions, who need significant interprofessional-led education to help manage their symptoms.

Weight stigma also perpetuates an antiquated and incorrect understanding of obesity and its treatment. Recommendations to “simply diet” and “exercise to lose weight” are inaccurate. While lifestyle changes are important for maintaining long-term health, they are not sufficient treatments for obesity. Dieting, the short-term restriction of food consumed in an effort to lose weight, can lead to long-term weight gain through a process known as weight cycling. Dieting has also been associated with other adverse health outcomes, such as worsening anxiety and depression. Additionally, dieting can result in increased cravings for food, which contributes to the onset of binge eating disorder.

Many people with obesity will avoid the medical system over time due to stigmatizing and emotionally harmful interactions with clinicians. We have countless stories of patients with higher weight feeling embarrassed when seeing medical providers because they weren’t offered gowns that fit their bodies. But delayed care leads to delayed or missed diagnosis of several conditions, such as cancer.

Clinicians may dismiss patient concerns with the “blanket blame” of obesity to explain symptoms that may be signs of serious illness. Weight loss in serious illness is an indicator of malnutrition, which increases complications and decreases quality of life. Still, malnutrition is often overlooked in people with obesity, because the health care team often feels it is ok for people with obesity to lose weight, regardless of the underlying cause.

The person walking into your exam room may carry these lived experience with them. Keeping this in mind helps create a safer, more supportive environment—one that does not further perpetuate harm.

As palliative care clinicians, we are trained to be excellent communicators. That said, there's always room to learn new skills to grow, so that you’re providing the highest-quality, patient-centered care. Here are seven ways you can recognize and address weight stigma in your practice:

We all absorb cultural messages that promote the pursuit of thinness and stigmatize larger bodies. It’s critical to reflect on your own implicit biases by asking yourself:

• How do I feel when caring for patients with obesity?
• Do I make judgements about their character, abilities, or intelligence based on their weight?
• What does my body language communicate? Do I maintain eye contact? Are my arms crossed across my chest? How is my tone of voice? How far am I physically away from the patient?
• Do I use person-first, non-judgmental language?

Tools such as Harvard’s weight-specific implicit bias test can help identify personal biases.

Strong communication builds trust—especially for patients who’ve experienced discrimination. While people of all sizes may struggle to adopt health-promoting behaviors, patients with obesity often report that their concerns are dismissed.

Avoid making assumptions. Ask every patient about their nutrition and physical activity in the same way, regardless of body size. Listen fully, without interruption, and validate their experiences.

Depression and anxiety are common symptoms in both people with serious illness and those with obesity, yet they are often underdiagnosed. A thorough history and physical examination, which includes frequent screening for depression and anxiety, must be performed on all patients, regardless of body size. Other complications should also be assessed and treated; people with serious illness often suffer from constipation, nausea/vomiting, appetite changes, and dyspnea. Do not write these off as due to obesity—treat these as symptoms associated with serious illness.

Pain is a complex symptom of serious illness; when patients have untreated pain, they have worse outcomes. People with obesity are often inadequately treated for pain. Ensure you complete a comprehensive pain assessment on all your patients and prescribe adequate and appropriate pain medication as needed.

Body size is influenced by many factors beyond personal control, including genetics, early life environment, and social drivers of health (such as food access).

People don’t have as much control over their body size as we are made to believe. A person’s genetics, epigenetics, early life environment, social drivers of health, including access to and availability of food, as well as a wide range of other factors, impact body weight.

Focus conversations on behaviors, symptoms, and preferences—not numbers on a scale. Ask your what their preferences are for actions they can take to care for their health. In serious illness, use guiding principles of communication, symptom management and pain management to address the needs of all your patients, regardless of body size.

The physical environment we practice in goes a long way in making patients feel comfortable. Consider:

• Are exam rooms accessible for people in larger bodies?
• Do you have wide chairs in waiting areas and a layout that is welcoming to someone with a larger body?
• Are gowns and medical equipment available in a range of sizes?
• Is the scale in a private, respectful setting? If it’s in a public hallway, this can potentially be a source of embarrassment or distress. Consider moving it to a closed room.

Thinking through these questions and making changes to your space can reduce embarrassment and signal respect for every patient.

Weight is an equity issue. Always use person-first language in your communication—verbal or written. Use person-first language, such as “person with obesity” or “person in a larger body,” rather than labeling someone as “obese.” Monitor how weight is discussed on rounds and clinical meetings—patients overhear more than we realize.

Do not engage in jokes involving body size or weight, and do not tolerate it by other members of the health care team or caregivers. Communication is key to combatting weight bias.

Many patients with obesity are distressed by any weight gain. Review medications that may affect weight and replace those which may contribute to weight gain when patients express this worry. Anxiety and depression, common symptoms in those with serious illness, should be treated with weight-neutral medications. Consider where medications such as GLP-1 agonists fit in with treatment of a serious illness. Always proceed with the patient’s desires and wishes in mind.

All patients with serious illness deserve compassionate, high-quality, whole-person care—regardless of their body size. We can do better, clinically and in our research. Being aware of and addressing weight bias in our clinical practice leads to improved patient and clinician experiences.

• Supportive Obesity Care offers education and resources for health professionals.
• The Obesity Action Coalition provides education and guidelines on how to assess and address weight bias.
• The UConn Rudd Center for Food Policy and Health aims to address weight-bias, stigma, and discrimination through research, education, and advocacy.
• Harvard’s weight-specific implicit bias test can help identify personal biases.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.