Reduce Health Inequities with Evidence-Based Obesity Care

Am J Manag Care. 2025;31(9):In Press

Weight bias and stigma in health care are pervasive and lead to significant inequities in health care for people living with obesity.

To effectively enact the principles of health equity, health care systems must adopt clinical definitions and evidence-based guidelines for obesity that align health care standards with well-established models for chronic disease care.

People living with obesity should be involved in planning for patient-centered care practices and policy.

Resources are available to support timely and effective action.

Implicit and explicit individual negative attitudes about a person because of their weight (weight bias) can lead to stigmatization and discrimination, impacting health care delivery and patient outcomes.1 Explicit bias involves individuals being aware of their negative attitudes or prejudices toward groups of people and consciously allowing these attitudes to influence their behavior.2 In contrast, implicit bias encompasses subconscious feelings, attitudes, prejudices, and stereotypes formed by prior influences and experiences.2 Individuals may be unaware that these subconscious perceptions, rather than objective facts, influence their decision-making. Both implicit and explicit biases are problematic because they contribute to discriminatory behavior and potentially suboptimal health care delivery. The majority of US adults living with obesity report experiencing stigmatization in the health care system because of their weight.3 Evidence of direct patient harm4 from the pervasiveness of weight stigma in the health care system and across society has driven international efforts to end it.5 Unfortunately, eliminating weight bias in society has been challenging. A recent study reports that implicit biases against sexuality, race, and skin tone decreased by 65%, 26%, and 25%, respectively, from 2007 to 2020; in contrast, implicit bias against body weight has only reduced by 1% over this same time.6 Young children and adolescents living with obesity frequently experience weight stigma.7 This is particularly concerning, as the evidence shows these early experiences cause adverse effects on obesity care and health that extend

Weight bias and weight stigma in health care can adversely affect standardized screening and medical diagnoses. For example, with respect to the medical diagnosis of obesity, more than half of adults with obesity do not receive a diagnosis8 compared with only 12.5% of patients with hypertension,9 despite similar levels of standardized screening.10 The disparities in health care services are even more significant for disease-focused clinical counseling, with only approximately 21% of patients with obesity receiving obesity management counseling11 compared with 80% of those with hypertension receiving counseling for blood pressure control. Although weight bias and stigma significantly impact standardized screening and medical diagnoses, they are not the only factors involved. Other elements, such as the level of health care provider training, the availability of resources, and systemic health care disparities, may also contribute to these differences in care.12,13

Weight stigma is generally considered a major contributor to the substandard emphasis on obesity care compared with the care afforded for other chronic diseases.14-16 One reason for this is that patients with obesity who experience weight stigma in health care settings may avoid seeking treatment from health care professionals for fear of being blamed and shamed for their weight.17,18 Experiencing weight stigma only serves to decrease the trust people with obesity have in their health care providers.19

Disconcertingly, nations with greater wealth or higher levels of obesity appear to have a more substantial implicit bias toward people with obesity.20 This implicit bias also helps explain why obesity care falls short of the standards expected for chronic disease care.

Disease-related stigma impacts the health and well-being of patients.21 Obesity stigma is associated with poor mental health outcomes, including depression, anxiety, and suicidal ideation20; poor physical health outcomes; and increased risk of mortality.7 Internalized weight bias (when a person applies negative beliefs about weight toward themselves and engages in self-devaluation) appears to mediate these adverse health outcomes.18 For those who hold internalized weight bias, studies demonstrate harm beyond mental health, including increased risk of poorer cardiometabolic health such as elevated hemoglobin A1c and metabolic syndrome.22,23

Various explicit and implicit biases in health care must be eliminated to decrease health inequities (ie, differences in health status and distribution of health resources).24 This is reflected by the American Hospital Association (AHA) statement that priority must be given to “addressing equity, diversity, and inclusion in health care [because] health inequities contribute to health disparities.”25 For health care systems that aim to align with these AHA principles, action must urgently be implemented to reduce weight bias against people living with obesity. Some effective measures can include (1) ensuring that physical environments can accommodate patients with larger body sizes or a higher weight (eg, chairs, scales, gowns)26; (2) implementing clinical practice recommendations that accurately align with the science, namely that obesity is a complex chronic disease characterized by neurohormonal abnormalities in the regulation of energy balance leading to excess or dysfunctional adiposity that impairs health; (3) addressing chronic obesity complications and related diseases that are responsible for impairing quality of life and for disease morbidity and mortality; (4) ensuring that patients receive medical evaluation, diagnosis, and disease staging27-31 as the basis for evidence-based individualized treatment and long-term support (eg, requires more than an “eat less and move more” approach)32; and (5) upskilling clinicians to provide empathetic and nonbiased care, including spending equal time with their patients regardless of body weight or size.33,34 Because internalized weight bias may adversely impact the inclination of patients to seek health care services and to access resources to support self-care, identifying and addressing internalized weight bias in patients with obesity must occur to optimize obesity care outcomes.33 Finally, weight stigma should also be addressed in health care policies. In January 2024, the World Obesity Federation released a position statement detailing weight stigma as a “social determinant of health and a human rights issue” and outlining key recommendations for reducing weight stigma in health care and public health policies.13,35

Similarly, to address social determinants of health, the AHA recommends that “[h]ospital leaders should educate key stakeholders, including physicians, nonphysician health care providers, and coding professionals of the important need to screen, document, and code data on patients’ social needs.”36 Weight bias and stigma should be included as critical social determinants of health when considering patients’ social needs due to both the pervasiveness of these social factors and the extensive evidence pointing to the negative impact of weight stigma on clinical practice and health care delivery, patient behavior, and patient health outcomes. Health care systems cannot meet goals for equitable care without addressing weight bias and stigma. The following points provide an actionable approach to achieving this goal:

Make health equity for people with obesity a core value: If a US health care system is prioritizing addressing health inequity, it must acknowledge and confront the most common health care inequity experienced by its patient population. This will require health care system education and explicit policy regarding weight stigma and bias.

Adopt better clinical definitions of obesity: Because there are extensive misconceptions about obesity, it is essential to promote and share a scientifically correct understanding of disease pathogenesis, natural history, and evidence-based therapeutics. Fortunately, multiple medical professional societies have published evidence-based clinical practice guidelines,32 diagnostic frameworks and classification systems,28,30,31,37,38 and education strategies that can help address obesity misconceptions.39

Align obesity care with chronic care models: Bias and stigmatization disrupt an effective chronic care model via adverse effects at all levels. Internalized weight bias results in patient disengagement and self-blame.40 Furthermore, implicit and explicit bias negate competent and empathetic management by health care professionals, work against establishing effective care programs in health systems, and diminish support for evidence-based care in society. Therefore, it is incumbent on health care professionals and health care systems to mitigate bias and stigmatization if there is intent to have an effective chronic care model for obesity. Multiple medical professional groups have developed recommendations for evidence-based application of the chronic care model to the care of people with obesity (eAppendix [available at ajmc.com]).

Explicitly include people with obesity in planning for patient-centered care practices and policy: People with obesity should be included in planning for patient-centered care.41 Patients’ experiences should be essential to policy development to address weight stigma and bias.42

In summary, health care systems can only correct the pervasive weight bias and stigma by acknowledging it and then working to make equity in health care a core value for their entire patient population. To act on the principles of health equity, systems will need to adopt updated clinical definitions and evidence-based guidelines for obesity and align obesity health care services and standards with existing, well-established models for chronic care. The burden of weight stigma and bias and the resulting inequities in health care for people with obesity have contributed to the development of many resources to support education and implementation (eAppendix). These evidence-based resources allow action instead of fostering potential ongoing harm by inaction.

Author Affiliations: ConscienHealth (TKK), Pittsburgh, PA; Massachusetts General Hospital (MGH), MGH Weight Center, Department of Medicine–Division of Endocrinology-Neuroendocrine, Department of Pediatrics–Division of Endocrinology, and Nutrition Obesity Research Center at Harvard (FCS), Boston, MA; University of Alabama at Birmingham (WTG), Birmingham, AL; Eli Lilly and Company (JPD), Indianapolis, IN; Bias 180 (XRS), Ontario, Canada.

Source of Funding: None.

Author Disclosures: Mr Kyle has consulted for Boehringer Ingelheim, Emerald Lake Safety, Novo Nordisk, Nutrisystem, and Roman Health Ventures. Dr Stanford has consulted for Amgen, Apnimed Inc, Clearmind Medicine Inc, Eli Lilly and Company, Empros Pharma AB, Ilant Health, Lifeforce, MelliCell Inc, Novo Nordisk, Pfizer Inc, Sweetch, and Vida Health. Dr Garvey has consulted on advisory boards for Allurion, Alnylam Pharmaceuticals Inc, Boehringer Ingelheim, Carmot Therapeutics Inc/Roche, Eli Lilly and Company, Fractyl Health Inc, Inogen Inc, Gan & Lee Pharmaceuticals, Keros Therapeutics Inc, Neurocrine Biosciences Inc, Novo Nordisk, Pfizer Inc, Regeneron Pharmaceuticals Inc, Terns Pharmaceuticals Inc, and Zealand Pharma A/S and has served as site principal investigator for multicenter clinical trials sponsored by his university and funded by Carmot Therapeutics Inc/Roche, Eli Lilly and Company, Epitomee Medical Ltd, Neurovalens, Novo Nordisk, Pfizer Inc, Terns Pharmaceuticals Inc, and Zealand Pharma A/S. Dr Dunn is employed by and owns stock in Eli Lilly and Company. Dr Ramos Salas has received speaker fees from Novo Nordisk (Portugal), Eli Lilly and Company (Sweden), and Blood Pressure Doctor (Sweden).