Weight-Based Stigma and Its Impact on Children With Obesity

More children in the United States live with obesity than any other chronic condition. The obesity rate among U.S. children and teens has more than tripled since 1980, according to the Centers for Disease Control and Prevention (CDC). Although there are numerous efforts underway to help children and adults reach and maintain a healthy weight, many efforts do not address the social consequences of obesity, specifically weight stigmatization and bias.

Weight stigma refers to the societal devaluation of a person because he or she has overweight or obesity, says Eileen Chaves, PhD, pediatric psychologist at Nationwide Children’s Hospital. Common stereotypes portray patients with obesity as lazy, unmotivated or lacking in discipline. In reality, obesity is a complex disease that has many different causes, including nutrition and eating patterns, medicinal side effects, physical activity levels, irregular sleep patterns, genetics and emotional stress.

Weight stigma and discrimination are often tolerated in society because of beliefs that stigma and shame will motivate people to lose weight. However, research shows that stigma further contributes to damaging psychological, social and physical health consequences. Because weight stigma occurs in nearly every setting, it is important for medical providers and pediatricians to provide a safe space for patients with overweight or obesity and establish a positive relationship with the patient. Dr. Chaves and her team are looking at how to improve the therapeutic relationship between a patient and their medical team, one of few modifiable factors of obesity.

“The therapeutic alliance of patient, provider and caregiver is powerful,” Dr. Chaves says. “Managing this alliance right away increases rates of patient retention and engagement. Our work aims to teach clinicians how to build a strong medical rapport that can help combat weight stigma and bias, starting with the first interaction.”

The Psychological, Social and Physical Health Consequences of Weight Stigma

Experiences of weight stigma dramatically impair quality of life for children with obesity. A landmark study by Schwimmer and colleagues revealed that children and adolescents with severe obesity had quality-of-life scores that were worse than children of the same age with cancer. With research showing that 70% of patients with obesity have experienced weight bias, this is a large population at risk of numerous psychological and physical health conditions.

Patients who face weight stigma and bias often have higher levels of depression, anxiety, substance use, suicidal thoughts and self-harm behaviors. They are also more likely to experience disordered eating, social isolation, decreased physical activity and avoidance of healthcare services — often contributing to weight gain and fueling cycles of worsening behaviors and comorbidities.

“It’s important to note that obesity doesn’t cause depression or anxiety,” says Dr. Chaves. “It’s the experience of weight bias and stigma as a person who lives life in a larger body that causes these psychological disorders.”

While patients with overweight or obesity are in the clinic, it’s important for medical providers to assess what comorbidities may be present. If any psychological, social or physical health consequences are indicated, pediatricians should provide resources and treatment options available to the patient such as mental health resources, support groups or therapy.

The Clinical Setting and Broaching Topics for Change

Primary care settings are important for overweight and obesity management, yet many primary care providers do not feel equipped to address obesity. The 5 As, which was initially developed by the U.S. Department of Health and Human Services for smoking cessation, is an effective tool for addressing obesity in the clinic.

The 5 As (Ask, Assess, Advise, Agree, Assist) are rooted in behavior change theory and are key recommendations for pediatricians to follow when discussing a patient’s weight during an appointment. This method of intervention takes a person-centered approach that improves patient autonomy and helps develop a positive relationship between the patient and caregiver.

Pediatricians and medical providers can also address weight stigma in the clinic by paying attention to their clinical setting, using patient-first language, increasing patient autonomy, and advocating for more training in residency and medical school courses.

“There is not just one thing we can do to tackle childhood obesity,” says Stephen Cook, MD, who joined Nationwide Children’s in August 2024 as chief of the Center for Healthy Weight and Nutrition. “We need to think globally and act locally. We need to have conversations about health at all sizes. Every corner of the community plays a role, and if we aren’t doing our part, starting right here in the clinic, then we are just getting farther behind.”

The Clinical Setting

Creating a safe, welcoming space for patients is essential to ensure patients feel comfortable when coming to the clinic to receive care. Hospitals and clinics should include comfortable seating and appropriately sized equipment, such as gowns or blood pressure cuffs, to accommodate patients of diverse body sizes. Additionally, marketing materials and other images throughout the hallways and appointment rooms should be inclusive and representative of the entire patient population.

When discussing weight-based topics with patients, medical providers should ask patients what words they prefer to use when talking about their bodies and their weight. Use neutral terms like ‘growth’ or ‘weight’ if you are not sure what the patient prefers. People-first language, which places the individual before the medical condition or disability, should be standard (i.e. a person with obesity or a child with overweight).

Providers should pay attention to the language used on patient-facing clinical documentation (i.e. post-visit documentation). Rather than focusing on what the patient is doing wrong, pediatricians should acknowledge behaviors the patient is doing well.

Training the Future

Recognizing and acknowledging the complexity of the etiology of obesity early on in a medical provider’s training works to dispel common blame stereotypes. Pediatricians should advocate for additional weight stigma training and education in medical schools, residency programs and continuing medical education programs. If weight bias and stigma are addressed before medical professionals even treat a patient, they will be more equipped with the resources to eliminate bias before it happens.

“If we start training residents at the very start of their training, the hope is they will be able to recognize their own implicit biases and the biases they see around them,” says Dr. Chaves. “I often say to other providers, it’s not ‘if’ you are going to see a patient with overweight or obesity, it’s how many times a day. Making sure you understand where your own biases are coming into play and addressing those before you even enter the clinic will go a long way.”

This article also appears in the Fall/Winter 2024 print issue. Download the full issue.

References:

1. Pont SJ, Puhl R, Cook SR, Slusser W; Section on Obesity; Obesity Society. Stigma experienced by children and adolescents with obesity. Pediatrics. 2017 Dec;140(6):e20173034.
2. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Canadian Family Physician. 2013 Jan;59(1):27-31.

Image Credit: Nationwide Children’s