exclude anti‐obesity medications from coverage. By recognizing obesity as a complex health issue and creating policies that reflect this, insurers may be pushed to expand coverage and increase equality in care across health conditions.
Policies and training
In addition to legislative actions, workplaces can adopt their own institutional policies and training initiatives to prevent weight‐based discrimination and stigmatization. For example, hiring practices can use blinded review of candidates when possible and focus on objective criteria for evaluation [16]. Experts have also recommended the inclusion of weight in workplace diversity, discrimination, and harassment training [130], a practice that is strongly supported by people with obesity [120]. Data from the MIDUS survey showed that the effects of obesity on chronic job discrimination were mitigated when individuals endorsed having supervisor or coworker support [131]. This finding highlights the importance of creating an inclusive work environment from the top down.
Educational institutions and professionals may also benefit from greater attention to weight in anti‐bullying curricula and teacher training. In a study that reviewed 275 published anti‐bullying interventions from 1966 to 2013, not a single intervention focused specifically on weight‐based bullying [132]. The public, educators, and parents strongly support school‐based policies to prevent weight‐based bullying [126–128]. The majority of adolescents also report a preference for classroom teachers to intervene with weight‐based peer victimization, particularly adolescents who experience frequent victimization [12]. Additional training for teachers may be needed to help implement these initiatives [126]. This may be particularly important for educators who are likely to witness or be informed of weight‐based bullying, such as PE teachers, school nurses and counselors, and educators who deliver obesity prevention or health‐based curricula [133,134].
Similar to training for educators, weight sensitivity training for health care professionals has the potential to reduce weight stigmatization of patients with obesity [120,135]. Some care units already require such training (e.g. for bariatric care). Considering the high likelihood that most providers will see patients with obesity in their practice, these trainings may be expanded widely throughout hospital systems. More research is needed to identify effective strategies for reducing weight‐biased attitudes and promoting the use of patient‐centered care approaches by health care trainees and professionals in their interactions with patients with obesity [28,135]. The American Board of Obesity Medicine was established to provide more advanced training to health care professionals in obesity treatment [136]. More attention to obesity could be beneficial earlier in training curricula, such as dispelling myths about weight controllability, identifying realistic weight loss goals, and practicing strategies for initiating conversations about weight when appropriate. Health practices can institute other structural policies, such as requiring adequately sized equipment for larger bodies and avoiding the use of stigmatizing medical terms (e.g. “morbid obesity” [137,138]). Finally, health care institutions can prohibit the use of BMI cutoffs as the singular criterion for determining whether or not patients are eligible for certain procedures (e.g. for fertility treatments or orthopedic surgeries), as this practice is discriminatory and often not rooted in evidence‐based practice.
Clinical intervention
At the individual level, psychological interventions can be used to target internalized stigma. Only a handful of studies have tested such interventions in persons with obesity. Results have been promising, although these studies have been small, short‐term, or without strong control groups. For example, one study tested an 8‐week group cognitive‐behavioral therapy (CBT) intervention designed to reduce WBI in a sample of eight adults with obesity who had experienced and internalized weight stigma [139]. Compared to a quasi‐control group with no intervention (n = 6), the intervention group reported greater reductions in WBI and weight‐related stereotype endorsement, as well as greater improvements in weight‐related self‐efficacy.
Other studies have combined stigma‐reduction interventions with weight management approaches. One randomized controlled trial (RCT) of 73 women with overweight/obesity tested a 3‐month Acceptance and Commitment Therapy‐based group intervention designed to reduce weight self‐stigma and promote healthy eating, compared to treatment as usual (TAU) individual medical and nutritional visits [140]. Results showed greater improvement in the intervention group versus TAU on measures of weight self‐stigma, eating behaviors, and quality of life. Another study combined a group CBT weight stigma‐reduction intervention with standard group behavioral weight loss (BWL) treatment in comparison to BWL alone. This 6‐month trial of 72 adults with obesity who had experienced and internalized weight stigma found significant reductions in some aspects of weight self‐stigma – namely self‐devaluation – in the intervention group compared to the BWL alone group [141]. Some benefits of the intervention were also found for eating and self‐monitoring, although significant improvements across both groups were found for stigma, weight, health behaviors, and psychological well‐being. Other studies have compared standard weight loss approaches to weight‐neutral healthy eating interventions (which included some content on internalized stigma but were not primarily designed to target this [112,142]). Findings from these studies have shown improvements across groups, although weight losses were significantly higher in the standard weight loss groups. Certainly, more research in this area is needed with larger samples and longer follow‐up.
Conclusion
Individuals with obesity face weight bias and stigma throughout their lifespan. The social consequences of weight stigma include denied opportunities in employment and education, reduced access to and quality of health care, and impaired interpersonal interactions and peer relationships. Weight bias can also become internalized and stigma self‐directed within individuals with a higher weight. Experiences and internalization of weight stigma have an adverse impact on mental and physical health beyond the effects of obesity itself. More research is needed to develop and test interventions for effectively preventing and reducing weight stigma and its negative downstream effects at the institutional, interpersonal, and individual levels.
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