In 2018, the Vienna Programme for Women’s Health commissioned an evaluative literature review to find out whether and in what form stigmatisation and discrimination against overweight/obese women take place in the health sector.

According to the Vienna Health Report 2016, almost a third of the Viennese population aged 15 and over is overweight. Women are less likely to be overweight or overweight than men. The causes of obesity are manifold. Genetic or hormonal factors, economic and industrial interests, people’s life situations such as education, financial resources or chronic stress all play a role and influence body weight.  Nevertheless, a widespread opinion is: “Fat people are to blame for their own body weight”. In the discussion on obesity, the aspect of discrimination and the associated health consequences have so far been ignored.

The result is that discrimination and stigmatization overweight women and men in the health sector is common. In fact, the health sector is an essential context for processes of standardization and stigmatization. Discrimination against overweight patients in the health sector manifests itself in different ways. Examples include inappropriate language, shorter treatment time, inadequate equipment, or incorrect diagnoses. The result is growing social inequality in patient care.

Out of fear of discrimination or a sense of shame, fat people postpone examinations or do not even take advantage of them. Serious consequences for the health of overweight people, but also for the costs of the health care system, are discussed in the literature.

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With the escalating prevalence of high weight and obesity, there has been a transformative shift in public perception within Western industrialized nations. What was once a marginal concern has evolved into a recognized health crisis demanding urgent attention. In the early 2000s, a small percentage of the German population viewed obesity as a pressing health matter, but today, the majority acknowledges the imperative need for action (Sikorski et al., 2011).

According to a recent representative survey, 71% of Germans find individuals with high weight aesthetically unpleasing, while 15% consciously avoid interacting with them. A staggering 85% believe that obese people face health restrictions, with 71% perceiving them as partially immobile. Furthermore, nearly half of the respondents feel that individuals with high weight are socially less accepted (Forsa, 2016).

These findings underscore the growing psychosocial challenges faced by overweight and obese individuals, marked by stereotyping, stigmatization, and discrimination. The healthcare sector emerges as a significant context for normalization and stigmatization processes (Jäger et al., 2015; Malterud/Ulriksen, 2011). (Schaffer, Buchinger:2019, 16)

Stigma and Discrimination against Individuals with High Weight: Definitions

The article delves into the definitions and manifestations of stigma and discrimination against individuals with high weight or obesity. Despite increased awareness of obesity as a chronic condition with multifactorial causes, negative perceptions and derogatory attitudes persist. Numerous studies spanning the last two decades indicate that stigmatization of overweight individuals is prevalent both in the general population and within specific professional sectors, such as education and healthcare.

The concept of social stigma is explored, describing it as a characteristic linked to strongly negative evaluations, leading to societal devaluation of individuals possessing that characteristic. High body weight or obesity is identified as a distinctive stigma due to its overt and non-concealable deviation from societal norms, referred to as weight stigma or obesity stigma in the literature.

The physical appearance of overweight individuals is judged against prevailing societal-cultural norms, where the slim, fit, healthy, and performance-oriented person is idealized. This judgment extends to attributions of negative traits and personality characteristics, such as laziness, lack of willpower, gluttony, lack of motivation, emotional disturbance, ugliness, unattractiveness, or lack of hygiene.

The article introduces the term “weight bias” or “sizeism” to describe discrimination resulting from social stigma, emphasizing the link between negative attributions, stereotypes, and actual unequal treatment of individuals with high weight. The distinction between stigma and bias is discussed in some studies, while others treat them as interconnected processes, with attribution and stigmatization viewed as inherent or precursors to discrimination.

There is consensus among the studies reviewed that there is a direct correlation between weight (BMI) and the experience of discrimination. The more pronounced the high weight, the more frequent and intense the perceived stigmatizing attitudes and reported experiences of discrimination.

Additionally, the article explores the concept of internalized stigma, where individuals internalize stigmatizing beliefs and assume responsibility for the attributed negative characteristics. This internalization can lead to self-directed prejudice, dissatisfaction with one’s body, attempts to lose weight, and challenges in fostering positive group preferences and mutual empowerment within the overweight community (Schaffer, Buchinger:2019, 16-18)

Causes of weight stigmatisation

The text explores the causes of weight stigma, emphasizing widespread stigmatizing attitudes towards individuals with high weight. It notes that weight-related stigma primarily arises from internal attributions, linking it to perceived individual misconduct. This reductionist understanding neglects the complex, multifactorial etiology of obesity, overlooking genetic predispositions and environmental influences.

The discussion on the causes of weight stigma highlights the role of perceived responsibility and self-blame. The evaluation tends to be more negative when an attribute, condition, or deviation from the norm is considered self-responsible. Many people attribute the increase in weight or the maintenance of high weight to lack of self-control, willpower, or motivation, interpreting it as self-inflicted. Prejudices and stereotypes against individuals with high weight intensify when their weight is perceived as self-imposed.

The text points out that obesity is often seen as a controllable condition caused by excessive eating and lack of exercise, despite the influence of biological, genetic, and environmental factors. The attribution of blame for one’s weight correlates with negative attitudes towards individuals with high weight and increasing BMI.

Ideologies such as individualism or political conservatism contribute to these attribution patterns, along with societal beauty ideals that contribute to the devaluation of larger bodies. The text suggests that the aesthetic aversion to body fat and a socio-culturally anchored rejection of individuals with high weight may be crucial factors in weight stigma. Additionally, the cultural preference for a slim body is linked to perceptions of self-control, personal responsibility, and commitment in a performance-driven society, qualities often denied to individuals with high weight (Schaffer, Buchinger:2019, 18-19)

Negative attributions and stereotypical assumptions about of high weight: “fat, lazy, smelly”

The negative attitudes of healthcare professionals (general practitioners, some specializing in obesity, nurses, medical students, dietitians, and fitness trainers) towards obese patients, as presented in studies and scientific reviews, involve stereotypical attributions such as laziness, lack of willpower, stupidity, dishonesty, unattractiveness, unhygienic behavior, sloppiness, insecurity, or even worthlessness. Obese patients are often assumed to be unmotivated, lacking self-control, and not adhering to treatment recommendations, demonstrating low cooperation (compliance). The higher the weight, the more undisciplined and unhealthy patients are perceived by medical or caregiving personnel. Adipose patients are generally thought to have poorer therapy outcomes compared to patients within the BMI-normal range. Citing international study results, the text exemplifies that over half of surveyed general practitioners in the USA consider their obese patients as difficult, unattractive, unappealing, and uncooperative, with one-third labeling them as lacking willpower, sloppy, and lazy. Similar attitudes are found in surveys conducted in England and France. U.S. doctors often attribute obesity to overeating, lack of exercise, and personal behavior problems, viewing the patients’ lack of motivation as the main problem in treatment. Healthcare professionals with negative attitudes toward overweight patients also tend to be those not subscribing to medical journals and lacking current knowledge in obesity research (Schaffer, Buchinger:2019, 20-21)

Interventions for stigma reduction / implications for the health sector

The considerations on weight stigma and weight discrimination in the healthcare sector and their consequences for individuals and the healthcare system lead to implications and interventions, broadly categorized into three main approaches in the literature.

Firstly, potential interventions focus on addressing public stigma by attempting to change the public perception of individuals with high weight. Secondly, recommendations and guidelines have been developed for the healthcare sector to guide the treatment of individuals with high weight. These guidelines cover aspects such as language use, spatial and medical facilities, anti-fat bias, and self-reflection.

Specific points, such as recommendations for an appropriate treatment environment and non-stigmatizing communication, have been detailed based on the literature review.

Recognizing that norms, stereotyping, and resulting attitudes are not easily influenced on an individual or societal level, there is a necessity to develop approaches with the affected individuals. These approaches aim to alleviate the consequences of experienced stigma/discrimination and internalized stigma (Schaffer, Buchinger:2019, 32)

Reduction of the public weight stigma

Efforts to reduce public obesity stigma face challenges, and their effectiveness is still an area of ongoing research. Strategies aimed at changing public perception of individuals with high weight include education on the causes of obesity, challenging stereotypes through empathetic portrayals, and being cautious about the unintended consequences of anti-obesity campaigns.

1. Education on Obesity Causes: Providing information on the complex causes of obesity, emphasizing environmental or genetic factors rather than personal responsibility, has shown limited effectiveness. Public attitudes tend to persist in the belief that obesity is primarily self-inflicted.
2. Empathy and Positive Portrayals: Attempts to evoke empathy and positive emotions through non-stereotypical depictions of people with obesity have yielded mixed results. While positive effects were observed with non-stereotypical media portrayals in the United States, increased empathy could also heighten awareness of the challenges associated with living with obesity, potentially reinforcing stereotypes.
3. Stigma Traps in Prevention Campaigns: Caution is advised in designing information and prevention campaigns. Some campaigns against obesity might unintentionally strengthen stigmatization, support stereotypes, and contribute to distorted eating behaviors. Recommendations for controlled eating behaviors and categorizing foods as “good” or “bad” can exacerbate unhealthy eating habits.

In conclusion, the research on the effectiveness of strategies to reduce public obesity stigma is limited, and caution is needed in implementing campaigns to avoid unintended negative consequences (Schaffer, Buchinger:2019, 32-34)

Brief summary of the article

Schaffer, Buchinger (2019) discusses weight discrimination in the healthcare sector, aiming to achieve health equity in Vienna. Two studies were commissioned in 2018, focusing on discrimination against women with high weight. The studies reveal patterns of discrimination at both structural and individual levels, including issues with accessibility, equipment, and communication in healthcare settings. Recommendations address both structural and individual discrimination. The results indicate the need for action in the healthcare sector. Weight discrimination leads to the exclusion of certain individuals from healthcare, impacting their well-being and potentially hindering timely disease detection. The studies emphasize the importance of considering the needs and fears of healthcare personnel. Overall, the article highlights the pervasive issue of weight discrimination and its consequences in healthcare.