Diabetes Core Update: Special Edition – Weight Bias and Stigma (Part 1)
Date: December 29, 2025
Host: Dr. Neil Skolnik
Guest: Dr. Rebecca Pearl, PhD, Associate Professor, University of Florida
Overview:
This special episode spotlights the critical issue of weight bias and stigma—especially their prevalence, consequences, and the impact within healthcare. Dr. Neil Skolnik and leading researcher Dr. Rebecca Pearl discuss definitions, evidence, and actionable strategies that healthcare professionals can use to reduce bias and improve patient care. The discussion centers on both the clinical and human ramifications of weight stigma, highlighting why the American Diabetes Association made this a foundational focus of its new Standards of Care for obesity.
Key Discussion Points & Insights
1. Definitions and Importance of Addressing Weight Bias and Stigma
- Weight Bias: Negative attitudes toward people based on body weight or size—often involving stereotypes such as laziness or lack of willpower.
- Weight Stigma: Societal devaluation due to body weight; often manifests as overt or subtle discrimination.
- Dr. Pearl (02:24):
"We define weight bias usually as negative attitudes towards someone on the basis of their body weight or size...most often we are thinking about people with a high body weight who are typically the most affected by weight bias...Weight stigma we often define as a societal devaluation of someone on the basis of their weight or size."
- Dr. Pearl (02:24):
- ADA’s Prioritization:
- The new Standards of Care for obesity from the ADA lead with weight bias and stigma, setting the tone for patient dignity and awareness among healthcare providers (03:30).
- Dr. Pearl:
"...any approach to treating obesity has to start with treating all patients with dignity and respect..." (03:45).
2. The Devaluation and Internalization of Stigma
-
Devaluation Means: Assigning less worth to someone because of weight, both externally and internally (05:49).
-
Internalized Stigma: When individuals adopt and believe negative societal messages—leading to lower self-esteem, self-worth, and mental health struggles.
- Dr. Pearl:
"I've been very interested in self-directed stigma or internalized weight stigma...they are aware that they are viewed and treated negatively by society and start to absorb those negative messages and apply them to themselves." (05:49)
- Dr. Pearl:
3. Sending Stigmatizing Messages—Society and Healthcare
- Overt and Subtle Messaging:
- Media, social media, family, education, workplace, and medical settings reinforce bias.
- Well-intentioned but critical comments from providers or family can wound deeply (07:29).
- Frequent examples in clinical settings: insensitive questioning, making assumptions based on BMI, lack of proper equipment, patronizing advice.
- Memorable Story:
- Dr. Skolnik shares a friend’s experience: "The doctor said, 'You realize that you need to lose weight,'...and...without asking anything, either permission to talk about things, or having any sense of what this individual...had already tried." (10:45)
4. Explicit vs. Implicit Bias
- Explicit Bias: Conscious, openly held negative beliefs.
- Implicit Bias: Unconscious, automatic stereotypes or attitudes.
- Both permeate medical interactions and can be measured independently.
- Physical Environment as Implicit Bias:
- Example: Absence of high-capacity scales, forcing patients to be weighed on loading docks—deeply humiliating, dehumanizing experiences that inhibit care-seeking. (12:30)
- Dr. Pearl:
"...their first exposure to weight stigma, being in a healthcare office when they were a child..." (07:29)
"...they had to go out to the loading dock of the building to step on a freight scale...how dehumanizing that is and how humiliating, and why would any patient want to ever return to that doctor's office..." (13:35)
5. Prevalence of Weight Bias Among Healthcare Providers
- Universal but Under-Recognized:
- High prevalence across healthcare professions, even among obesity specialists.
- Biases develop early in clinical training and vary by specialty.
- Studies show more negative attitudes toward high-weight patients than other marginalized groups.
- Dr. Pearl:
"Short story is weight bias, both implicit and explicit, is pretty highly prevalent across many different kinds of healthcare professionals...healthcare professionals are no exception..." (15:29)
6. Consequences of Weight Bias and Stigma
- Not Just Morally Wrong, But Harmful:
- Strong, consistent evidence links experiencing/internalizing stigma with:
- Poorer mental health: Depression, anxiety, substance use, eating disorders, suicidality (esp. youth)
- Physical health: Chronic stress, physiological changes (cortisol, inflammation), and increased risk of chronic diseases
- Avoidance of health-promoting behaviors (healthcare, physical activity)
- Reduced success in weight management or chronic disease treatment
- Worsened health outcomes independent of BMI or actual weight
- Dr. Pearl:
"...there can be some pushback against the idea of reducing stigma for weight...because people think that stigma can motivate people to engage in healthy behaviors and lose weight...over and over again, we see the exact opposite..." (18:07)
- Strong, consistent evidence links experiencing/internalizing stigma with:
7. Mechanisms: How Stigma Leads to Worse Outcomes
- Behavioral Responses:
- Stress from bias leads to unhealthy eating, discouraging thoughts, avoidance of care, and giving up on goals.
- Internalized stereotypes sap self-efficacy and motivation (21:39).
8. Solutions: Strategies for Reducing Weight Bias in Healthcare
- Self-Awareness:
- Honest self-reflection by clinicians regarding assumptions and attitudes.
- Education:
- Seek to understand patient perspectives and treatment complexities.
- Listen to lived experiences; update knowledge on obesity etiology and evidence-based management.
- Communication:
- Ask permission before discussing weight or conducting weigh-ins (26:33).
- Use person-first language ("person with obesity" vs. "obese person"); ask for preferred terms (26:50).
- Employ patient-centered, open-ended questions and motivational interviewing.
- Lead with curiosity, not directives.
- Dr. Skolnik:
"...if we lead with curiosity rather than telling people what to do, asking them about their thoughts and what they have tried first, done first, where they would like to go next..." (29:03)
- Dr. Pearl:
"I love that of leading with curiosity rather than lecturing, because that really shows that you're not making assumptions..." (29:34)
- Dr. Skolnik:
- Validate patients’ experiences and preferences; respect if patients don’t wish to discuss weight.
- Office Environment:
- Ensure accessibility: high-capacity scales, appropriately-sized furniture, cuffs, gowns.
- Avoid Over-Reliance on BMI:
- Don’t make health decisions or deny care on BMI alone; use comprehensive health history and metrics.
9. The Critical First Minutes of a Visit: Building Trust
- Trust and Vulnerability:
- Weight discussions are sensitive—how clinicians open the conversation can create or undermine trust.
- Open with permission and empathy, check patient readiness, and plan for ongoing support (e.g., follow-ups, referrals). (32:15)
- Dr. Pearl:
"Starting with asking permission...is it okay if we talk about your weight today? And if someone says yes, then you can follow up with these more open-ended questions..." (32:15)
"...showing that you're invested in them as a person and in their care." (33:50)
10. Policy-Level Impacts of Stigma
- Insurance and Medication Access:
- Attitudes that obesity is a personal responsibility or cosmetic concern diminish policy support for treatment coverage (e.g., GLP-1s).
- Dr. Pearl:
"There is this general belief that people should be able to manage their weight on their own without comprehensive care...We would never say that for other kinds of health conditions like hypertension or diabetes..." (34:52)
11. Final Thoughts
- Clinician Vigilance for Self-Stigma:
- Listen for signs of self-blame and offer validation and kindness.
- Dr. Pearl:
"...if they hear their patients speaking about themselves in a really cruel, unkind way...there are those small moments for intervention to just give that little bit of extra validation and encouragement and kindness that can go a long way." (37:03)
Notable Quotes & Memorable Moments
-
“Any approach to treating obesity has to start with treating all patients with dignity and respect.”
— Dr. Rebecca Pearl (03:45) -
“Bias is part of being human. So all human beings have biases…healthcare professionals are no exception to that.”
— Dr. Rebecca Pearl (15:29) -
“We know that still BMI is often used inappropriately to deny patients care...without really getting a full assessment of a person's weight history, of their full health history, and using other health metrics.”
— Dr. Rebecca Pearl (27:55) -
“Lead with curiosity rather than telling people what to do.”
— Dr. Neil Skolnik (29:03) -
“There is this general belief that people should be able to manage their weight on their own...We would never say that for other kinds of health conditions like hypertension or diabetes.”
— Dr. Rebecca Pearl (34:52) -
“If they hear their patients speaking about themselves in a really cruel, unkind way...there are those small moments for intervention to just give that little bit of extra validation and encouragement and kindness that can go a long way.”
— Dr. Rebecca Pearl (37:03)
Timestamps for Key Segments
- 00:02–01:16: Introduction; overview of the importance of weight bias and stigma.
- 02:24: Definitions and scope of weight bias and stigma.
- 05:49: Devaluation and internalized weight stigma.
- 07:29: How society and healthcare convey stigmatizing messages.
- 10:45: Anecdote on the impact of uncaring provider comments.
- 12:30: Distinctions between implicit and explicit bias; environmental barriers.
- 15:29: Prevalence of bias among healthcare providers.
- 17:37: Consequences—health, psychological, and behavioral impacts.
- 23:43: Strategies to diminish bias in healthcare.
- 26:33: Practical strategies; permission, language, environment.
- 29:03: Leading with curiosity in patient conversations.
- 32:15: Building trust through sensitive weight discussion.
- 34:52: Policy implications—coverage and treatment access.
- 37:03: Clinician role in combating internalized stigma.
Summary Tone
The discussion remains clinically focused, empathetic, and practical, offering real-world context, patient stories, and actionable strategies. The hosts emphasize humility, reflection, and continual growth for clinicians, with humanity and dignity at the core of both practice and patient relationships.
For more insights and resources, visit www.diabetesjournals.org.