Research has shown that stigma has physical and psychological consequences. Rebecca L. Pearl, PhD, discusses how stigma in health care settings affects the health and quality of life of people with overweight, obesity, or diabetes, and how health care professionals can prevent and reduce stigma in their interactions with patients.

Q: What is stigma, and what are the main sources of stigma for people with overweight, obesity, or diabetes?

A: When we talk about stigma, we’re talking about negative attitudes and stereotypes about people based on certain traits or characteristics. Stigma can also appear as discrimination or unfair treatment. In the context of weight and diabetes, stigma often includes negative and misguided assumptions that individuals are lazy, lack self-control, don’t care about their health, or are to blame for their weight or diabetes.

Stigma occurs at multiple levels. At the societal level, messages in the news about weight and diabetes often convey blame and characterize these diseases as issues people are responsible for causing. Policies that protect against weight discrimination are lacking, and anti-bullying laws usually don’t specify weight as a protected characteristic.

Stigma can be experienced interpersonally as critical comments, teasing, or bullying from sources like family members, peers or friends, coworkers or employers, educators, or even strangers in settings such as public transportation, restaurants, or clothing stores.

People may also experience weight or diabetes stigma in health care settings. For example, patients may be told that they’re required to lose quite unrealistic, and often arbitrary, amounts of weight to be eligible for a certain procedure. They often are not given support or referrals for appropriate treatment. Weight management treatments are often not covered by insurance. This lack of insurance coverage may be driven, in part, by stigma and bias and the belief that people should be able to lose weight on their own.

People can also internalize stigma that’s around them by applying negative stereotypes and blame to themselves, also called self-stigma.

Q: How does stigma affect people with diabetes who have overweight or obesity?

A: We know that adults with type 2 diabetes report high rates of weight stigma, and diabetes stigma is often directed toward adults in larger bodies.

Internalized diabetes stigma is associated with more depression and anxiety, less social engagement, greater diabetes-related distress, and impaired diabetes management and self-care behaviors. Research has found that diabetes stigma is also associated with higher A1C. In addition, stigma can affect disclosure of diabetes and related complications to health care professionals, families, and employers.

Research on diabetes stigma is relatively newer than research on weight stigma, but we know from decades of research that weight stigma has significant effects on mental and physical health, use of health care, and overall quality of life.

Q: How common is the experience of weight stigma among people with diabetes and overweight or obesity?

A: There’s little research about the overlap of diabetes and weight stigma. In a recent study of more than 1,000 adults with type 2 diabetes, half reported weight-stigmatizing experiences such as teasing, discrimination, or other unfair treatment because of their weight, and up to 60% of participants reported weight stigma in a health care context. Less is known about weight stigma among adults with type 1 diabetes and about the prevalence and impacts of weight stigma among children and teens with diabetes.

Q: Do people with diabetes experience other forms of stigma?

A: Most of the research on the interaction of weight with diabetes stigma has focused on adults with type 2 diabetes. However, many adults with type 1 diabetes also report experiencing stigma and often are blamed for not having “good enough” self-management of their diabetes. Individuals with type 1 diabetes are also the target of negative assumptions due to their use of needles or devices.

Other characteristics such as race, ethnicity, gender, sexual orientation, or disability may affect how people with diabetes and overweight or obesity are viewed or treated by others.

Q: When should health care professionals screen for stigma, and which tools should they use?

A: More organizations and health care professionals are considering how they can include stigma in their screening as part of standard care. Stigma has a significant impact on patients’ quality of life and can affect their health behaviors and their use of health care.

Health care professionals can use simple questions to screen for stigma, such as, “Does your diabetes or weight affect how you think and feel about yourself?” or “Do you ever feel judged or mistreated by others due to your diabetes or weight (including in health care settings)?” These questions can help to start a conversation with patients about how their diabetes or weight affects them. Creating space for a supportive, validating dialogue about stigma has the potential to strengthen the patient-provider relationship.

There are also validated measures of diabetes stigma that can be used for screening, such as the Diabetes Stigma Assessment Scales for type 1 diabetes and type 2 diabetes. Both assessment scales also have shorter subscales that separate out questions about judgment and blame, being treated differently, and self-stigma.

For weight stigma, there’s a Weight Bias Internalization Scale that assesses self-stigma.

Q: How can health care professionals reduce the stigma that patients experience during health care visits?

A: Health care professionals can take multiple approaches to reduce stigma.

Remember that there are structural problems in our society that keep people from having access to healthy foods or to the health care they need. These structural problems also keep people from engaging in health-promoting behaviors. Other stressors in people’s lives similarly affect their behaviors.

Avoid making assumptions about patients based only on their weight, their A1C, or other health metrics. Use open-ended questions when talking with patients about themselves and their health behaviors, and ask with curiosity, not with blame or judgment. Recommending eating less and moving more, without offering any support, is not very helpful. Instead, appreciate all the barriers that people face when managing their weight and diabetes. Work with the patient to develop realistic goals and provide strategies to achieve those goals.

Ask patients for permission to weigh them. We know from research that weighing is a very common reason patients avoid doctor’s visits. If a patient does decline being weighed, then the health care professional should respect that decision and have a conversation to understand the patient’s concerns.

Ask patients what terms they’re most comfortable using when talking about weight. For example, body mass index, or BMI, is something that’s very commonly used but often not in a helpful way. Talk with patients about what BMI means, why you may or may not be using BMI, and why BMI is not a perfect measure of their health. Use different health metrics when possible, and different terms to discuss weight if patients prefer them.

Make sure that the office space is an inclusive and safe space for all bodies. Have high-capacity scales; wide chairs; and appropriately sized blood pressure cuffs, gowns, and tables so that patients don’t feel uncomfortable from the moment that they step into the office.

Avoid terms such as “morbid obesity” in patients’ charts and when talking with patients. “Class three obesity” is perceived as a less stigmatizing diagnosis, or simply use more neutral terms such as “weight.” Use phrases such as “high/low glucose” or “manage glucose within your target range” instead of phrases like “glycemic control.” “Control” can suggest that if glucose levels are not within the target range, patients are not doing enough to control their numbers and are therefore to blame. 

Q: Which interventions are recommended to help patients manage stigma?

A: Health care professionals may recommend resources such as counseling or peer support groups. These interventions can help patients cope with stigma, gain validation and support, and ward off the negative self-talk that can be driven by internalized stigma. Getting involved in advocacy can also help patients feel empowered to combat stigma.

I do want to highlight that to truly make headway in eliminating stigma, we need structural interventions to change how people with diabetes and people with a higher body weight are viewed and treated in our society and within the health care system.

Q: What research is being done on stigma and diabetes, overweight, and obesity?

A: Much of the research on diabetes stigma is being conducted in other countries. More work in this area has recently started in the United States and is still very much needed. Researchers can begin to include measures of stigma in their work and take stigma seriously as an important factor and outcome in diabetes research. Some specific areas for research include health consequences of overlapping forms of stigma, such as stigma related to weight, diabetes, race, gender, and other factors. There’s also a need to develop and test evidence-based interventions to manage weight stigma and diabetes stigma, especially internalized stigma.

Do you have any experience screening and managing stigma? Tell us in the comment section below.

Resources

• Diabetes Language Guide, from dStigmatize

• The Use of Language in Diabetes Care and Education, from the American Diabetes Association

• What You Say Matters, from the Association of Diabetes Care and Education Specialists

• Weight Bias Exists in Health Care Settings, from University of Connecticut

• Weight Bias in Healthcare (PDF, 1.9 MB) , Obesity Action Coalition