Addressing Weight Stigma in Medical Education: Insights and Strategies From a Nutrition Curriculum Review

Abstract

Background

Weight stigma in healthcare settings is implicated in lower quality of care for higher-weight patients. Physicians’ implicit and explicit antifat bias can undermine rapport, reduce health education, and discourage preventive care, eroding patient trust and fueling healthcare avoidance. Because medical education shapes trainees’ attitudes through both formal curricula and hidden cultural norms, it represents a critical leverage point for stigma reduction. Yet most interventions are stand-alone workshops that remain separate from core content and have limited reach.

Methods

We conducted a grounded theory analysis of the preclerkship nutrition curriculum at a large US medical school to examine how weight stigma is embedded in core teaching. Fifteen pre-recorded lectures (10.2 h) delivered by 13 faculty members were independently reviewed by a multidisciplinary team of medical students and a faculty expert in weight stigma. Reviewers documented potential instances of stigma in structured memos. Through iterative coding and team consensus, we developed conceptual categories and integrated these into broader themes.

Results

Reviewers generated 123 memos capturing stigmatizing language, attitudes, and framing. Five themes emerged: (1) stigmatizing terminology and imagery; (2) assumptions about the controllability of weight; (3) judgments about the behavior and health of higher-weight patients; (4) overemphasis on weight as a marker of health; and (5) statements that reinforce socially constructed body ideals and moralize food and eating. We propose a literature-informed framework for educators: adopt neutral, precise language; challenge weight-based stereotypes; highlight multifactorial determinants of health; avoid reinforcing body ideals or moralizing food; and use content warnings for sensitive topics.

Conclusions

Early exposure to weight-normative messages in foundational curricula can perpetuate antifat bias in clinical practice. Integrating stigma-reduction strategies into core teaching offers a promising approach to dismantle structural weight stigma and promote equitable, person-centered care, and warrants evaluation.

Introduction

Weight stigma describes the negative attitudes and beliefs directed toward individuals with higher weights (ie, antifat bias), leading to inequitable treatment. Those who experience weight stigma, independent of body mass index (BMI), are at increased risk of depression, anxiety, social isolation, substance use, suicidal ideation, negative body image, binge eating, and exercise avoidance.^1,2 In healthcare settings, weight stigma is implicated in lower quality of care for higher-weight patients. Physicians are known to have both implicit and explicit antifat bias, which can affect patient interactions. ¹ For example, physicians have been shown to build less rapport with and provide less health education to higher-weight patients. ¹ Additionally, higher-weight patients may receive fewer cancer screenings, further undermining care. ¹ These experiences can erode patient-provider trust, contribute to nonadherence and healthcare avoidance, ³ and hinder effective treatment.^1,4 Weight stigma in healthcare can also manifest in the physical environment (eg, design, seating, and equipment), clinical algorithms, and diagnostic criteria (eg, anorexia nervosa). ⁵

Medical education plays a formative role in shaping trainees’ beliefs about weight, through both formal curricula and the hidden curriculum of cultural norms and role modeling in classroom and clinical settings.^6,7 Formal curricula remains largely weight-centric, emphasizing the diagnosis of “obesity” by BMI and training clinicians to counsel patients on weight loss, with little explicit attention to weight stigma or bias and their impact on patient care. ⁸ Weight stigma may also be perpetuated by educators themselves; nearly 40% of medical students report hearing derogatory remarks about higher-weight patients from their instructors. ⁹ Although many medical trainees enter medical school with implicit and explicit biases toward higher-weight individuals, they may be more receptive to new information than more established clinicians,^1,10 making medical education a critical leverage point for reducing weight stigma.

Most weight stigma interventions in medical education have utilized adjunctive workshops and activities for trainees. ¹¹ Although these efforts show promise in raising awareness and reducing self-reported stigma, ¹⁰ they are time-intensive and disconnected from core content, which ultimately limits their reach and sustainability. ¹² Comprehensive stigma reduction efforts should go beyond supplementary programming ¹³ and address the stigma within the core curriculum, especially in foundational topics like nutrition. ⁵

Methods

This qualitative study used a grounded theory approach to inductively explore how weight stigma appears in preclerkship medical education. Grounded theory is a qualitative research method in which theory is generated inductively from systematic engagement with data.^14,15 Analysis involves iterative coding, constant comparison, and team discussion to develop conceptual themes, which are then linked to existing literature.^14,15

The analysis involved a detailed curricular review of the nutrition and metabolism curriculum at a large US medical school. Nutrition was selected given the frequent coverage of relevant topics (eg, weight, body size, and diet).^14,15 Fifteen lectures totaling 10.2 h delivered by 13 medical school faculty were available as recorded videos. The lectures included topics such as Obesity and Satiety, Macronutrients, Nutrition and Population Health, Healthy Nutrition Counseling, Medical Weight Management, Bariatric Surgery, and a patient panel.

Included materials consisted of all pre-recorded lectures focused on nutrition and metabolism that were offered as part of the preclerkship medical curriculum during January to February 2022, as well as a virtual patient panel recorded during the same curricular block. Excluded materials included lectures outside this curricular block, live sessions without recorded content, and curricular content not focused on nutrition or metabolism. Because this study reviewed the entirety of the available nutrition curriculum relevant to the research question, rather than sampling from a larger pool, a traditional sample size calculation or power analysis was not applicable. This comprehensive review enhanced qualitative rigor by encompassing the full scope of relevant instructional materials.

Analysis

The analytic process followed 4 grounded theory phases:^14,15

Conceptual development (memo review)

Category development (clustering and refining codes)

Theoretical integration (organizing into conceptual themes)

Contextualization (linking themes to existing literature)

To identify key concepts and patterns related to weight stigma, a review team consisting of 4 medical students with prior knowledge of weight stigma and one faculty member from the Department of Nutritional Sciences with expertise in weight stigma reviewed all 15 lectures. Stigma was defined as language, attitudes, or content that stereotyped, judged, or discriminated against individuals based on body size. Each lecture was independently reviewed by the faculty member and at least one medical student. Reviewers created analytic memos documenting potential instances of weight stigma. Each memo included a summary of the instance, a timestamp or slide number, and a reviewer-generated descriptive label to facilitate comparison across lectures and support conceptual development.

Three medical students independently reviewed each memo and developed preliminary categories characterizing the observed stigma. The full review team then adjudicated and refined the preliminary categories using an iterative process that involved reviewing content flags, identifying broad concepts, reviewing clarifying examples, revising/refining concepts, and aggregating the concepts into higher-order categories. Detailed category descriptions with specific examples observed within the curriculum were developed to integrate the emerging conceptual insights into coherent themes. To contextualize these findings, a literature review was performed to identify recommendations and guidelines aligned with observed themes, which then informed the development of possible strategies for reducing weight stigma.

Initial content review and conceptual development, including memo review, were conducted between July and August 2022. Subsequent analytic phases, including category development, theoretical integration, and contextualization, were conducted from September 2022 through April 2023.

This study did not involve human subjects. It analyzed recorded curricular content and did not link findings to individual faculty members. Permission to review the nutrition lectures was obtained from co-author Dr Cherry-Bukowiec, the nutrition sequence lead. Access to the video lectures was provided to student and faculty reviewers for the sole purpose of identifying weight-related content and developing recommendations to reduce weight stigma in medical education. No identifying information about individual faculty members was retained during coding or analysis, ensuring confidentiality. As the study did not involve human participants or identifiable private information, informed consent was not applicable and institutional review board approval was not required.

Results: Identified Themes of Weight Stigma

The lecture review process generated 123 memos that captured weight stigma in various forms, including overt weight stigma, messaging that may perpetuate stigma, imprecise, or oversimplified discussions of weight, and other concerns regarding the presentation of weight-related content. Through iterative review, 5 major themes emerged (Table 1):

Stigmatizing terminology and imagery;

Assumptions regarding the controllability of weight;

Judgments about the behavior and health status of higher-weight patients;

Overemphasis on the role of weight in overall health; and

Statements that uphold socially constructed body ideals and moralize food/eating.

Table 1.

Themes of Weight Stigma Identified in Curricular Content.

Theme	Examples
1. Stigmatizing terminology or imagery	Unnecessarily negative language to describe obesity (ie, “grim”, “crisis”, “suffer with obesity”) Terminology such as “the obese” and “chunky kid” Photographs that depict people with larger bodies in dehumanizing ways
2. Assumptions regarding the controllability of weight	Implication that obesity is due to personal decisions and/or actions (ie, “if you are going to be obese” and patients with obesity making the “right” choices) Description of weight loss as a “mental game”
3. Judgements about the behavior and health status of people with larger bodies	Terminology such as “overeating” or “unmotivated” Comparison between having a larger body and “watching too much TV”
4. Overemphasis on the role of weight in overall health	Imprecision with definitions (ie, use of “obesity” interchangeably with other health conditions such as diabetes) Suggestion that weight loss inherently results in improved well-being (ie, “patients are much healthier and happier as a result”) Assumption that obesity and fitness are oppositional
5. Statements that uphold socially constructed body ideals and moralize food/eating	Creation of right/wrong dichotomy in the discussion of the “right” foods to be eating (ie, “crappy foods”, “right” choices) Promotion of thinness or weight loss as inherently healthy, better, happier, virtuous (ie, “better body”, “ideal body weight”)

Collectively, these themes reflect weight-normative perspectives, which prioritize weight as a primary indicator of health and assume individual responsibility for weight, overlooking social, economic, and genetic contributors.^8,16

Results: Framework for Change

To inform the development of a framework for reducing weight stigma in medical education, we conducted a targeted review of existing recommendations addressing weight stigma in medical training,^6,11,17–19 as well as literature and guidelines related to weight-related terminology and imagery,^13,20–23 and the science of weight regulation and weight controllability.^24–27 This literature was explicitly linked to the conceptual themes generated through the grounded theory analysis to ensure that the resulting framework was both evidence-informed and practically relevant.

Informed by the theme related to socially constructed body ideals and the moralization of food and eating, we also considered the potential impact of stigmatizing curricular content on medical students themselves. Prior research indicates that exposure to weight stigma may contribute to poorer wellbeing among medical students with higher body weights, ²⁸ and may be particularly salient for students carrying varying degrees of traumatic stress related to prior weight-based experiences. ²⁹

Based on this synthesis, we developed a preliminary framework to provide practical guidance for educators to foster a more inclusive and evidence-aligned learning environment for medical trainees. The framework includes 5 strategies (Table 2):

Use neutral, precise language, and avoid dehumanizing terms^13,20–23;

Challenge weight-based assumptions and stereotypes^6,17,27;

Emphasize multifactorial determinants of health^4,10,11;

Avoid reinforcing body ideals and moralizing food choices^9,18,24; and

Use content warnings when discussing potentially distressing weight-related topics.^9,18,24

Table 2.

Strategies for Reducing Weight Stigma in Medical Education Curricula.

Strategy	Content to Avoid	Content to Include
#1: Use neutral, precise language and avoid dehumanizing terms13,20–23 Note: There is no one term accepted by all people in larger bodies. Some may prefer terms such as “overweight” or “obese,” while others may utilize the term “fat” as a reclaimed neutral descriptor. For others, these terms may be perceived as pathologizing or pejorative. We advise adherence to media guidelines and the recommendations below while also acknowledging different preferences in terminology do exist Additionally, it is recommended to ask patients what language they prefer providers use in healthcare settings	Dehumanizing Language & Terminology: Pejorative and otherwise negative wordings Negative adjectives and adverbs (ie, “lazy”, “severely”, and “morbidly”) Combative language that positions higher weight people as adversaries (ie, “war on obesity”, “fight obesity”, “obesity crisis”) References with strong negative connotations (ie, “curse”, “strain”, “plague”, “epidemic”, “suffer”, “struggle”) Dehumanizing Imagery: Images that place unnecessary emphasis on excess weight or that isolate an individual's body parts Depictions of behaviors such as overeating or being sedentary that serve to reinforce stereotypes Depersonalizing compositions such as headless bodies, or close-ups of body parts that place unnecessary emphasis on weight	Neutral Language & Terminology: Nonstigmatizing language meets 3 criteria: Accurately describes bodies without pathologizing them Not used as a slur Does not evoke past trauma Examples of neutral nonstigmatizing language to describe larger bodies include “higher-weight”, “larger-bodied”, “higher end of the weight spectrum”, and “person of size” Person-first language is often used when addressing people with some chronic diseases as it avoids labeling them by their illness. Although person-first language (“people with obesity” or “people affected by obesity” rather than “obese people” or “the obese”) is recommended by many professional organizations, it does not meet the criteria above for nonstigmatizing language Precision with Definitions: Distinguish between “diet” to describe general eating patterns versus weight loss diets Clarify how the term “obesity” is being defined (ie, using a BMI cutoff or adiposity or other indicator) and avoid using it as a proxy for other diseases
#2: Challenge weight-based assumptions and stereotypes6,17,27 Note: The assumption that weight is highly controllable and therefore primarily a reflection of personal actions was frequently identified in the curricular review. This assumption, which is prevalent in healthcare and among medical students, reinforces judgmental attitudes about the behaviors and character of people with larger bodies. Increasing awareness of such stereotypes and providing education about the multiple factors that influence weight (on an individual and population level), as well as the impact of weight stigma on health and healthcare, are important components of efforts to counteract weight stigma	Assumptions about the Controllability of Weight: Statements claiming that weight is highly controllable (ie, “having a better diet”, “exercising more”, “calories in and calories out”, “eat less, move more”) Terms that imply weight status is exclusively dependent on personal behaviors (ie “overeating”, “willpower”, “eat healthier”) Judgements Regarding Behavior and Health Status of People with Larger Bodies: Judgmental language regarding health behaviors, work ethic, and personal character (ie, “unmotivated”, “lazy”, “undisciplined”, “sloppy”) Exclusive or excessive focus on weight, body size, or body shape as a proxy for health rather than other markers of health status Statements that suggest fatness and fitness are mutually exclusive	Complexity of Weight: Acknowledge the genetic, environmental, social determinants of weight (ie, “weight is mediated by a complex intersection of genetic, environmental, and social factors that are not yet fully understood, but we do know that…”) Discuss challenges associated with weight loss maintenance such as decreased energy expenditure, increased appetite, environmental factors, and weight cycling Acknowledge the heterogeneity in health, health behaviors, and life experiences of individuals across weight spectrum (ie, there is no health behavior that only larger people engage in and no health condition that only affects higher weight people) Impact of Weight Stigma on Health and Healthcare: Define weight stigma and discuss examples of how it negatively impacts health and healthcare, such as: People with higher weight may be given diet and exercise counseling rather than treatment for an underlying condition Physicians have been shown to provide suboptimal care to patients with larger bodies. Weight stigma can mediate weight gain
#3: Emphasize multifactorial determinants of health4,10,11 Note: While correlations between weight and some health indicators/outcomes are well-established, epidemiological studies rarely adequately adjust for all potential cofounders of the relationship and typically do not examine weight stigma and its sequelae (ie, delayed diagnosis due to lower screening, healthcare avoidance) as potential contributors. Epidemiological data may also be used to draw inferences about the impact of weight loss interventions, which likely do not accurately represent the true impact of such interventions. As such, the following recommendations serve as a guide for stigma-reduction while having a robust discussion of the relationship between weight, weight loss, and health	Overemphasis on the Role of Weight in Health: Implications that weight loss is associated with immediately improved health for patients Statements that regard weight loss as a “cure all” without risks Assumptions that health improvements seen within the setting of weight loss interventions are due to the weight loss itself (and not behavioral changes, increased support, or reduction in weight stigma that accompanies weight loss) or are sustainable	Include Discussion of Risks Associated with Weight Loss: Discuss the sustainability and long-term outcomes of weight loss. Acknowledge the risk that health problems may persist or not be helped by weight loss Discuss the potential physical and psychological risks associated with intentional weight loss and dieting for people across the weight spectrum Discuss the role of informed consent with respect to weight loss including offering other alternatives (ie, evidence-based treatments that would be provided to thinner patients) and respecting patient autonomy Discuss Confounders and Mediators that Influence Obesity and Disease Risk: Include discussion of key confounders such as physical activity and social determinants of health when presenting correlational data on obesity and disease risk Include discussion of key mediators (ie, lower quality care, healthcare avoidance, and weight stigma) when presenting correlational data on obesity and disease risk. Acknowledge health benefits of behavior change independent of body size Include Discussion of the History and Limitations of BMI: Discuss the shortcomings of BMI including the derivation and implementation of the metric. Key points to include: Nondifferentiated; does not account for body composition Poor predictive value as a measure of health Standardized on white males for population level analysis How BMI can limit access to care (ie, BMI cutoffs for surgery, insurance coverage for eating disorders) Shortcomings of using a population-based metric for individual treatment decisions Arbitrary changes made to BMI categories in 1998 Misclassification when BMI and other measures of adiposity are used as proxies of health
#4: Avoid reinforcing body ideals and moralizing food choices9,18,24 Note: Attitudes about weight, body size, and nutrition are strongly influenced by society. Patients and physicians are steeped in a culture where there are wellness and diet industries devoted to fabricating ideals about the correct way to look and eat. Deconstructing myths and ideals put forth by capitalism is an important piece of addressing weight stigma. Additionally, colonialism and white supremacy have a known impact on modern American culture's view of fatness (for more reading on this, see “Fearing the Black Body: The Racial Origins of Fat Phobia” by Dr Sabrina Strings)	Echoing the Language of Diet Culture: Moralization of specific foods and food groups (ie, “bad”, “junk”, and “crappy”), instead, use more neutral terms (ie, “more calorically dense”, “more nutrient dense”) Promotion of thin bodies as inherently healthier, better, and/or happier (ie, “better body”, “ideal body weight”) Promotion of fad (nonevidence-based) diets and commercial weight loss diets Eating Disorder Triggers: Second-person language when discussing dietary recommendations (ie, “when you do intermittent fasting”). Instead, use third person language (ie, “when research participants performed intermittent fasting”)	Discuss the Cultural and Historical Context of Weight and Dieting: Incorporate discussion of diet culture, racialized body ideals, and the role of capitalism in recommendations such as commercial weight loss diets Mitigate Eating Disorder Triggers: Use third person language (ie, “when research participants performed intermittent fasting”)
#5: Use content warnings when discussing potentially distressing weight-related topics29,30 Note: Obesity, dieting, weight stigma, and other topics can be difficult for those with weight-related traumatic experiences and/or a history of an eating disorder. Here are some general best practices for content warnings	Content warnings that focus on the intent rather than the impact of the material being discussed. For example, saying “this content means well and is not intended to cause harm”	Focus on the impact of the content rather than the intent. For example, “weight stigma is pervasive in medicine and, although we are working to mitigate stigma in the curriculum, this content may contain bias and we welcome any feedback” Acknowledgment that students, or people in students’ lives, may have had personal experience with body image, diet culture, eating disorders and/or disordered eating, etc.

Discussion

The early exposure to weight stigma in medical education, as identified in this grounded theory analysis, presents a critical opportunity to reduce stigma and promote more inclusive practices. We identified 5 patterns of weight stigma that reinforce weight-normative perspectives. These findings closely parallel those of Olson et al, who described how medical education can introduce and perpetuate weight stigma. ⁶ Their work highlighted how teaching that frames body weight primarily as a biomedical characteristic reinforces a weight-normative view of health, a theme reflected in our findings on assumptions about the controllability of weight and on judgments about the behavior and health status of higher-weight patients. ⁶ Our analysis extends this perspective by showing how curricular statements that uphold socially constructed body ideals and moralize food and eating can deepen stigma. Similar to our study, the Olson et al noted that stigmatizing language is often modeled in case discussions of higher-weight patients and in teaching about weight-associated conditions, and that weight is inappropriately centered in treatment planning. ⁶ They also emphasized that individuals at higher weights are rarely recognized as a marginalized group.

Together, these studies underscore the need to shift toward a weight-inclusive approach, which defines health as more than body size, actively challenges weight stigma, and promotes person-centered care. Such an approach encourages learners to engage patients with respectful curiosity and nonjudgmental inquiry into each person's lived experience of body size and health. These efforts can help address structural stigma and foster stigma resistance among students.^31,32 Importantly, meaningful change must extend beyond curricular content (eg, lectures and educational materials) to include medical educators themselves,^7,33 and should not be confined to isolated programs that operate within an otherwise weight-normative institutional context. ¹³ Programs that support educators in recognizing and addressing bias have the potential to improve teaching practices and shift broader institutional norms. ¹

The strengths of this study include a robust review of all lectures from an entire section of a curriculum, covering a breadth of topics related to nutrition and various lecturers. Additionally, multiple reviewers reviewed each lecture to help decrease personal bias. However, the analysis is limited by the scope of the reviewed curriculum. Including lectures from other medical schools and/or curricular areas (eg, cardiology and pediatrics) could have revealed different patterns of weight stigma.

Conclusion

Early exposure to weight stigma in medical education has lasting implications for patient care. This study highlights how weight stigma is embedded in a foundational curriculum and offers a practical, literature-informed framework for change. Through inclusive curricula and educator support, medical education can play a central role in dismantling weight stigma and promoting more equitable care. Future areas of study include examining the usability of these recommendations, their effectiveness in mediating curricular change, and their impact on medical student attitudes and behaviors. Ongoing evaluation, adaptation, and refinement of the proposed strategies will be essential to account for the evolving nature of medical education and shifting language practices.