Most Americans with obesity perceive themselves as only having overweight regardless of race or ethnicity, whereas experiences of weight stigma and bias differ across White, Black, and Hispanic groups with obesity, new research found.

“Clinicians need to know their patients, understand them from a cultural and racial perspective, and tailor treatment plans to align with their expectations and needs. This will improve motivation, engagement, and adherence,” study author Rodolfo J. Galindo, MD, Director of the Comprehensive Diabetes Center, Lennar Medical Center, University of Miami Health System, told Medscape Medical News.

Obesity medicine physician scientist Fatima Cody Stanford, MD, Massachusetts General Hospital and Harvard Medical School, Boston, told Medscape Medical News that the new findings add “an important, clinically relevant nuance that weight stigma is not monolithic and that experiences and attitudes can differ meaningfully across racial/ethnic groups among adults living with obesity.”

Stanford, who is also associate professor of medicine and pediatrics at Harvard, advised clinicians to ask patients with obesity, “Would it be okay if we talked about your weight and how it may be affecting your health?” and to “avoid moralizing or blame and explicitly acknowledge the biological and environmental drivers of obesity.”

And, since many may not realize that their BMI places them in the obesity category, “don’t assume shared language or awareness…the starting point is often to elicit the patient’s own understanding,” she said.

Only a Quarter With Obesity Know They Have It

The study, called USA-OBESTIGMA, involved 296 individuals with obesity (BMI ≥ 30) seen at two academic outpatient medical clinics, one in South Florida and the other in Atlanta. The findings were published online in the International Journal of Obesity. The study was an initiative of the Spanish Society of Obesity, which conducted a similar analysis among people with obesity in Spain, Egypt, and other countries.

The participants completed three validated instruments on the same day: the 13-item Anti-Fat Attitudes (AFA) Scale, which assesses fear of obesity and antipathy towards people with obesity, the 10-item Brief Stigmatizing Situations Inventory (SSI-B) scale assessing lifetime experiences of weight-related stigma across various societal domains, and the 11-item Weight Bias Internalization Scale (WBIS), a questionnaire measuring the internalization of negative weight stereotypes.

The 296 participants had a mean age of 54.8 years, mean BMI of 36.7, and 59% were women. The majority (42%) were Hispanic, 23% were White, and 35% Black individuals.

While they all had obesity, the proportions who perceived that they did were just 24% of Hispanic, 29% of White, and 19% of Black individuals. In contrast, self-perception of overweight was reported by 72%, 69%, and 73%, respectively. The other 4%, 2%, and 8%, respectively, perceived themselves as having normal weight.

Galindo, who is also associate professor of medicine at the University of Miami Miller School of Medicine, Miami, noted, “We were impressed by the high rates of weight misperception, particularly among Hispanic and Black [individuals]. These ethnic groups have distinct cultural norms about body image, especially for women. For example, women from the Caribbean islands and Latin America, as well as African Americans are ‘culturally expected’ to have ‘voluptuous and curvy bodies and prominent hip areas,’ regardless of the negative effects of abdominal obesity.”

Antifat Bias, Experience of Stigma Varied by Race

On the AFA survey measures of weight-related perception and prejudices, the Hispanic individuals had significantly higher scores than did White or Black participants (P < .0001). After adjustment for multiple covariates (age, sex, income, education, and BMI), total AFA scores were significantly lower for Black individuals than for Hispanic individuals (P < .001), while there was no significant difference between the White and Hispanic groups (P = .334).

Galindo noted, “we were not surprised by the higher scores on aversion and prejudice among Hispanic [individuals], as observed this in previous studies. Higher AFA scores indicate that Hispanic [individuals] ‘don’t like people with obesity’ and feel prejudice. Nevertheless, we were impressed by the lower AFA scores in African Americans, indicating a more receptive group towards people with this chronic condition.”

However, on the SSI-B, White individuals had higher total scores than both Hispanic and Black individuals (P < .0001). In particular, White individuals more often reported “having a doctor recommend a diet, even if they did not come in to discuss weight loss” (94.11% vs 83.78% for Hispanic adults and 80.95% for Black adults; P = .01), and “not being hired because of your weight, shape, or size” (72.07% vs 27.04% for Hispanic adults and 23.80% for Black adults; P < .0001).

After adjusting for multiple covariates, White individuals had significantly higher SSI-B scores than Hispanic individuals (P < .001), whereas there was no significant difference between the Black and Hispanic groups (P = .476).

Stanford advised that clinicians “offer evidence-based options without ‘diet-only’ reflexes…avoid reflexive and noncontextual advice and instead use shared decision-making, evidence-based treatment pathways, and follow-up.”

On the WBIS, Hispanic and White individuals had significantly higher scores than Black individuals (P = .0006), and this persisted after adjustment for covariates (P < .001). There was no significant difference between White and Hispanic individuals (P = .055). Overall WBIS scores decreased with age.

Galindo noted, “As observed in Spain, we found that younger individuals had more severe stigmatizing experience scores. This highlights a need for a more inclusive environment for people with obesity in Europe and the US, starting at young age.”

Stanford pointed out that the cross-sectional study design limits causal inference regarding how experiences of stigma shape internalization over time and that the specialist settings limit generalizability to primary care or community settings. Moreover, she noted, defining obesity with BMI alone rather than incorporating complications and central adiposity is a known limitation.

She added that the study “is a reminder that how we raise the topic matters as much as whether we raise it. Building trust, using nonstigmatizing language, and connecting weight to individualized health outcomes can improve engagement and reduce care avoidance.”

Indeed, Galindo said, “Patients with obesity, or any condition, need to see and feel we genuinely care for them in a compassionate way, providing culturally appropriate recommendations.”

This study was supported by internal funds support to Galindo from the Division of Endocrinology at the University of Miami Miller School of Medicine. He is supported in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health and has received research support from Novo Nordisk, Eli Lilly, Boehringer Ingelheim, and Dexcom, and consulting/advisory from Abbott Diabetes Care, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Eli Lilly, Novo Nordisk, and Medtronic. Stanford has been an advisor/consultant for the following: Calibrate Health, GoodRx, Pfizer, Eli Lilly, Boehringer Ingelheim, Gelesis, Vida Health, Life Force, Ilant Health, MelliCell, Novo Nordisk, Amgen, Currax. 

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.