The way clinicians talk about weight can leave lasting impressions, shaping how patients view themselves and engage with healthcare. In weight management care, patients commonly report experiencing weight stigma—an issue consistently linked to higher rates of healthcare avoidance. While surveys often highlight provider communication as a primary driver, UI Healthcare Endocrinologist Kathleen Robinson, MD, PhD, sought a broader understanding of how clinical encounters can perpetuate weight stigma.
Robinson’s recent study, published in Obesity Science and Practice, demonstrates how physical examination and a clinic’s built environment contribute to patient-reported weight stigma. Her findings reveal that direct communication alone does not explain patterns of healthcare avoidance, suggesting that current clinical processes and infrastructure underlie negative patient experiences.
To investigate factors influencing patient experiences, Robinson used the Weight Stigma in Healthcare Inventory (WSHCI), a survey tool designed to capture a wide range of stigmatizing encounters in clinical settings. Two participant groups—one recruited through ResearchMatch and another through a national Qualtrics survey panel—completed the inventory online.
Robinson and her team analyzed individual experiences of stigma and the cumulative number of stigmatizing encounters, adjusting for demographic factors. Among the 524 respondents, every stigma-related item on the WSHCI was significantly associated with avoiding care. The strongest effects were linked to the physical exam portion of appointments.
Physical exams: where stigma peaks
Robinson was initially surprised by the pronounced impact of physical-exam-related experiences, as she expected each domain to have similar associations with avoidance. But her clinical experience quickly explained the pattern.
“A physical exam requires a lot of trust in your healthcare provider,” Robinson said. “Patients may be changing into a gown and allowing access to their body in ways they otherwise never would. If they aren’t treated carefully and kindly during this time, that trust can be betrayed by a negative comment or even a nonverbal cue.”
To help mitigate stigma during visits, she encourages clinicians to:
- Ask permission before weighing a patient or bringing up weight-related topics.
- Save weight-related discussions for a portion of the visit outside the physical exam.
- Ask permission before repositioning a patient, using a respectful tone and avoiding body-related remarks or nonverbal judgements.
- Communicate clearly about what they are examining and why, reinforcing trust throughout the interaction.
The role of built environment
Although Robinson has observed positive change within weight management care, she hopes to see further progress in both individual and institutional practices.
For example, healthcare training programs that teach students, residents, and faculty how to recognize and combat weight stigma can reduce the likelihood of healthcare avoidance. But training alone is not enough. Robinson’s study also examined how a clinic’s built environment—the physical space and tools available—can reinforce stigma.
“It’s important that we have the appropriate equipment to treat larger patients,” she said. “This includes blood pressure cuffs and exam tables of the right size, as well as waiting-room furniture that can accommodate different-sized bodies. Some of this is emerging more into clinical practice, but there’s still more work to do.”
While acknowledging that costs may pose a challenge, Robinson emphasizes the importance of clinics including accommodating imaging equipment like scales, MRI machines, and CT scanners.
On the horizon
Robinson’s team is now examining how weight stigma and healthcare avoidance may influence metabolic health outcomes. They are currently reviewing healthcare data and collecting survey responses from the Kaiser Permanente Washington population to better understand the downstream effects of healthcare stigma.
Despite challenges raised in her research, Robinson remains optimistic, noting changing attitudes about weight across various disciplines.
“To a patient who has been affected by weight stigma, I would say that healthcare providers are becoming more aware of this concern,” she said. “I would recommend finding a provider who is sensitive to their needs—especially some of our PCPs here at Iowa, who are wonderful and attuned to these matters. I have seen attitudes shifting over time, and I’m hopeful that even more positive change is ahead.”