About this course:
This course provides an overview of the obesity epidemic and the associated weight bias and stigma sweeping the healthcare system leading to decreased healthcare utilization by individuals living with obesity. It discusses strategies to overcome this detrimental dynamic and increase awareness to ensure equal access to quality care.
Weight Bias and Obesity Stigma in Healthcare
This course provides an overview of the obesity epidemic and the associated weight bias and stigma sweeping the healthcare system leading to decreased healthcare utilization by individuals living with obesity. It discusses strategies to overcome this detrimental dynamic and increase awareness to ensure equal access to quality care.
Upon completion of this module, learners should be able to:
- describe the obesity epidemic and classification system of body mass index (BMI)
- define and distinguish between weight bias, obesity stigma, sizeism, weight discrimination, implicit bias, and explicit bias
- identify the consequences of weight bias and obesity stigma in healthcare
- discuss evidence-based obesity guidelines and strategies to reduce bias and inequities in obesity prevention and care to improve patient outcomes
The obesity epidemic is a major global health challenge, and despite its negative impact on health, it is projected to rise substantially over the next several decades. Obesity is associated with several leading causes of preventable death, including heart disease, stroke, type 2 diabetes mellitus (T2DM), and certain cancers. A body weight higher than what is considered healthy for a particular height is described as overweight or obesity. The Centers for Disease Control and Prevention (CDC, 2022b, 2022d) define obesity as abnormal or excessive fat accumulation in relation to height that presents an adverse health risk. Body mass index (BMI) is the most common screening tool for weight, and a BMI of 30 or higher indicates obesity (see Table 1; World Health Organization [WHO], 2021). Research demonstrates that individuals who are overweight or obese are often subjected to scrutiny and unfair treatment. Weight bias is ubiquitous in society and prevalent within workplace settings, educational systems, and media outlets. It has been cited as the fourth most common form of discrimination among US adults, becoming more prevalent than discrimination based on race or ethnicity. Correspondingly, studies have shown that one of the biggest challenges in healthcare is provider stigma and bias. Treating obesity and obesity-related illnesses is complex, and healthcare provider (HCP) frustrations, beliefs, and biases may manifest in overt or subtle forms. This perceived discrimination causes shame and embarrassment for the patient leading to hesitancy in seeking medical care. Thus, healthcare-related weight bias fuels the obesity epidemic, as patients avoid seeking medical attention, engage in stress eating, and have poorer overall health outcomes (Alberga et al., 2019; Tomiyama et al., 2018; Wang et al., 2020).
BMI calculates a person’s weight (in kilograms [kg]) divided by the square of height (in meters[m]). A high BMI can indicate excess body fat and is strongly correlated with adverse health outcomes (CDC, 2022b). According to the WHO (2021), BMI is the most useful population-level measurement tool for measuring overweight and obesity, as it can be utilized in both males and females and across the lifespan.
Adult BMI Chart
18.5 – 24.9
Obesity Class I
30.0 – 34.9
Obesity Class II
35.0 – 39.9
Obesity Class III
Scope of the Problem
Worldwide obesity has tripled since 1975 and has become more prevalent than smoking or the opioid crisis (CDC, 2022a; WHO, 2021). Obesity affects more than 650 million adults and 125 million children worldwide (World Obesity Federation [WOF], 2022a). According to data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES), the prevalence of obesity among US adults aged 18 and older was 41.9%, and severe obesity was 9.2%. Among children and adolescents aged 2 through 19, obesity prevalence has tripled since 1980, rising from 5.5% to 19.7% (Stierman et al., 2021). Obesity rates are climbing; by 2030, 78% of Americans are expected to be overweight or obese (Wang et al., 2020). Globally, 1 in 5 women and 1 in 7 men worldwide are expected to have obesity by 2030. Five countries (i.e., the US, China, Russia, India, and Brazil) account for one-third of adult obesity worldwide (WOF, 2022b). On September 27, 2022, the CDC newsroom published a press release regarding the urgent need to address widespread national disparities in obesity as emerging data revealed at least 35% of adult residents are obese in 19 states, more than doubling the number of states with a high obesity prevalence in 2018. Rural areas across the US have higher rates of obesity and severe obesity. According to the State of Obesity 2022 report published by Trust for America’s Health (TFAH, 2022), Nebraska, North Carolina, and South Dakota had adult obesity rates exceeding 35% for the first time in 2021. Comparatively, no US state had adult obesity rates surpassing 15% in 1985, 20% in 1991, or 25% in 2000. In 2006, only two US states (West Virginia and Mississippi) exceeded 30% in adult obesity rates (TFAH, 2022).
Asian adults have the lowest obesity rates of all the race or ethnicity groups in the US. Black and Hispanic populations and individuals of all races aged 40 to 59 are at the highest risk. According to the 2017-2020 NHANES survey, Black American adults had the highest obesity rate (49.9%), followed by Latino (45%), White (41%), and Asian (16%) adults. By gender, 57.9% of Black women were obese compared to 39.6% of white women. Black men had an obesity rate of 40.1%, slightly lower than white men (43.1%; Stierman et al., 2021). As noted in the Weighing Down America: 2020 update, there has been significant growth in obesity prevalence between 2014 and 2018 within the male population, particularly white males and males of all races aged 20 to 59 (Lopez et al., 2020).
Childhood obesity is one of the most severe public health challenges, as overweight children are more likely to become obese as adults and endure significant health consequences related to lifelong obesity (CDC, 2022a). As the obesity epidemic expands, children reportedly consume increased quantities of high-calorie, energy-dense foods without a corresponding increase in physical activity, promoting unhealthy weight gain and chronic obesity (TFAH, 2022). Early evidence suggests that the COVID-19 pandemic has significantly exacerbated childhood and adult obesity. In a pooled, secondary analysis of 373 children in Massachusetts (aged 8–12 years), the monthly BMI increase more than doubled for children whose 6-month study visit occurred post-pandemic compared to pre-pandemic. Correspondingly, post-pandemic activity levels were significantly diminished compared to pre
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Obesity is associated with an increased risk of death, especially among adults younger than 65. Obese adults are nearly two times more likely to die before age 70 than adults who maintain a healthy weight (Turner et al., 2018). After cigarette smoking, obesity is the second leading cause of preventable deaths in the US (Wang et al., 2020). In 2019, obesity-related illnesses accounted for more than 5.0 million deaths globally, and more than 50% of these deaths were among people younger than 70. Compared to those with a healthy weight, people with obesity are at increased risk for serious health conditions, including coronary heart disease, hypertension, hyperlipidemia, T2DM, stroke, gallbladder disease, breathing problems, and osteoarthritis. T2DM, coronary heart disease, vascular dementia, and stroke represent 68% of the 257,313 deaths attributable to obesity in 2018 (Lopez et al., 2020; WOF, 2022b). Further, being overweight and obese increases the risk of being diagnosed with 13 types of cancer (see Figure 1). Excess body weight leads to chronic inflammation and increased insulin levels, insulin-like growth factor, and sex hormones. The risk for cancer increases as the severity of weight gain rises and the longer a person remains overweight. Nearly 20% of all cancers and about 16% of cancer deaths in the US are related to excess body weight, physical inactivity, and poor nutrition (CDC, 2022c, 2022d).
13 Cancers Associated with Overweight and Obesity
Causes and Contributing Factors
The etiology of obesity is a complex interplay of multiple factors; however, most commonly, it is the consequence of an ongoing imbalance between excess calorie consumption and limited calorie expenditure. Mass media is one of the major driving forces behind the social acceptance and stigmatization of obesity, as cultural importance and social value have become directly correlated with body image. The media routinely perpetuates stereotypical illustrations of obese individuals and reinforces the social acceptance of weight bias. ‘Thin' is promoted as the ideal appearance, representing self-discipline, whereas ‘fat' is associated with failure, laziness, and an open invitation for public scrutiny. Individuals with obesity endure stigma from all avenues of life, including educators, employers, supervisors, coworkers, friends, and family. There are well-documented inequalities in employment, education, interpersonal relationships, and opportunities among individuals with obesity.
Socioeconomic, environmental, and cultural influences also contribute to obesity. Studies demonstrate that children's diet and physical activity habits are primarily influenced by their environment. These influences include social and economic factors, agricultural and food processing policies, and physical activity patterns (CDC, 2022d). Social and behavioral factors, such as unemployment, excessive drinking, tobacco use, post-secondary education, and single-parent households, strongly correlate with obesity. Obesity rates are lower among adults living in higher-income homes and those who earned college degrees (Lopez et al., 2020; Stierman et al., 2021). Research demonstrates that genetics and epigenetic variations contribute to a predisposition to obesity for some individuals. These variations are thought to alter the body’s metabolic regulation of neural pathways, hormones, and appetite centers, impacting insulin resistance, inflammation, and fat deposition. However, genetic mutations cannot entirely explain the heritability of obesity, and these mechanisms remain under investigation (Tirthani et al., 2022).
Obesity is one of the biggest drivers of US healthcare spending, costing about $173 billion annually. Medical costs for adults with obesity are $1,861 higher than those with a healthy BMI, and these numbers rise alongside BMI (Lopez et al., 2020; Ward et al., 2021). In a 2021 study by Cawley and colleagues (2021) examining the direct medical costs of obesity in the US, adults with obesity incurred 100% higher annual medical costs than normal-weight comparisons. In addition, costs increased significantly alongside the obesity class, from 68.4% for obesity class I to 233.6% for obesity class III. By contrast, only three years prior, Turner and colleagues (2018) found adults with obesity incur 42% higher medical costs per capita than their normal-weight counterparts (Turner et al., 2018). In 2018, the Milken Institute estimated obesity to cost roughly 6.76% of gross domestic product (GDP; $1.39 trillion) compared to 5.57% of GDP ($0.976 trillion) in 2014. These numbers include direct costs for medical treatment and indirect costs for lost productivity (i.e., missed workdays). According to the report, hypertension, T2DM, chronic back pain, and osteoarthritis represent 77% ($1.07 trillion) of obesity costs (Lopez et al., 2020). The WOF (2022b) forecasts the global economic costs of overweight and obesity to increase to over $3 trillion by 2030 and $18 trillion by 2060. Further, the COVID-19 pandemic may increase these estimates even higher.
Obesity is exceedingly stigmatized within society, and individuals have become vulnerable to negative bias, prejudice, and discrimination across healthcare settings. The devaluation of people based on their weight has been rising for decades and is considered the last socially acceptable form of prejudice. Weight bias, also called sizeism, is discrimination or prejudice against people because of their size or weight. It refers to negative attitudes, beliefs, assumptions, stereotypes, and judgments toward individuals who are overweight or obese. Weight bias can emerge in subtle forms through social exclusion and rejection, or it can be expressed directly with teasing or physical aggression. In addition, weight bias can lead to weight stigma, a socially degraded characteristic such as a stereotype or label affixed to a person that interferes with the individual's identity, causing them to feel socially discredited. Obesity stigma can progress to actions against people, such as exclusion and marginalization. Weight discrimination is unequal and unfair treatment due to weight. Common examples of weight discrimination include being denied a position or job promotion, reduced access to medical procedures, or inferior medical care. Fatphobia is the fear or hatred of fat bodies (Alberga et al., 2019; Bradley & Dietz, 2017; UC Davis, 2021).
Bias is generally considered to be either implicit or explicit. Implicit bias refers to automatic and subconscious attitudes, often occurring outside of awareness and in contrast to explicitly held beliefs. Implicit bias may influence individual behavior without clearness or insight into the rationale. Internalized weight bias is the self-directed stigmatizing attitudes people have based on social stereotypes about their perceived weight status. It leads to poor self-esteem as individuals develop negative beliefs about themselves due to their weight. Explicit bias refers to an individual's conscious, outward, and intentionally expressed opinions and beliefs (Hill et al., 2021; UC Davis, 2021; WHO, 2021). Puhl and Suh (2015) examined trends of weight discrimination between 1995 and 2005, and their findings demonstrated a 66% rise in weight discrimination. Since then, the numbers have steadily climbed to surpass rates of discrimination due to race, ethnicity, physical disability, or sexual orientation. Recent studies demonstrate the pervasiveness of weight bias. At least 42% of US adults report experiencing weight stigma during their lifespan, with HCPs and coworkers cited as top offenders. As the obesity epidemic expands, the probability of being discriminated against rises (Lee et al., 2021; Puhl et al., 2021). According to data from the University of Connecticut (UCONN) Rudd Center for Food Policy and Obesity (n.d.-a; n.d.-b), 54% of adults with obesity experience weight bias from coworkers, and 69% experience weight prejudice from HCPs. Children with obesity are 63% more likely to be bullied than their normal-weight peers.
Weight Bias in Healthcare
Studies demonstrate that discriminatory weight practices are standard in healthcare settings, and weight bias among HCPs may surpass that of the general population. HCPs spend less time caring for and counseling patients with obesity, develop less rapport and have decreased expectations. Further, HCPs focus less on patient-centered care and offer fewer treatment interventions or options. Further, there is a reduced focus on health exams, screenings, and preventative medicine (Abrams, 2022; Sobczak & Leoniuk, 2021). According to a 2021 study examining the association between weight stigma and healthcare experiences across the US and five other countries, two-thirds of participants from each country reported experiencing weight stigma from doctors (Puhl et al., 2021). Many patients who have felt stigmatized by HCPs avoid returning for further treatment or engage in ‘doctor-shopping,’ reducing the continuity and quality of their medical care. According to Alberga and colleagues (2019), patients with obesity feel their HCPs attribute all of their health problems to their weight, make faulty assumptions about their health behaviors, and assume they willingly engage in overeating. Experiencing bias in a healthcare setting reduces the trust in HCPs and thus delaying care or avoiding treatment for medical conditions (Brown et al., 2022; Hill et al., 2021).
When patients with obesity seek assistance from HCPs, the most commonly offered help they receive can reinforce and intensify shameful feelings they may already be experiencing. In turn, patients have an increased likelihood of canceling follow-up medical appointments. Research illustrates that shame is not an effective tool to encourage weight loss; it more commonly leads to weight gain due to stress eating, increased caloric intake, and unhealthy behaviors like binge eating. Some patients turn to food to dissociate from their negative feelings and experiences. Thus, people who experience weight discrimination are more likely to transition from overweight to obese. In addition, they are more likely to avoid exercising and report feeling uncomfortable and embarrassed exercising in public gyms. Even when well-intentioned HCPs counsel patients on simplistic, one-size-fits-all behavioral weight loss strategies, such as the "eat fewer carbohydrates, fat, and sugar, and exercise more," these uninspiring approaches can make patients feel powerless. Patients become more socially isolated as their obesity worsens, leading to emotional and psychological distress, such as poor self-esteem, negative body image, and feelings of worthlessness and embarrassment. As a result, patients are at increased risk for serious mental health conditions such as depression, anxiety, self-harm, and suicidality. When this occurs, the illness remains untreated, and the patient enters a vicious cycle of hopelessness and helplessness, as they cannot overcome the behavior alone. This brutal cycle, as portrayed in Figure 2, leads to an increased risk for morbidity from obesity-driven conditions, adverse overall health outcomes, poor quality of life, early mortality, and rising costs to the healthcare system (Abrams, 2022; Brown et al., 2022; Fruh et al., 2016; Pearl & Puhl, 2018; Puhl et al., 2021; WHO, 2021).
The Cycle of Obesity Impacted by Weight Bias in Healthcare
(Puhl et al., 2021)
Weight bias has been observed and documented in nearly every aspect of healthcare, including attitudes of front desk reception staff, patient transport, nursing, and hospital volunteers. Surveys demonstrate physician attitudes toward patients who are overweight and obese are harmful, viewing patients as lazy, weak-willed, non-compliant, unsuccessful, dishonest, lacking self-control, and less intelligent than normal-weight equivalents. As BMI increases, physicians report increasingly negative attitudes, such as having less respect, reduced patience, and diminished compassion for them. Patients with obesity may be viewed as less desirable and a waste of the physician's time. Many physicians blame obesity for nearly every ailment, illness, or symptom the patient describes, even when their symptoms are unrelated to weight, such as a cold or virus. In addition, physicians tend to blame patients for being overweight, believing that obesity is a behavioral problem caused by inactivity and overeating (Panza et al., 2018; Puhl et al., 2021; Rubino et al., 2020).
In a thematic analysis of 21 studies examining perceptions of weight bias and its impact on patient engagement with primary healthcare services, researchers identified the following significant themes: contemptuous, patronizing, and disrespectful treatment, lack of training, ambivalence, attribution of all health issues to excess weight, assumptions about weight gain, barriers to health care utilization, low trust and poor communication, avoidance or delay of health services, and ‘doctor shopping’ (Alberga et al., 2019). In a nationwide study, Sobczak & Leoniuk (2021) asked 184 medical professionals about their experiences and opinions of obesity and weight discrimination. More than 65% of professionals viewed poorer HCP attitudes toward patients with obesity as a common phenomenon. Almost half (48.4%) witnessed medical staff’s discriminatory behaviors towards patients with obesity, with the most commonly cited behaviors including appearance-mocking (96.6%), looks of disgust and repulsion (96.2%), and scaring a patient with the necessity to lose weight (57.7%). Further, participants also acknowledged limited access to dedicated medical equipment (62.4%) suitable for patients with obesity as a discriminatory limitation in the workplace (Sobczak & Leoniuk, 2021).
Ward-Smith and Peterson (2015) obtained data regarding the self-reported attitudes and beliefs of 358 nurse practitioners (NPs) toward patients with obesity. NPs perceived patients who were overweight or obese as less successful than others, unsuitable for marriage, untidy, and unhealthy. Puhl and colleagues (2021) enrolled 13,996 adults across six countries in an internationally-available behavioral weight management program. Participants completed online surveys examining their experiences of weight stigma, including perceived quality of care, avoidance or delay of seeking care, experiences with providers, and perceived weight stigma from doctors. Two-thirds of participants in each country reported experiencing weight stigma from doctors. Participants with higher internalized weight bias reported greater healthcare avoidance, increased perceived judgment from doctors due to their body weight, lower frequency of obtaining routine checkups, less respect from HCPs, and lower quality of healthcare services (Puhl et al., 2021).
Beyond the attitudes of HCPs and staff, tangible weight biases are prevalent within the physical environment of many healthcare settings, including inappropriately sized medical equipment. Medical office waiting room chairs may be too small or have arms preventing patients with obesity from fitting comfortably. Extra-large adult blood pressure cuffs or thigh blood pressure cuffs are routinely lacking, and surveys reveal that most medical offices do not have scales that record weight over 350 pounds. According to UCONN’s Rudd Center for Food Policy and Health (n.d.-a), only 1 in 11 physician offices have a scale to accommodate patients weighing more than 300 pounds. Patients describe derogatory and embarrassing weight practices, such as being weighed in a public area (e.g., hallway or waiting room), staff discussing or disclosing weight in front of others, or being subjected to unsolicited weight commentary from staff. Additionally, patient gowns are rarely large enough to fit patients with obesity, rendering them humiliated and vulnerable as they cannot adequately cover themselves while waiting for the HCP (Fruh et al., 2016; Puhl et al., 2021).
Obesity Management Guidelines
There are several evidence-based obesity management guidelines published by credible organizations and grounded in extensive research and expert consensuses, such as the American Heart Association (AHA), American College of Cardiologists (ACC), The Obesity Society, National Heart, Lung, and Blood Institute (NHLBI), and the US Preventative Services Task Force (USPSTF). Despite their wide prevalence and accessibility, implementing obesity guidelines across clinical settings is lacking (Turner et al., 2018). The USPSTF (2018) recommends that adults with a BMI equal to or greater than 30 are offered or referred for intensive behavioral therapy (IBT). The USPSTF and the Centers for Medicare and Medicaid Services (CMMS) recommend that obesity counseling is provided at least twice monthly in an individual or group setting for at least six months. The IBT interventions outlined by the USPSTF are designed to help individuals achieve or maintain clinically significant weight loss through dietary changes and increased physical activity. Clinically significant weight loss is considered a 5% or greater reduction in body weight. IBT interventions are grounded in problem-solving skills to identify barriers, self-monitoring of weight, peer support, and relapse prevention as part of the treatment plan. IBT consists of a dietary and nutritional assessment by a medical provider, registered dietician, or nutritionist to promote sustained weight loss through high-intensity interventions in diet and exercise. IBT interventions are generally consistent with the ‘5-A framework' (see Table 2; CMMS, 2011; LeBlanc et al., 2018; USPSTF, 2018).
Intensive Behavioral Therapy (IBT) 5-A Framework
Ask about (assess) behavioral health risks and factors affecting behavior change goals.
Provide clear, specific, and personalized behavior change advice, such as information about personal health harms and benefits.
Select patient-centered appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
Implement behavior change techniques (e.g., self-help, counseling), and help the patient achieve agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments (i.e., pharmacological therapy or bariatric surgery) when indicated or desired.
Schedule follow-up appointments to provide ongoing assistance and support and to modify the treatment plan as needed, including referral to more intensive or specialized treatment modalities as indicated.
The USPSTF also recommends using tools to support weight loss or weight loss maintenance, such as food scales, pedometers, smartphone applications tracking calorie intake and energy expenditure, and exercise videos. In addition, pharmacotherapy and bariatric surgery are considered effective strategies to support clinically significant weight loss in some individuals with obesity (Leblanc et al., 2018; Ritten & LaManna, 2017).
The USPSTF (2018) additionally recommends screening adults for the following:
- abnormal blood glucose levels and T2DM
- high blood pressure, statin use in persons at risk for cardiovascular disease
- counseling for tobacco smoking cessation
- aspirin use in certain persons for the prevention of cardiovascular disease
The USPSTF (2017) recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer referrals to comprehensive, intensive behavioral interventions to promote improvements in weight status. Specific evidence-based recommendations from the USPSTF remain incomplete for this age group; there is currently an update in progress for the final recommendation statement regarding obesity in children and adolescents. The National Association of Pediatric Nurse Practitioners recommends assessing height and weight parameters, including height-to-weight ratio, in children younger than 2 years, and BMI in children 2 years and older (USPSTF, 2017; 2018).
Legislation and Action
Effective obesity prevention requires intervening at all levels of society. Governmental and state policies are promising as they are wide-reaching. Obesity-related legislation in the US has increased over the last 20 years. In 2004, the WHO’s Global Strategy on Diet, Physical Activity and Health became a global framework and catalyst for regional and national action, promoting and protecting health through healthy eating and physical activity (Kobes et al., 2022; WHO, 2004). The National School Lunch Program (NSLP) is a federally-assisted meal program in public and private schools, providing nutritionally balanced, low-cost, or free lunches to children during school days. The program was established under the National School Lunch Act, signed by President Harry Truman in 1946 (US Department of Agriculture, 2019). In 2010, after years of evidence demonstrating that NSLP meals were contributing to the childhood obesity epidemic, Congress reformed the nutritional standards of the program by enacting the Healthy, Hunger-Free Kids Act. After implementing these reforms, Healthy Eating Index (HEI) scores increased from 58% to 82%. Since then, additional programs have been implemented in schools, replacing sugary snacks, sodas, and high-fat foods with healthier, more nutritiously-dense selections (Hayes & VanHorn, 2021).
In 2011, the CMMS printed a memo stating the following:
“The evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the US Preventive Services Task Force” (CMMS, 2011, p.1).
With the publication of this memo, obesity counseling, treatment, and management became billable medical appointments. The goal was to enhance the medical management of obesity to combat the rapidly growing obesity epidemic (CMMS, 2011). In 2013, the American Medical Association (AMA) House of Delegates endeavored to dispel some of the biases toward obesity by instating a new policy in which they recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention (AMA, 2013).
Currently, Medicare Part B covers BMI screenings and behavioral counseling to help patients lose weight. According to Medicare and ICD-10-CM official guidelines for coding and reporting for FY 2022, beneficiaries who meet criteria for obesity based on a BMI of 30 or greater are deemed eligible for the following services (CMMS, 2022; Medicare Rights Center, 2022):
• One face-to-face visit every week for the first month
• One face-to-face visit every other week during months 2 through 6
• One face-to-face visit every month during months 7 through 12 if the beneficiary meets the weight loss requirement during the first 6 months (see Box 1)
Weight Loss Requirement
After the first 6 months of therapy, patients must be re-screened for obesity, at which time the HCP determines how much weight has been lost since the initial screening. To qualify for additional monthly face-to-face visits during months 7 through 12 of behavioral therapy, patients must lose at least 3 kg (6.6 lbs.) during the first 6 months of treatment. HCPs can reassess for another Medicare-covered obesity screening after 6 months have passed.
(CMMS, 2022; Medicare Rights Center, 2022)
HCPs should be aware that ICD-10-CM guidelines stipulate that the associated diagnosis (such as overweight or obesity) must be documented by the provider with the appropriate ICD-10-CM BMI code (CMMS, 2022; Medicare Rights Center, 2022).
In 2021, Congress passed the Treat and Reduce Obesity Act of 2021 (S.596), expanding Medicare coverage to include screening and treatment for obesity from various HCPs. According to the act, Medicare coverage was expanded to IBT for obesity furnished by any of the following (Carper, 2021):
- “(i) A physician (as defined in subsection (r)(1)) who is not a qualified primary care physician
- (ii) Any other appropriate health care provider (including a physician assistant, nurse practitioner, or clinical nurse specialist (as those terms are defined in subsection (aa)(5)), a clinical psychologist, a registered dietitian, or nutrition professional (as defined in subsection (vv))).
- (iii) An evidence-based, community-based lifestyle counseling program approved by the Secretary.”
According to the act, coverage for the above therapies must be furnished (Carper, 2021):
- “(i) upon referral from, and in coordination with, a physician or primary care practitioner operating in a primary care setting or any other setting specified by the Secretary; and
- (ii) in an office setting, a hospital outpatient department, a community-based site that complies with the Federal regulations concerning the privacy of individually identifiable health information promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, or another setting specified by the Secretary.”
Finally, to ensure a collaborative effort, the HCP or lifestyle counseling program must communicate any recommendations or treatment plans to the referring physician or primary care practitioner (Carper, 2021).
Obesity Training for HCPs
Obesity is a complex, chronic disease, and successful treatment is multimodal and individualized. HCPs must remain familiar with the various treatment modalities available to help patients achieve and maintain a healthy BMI. However, most HCPs lack formal training in obesity management and are inadequately educated on the subject. There is still no standardized obesity-related education and training for HCPs. While there is an abundance of obesity management guidelines, there is an overall lack of uniformity and consensus on disease staging, best practice guidelines, disease prevention, management, and treatment. In general, obesity guidelines have not been consistently or effectively translated to clinical practice settings, partly due to the lack of alignment and consensus among the approaches (Ritten & LaManna, 2017). Surveys demonstrate that less than 25% of physicians report feeling sufficiently trained to counsel patients on healthy eating, physical activity, and weight management (Bradley & Dietz, 2017). In a study surveying 834 physicians and nurses, findings highlighted a lack of knowledge to diagnose obesity and a lack of confidence and training to care for these patients. According to the survey, one-third of participants did not know how to calculate BMI accurately. Only half of providers felt it was part of their role to care for patients with obesity, but 55% felt they were inadequately trained or prepared to do so (Della Torre et al., 2018). Turner and colleagues (2018) assessed HCP knowledge of evidence-based guidelines for the nonsurgical treatment of obesity using a nationally representative sample of 1,506 physicians and NPs. Findings demonstrated that HCPs' understanding of appropriate clinical care for obesity is inconsistent with evidence-based recommendations. Most participants (84%) failed to identify practices consistent with evidence-based obesity treatment guidelines for numerous survey questions. Only 49% correctly identified that 150 minutes of moderate-intensity physical activity per week is the guideline-recommended minimum level of physical activity to achieve substantial health benefits (Turner et al., 2018).
Medical and nursing schools have only recently begun integrating dedicated obesity training and management into their curriculum. Research studies are beginning to evaluate various strategies and methods to educate and train students and HCPs on obesity management. For example, Luig and colleagues (2020) developed a course based on the 5A’s of obesity management (see Table 2), offering a framework of lectures and resources to improve medical residents’ knowledge and confidence in obesity counseling. They evaluated the impact of the course on residents’ attitudes, beliefs, and competence with obesity counseling and required them to write narrative reflections regarding their experience. After completing the course, residents reported improved attitudes toward people with obesity and increased confidence in obesity counseling. Results demonstrated residents’ improvement in the following areas: assessing the root causes of weight gain, advising patients on treatment options, agreeing with patients on health outcomes, assisting patients in addressing their barriers, counseling patients on weight gain during pregnancy, counseling patients on depression, anxiety, and the iatrogenic causes of weight gain, and referring patients to interdisciplinary providers for care. Further, qualitative analyses of the narrative reflections indicate an increase in the residents’ confidence and competency in obesity management and improved ability to empathically engage with patients (Luig et al., 2020).
Oliver and colleagues (2020) integrated a Curriculum Embedded Weight Sensitivity Training program (CeWebs) into an undergraduate nursing program to improve attitudes and beliefs toward patients with obesity. Researchers evaluated students’ pretest and post-test attitudes and opinions. Findings revealed a significant increase in post-test scores, suggesting that embedding weight sensitivity training into undergraduate nursing curricula may improve attitudes and beliefs toward patients with obesity (Oliver et al., 2020). In addition, Fruh and colleagues (2020) recruited 45 NP students to complete modules designed to train HCPs on obesity management. Comparison of pre-and post-test assessments revealed a significant improvement in the participants’ mean knowledge score after the training. Results also showed statistically significant improvement in comfort level, competency, and perceived skills in treating patients with overweight and obesity (Fruh et al., 2020). Unfortunately, despite these continuing efforts, there remains a paucity of obesity education throughout the world despite the high prevalence of obesity and the well-documented need (Mastrocola et al., 2021).
Eradiating Weight Bias in Healthcare
It has become nearly impossible to work in healthcare and not be faced with the complex challenges of obesity. HCPs serve vital roles in the prevention, treatment, and control of obesity and need to draw upon science to inform and support their approach to obesity care. Knowledge can be taught or learned. While nursing theory and evidence-based guidelines are taught, caring is learned through experience. The same principles apply when caring for patients with obesity. The entire medical community must learn how to promote and embrace a shift from an individual medical perspective to a structural social perspective regarding obesity. To effectively care for patients with obesity and combat the rising obesity epidemic, professionals must embrace new practice approaches to break the vicious cycle. Adapting fresh perspectives, accepting obesity as an actual medical condition, and recognizing its dynamic interaction with contextual social factors are essential (USPSTF, 2019).
Weight bias and obesity stigma are finally starting to be addressed within updated obesity prevention and treatment guidelines. In 2017, the Obesity Medicine Association (OMA) published guidelines providing specific recommendations for patient-friendly office equipment, such as sturdy‚ armless chairs, extra-large patient gowns, and large adult blood pressure cuffs for patients with an upper-arm circumference greater than 34 cm. In addition, the guidelines emphasize the need for weight scales that can record up to 500 pounds. Many offices, hospitals, and healthcare settings require restructuring to remove these tangible biases from the physical environment. Private locations should be provided for weighing patients, as many patients feel anxious about being weighed or measured in a public space. The OMA published the 2021 Obesity Algorithm® as a clinical practice tool and template for starting an obesity medicine practice and practical recommendations for treating patients with obesity in the office and by telehealth services (OMA, 2017; 2021; Fruh et al., 2016).
It is the responsibility of each HCP to become accountable for their own pre-existing implicit and explicit biases, as the first step toward changing the culture is for each individual to recognize biases within themselves. HCPs must take responsibility for the messages they send to patients. Obesity is a disease, and like any disease, it needs to be addressed; with empathy, compassion, respect, and evidence-based, patient-centered medical care. Obesity and weight management counseling are sensitive topics, and those in need of weight loss respond more positively to an empathetic, honest approach. HCPs must recognize that patients have had prior negative experiences, and the topic must be approached with sensitivity and without judgment. Research demonstrates that patients who receive empathetic, nonbiased care are much more likely to follow advice from providers, leading to better health outcomes (UCONN Rudd Center for Food Policy and Health, n.d.-b).
As a medical community, how patients with obesity are referred to must be transformed to eliminate labeling, remove stereotypes, and reframe insensitive language. Weight neutrality should be adapted and enforced throughout medical care in all dialects and engaging in "people-first" language. Labeling individuals by their obesity (i.e., "obese patient") can exacerbate the widespread extent of weight bias in healthcare. It is advised that HCPs adopt people-first language (i.e., "patients with obesity") to preserve and uphold the respect and dignity of these individuals (UCONN Rudd Center for Food Policy and Health, n.d.-a; n.d.-b). There are severe consequences for employers, employees, organizations, and students who make derogatory racial slurs in the 21st Century. Institution policy changes can undergo valuable and straightforward modifications to enforce the transition to weight-neutral language (Turner et al., 2018).
Using Weight-Neutral Language and Communication
Language to Avoid
Language to Use
Fat, chubby, heavy, large size
Patient with obesity
Treating the obese patient
Treating the patient with obesity
(UCONN Rudd Center for Food Policy and Health, n.d.a; n.d.b)
Employers should mandate sensitivity training and competencies to create a benchmark in obesity care. Medical and graduate schools should develop curricula for healthcare students to spearhead and eradicate the problem early in their education. Individuals with obesity have become a vulnerable and targeted population. The medical community is responsible for shifting the focus away from the numbers on the scale and toward changing behavior and improving health. The consequences of weight bias and obesity stigma do not just impact the individual, as there are equally major public health ramifications. Impaired obesity prevention efforts lead to increased health disparities, social inequalities, and disregard for societal and environmental contributors to obesity. Accordingly, as morbidity and mortality rise, so do the costs to the US healthcare system and economy (Turner et al., 2018). Healthcare professionals can serve as positive influences by making appropriate changes and delivering evidence-based, cost-effective medical care utilizing the defining principles of weight neutrality. These changes are pivotal to combating the obesity epidemic, eradicating this last socially acceptable form of prejudice, improving global health outcomes, and rescinding the financial burden on the US economy (Abrams, 2022; Bradley & Dietz, 2017; Lee et al., 2021; Ritten & LaManna, 2017).
Training and Resources for Nurses and NPs
Several post-graduate continuing education (CE) and certification programs are available for nurses and NPs. The American Academy of Physician Assistants (AAPA) offers an online, self-paced professional certification program for physician assistants (PAs) and NPs to develop the necessary skills to establish and implement obesity management best practices within the primary care setting (AAPA, n.d.). The American Association of Nurse Practitioners (AANP) offers various obesity and weight management CE activities for NPs. They offer an opportunity to join the Obesity Specialty Practice Group (SPG) to collaborate with colleagues who share clinical expertise in obesity (AANP, n.d.). Similarly, the Nurses Obesity Network (NON) represents a group of nursing organizations committed to changing how nurses view, treat, and care for people with obesity. NON offers obesity patient toolkits, resources, and opportunities to become an advocate for better obesity care (NON, n.d.). UCONN’s Rudd Center for Food Policy and Health (n.d.-a) created online learning modules to educate HCPs about the consequences of weight bias and obesity stigma. The modules highlight the importance of addressing weight bias in broader health communication within and outside the medical setting. They also offer a weight bias toolkit containing a series of training modules designed to help HCPs across practice settings implement solutions and resources to improve care for people with obesity.
- Weight bias and obesity stigma must be integrated with evidence-based obesity guidelines.
- HCPs must examine their conscious (explicit) and subconscious (implicit) biases to disrupt the weight bias cycle.
- HCPs must be equipped with practical and innovative interventions and tools to sustainably reduce weight stigmatizing attitudes and address weight in a culturally sensitive, non-offensive, nonjudgmental manner.
- Tangible weight bias should be removed from the physical environment of medical offices and hospitals, and all language should be reformed to mandate weight neutrality.
- HCPs would benefit from required competencies through a stigma-awareness-raising lens.
- Patients who receive empathetic, nonbiased care are much more likely to follow advice from HCPs, leading to healthier outcomes for the patient, the population, and the economy (Abrams, 2022; Fruh et al., 2020; LeBlanc et al., 2018; Puhl et al., 2021; Ritten & LaManna, 2017)
Abrams, Z. (2022). The burden of weight stigma. American Psychological Association Monitor on Psychology, 2022(03). https://www.apa.org/monitor/2022/03/news-weight-stigma
Alberga, A. S., Edache, I. Y., Forhan, M., & Russell-Mayhew, S. (2019). Weight bias and health care utilization: a scoping review. Primary Health Care Research & Development, 20, e116. https://doi.org/10.1017/S1463423619000227
American Academy of Physician Assistants. (n.d.). 2022-2023 obesity management in primary care training ad certificate program. Retrieved December 18, 2022, from https://www.aapa.org/cme-central/primary-care-obesity-management-certificate-program/
American Association of Nurse Practitioners. (n.d.). Obesity and weight management: AANP resources by therapeutic area. Retrieved December 18, 2022, from https://www.aanp.org/practice/clinical-resources-for-nps/clinical-resources-by-therapeutic-area/obesity-and-weight-management
American Medical Association House of Delegates. (2013). Resolution: 420 (A-13) Recognition of obesity as a disease. https://media.npr.org/documents/2013/jun/ama-resolution-obesity.pdf
Bradley, D., & Dietz, W. (2017). Provider competencies for the prevention and management of obesity- June 2017. https://www.lsuhsc.edu/administration/academic/cipecp/docs/Provider-Competencies-for-the-Prevention-and-Management-of-Obesity(1).pdf
Brown, A., Flint, S. W., & Batterham, R. L. (2022) Pervasiveness, impact and implications of weight stigma. eClincalMedicine, 47(101408). https://doi.org/10.1016/j.eclinm.2022.101408
Carper, T. (2021, March 4). S. 596 – 117th Congress (2021-2022): Treat and reduce obesity act of 2021. https://www.congress.gov/bill/117th-congress/senate-bill/596/text
Cawley, J., Biener, A., Meyerhoefer, C., Ding, Y., Zvenyach, T., Smorlarz, B. G., & Ramasamy, A. (2021). Direct medical costs of obesity in the United States and the most populous states. JMCP, 27(3), 354-366. https://www.jmcp.org/doi/pdf/10.18553/jmcp.2021.20410
Centers for Disease Control and Prevention. (2022a). Behavioral risk factor surveillance system. Retrieved from https://www.cdc.gov/brfss/index.html
Centers for Disease Control and Prevention. (2022b). Defining adult overweight & obesity. https://www.cdc.gov/obesity/basics/adult-defining.html
Centers for Disease Control and Prevention. (2022c). Obesity and cancer. https://www.cdc.gov/cancer/obesity/index.htm
Centers for Disease Control and Prevention. (2022d). Overweight & obesity. https://www.cdc.gov/obesity/
Centers for Disease Control and Prevention Newsroom. (2022). Number of states with high rates of adult obesity more than doubles. https://www.cdc.gov/media/releases/2022/p0927-states-obesity.html
Centers for Medicare & Medicaid Services. (2011). Decision memo for intensive behavioral therapy for obesity (CAG-00423N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&NCAId=253
Centers for Medicare & Medicaid Services. (2022). ICD-10-CM official guidelines for coding and reporting FY 2022. https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf
Della Torre, S. B., Courvoisier, D. S., Saldarriaga, A., Martin, X. E., & Farpour-Lambert, N. J. (2018). Knowledge, attitudes, representations, and declared practices of nurses and physicians about obesity in a university hospital. Training is essential. Clinical Obesity, 8(2),122-130. https://doi.org/10.1111/cob.12238
Fruh, S. M., Golden, A., Graves, R. J., Minchew, L. A., Platt, T. H., Hall, H. R., Williams, S. G., Mehari, K., Sims, B. M., Hauff, C., & Cheese, C. (2020). Competency in obesity management: An educational intervention study with nurse practitioner students. Journal of the American Association of Nurse Practitioners, 31(12), 734-740. https://doi.org/10.1097/JXX.0000000000000218
Fruh, S. M., Nadglowski, J., Hall, H. R., Davis, S. L., Crook, E. D., & Zlomke, K. (2016). Obesity stigma and bias. Journal of Nurse Practitioner, 12(7), 425-432. http://doi.org/10.1016/j.nurpra.2016.05.013
Hayes, T. O., & VanHorn, M. (2021). Health and education impacts of the school breakfast program and national school lunch program. https://www.americanactionforum.org/research/health-and-education-impacts-of-the-school-breakfast-program-and-national-school-lunch-program/
Hill, B., Bergmeier, H., Incollingo Rodriguez, A. C., Barlow, F. K., Chung, A., Ramachandran, D., Savaglio, M., & Skouteris, H. (2021). Weight stigma and obesity-related policies: A systematic review of the state of the literature. Obesity Reviews, 22(11), e13333. https://doi.org/10.1111/obr.13333
Kobes, A., Kretschmer, T., & Timmerman, M. C. (2022). The association between obesity-related legislation in the United States and adolescents’ weight. Health Policy OPEN, 3, 1-6. https://doi.org/10.1016/j.hpopen.2021.100056
LeBlanc, E. S., Patnode, C. D., Webber, E. M., Redmond, N., Rushkin, M., & O’Connor, E. A. (2018). Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: Updated evidence report and systematic review for the US preventative services task force. JAMA, 320(11), 1172-1191. https://doi.org/10.1001/jama.2018.7777
Lee, K. M., Hunger, J. M., & Tomiyama, A. J. (2021). Weight stigma and health behaviors: Evidence from the Eating in America Study. International Journal of Obesity, 45, 1499-1509. https://doi.org/10.1038/s41366-021-00814-5
Lopez, C., Bendix, J., & Sagynbekov, K. (2020). Weighing down America: 2020 update. Milken Institute, 1-30. https://milkeninstitute.org/report/weighing-down-america-2020-update
Luig, T., Wicklum, S., Heatherington, M., Vu, A., Cameron, E., Klein, D., Sharma, A. M., & Campbell-Scherer, D. L. (2020). Improving obesity management training in family medicine: Multi-methods evaluation of the 5AsT-MD pilot course. BMC Medical Education, 20(5), 1-11. https://doi.org/10.1186/s12909-019-1908-0
Mastrocola, M. R., Roque, S. S., Benning, L. V., & Stanford, F. C. (2021). Obesity education in medical schools, residencies, and fellowships throughout the world: A systematic review. International Journal of Obesity, 44(2), 269-279. https://doi.org/10.1038/s41366-019-0453-6
Medicare Rights Center. (2022). Body mass index screenings and behavioral counseling. https://www.medicareinteractive.org/get-answers/medicare-covered-services/preventive-services/body-mass-index-screenings-and-behavioral-counseling
Obesity Medicine Association. (2017). Obesity guidelines. https://obesitymedicine.org/2017-obesity-guidelines/
Obesity Medicine Association. (2021). 2021 obesity algorithm. https://obesitymedicine.org/obesity-algorithm/
Oliver, T. L., Qi, B., Shenkman, R., Diewald, L., Smeltzer, S. C. (2020). Weight sensitivity training among undergraduate nursing students. Journal of Nursing Education, 59(8), 453-456. https://doi.org/10.3928/01484834-20200723-06
Panza, G.A., Armstrong, L. E, Taylor B, A., Puhl, R. M., Livingston, J., & Pescatello, L. S. (2018). Weight bias among exercise and nutrition professionals: A systematic review. Obesity Rev, 19(11), 1492-1503. https://doi.org/10.1111/obr.12743
Pearl, R. L., & Puhl, R. M. (2018). Weight bias internalization and health: A systematic review. Obesity Reviews, 19(8), 1141-1163. https://doi.org/10.1111/obr.12701
Puhl, R. M., & Suh, Y. (2015). Health consequences of weight stigma: Implications for obesity prevention and treatment. Current Obesity Rep, 4(2), 182-190. https://doi.org/10.1007/s13679-015-0153-z
Puhl, R. M., Lessard, L. M., Himmelstein, M. S., & Foster, G. D. (2021). The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLoS One, 16(6), e0251566. https://doi.org/10.1371/journal.pone.0251566
Ritten, A., & LaManna, J. (2017). Unmet needs in obesity management: From guidelines to clinic. Journal of the American Association of Nurse Practitioners, 29(51), S30-S42. https://doi.org/10.1002/2327-6924.12507
Sobczak, K., & Leoniuk, K. (2021). Attitudes of medical professionals towards discrimination of patients with obesity. Risk Management Healthcare Policy, 14, 4169-4175. https://doi.org/10.2147/RMHP.S317808
Stierman, B., Afful, J., Carroll, M., Chen, T., Davy, O., Fink, S., Fryar, C. D., Gu, Q., Hales, C. M., Hughes, J. P., Ostchega, Y., Storandt, R. J., & Akinbami, L. J. (2021). National health and nutrition examination survey 2017–March 2020 prepandemic data files- Development of files and prevalence estimates for selected health outcomes. NHSR, 158. http://dx.doi.org/10.15620/cdc:106273
Tirthani, E., Said, M. S., & Rehman, A. (2022). Genetics and obesity. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK573068/
Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16(123). https://doi.org/10.1186/s12916-018-1116-5
Trivedi, M., Frisard, C., Crawford, S., Bram, J., Geller, A. C., Pbert, L. (2022). Impact of COVID-19 on childhood obesity: Data from a paediatric weight management trial. Pediatric Obesity, 17(12), e12959. https://doi.org/10.1111/ijpo.12959
Trust for America’s Health. (2022). State of obesity 2022: Better policies for a healthier America. https://www.tfah.org/wp-content/uploads/2022/09/2022ObesityReport_FINAL3923.pdf
Turner, M., Jannah, N., Kahan, S., Gallagher, C., & Dietz, W. (2018). Current knowledge of obesity treatment guidelines by health care professionals. Obesity, 26(4), 665-671. https://doi.org/10.1002/oby.22142
UC Davis. (2021). Weight stigma. https://shcs.ucdavis.edu/weight-stigma
UCONN Rudd Center for Food Policy and Health. (n.d.-a). Toolkits for health care providers: Preventing weight bias- Helping without harming in clinical practice. Retrieved on December 17, 2022, from http://biastoolkit.uconnruddcenter.org/index.html
UCONN Rudd Center for Food Policy and Health. (n.d.-b). Weight bias & stigma. Retrieved on December 17, 2022, from https://uconnruddcenter.org/research/weight-bias-stigma/
US Department of Agriculture. (2019). National school lung program (NSLP) fact sheet. https://www.fns.usda.gov/nslp/nslp-fact-sheet
US Preventative Services Task Force. (2017). Final recommendation statement- Obesity in children and adolescents: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-children-and-adolescents-screening#fullrecommendationstart
US Preventative Services Task Force. (2018). Weight loss to prevent obesity-related morbidity and mortality in adults: Behavioral interventions. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions
US Preventative Services Task Force. (2019). Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: Recommendation statement. American Family Physician, 99(8), 516-517. https://www.aafp.org/afp/2019/0415/od1.html
Wang, Y., Beydoun, M. A., Min, J., Xue, H., Kaminsky, L. A., & Cheskin, L. J. (2020). Has the prevalence of overweight, obesity, and central obesity leveled off in the United States? Trends, patterns, disparities, and future projections for the obesity epidemic. International Journal of Epidemiology, 49(3), 810-823. https://doi.org/10.1093/ije/dyz273
Ward, Z. J., Bleich, S. N., Long, M. W., & Gortmaker, S. L. (2021). Association of body mass index with health care expenditures in the United States by age and sex. PLOS One, 16(3), e0247307. https://doi.org/10.1371/journal.pone.0247307
Ward-Smith, P., & Peterson, J. (2015). Development of an instrument to assess nurse practitioner attitudes and beliefs about obesity. Journal of the American Association of Nurse Practitioners, 28(3), 125-129.
World Health Organization. (2004). Global strategy on diet, physical activity, and health- 2004. https://www.who.int/publications/i/item/9241592222
World Health Organization. (2021). Overweight and obesity. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
World Obesity Federation. (2022a). Obesity atlas 2022 estimates current and future global prevalence and consequence of obesity. https://jheor.org/post/1460-obesity-atlas-2022-estimates-current-and-future-global-prevalence-and-consequences-of-obesity
World Obesity Federation. (2022b). The economic impact of overweight & obesity in 2020 and 2060: 2nd edition with estimates for 161 countries. https://data.worldobesity.org/publications/WOF-Economic-Impacts-2-V2.pdf