³ Departamento de Educación Continua, Dirección de Enseñanza, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz.

Correspondence: Ximena Ramos Salas Chair, Board of Directors, Bias 180, Österlånggatan 12, 290 32 Kristianstad, Sweden. Phone: +46 (708) 81-0111 Email: ximenars@gmail.com

The link between obesity and mental health is complex and often overlooked (Sharma, 2012). Although, there are many gaps in the literature, there is an understanding that a bi-directional relationship between obesity and mental health exists (Taylor et al., 2020). On the one hand, some individuals with obesity present with a wide range of mental health conditions, which can promote weight gain and act as significant barriers to obesity treatment (Taylor et al., 2012). On the other hand, studies indicate that some patients with mental illness have higher rates of obesity, hypertension, dyslipidemia, metabolic syndrome, and diabetes than the general population (Taylor et al., 2008).

Mental illness can increase the risk of obesity in many ways and heighten the risk of cardiometabolic diseases. For example, somatic symptoms of depression such as sleep and appetite alterations have been associated with diabetes, erectile dysfunction, and hypercholesterolemia (Ditmars et al., 2022). Some mental health conditions are also associated with unhealthy behaviours such as smoking, alcohol, and drug use. It is estimated that about 20% of people with a mental illness have a co-occurring substance use problem (Rush et al., 2008). There are also biological changes associated with mental illness, including inflammation, hypothalamic pituitary adrenal axis dysregulation and abnormal levels of circulating signaling proteins involved in weight regulation that can lead to weight gain (Taylor & Macqueen, 2010). In addition, psychiatric medications can have weight gain as a side effect (Taylor et al., 2020). Some patients with obesity who are prescribed psychiatric medications report stopping taking them to avoid weight gain. This can hinder the treatment of mental health conditions.

Both obesity and mental illness are highly stigmatized in society, and patients living with these conditions perceive and experience biased, stigmatizing, and discriminatory treatment in healthcare, education, and employment (Rössler, 2016; Rubino et al., 2020). Medical students and healthcare professionals, including mental health professionals, have biased beliefs and attitudes towards patients with mental illness and those living with obesity (McDaid, n.d.; Lawrence et al., 2021; Wington & McGaghie, 2001). Biased attitudes and believes among healthcare professionals are associated with stigmatizing treatment in healthcare settings and can include prejudicial, disrespectful, and discriminatory healthcare practices. Discriminatory healthcare practices can include unfair treatment because of one’s weight or mental illness such as denial of healthcare services (e.g. cancer screening services) (Hawley et al., 2024; Murphy, 2021).

Health related bias, stigma and discrimination in healthcare, education, and employment can lead to poor health, education, and socio-economic individual and population level outcomes, which can contribute to health and social inequalities. Within the field of public health, stigma is considered a social determinant of health because it drives health and social inequalities, independent of any illness or condition a person may have (Hatzenbuehler et al., 2013). Weight-related discrimination translates into a 60% higher risk of mortality, exceeding that caused by other forms of discrimination (Sutin et al., 2015).

Weight bias, stigma and discrimination translates into inequities in employment settings, health-care facilities, and educational institutions, in part due to widespread negative stereotypes that people with obesity are lazy, unmotivated, lacking in self-discipline, less competent, noncompliant, and sloppy (Friedman et al., 2005). Some individuals with living with obesity may internalize weight biased beliefs and attitudes, affecting their health and wellbeing as well as their health behaviours (Ramos Salas et al., 2019). For example, some individuals with obesity may believe that the stigmatizing attitudes or unfair actions against them are deserved because they should be able to manage their own weight (Patton et al., 2023). Patients who believe that obesity is their own fault and responsibility may not seek evidence-based obesity treatment from qualified health professionals and may instead try to manage their weight using unsafe strategies that ultimately may lead to more weight gain (Sharma & Ramos Salas, 2018).

Weight stigma can also impact physical and mental health outcomes and increase risk for all-cause mortality independently of weight or BMI status (Sutin et al., 2015). For example, weight stigma is associated with mental health outcomes such as stress, mood, or anxiety disorders, eating disturbances, depression, and body image dissatisfaction (Levinson et al., 2024; Emmer et al., 2020). Moreover, weight-related stigmatization is a risk factor for low self-esteem and body dissatisfaction, and greater frequency of stigmatization is one of the five factors associated with depression and anxiety (Ma & Xiao, 2010).

More recent studies demonstrate that internalized weight bias may also mediate mental health outcomes (Pearl & Puhl, 2016). In other words, when people believe that the negative or unfair treatment they receive is deserved, mental health outcomes worsen. Patients with obesity who experience weight stigma in healthcare report that healthcare professionals do not listen to their health concerns and that they often blame every ailment they present with solely on their weight (Kirk et al., 2014). Individuals living with obesity who have experienced weight bias and stigma from healthcare professionals may delay or avoid healthcare services for fear of being blamed and shamed for their weight (Alberga et al., 2019; Phelan et al., 2022). Ultimately, a lack of trust between healthcare providers and patients living with obesity can impact communications and the therapeutic relationship, which may in turn impact health behaviours and health outcomes (Vallis et al., 2020).

Patients with mental illness also experience significant bias, stigma, and discrimination (Sutin et al., 2015). Stereotypes about people with mental illness include that people with mental illness are dangerous, incompetent, unpredictable, and to blame for their illness (American Psychiatric Association [APA], 2024; Centre for Addictions and Mental Health [CAMH], n.d.; Fresán et al., 2018). These stereotypes can lead to healthcare professionals and systems offering a lower standard of care for people with mental illness (APA, 2024). For example, healthcare professionals who hold biased beliefs and attitudes towards people with obesity or mental illness may assume that patients will not comply with healthcare recommendations and therefore will not offer necessary interventions to patients.

Stigma is a global problem and can be a barrier for public policy measures to address obesity and mental illness (Rössler, 2016; Nutter et al., 2024). Specifically, weight bias and mental health stigma can reduce the willingness of public policymakers to invest in mental health and obesity (McDaid, n.d.; Ramos Salas et al., 2017). Given the prevalence and impact of obesity, mental illness, and related stigma to healthcare systems and society, it is imperative that direct action is taken to recognize, identify and address the intersection between obesity and mental health, while also reducing bias, stigma and discrimination for people affected by these conditions. Possible actions to address obesity and mental illness stigma include: 1) prioritizing obesity and mental illness stigma within healthcare systems, education, and employment, all mental health professionals should encourage patients to share their experiences of stigmatization to prevent them from isolating themselves or foregoing health promoting and leisure activities due to these types of experiences; 2) Conducting timely and local research on obesity and mental illness stigma; 3) Developing collaborative, evidence-informed and patient-centred interventions to address obesity and mental illness stigma in healthcare, education, employment and public policy; 4) Challenging the social stigma associated with obesity and mental illness among healthcare professionals, educators, and policy makers through public awareness campaigns, highlighting the numerous causes of obesity and mental illness and supporting all evidence-based interventions, including cognitive behavioral therapy; 5) Creating and implementing stigma reduction training programs for healthcare professionals, employers, teachers, and policy makers; and 6) Creating public policies or legislations to protect patients against obesity and mental illness bias, stigma and discrimination. Ultimately, by becoming more aware of the intersection of obesity, mental illness and stigma, we can help challenge stereotypes, change clinical practices, improve healthcare services and systems, and impact patient health outcomes.

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Ramos Salas, X., & Esquivias-Zavala, H. (2024). The Crucial Intersection: Understanding Obesity, Mental Health, and Weight Stigma in Mental Health Care. Salud Mental, 47(4), 147-149. DOI: 10.17711/SM.0185-3325.2020.019