The Role of Body Image and Refusal to be Weighed: Implications for Primary Healthcare

Context: Stigma related to body size reduces healthcare quality and leads to healthcare avoidance, particularly for women. Barriers include weight bias from providers, lack of appropriately sized equipment for larger bodies, and internalized weight stigma and shame by patients.

Objective: To examine the relationship between body appreciation and refusal to be weighed and explore reasons for refusal.

Study design. A cross-sectional online survey was conducted in January 2021 using a convergent mixed-methods approach.

Population studied. Adult cisgender women in the United States speaking English as their first language were recruited through a convenience sample by sharing the survey link on social media.

Methods: The dependent variable was a binary outcome asking if participants had ever refused to be weighed. The primary independent variable, body appreciation, was measured with the Body Appreciation Scale-2. Multivariate logistic regression was used, controlling for socioeconomic status, race, age, and BMI. Both thematic and content analyses were performed on qualitative data.

Results: 384 women aged 19-65 responded to the survey, including 66.4% white, 25.8% black, and 7.8% other. Half of participants reported they thought it was okay to refuse to be weighed by a healthcare provider (50.1%) and almost a third reported ever refusing to be weighed by a provider (32.3%). After adjusting for covariates, body appreciation significantly predicted refusing to be weighed (OR =.60, CI=0.40-0.92), with higher body appreciation decreasing the odds of refusal. Qualitative results showed women most commonly reported refusing to be weighed because of its negative impact on their mental health (52%), including increased feelings of shame and anxiety. Almost a third (27%) stated they refused to be weighed because of concerns about the patient-provider relationship, including not trusting their provider (27%) and fearing their provider would laugh at them (9.5%). A quarter (24%) cited direct concerns about weight discrimination, based on prior negative experiences with providers, or anticipating weight discrimination.

Conclusions: With obesity affecting 42% of US adults, there is an urgent need to identify modifiable factors to deliver weight-inclusive healthcare, particularly for primary care as the frontline of healthcare delivery. Competencies for weight-inclusive healthcare should include body appreciation and strengthening patient-provider relationships and trust.