Weight talk in healthcare - stigma, discrimination, or bias related to a person’s body size - has profound implications for health equity, physical and mental health. Despite its significant impact on healthcare access, quality, and outcomes; 'weight stigma impact' is notably absent from the NHS Core20PLUS5 framework - a strategic initiative aimed at reducing health inequalities across the most disadvantaged populations.

The omission of weight stigma from this initiative is concerning, as it perpetuates a cycle of marginalisation. Particularly in underserved communities, health inclusion groups and the 5 clinical areas. This oversight may stem from long-standing societal and medical biases that frame weight as a personal issue, rather than recognising it as a complex, multifactorial experience intertwined with social determinants, including poverty and discrimination.

Incorporating weight stigma into the Core20PLUS5 framework is essential for addressing the systemic biases that hinder meaningful healthcare engagement, improving trust, and ensuring all individuals - regardless of body size - receive compassionate, non judgemental care.

Centering this issue within the NHS framework will contribute to a more inclusive healthcare system, enhance health outcomes across populations, and support the achievement of the framework’s long-term goals of reducing health disparities.

The "Core20" represents the most deprived 20% of the population, as identified by the Index of Multiple Deprivation (IMD). Individuals in these areas often face compounding social determinants of health, including poor access to resources and services. Weight stigma amplifies these challenges:

• Reduced Access to Care: Stigmatised individuals may delay or avoid seeking care, fearing judgement.

• Quality of Care: Implicit biases may lead to misdiagnoses or inappropriate treatment recommendations.

• Intersectionality: Deprivation often overlaps with higher weight, exacerbating stigma-related barriers.

Addressing weight stigma in Core20 communities ensures healthcare is delivered equitably, aligning with the framework's goal to narrow avoidable mortality gaps.

The PLUS aspect of the strategy highlights groups experiencing health inequities beyond the Core20, such as minority ethnic groups, those with complex health conditions, and socially excluded groups. Weight stigma disproportionately impacts these populations:

• Minority Ethnic Groups: Cultural and systemic factors can magnify the impact of weight stigma, leading to mistrust and reduced engagement with healthcare services.

• People with Multiple Long Term Conditions: Many in this group self-blame for their health condition and may face compounded stigma related to their body size and health status; weight is often mis-assumed causal and not correlate to a health condition.

• Socially Excluded Groups: Populations like migrants, individuals experiencing homelessness, and those in the justice system often encounter heightened stigma, further restricting access to compassionate care.

Acknowledging and addressing weight stigma in the PLUS strategy ensures equitable and effective interventions for these vulnerable groups.

Weight stigma intersects with all five clinical focus areas of the Core20PLUS5 framework, creating barriers to equitable care, preventive medicine and health improvement. Tackling stigma is essential for progress in these areas:

1. Maternity Individuals with larger bodies may experience judgemental attitudes in maternity care, impacting trust and engagement. Stigma can discourage access to prenatal services, disproportionately affecting women from deprived and different backgrounds. Addressing this issue helps ensure that maternity services meet the framework’s goals for equitable care.

2. Severe Mental Illness (SMI) People living with SMI often encounter dual stigma regarding their mental health and body size. This bias can deter individuals from engaging in annual health checks, exacerbating health disparities. Reducing stigma enhances participation and fosters holistic care.

3. Chronic Respiratory Disease Respiratory health challenges, such as chronic obstructive pulmonary disease (COPD), are prevalent in deprived communities. Weight stigma in respiratory care settings can discourage individuals from accessing pulmonary rehabilitation or preventive services, limiting opportunities to reduce exacerbations and hospitalisations.

4. Early Cancer Diagnosis Weight stigma can delay cancer detection, as individuals may avoid screening and diagnostic services due to fear of judgement. These delays are particularly harmful in deprived populations, where cancer outcomes are already poorer. Creating supportive and stigma-free environments is critical for achieving national cancer detection goals.

5. Hypertension Case Findings and Lipid Management Hypertension and cardiovascular health are closely tied to systemic inequities. Weight stigma can deter individuals from participating in screenings or adhering to care plans. When 'weight management' is presumed, and previously been a failure point, weight cycling can increase cardiovascular risk. Eliminating stigma improves trust and engagement, supporting prevention efforts for strokes, heart attacks, and related conditions.

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Weight stigma in maternity care undermines the quality of care and the patient-provider relationship, leading to detrimental outcomes. Cunningham et al. (2023) identified that pregnant individuals with larger body sizes often experience shaming, reduced autonomy, and harmful assumptions from healthcare providers, discouraging engagement with prenatal services. These interactions are linked to delays in seeking care and increased stress during pregnancy, disproportionately affecting vulnerable populations.

Further evidence from the RESPCCT initiative (Malhotra et al., 2024) quantified disparities in maternity care, revealing that individuals with larger body sizes frequently face mistreatment, including dismissive attitudes and coercion, particularly during labor and delivery. Addressing implicit biases through weight-neutral care and provider training can enhance respectful, equitable maternity services.

Adopting holistic, individualised care approaches mitigates stigma's effects, ensuring better outcomes for parents and infants. Addressing this stigma aligns with NHS Core20PLUS5 goals to improve access to high-quality maternity care for underserved populations.

Individuals with severe mental illnesses (SMIs) face compounded stigma related to both their mental health conditions and body size, creating significant barriers to comprehensive care. Weight stigma in healthcare settings can deter patients from accessing essential services, such as annual health checks, which are critical for managing their physical and mental health. For individuals with SMI - who already experience a life expectancy gap compared to the general population - these barriers exacerbate health inequalities and delay timely interventions (Dang et al., 2023; Garber et al., 2019; Wassenaar, 2023).

Weight stigma is particularly detrimental in the context of eating disorders, which have the highest mortality rates among mental health conditions. Research demonstrates that weight stigma contributes to the underdiagnosis of conditions such as atypical anorexia nervosa in individuals with larger body sizes, as their weight may be perceived as "normal" despite severe health risks from food restriction. This oversight delays life-saving treatments and worsens outcomes for individuals already navigating complex health challenges (Cunning & Rancourt, 2023; Wassenaar, 2023).

Furthermore, stigma perpetuates harmful narratives that tie self-worth to body size, increasing risks of depression, anxiety, and suicidal ideation in individuals with SMI. Internalised weight stigma has been linked to higher rates of disordered eating behaviors, compounding the difficulty of treating co-occurring mental health issues. These challenges highlight the need for trauma-informed, weight-neutral care that prioritises holistic well-being. Initiatives to dismantle weight stigma, such as healthcare provider training and patient-centered support systems, are critical for creating equitable healthcare environments (Dang et al., 2023; Wassenaar, 2023).

By addressing these biases, the NHS can align with its Core20PLUS5 framework to improve access to compassionate, equitable care for individuals with SMI, promoting better health outcomes and reducing disparities.

Weight stigma significantly affects individuals living with chronic respiratory conditions, such as Chronic Obstructive Pulmonary Disease (COPD). This issue is particularly pronounced among marginalised and socioeconomically disadvantaged communities, where biases related to weight in healthcare settings can exacerbate existing health disparities. Healthcare providers who harbour negative assumptions about patients' weight may inadvertently undermine the patient-provider relationship, leading to delays in diagnosis and treatment (Snyder et al., 2020; Phelan et al., 2015). For instance, individuals may hesitate to engage in essential services like pulmonary rehabilitation due to fears of being judged or stigmatised based on their weight (Puhl et al., 2021). 

Recent research has underscored the detrimental effects of weight talk on health outcomes, particularly for patients with COPD. A systematic review by Phelan et al. Phelan et al. (2015) highlighted that weight bias in medical settings fosters an environment where individuals feel unwelcome, which discourages them from seeking preventive care or adhering to prescribed treatments. Additionally, Snyder et al. Snyder et al. (2020) found that weight stigma during medical visits negatively impacts various aspects of the provider-patient relationship, including trust and empathy, which are crucial for effective healthcare delivery. Furthermore, Puhl et al. Puhl et al. (2021) demonstrated that internalised weight stigma can lead to adverse healthcare experiences, such as delaying or avoiding necessary medical care. 

Addressing weight stigma and its harmful consequences in healthcare is vital for improving the quality of care and outcomes for patients with chronic respiratory conditions. This approach aligns with health equity initiatives aimed at reducing health inequities and respiratory-related hospitalisations in underserved populations. Tackling weight stigma is not only essential for enhancing individual health outcomes but also plays a pivotal role in achieving broader public health goals, including reducing disparities in the management and outcomes of respiratory diseases.

Fear of judgment and internalised self-stigma based on body size is a significant barrier that prevents many individuals from attending essential cancer screenings, including cervical cancer screenings. Research indicates that individuals with higher body weights often experience internalised self-shaming and fear of stigma from healthcare professionals, which can lead to avoidance of screening services and consequently delayed diagnoses (Puhl et al., 2021; , Bidstrup et al., 2021).

This weight stigma contributes to health disparities, particularly among marginalised populations, where individuals face discrimination based on their body size. Such discrimination is prevalent in medical settings, where healthcare providers may harbor negative assumptions about patients' health or lifestyle due to their weight, creating an unwelcoming environment that deters individuals from seeking necessary care (Puhl et al., 2021). 

A specific area where weight stigma profoundly impacts health outcomes is in cervical cancer screenings. A systematic review by Bidstrup et al. (2021) highlights that internalised weight stigma mediates the relationship between experienced weight stigma and various health outcomes, including healthcare access (Bidstrup et al., 2021). Furthermore, a study by Marlow et al. (2015) demonstrated that women with higher body mass indexes (BMI) are significantly less likely to participate in routine cervical cancer screenings, which can lead to undetected cervical cancer development. This issue is particularly pronounced in lower socioeconomic groups, where barriers to accessing healthcare are already significant. A systematic review by Puhl et al. (2021) emphasises that weight stigma, combined with socioeconomic factors, exacerbates health inequities and increases the likelihood of late-stage cancer diagnoses, where treatment is more challenging and survival rates are lower (Puhl et al., 2021; , Bidstrup et al., 2021). 

Addressing weight stigma in healthcare settings is critical for improving participation in screening programs. Research by Lee et al. (2021) indicates that creating a non-judgmental environment, where patients feel respected and understood regardless of their body size, can lead to higher participation rates in preventive care, including cancer screenings (Lee et al., 2021). By fostering inclusive and accessible diagnostic pathways, healthcare systems can enhance early cancer detection, which is vital for improving survival rates. The goal of diagnosing a higher percentage of cancers at early stages becomes more achievable when strategies are implemented to reduce weight-related stigma and encourage earlier participation in screenings (Puhl et al., 2021; , Lee et al., 2021). A supportive and inclusive approach will not only improve health outcomes for individuals with larger body sizes but also help reduce disparities in cancer care, particularly for those in deprived communities (Puhl et al., 2021; , Bidstrup et al., 2021).

Weight stigma significantly impedes effective hypertension management, particularly among individuals in underserved communities. Research indicates that negative experiences with healthcare providers, often rooted in weight bias, can lead to avoidance of medical care, including screenings and adherence to treatment plans. For instance, Puhl, Lessard, and Heuer (2021) highlight that a substantial proportion of individuals engaged in ‘weight management’ reported experiencing stigma from healthcare professionals, which can deter them from seeking necessary medical attention. This stigma not only affects patient-provider interactions but also contributes to a cycle of shame and avoidance, further exacerbating health disparities in hypertension management (Hunger & Major, 2015; Puhl & Suh, 2015). 

Moreover, the psychological impact of weight stigma can lead to maladaptive coping mechanisms, such as emotional eating, which may worsen hypertension and other health conditions (Wu & Berry, 2017). Himmelstein, Puhl, and Quinn (2018) emphasize that coping responses to weight stigma are critical to consider in health interventions, as they can significantly influence health behaviors and outcomes.

The internalisation of weight stigma can lead to self-stigmatisation, where individuals begin to accept negative societal beliefs about their weight, further diminishing their motivation to engage in health-promoting behaviors (Pearl & Puhl, 2019). This internalised stigma is particularly pronounced in underserved populations, where access to supportive healthcare is already limited (Idemudia & Nwankwo, 2018). 

To address these challenges, cultivating an inclusive healthcare approach that emphasises trust and respect is essential. Implementing weight-inclusive strategies can help mitigate the effects of stigma and improve patient engagement in hypertension initiatives. For example, Lee and Puhl (2021) advocate for the removal of stigmatising language and weight-centric outcomes from health policies, suggesting that such changes could enhance population health by fostering a more supportive environment for individuals struggling with their health. Additionally, training healthcare providers to recognise and combat their biases can lead to more respectful interactions, ultimately improving patient outcomes and reducing the prevalence of cardiovascular events (Teixeira & Budd, 2010). 

Addressing weight stigma is crucial for optimising hypertension management, and lipid management particularly in underserved communities. By fostering an inclusive healthcare environment that prioritises respect and understanding, health initiatives can enhance patient engagement, improve adherence to treatment plans, and ultimately reduce health disparities associated with hypertension.

Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally.

Weight stigma should be included in the Core20PLUS5 framework because it represents a significant barrier to equitable healthcare, particularly for individuals in underserved communities. By creating Stigma Informed Teams at a systems level, the NHS can improve healthcare access, build trust, and promote engagement with essential health services, which is crucial in reducing health disparities and improving outcomes.

Weight bias, particularly in deprived areas, exacerbates existing health inequities, discouraging individuals from seeking care, adhering to treatment plans, or participating in preventive screenings. Given that people in deprived areas are disproportionately affected, tackling weight stigma is essential for reducing avoidable mortality rates and improving overall health outcomes.

Furthermore, addressing weight stigma aligns with broader public health goals outlined in the NHS Long Term Plan (LTP), which aims to prevent 150,000 strokes, heart attacks, and cases of dementia by 2029. By fostering a non-judgemental and inclusive healthcare environment, the NHS can reduce the negative impact of weight stigma on patient engagement. Additionally, addressing weight stigma contributes to reducing the economic burden of multiple long term conditions, lack of equitable access is responsible for billions of pounds in healthcare costs and lost productivity each year.

Ultimately, including stigma-informed care within the Core20PLUS5 framework will not only improve health outcomes but also help achieve long-term health equity goals. A healthcare system that is compassionate, unbiased, and inclusive of all individuals, regardless of body size, will create a more supportive environment for managing chronic conditions, reducing premature deaths, and addressing the core determinants of health. This approach will be instrumental in achieving the NHS’s vision for a healthier and more equitable future for all populations.

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Stangl, A.L., Earnshaw, V.A., Logie, C.H. et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 17, 31 (2019). https://doi.org/10.1186/s12916-019-1271-3

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