Our literature search identified only two empirical studies - one RCT [22] and one qualitative study [48] - that explored stigmatisation related to weight loss from the new GLP-1 receptor agonists. Both studies found that negative attitudes persist, with the public and healthcare professionals alike viewing the medication as a ‘shortcut’ and questioning its legitimacy. More studies are clearly needed to confirm these findings.

The two identified studies did not examine methods for reducing stigma, but useful lessons might be learnt from research that examined patient experiences with stigma before and after bariatric surgery, or from fields that have successfully reduced other forms of stigma.

Lessons Learned from Patient Experiences with Bariatric Surgery

Numerous studies have examined stigma related to weight loss following bariatric surgery. These studies consistently show that stigma towards individuals with obesity is deeply rooted in societal attitudes. Even after achieving normal weights, individuals who undergo bariatric surgery often continue to face various forms of stigma, and weight loss through surgery is frequently viewed with scepticism compared to traditional methods like diet and exercise. For example, several experimental studies found that people who lost weight through bariatric surgery were evaluated more negatively than those who lost weight through behavioural methods [49,50,51]. In the largest of these studies, 138 women and 137 men from Australia were recruited via Amazon Mechanical Turk. Participants were shown a photograph of a woman with obesity, followed by a 1-year follow-up image after she had lost 95 pounds (45 kg) [49]. Subsequently participants were then randomly assigned information about how she lost the weight—either through strict dieting, regular exercise, gastric bypass surgery, or surgery plus regular exercise. Those informed that the woman had lost weight through surgery rated her more negatively than those who believed she had used diet and/or exercise alone. The participants who learned she had used surgery plus exercise rated her in-between. By contrast, the woman who lost weight solely through diet and exercise was rated as least lazy, least sloppy, and most competent and responsible for her weight loss. Mediation analyses showed that differences in ratings of laziness and competence were largely due to perceptions of personal responsibility for the weight loss.

Other studies similarly demonstrate that weight loss through surgery can have consequences for hiring and employment. For instance, a US-based study examined the stigma associated with surgical weight loss and found it led to significant social repercussions, including discrimination in hiring practices [52]. The study revealed that individuals who learned about a person’s past obesity and subsequent weight loss through surgery rated that person less favourably in terms of employability and personality traits compared to persons who lost weight through diet and exercise, hightlighting strong external stigma. These results underscore that even after significant weight loss, individuals may still face negative judgments based on their past weight status and the methods used to lose weight. While effective obesity medications may theoretically help challenge misconceptions and reduce stigma, it cannot be assumed that external stigmatisation will decrease nor that individuals who achieve significant weight loss will automatically experience improvements in self-esteem or body image.

Several qualitative studies and reviews have examined the motives, expectations, and perspectives of patients prior to bariatric surgery. For instance, Cohn et al. [53] reviewed 28 qualitative studies focusing on patients’ motives and expectations before bariatric surgery. They reported that patients generally expected post-surgery weight loss to have positive psychosocial benefits that would strengthen their personal identities, relationships, and improve engagement in public and professional life [53]. However, while patients often anticipated improved psychosocial well-being after surgery, findings from other reviews examining post-surgery experiences challenge these expectations [54, 55]. Coulman et al. [54] systematically reviewed 33 qualitative studies focusing on perspectives related to psychological health, sexual life, body image, and social relations among patients living with the outcomes of bariatric surgery. They found that patients sought a sense of control and normality, though their experiences were mixed. Initially, patients felt more in control of their weight and eating habits, but this sense often declined over time - particularly with some weight regain - leading to negative psychological experiences. Issues such as the need for plastic surgery to remove excess skin after bariatric surgery were highlighted as contributing factors to the negative psychological experiences. A recent study found that the psychological issues remained unresolved even after plastic surgery, suggesting that physical appearance was not the sole factor contributing to a negative self-image [56].

A recent qualitative study interviewed 18 individuals several years after bariatric surgery [57] focusing on coping strategies for stigma, self-esteem, and body dissatisfaction. It suggested that ten years post-surgery, many individuals continued to experience body dissatisfaction and viewed their bodies as deviant from social norms, often due to excess skin. This aligns well with the research showing that body image remains significantly worse in post-bariatric surgery patients compared to the general population [54, 58]. Furthermore, a qualitative study by Dimitrov Ulian et al. [59] additionally found that women who had undergone bariatric surgery continued to experience weight stigma regardless of the size of their weight loss, and felt judged for taking what was perceived as an ‘easy way out’ to lose weight.

Most recently, a scoping review by Garcia et al. [60] explored the experiences and consequences of bariatric surgery stigma among patients across 28 studies. They found that patients often internalised stigma and reported feeling shame for choosing surgery. Many continued to face negative comments and judgment when disclosing their decision to undergo, or revealing they had undergone, surgery. Consequently, many chose not to disclose their decision to others. This stigma also impacted their decision-making process leading some to delay their choice for surgery, some to seek it abroad, and some to opt out entirely.

The persistence of stigma even after significant weight loss following bariatric surgery suggests that individuals using the novel obesity medication may also continue to face stigma despite achieving their weight loss goals. Just as with bariatric surgery, society may perceive the use of medication for weight loss as a shortcut, reinforcing that weight control should be achieved solely through willpower. Indeed, in agreement with the results from the recent randomised study evaluating weight-related stereotypes toward a woman using a GLP-1 agonist for weight loss [22], several recent media reports indicate that people using new obesity medications are judged for ‘cheating,’ leading some to choose not to disclose their decision to use these drugs [23,24,25,26, 47].

Previous literature indicates that cultural perceptions of body image can influence societal acceptance of bariatric surgery. In some regions, this may reduce external stigma, while in others it may heighten it, as documented in a study examining the varying experiences of stigma related to bariatric surgery across different countries [61]. Likewise, cultural differences in the experience, acceptance, and use of the new medications could potentially influence the degree and the nature of stigma. A more nuanced understanding of how different groups experience stigma could potentially provide relevant insights for reducing stigma associated with new obesity medications. Proactively addressing these stigma-related challenges seems essential as the effective medications for obesity become more prevalent in obesity management.

Lessons learned from studies addressing educational efforts to reduce weight stigma.

A recent review of 25 interventional studies aimed to identify strategies to reduce weight bias among healthcare trainees and students. They identified five strategies for reducing weight stigma: (i) increased education, (ii) providing information about causes and controllability, (iii) fostering empathy, (iv) promoting a weight-inclusive approach, or a combination of these [62], and concluded that it is essential to address weight stigma early and continuously in healthcare education, and focus on genetic and socioenvironmental factors. They also concluded that a shift from a weight-centric to a health-focused, weight-inclusive approach is necessary.

Other studies have investigated whether viewing obesity as a disease rather than a personal responsibility could help reduce weight stigma. For example, an experimental study randomised 309 participants to read one of three texts that either presented obesity as a disease; did not present it as a disease; or a text that did not address obesity [63]. Participants who read the text framing obesity as a disease subsequently had more positive attitudes toward individuals with obesity than those who read the other texts. In another experiment, 365 healthcare professionals were divided into two groups: one group was instructed to view severe obesity as a disease, while the other group was not [64]. Both groups then reviewed a hypothetical medical profile of a patient with both obesity and migraines. Healthcare professionals (49% doctors, 31% nurses, and 20% physiotherapists, dieticians, and psychologists) who were asked to view obesity as a disease suggested more migraine-related treatments than those in the group where obesity was not considered a disease. Both these studies suggest that stigma towards obesity may decrease when people understand obesity as a disease caused by genetic and medical factors.

Lessons Learned from Campaigns to Reduce Stigma Associated with HIV/AIDS

The HIV/AIDS epidemic in the 1980s was accompanied by significant stigma and discrimination against those affected. The subsequent efforts made to reduce stigma surrounding both HIV/AIDS and substance abuse, although differing in various aspects such as etiology, transmission risk, treatment options, and the repercussions of non-treatment, there are similarities with obesity regarding negative societal attitudes, moral judgment, and blame. The introduction of effective treatments and the initial absence of anti-discrimination protections in comparable conditions may offer insights into mitigating weight stigma associated with pharmacologically induced weight loss through educational interventions.

In the early years after the first cases of AIDS gay societies and communities played an important role in reducing stigma and discrimination. Government response was slow and gay activists and organisations took matters into their own hands, creating support networks, public education campaigns, and activist movements, advocating for increased research funding, better access to treatment, policies to protect the rights of people with HIV/AIDS, and generally raising awareness about the disease. With the later introduction of antiviral treatments also public educational programs, that significantly contributed to improve societal attitudes toward individuals living with HIV were introduced, highlighting the importance of accurate information in challenging myths and advancing understanding [65]. Indeed, unlike obesity, where the stigma has only recently been addressed in joint international consensus statements [1, 9, 66], the United Nations General Assembly Special Session on HIV/AIDS in 2001, followed by the Joint United Nations Programme on HIV/AIDS in 2007, emphasised that stigma and discrimination were significant barriers to effective treatment and prevention efforts, leading to initiatives that focused on community engagement and education [67].

Campaigns and education efforts aimed to reduce discrimination and moral judgment against those with HIV/AIDS by specifically educating the public about HIV transmission, treatment possibilities, and the realities of living with the virus. This helped reduce moral judgments, but also emphasised that reducing stigma was important to improving health outcomes [68]. As a result, the narrative around HIV shifted, framing HIV as a medical condition that could affect anyone. This allowed patients to re-enter social life with fewer stigmas attached [68, 69]. Also, while initially medication use for HIV/AIDS was viewed by the public as a sign of weakness or an easy solution, and as antiretroviral therapy transformed HIV from a fatal disease into a manageable chronic condition, the visible signs of the disease diminished, and public perceptions shifted positively, recognising the importance of medical treatment rather than viewing it as a personal failing [70].

The evolution of stigma surrounding AIDS before and after the antiviral treatments, illustrates how societal attitudes towards medical conditions can change [65]. However, while obesity itself is not a death sentence, the societal adaptation to effective HIV treatments may still provide useful insights into how attitudes toward the new obesity medications could evolve as their effectiveness becomes more widely acknowledged. However, in the case of HIV/AIDS, despite the extensive public education campaigns, medical advancements, and legal efforts to address stigma, the condition still carries a significant level of stigma, albeit less than in earlier decades.

Also, anti-discrimination protections for people with HIV/AIDS emerged and were strengthened by the Americans with Disabilities Act (ADA) in 1990, providing legal support for those facing unfair treatment due to HIV/AIDS. These protections applied across the entire United States and this example provides important learnings of how legal frameworks can be used to combat stigma and protect vulnerable populations [71]. The US Affordable Care Act prohibits discrimination based on health status, but as noted by Pomeranz and Puhl, the law still does not explicitly list obesity as a protected disability [71]. The Act can provide some protections for people with obesity and there have been a few court decisions that have recognised severe obesity as a potential disability under certain circumstances, which has helped protect some people with obesity in relation to health insurance coverage. In the UK the disability laws require employers and employees to not discriminate or harass their colleagues with obesity and to provide reasonable adjustments in the workplace where discrimination is a possible outcome of behaviors or policy arrangements [72]. In EU, the European Court of Justice ruled in 2014 that while obesity itself is not a protected characteristic under EU anti-discrimination law, severe obesity can in some cases be considered a disability if it causes long-term physical, mental or psychological impairments [73].

Similar to protections under the ADA for HIV/AIDS, obesity should be listed as a protected characteristic within anti-discrimination laws in EU and other countries. For example, the European Court of Justice recognizes obesity as a disability and UK disability laws require employers to make reasonable accommodations for employees with obesity to prevent discrimination. Legislation could also require organisations, particularly in healthcare to implement training and policies aimed at reducing obesity stigma to protect against obesity-related stigma and promote fair treatment. In Denmark, a recent citizen proposal has initiated efforts to enforce legislative changes aimed at protecting individuals with diverse body sizes. This proposal suggests including ‘body size’ as an explicitly protected characteristic, on par with ‘disability,’ in Sect. 266 b of the Penal Code and the “Act on the Prohibition of Discrimination in the Labour Market.”

The case of HIV demonstrates the deep-rooted resilience of stigma. In HIV/AIDS, stigma is not solely linked to the disease but also to cultural, social, and historical factors - such as sexuality, drug use, and fear of contagion - which are challenging to eradicate through awareness alone. Obesity faces similar issues. It is not just a shift in medical understanding that is required but also a change in entrenched cultural attitudes regarding personal discipline and moral judgement. Like with HIV/AIDS, public education campaigns targeting obesity stigma are essential, but they must extend beyond the biological and medical aspects to address the complex social, moral, and psychological factors contributing to this stigma.”

Substance use disorders are another group of diseases with significant stigma and negative societal values around personal responsibility, self-control, and health morality, regardless of the availability of treatment. Obesity is similarly viewed by many as a dependency disease. Lessons may therefore also be learned from studies addressing how the introduction of treatments like disulfiram (Antabuse) has influenced societal stigma towards alcoholism or how nicotine replacement therapies have influenced stigma towards smoking. However, while studies have examined changes in perception of smoking and alcoholism over time, few studies have specifically investigated how views on alcohol or smoking addiction may have changed before and after the introduction of Antabuse and nicotine replacements [74]. Thus, research on whether the introduction of methadone has contributed to positive changes in societal attitudes towards drug addiction and treatment remains limited. Individuals receiving methadone continue to face discrimination, including in healthcare settings, where they may be perceived as lacking motivation or compliance [75]. A recent opinion paper described how governments, institutions, and educational bodies increasingly recognise that substance use treatment, policies, and language need to evolve to provide better societal understanding of and support for affected individuals [76].

Religious and Moral Roots of Obesity Stigma

Most studies on obesity stigma were from Western societies, where stigma surrounding obesity may be linked to moral teachings and norms rooted in Christian, particularly Protestant, traditions. Research in psychology and theology supports this, showing that negative societal attitudes towards obesity are rooted in perceptions of immorality or uncleanliness [67]. In societies that follow these values, stigma can be reinforced by the strong emphasis on personal responsibility and moral judgment, viewing self-control, persistence, and dedication as essential for success, and suffering as a necessary part of personal growth [77].

Understanding the interplay between these moral teachings and societal perceptions may be of importance for addressing the stigma associated with obesity [67]. The notion that “the pure do not suffer” adds to the problem by implying that individuals with obesity have failed to maintain control over their bodies and.

lives, and need to show stamina, “pull themselves together” and lose weight through sheer willpower. When effective obesity medications are used, societal perceptions may label this as “cheating,” suggesting that true success can only be achieved through hard work such as diet and exercise. This stigma is furthermore founded by the belief that those who have experienced obesity cannot any more be considered “pure” or in control, as their past struggles are viewed as evidence of moral failure. Such biases may further make it difficult for those affected to seek help with weight loss.

Limitations and Future Directions

Although several media reports highlight substantial stigma associated with the use of the new obesity medications, the scientific literature—both qualitative and quantitative—remains limited, and the field is still in it’s infancy including studies examining strategies for how to mitigate stigma related to weight loss from the new obesity medications.

The differences by nature, between losing weight by bariatric surgery and by medication for obesity also restrict the generalisability of findings from one to the other. Bariatric surgery involves invasive procedures and significant physical transformations, making it difficult to fully compare weight loss stigma experienced by those who undergo surgery with that faced by individuals using medications. As a result, more research is needed to understand the specific dynamics of stigma related to these newer obesity medicine treatments. Also, the parallels between the stigma associated with obesity medications and that faced by individuals using medications for conditions like HIV/AIDS, while potentially informative, might still oversimplify the complexities associated obesity stigma and fail to take account for the unique social and moral connotations surrounding weight, body image, and personal responsibility. In addition, while it is recognised that there are clear disparities in access to the novel obesity medications, it is beyond the scope of the paper to fully address these structural inequalities comprehensively. Finally, this narrative review primarily draws from selected databases like PubMed and PsycINFO, potentially leading to overlooking of some relevant interdisciplinary insights from public health, sociology, and anthropology potentially affecting the depth of the analysis. In this regard, a recent paper by Hunt et al. [78] explored the evolutionary perspectives on addiction, framing obesity as a condition shaped by evolutionary factors rather than personal failings. The authors argue that modern environments overstimulate the brain’s reward system, leading to maladaptive behaviours like overeating. They suggest this understanding could help shift the narrative away from blaming individuals for their obesity, as GLP-1 agonists, help regulate this reward system, thus positioning obesity as a biological issue rather than a moral or behavioural one. The paper aligns with the broader view that our responses to food, similar to behavioural addictions like video games or social media, are deeply rooted in evolutionary history, and supports the idea that medicalisation and the development of effective treatments may reduce both internal and external stigma associated with obesity. The paper argues that by educating the public about the evolutionary and biological factors contributing to obesity, the narrative may shift from individual blame to recognising obesity as a complex medical condition, potentially fostering more supportive and less stigmatising environments in healthcare, workplaces, and social settings (Table 1).

Table 1 Mitigating strategies to reduce stigma, discrimination and bias related to the new medication

Important steps have already been taken to inform healthcare professionals, policymakers, and the public about the stigma associated with obesity, and as discussed above, international multidisciplinary groups of experts and representatives from relevant scientific organisations have recently launched several joint consensus statements with recommendations to eliminate weight bias [1, 9, 59]. However, while it is believed, and advocated for, that educating people about the causes of obesity can reduce obesity stigma, evidence for such efforts remains limited [79]. Some of the recent suggestions have been that future stigma-reduction programmes should also include information about the significant effort that many people living with overweight and obesity invest into maintaining a healthy diet and exercise regime, even if those efforts do not always result in weight loss. This approach aims to challenge assumptions about the perceived lack of effort among individuals with obesity [49].