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Review

Weight Stigma in Physical and Occupational Therapy: A Scoping Review

by
Jason Brumitt
1,* and
Katherine Turner
2
1
Doctor of Physical Therapy Program, College of Allied Health, George Fox University; Newberg, OR 97132, USA
2
Occupational Therapy Program, College of Allied Health, George Fox University; Newberg, OR 97132, USA
*
Author to whom correspondence should be addressed.
Obesities 2025, 5(2), 46; https://doi.org/10.3390/obesities5020046
Submission received: 29 April 2025 / Revised: 27 May 2025 / Accepted: 29 May 2025 / Published: 12 June 2025
Browse Figure
Versions Notes

Abstract

:
Background: Weight stigma describes the negative attitudes held toward people with obesity. Weight bias stereotypes have been previously reported in physicians, physician assistants, nurses, registered dieticians, psychologists, and students enrolled in healthcare professional education programs. Physical and occupational therapists (PTs and OTs) are healthcare providers who evaluate and treat individuals across their lifespan. A PT or an OT who harbors weight bias may create an environment where the patient may fail to optimize their rehabilitation recovery. The first purpose of this scoping review was to identify the prevalence of weight bias in PT and OT clinicians and students. The second purpose was to evaluate the effectiveness of interventions at reducing weight bias in these populations. Methods: The CINAHL, PubMed, and Google Scholar databases were searched, and 15 articles met the inclusion criteria. Results: In each study, PT and/or OT clinicians and/or students demonstrated weight bias. A minimum of approximately twenty percent of surveyed participants had weight bias, with one study reporting over eighty percent of subjects expressing negative attitudes. Three of the studies reported mixed results (i.e., improvement or worsening) regarding weight bias scores after intervention. Conclusions: PT and OT clinicians and students demonstrate weight bias similar to other healthcare professionals. Future research is warranted to identify educational interventions that reduce bias within these populations.

1. Introduction

Weight stigma (also known as fat phobia, weight bias, or anti-fat bias) describes the negative attitudes held toward people with excess body weight. Individuals who possess anti-fat bias often stereotype people who are obese as being lazy, unsuccessful, sloppy, or undisciplined and may attribute their size to lacking willpower [1,2,3,4,5,6]. Weight stigma can be represented explicitly or implicitly. People with explicit weight bias are conscious of their attitudes, and their beliefs influence their thoughts and behaviors. An implicit weight bias is an unconscious negative attitude held towards those who are obese. Although one is not consciously aware of their anti-fat bias, this attitude may contribute to negative interactions with individuals with excess body weight.
Individuals with obesity report experiencing stigma throughout their lifespan [7,8,9,10,11,12]. Common sources of stigma include individuals that people interact with daily: family members, teachers, classmates, co-workers, and supervisors [13,14]. Additional sources of perceived weight stigma include healthcare providers [13]. Anti-bias stereotypes have been previously reported in physicians, physician assistants, nurses, registered dieticians, psychologists, and students enrolled in healthcare professional education programs [15,16].
Stigma in healthcare has a negative impact on services delivered to patients with obesity. Providers with weight bias spend less time with patients with obesity during a visit, there is less overall discussion during the visit, they provide less intervention, and they fail to build the same level of emotional rapport when compared to interactions with patients who are of lower weight [17,18,19,20]. Weight bias has also been observed in medical students [15,21]. For example, Persky and Eccelston evaluated the behavior of medical students interacting with a digital, virtual female patient [21]. When interacting with a virtual female patient with obesity, the medical students had more negative stereotyping, expected less adherence to intervention, and utilized less visual contact when compared to virtual female patients who were not obese [21].
Experiencing weight stigma in a healthcare environment has negative consequences that may contribute to the worsening of one’s health state. Patients who experience weight stigma report feeling embarrassed, desire to seek a new medical provider, and may avoid future medical appointments [22,23,24]. Exposure to weight bias increases the risk of anxiety, depression, a worsening of self-esteem, and suicidality [25,26,27,28,29,30]. Bucchianeri et al. analyzed survey responses from adolescents (n = 2793; mean age 14.4 y [SD 2.0]) who participated in the Eating and Activity in Teens (EAT 2010) study. Weight-based harassment was associated with a significantly greater risk of cigarette use (both genders), alcohol use (both genders), and marijuana use (male gender). There was a significant correlation between weight-based harassment and symptoms of depression in this population. Weight-based harassment was also associated with a significantly greater risk of self-harm behavior (girls OR = 1.77 [95% CI: 1.38, 2.28]; boys OR = 1.89 [95% CI: 1.38, 2.60]. Adults who experience weight stigma are also at risk of mental health concerns. Weight stigma was associated with anxiety and depression symptoms, binge eating and purging during the past month, and risk of eating disorders in college-aged individuals [29]. In a sample of adults who had experienced weight bias, almost 40% of adults experienced anxiety, and over 50% experienced symptoms of depression [30]. Weight stigma is also associated with persistent obesity [31,32,33,34,35]. Patients may deal with exposure to weight stigma by avoiding physical activity or using food as a coping mechanism [36].
Physical and occupational therapists (PTs and OTs) are healthcare providers who evaluate and treat individuals across their lifespan. PTs and OTs interact with patients on a regular basis with rehabilitation treatments provided daily, several times a week, or on a weekly basis [37,38,39]. The frequency of therapeutic sessions may help patients to optimize health and function after an injury. In some settings (e.g., inpatient hospital, skilled nursing), PTs and OTs co-treat, providing simultaneous treatment for a patient [40,41]. A PT or an OT who harbors weight bias may create an environment where the patient may experience embarrassment or disrespect, may avoid subsequent treatment sessions, and ultimately may fail to optimize their rehabilitation recovery.
Lawrence et al. published a systematic review that reported explicit and implicit weight bias in healthcare providers [16]. Seventeen studies met the inclusion criteria, with most of the studies representing populations consisting of medical doctors, medical students, and nurses [16]. Only two studies exclusively reported bias in PTs, and no studies reported bias in OTs [16]. The aforementioned systematic review may not reflect the extent of weight bias within PT and OT professionals or students. Therefore, a scoping review of the literature to assess the extent of weight bias in these professions is warranted. There are two aims to this scoping review. The first aim is to identify the prevalence of weight stigma in PT and OT clinicians and students. It was hypothesized that weight bias would be present in PT and OT clinicians and students. The second aim is to evaluate the effectiveness of interventions to reduce (i.e., improve) bias in these populations. It was hypothesized that educational interventions will reduce bias within PT and OT clinicians and students.

2. Materials and Methods

A primary review of the literature was performed in April of 2025 utilizing the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed electronic databases. The following keywords or keyword combinations were searched: weight stigma, weight bias, fatphobia, anti-fat bias; weight stigma OR weight bias OR fatphobia OR anti-fat bias; weight stigma AND physical therapy, weight stigma AND occupational therapy, weight bias AND physical therapy, weight bias AND occupational therapy, anti-fat bias AND physical therapy, anti-fat bias AND occupational therapy, fatphobia AND physical therapy, fat phobia AND occupational therapy, anti-fat bias AND physical therapy, anti-fat bias AND occupational therapy (Table 1). The keywords and keyword combinations were selected based on the authors’ experience. Table 1 presents the keywords and keyword combinations and Boolean operators (e.g., and, or) utilized in the initial search strategy.
A subsequent literature review utilizing CINAHL AND PubMed was performed using the following search string: “weight bias AND physical therapy OR weight bias AND occupational therapy OR anti-fat bias AND physical therapy OR anti-fat bias AND occupational therapy OR fat phobia AND physical therapy OR fatphobia AND occupational therapy OR anti-fat bias AND physical therapy OR anti-fat bias AND occupational therapy”. This search resulted in 93 references (Figure 1).
Articles were screened initially by title and abstract. Identified articles were included if the subject population consisted of PT and/or OT clinicians, PT and/or OT assistants, or students and evaluated weight stigma via surveys or participant interviews. Table 2 presents frequently utilized weight stigma tools and an interpretation of scores. An article was excluded if the study was not published in a peer-reviewed journal or the study’s subject population lacked the inclusion of PT or OT clinicians, PT or OT assistants, or students (Figure 1).
A secondary literature review search was performed using Google Scholar using the keyword combination search strategies presented in Table 1. Keyword combinations that had previously resulted in 100 or fewer citations were entered into Google Scholar. The first 50 entries were screened for each keyword combination. Four unique references were identified that met the inclusion criteria.
A scoping review methodology was determined to be the appropriate study design to identify all forms of evidence related to this topic and to identify potential gaps in knowledge [42]. The PRISMA extension for Scoping Reviews (PRIS-MA-ScR) checklist was used to guide the performance of this review. This scoping review was registered with the Open Science Framework (doi.org/10.17605/OSF.IO/FHUJS).
Table 2. Description of weight bias tests.
Table 2. Description of weight bias tests.
ScaleDescriptionInterpretation of Scores
Anti-fat Attitudes Questionnaire [43,44,45]13-item tool utilizing a 10-point Likert scale.
Subjects rate statements regarding individuals who are overweight or with obesity (0 = very strongly disagree to 9 = very strongly agree).		Total and subdomain scores are calculated
Scores above 0 identify anti-fat bias
Attitudes Towards Obese Persons Scale (ATOP) [46,47]20-item tool utilizing a 6-point Likert scale.
Questions assess one’s agreement or disagreement with a statement (range +3 “agree” to −3 “disagree”).
Scores range from 0 to 120.		Scores of 61 to 120 indicate a positive attitude toward people with obesity
Attitudes Toward Obesity—Prejudicial Evaluation and Social Interaction Scale (AO-PESIS) [48]22-item tool utilizing 10-point Likert scale
Assesses healthcare provider prejudicial attitudes. The two subscales are prejudicial evaluation and social interaction.
Scores range from 1 (strongly disagree) to 10 (strongly agree).		Higher total or subscale scores indicated a greater negative attitude toward people with obesity
Beliefs About Obese Persons (BAOP) [46]Eight-item tool utilizing a six-point Likert-type scale (scores range from −3 “I strongly disagree” to +3 “I strongly agree”).
Scores range from 0 to 48.		Higher scores indicate one believes that obesity is not under control of the patient
Fat Attitudes Assessment Toolkit [49]49-item tool utilizing a 7-point Likert scale.
Scores range from 1 (strongly disagree) to 7 (strongly agree). The survey has five subscales, two complexity scales, two composite scores, and two independent domains.		Lower scores are associated with a negative view of individuals with obesity
Higher subscale scores [49]:
Fat acceptance subscale = “beliefs that are positive toward fat people”
Complexity scales = “beliefs that factors beyond an individual control contribute to fatness”
Responsibility subscale = “respondents do not attribute fatness to be an individual’s responsibility”
Self-reflection subscale = “appraisal of own body weight…with higher scores indicating positive self-assessment”
Fat Phobia Scale [50]14-item tool utilizing 5-point Likert scale.Scores above 2.5 are associated with weight stigma, with higher scores indicating greater bias
Modified Weight Bias Internalization Scale [51]11-item tool utilizing a 7-item Likert scale (range: strongly agree to strongly disagree).
Average scores range from 1 to 7.		Higher scores are associated with internalized weight bias
NEW (Nutrition, Exercise, and Weight management) Attitudes Scale [52]31-item tool utilizing a 5-point Thurstone scale. Items are related to exercise, nutrition, weight management, and non-specific domains.
Scores range from −118 to 118.		Higher scores indicate positive attitude toward people with obesity
Perceived Weight Bias in Healthcare [47,53]7-item tool utilizing a 5-point Likert-scale. Assesses one’s perception of weight bias in their peers, teachers, and clinicians
(range: strongly agree to strongly disagree).
Weight Implicit Association Test [54]Scores determine strength of preference for fat or thin people.
Scores range from −2.0 to 2.0.		−0.14 to 0.14, no preference
0.15 to 0.34, slight preference for thin people
0.35 to 0.64, moderate preference for thin people
0.65 or higher, strong preference for thin people

3. Results

3.1. Weight Stigma Scores for Physical Therapy Professionals

Nine studies reported weight stigma scores for PT clinicians, PT assistants (see Section 3.3), and/or PT students [43,45,47,55,56,57,58,59,60]. Eight tools were utilized to determine the prevalence of weight bias in these populations: the Anti-Fat Attitudes Questionnaire (AFA), Attitudes Toward Obese Persons Scale (ATOP), Beliefs About Obese Persons (BAOPs), Fat Phobia Scale, Fat Attitudes Assessment Toolkit (FAAT), NEW (Nutrition, Exercise, and Weight management) Attitudes Scale, Perceived Weight Biase in Healthcare (PWBH), and Weight Implicit Association Test (WIAT) (Table 3). The studies include clinicians and/or students from six countries: Australia, Canada, Israel, the Republic of Ireland, Singapore, and the United States (US) [43,45,47,55,56,57,58,59,60].
Setchell et al. evaluated explicit and implicit bias in 256 Australian physiotherapists (mean age 42 (11); females = 194) [43]. Subjects were presented case studies that could include individuals of normal weight or who were overweight. The mean AFA score was 3.2 (1.1), and the mean subscale scores were willpower, 4.9 (1.5); fear, 3.9 (1.8); and dislike, 2.1 (1.2) [43]. Free-text responses to cases of patients who were overweight generated five themes of implicit biases: “negative language when speaking about weight in overweight patients”, “focus on weight management to the detriment of other important considerations”, “weight assumed to be individually controllable”, “directive or prescriptive responses rather than collaborative”, and “complexity of weight management not recognized” [43]. A subsequent study by Setchell et al. utilized discourse analysis to identify stigma in 27 Australian physiotherapists (mean age 39 (range 23–72); females = 18) [55]. Four discourses developed from the focus group interviews: “patients who are overweight are little affected by stigma”, “patients who are overweight are difficult to treat”, “weight has simple causes (diet and exercise)”, and “weight is important in physical therapy” [55]. Setchell et al. concluded from these discourses (i.e., “ways of thinking and speaking about weight”) that some physiotherapists may possess attitudes and beliefs that could lead to negative patient–clinician interactions [55].
Jones et al. collected ATOP and BAOPs scores from Canadian physiotherapists via an online survey (n = 383) and in person (n = 27) during an educational seminar (see Section 3.2) [56]. The mean ATOP scores (in person = 71.3 (13.7); online = 72.6 (15.3); p = 0.66) were similar between groups and suggested a “somewhat positive attitude” towards those who are obese [56]. The BAOPs (in person = 17.4 (6.4); online = 19.4 (7.7); p = 0.19) scores were also statistically similar. Lower BAOPs scores are associated with a belief that one’s obesity is under their control; 76% of the study participants scored below 24 (BAOPs scores range from 1 to 48) [56].
Webber et al. assessed weight stigma in 221 Canadian physiotherapist clinicians (n = 187) and students (n = 34) using the FAAT [60]. This population generally had positive attitudes toward people who are obese, except on the Attractiveness (72% had neutral or disagree scores), Responsibility (82% had neutral or disagree scores), and Discrimination (38% had neutral or disagree scores) subscales (median scores for each subscale were below 5.0) [60]. There were some significant differences in the median subscale scores between groups based on age (>40 years or ≤40 years) [60]. Older individuals had more positive attitudes on the subscales of Discrimination and the Fat Acceptance Composite score compared to younger individuals (p = 0.001 and 0.027, respectively) [60].
A total of 285 Israeli physical therapists (mean age 39.6 [10.1] y; female = 223) demonstrated various levels of weight stigmatization, with a mean Fat Phobia Scale score of 3.6 [0.5], a mean AFA score of 3.3 (1.2), and a mean BAOPs score of 16.4 (5.6) [45]. The AFA subscale scores (range 0–9) illustrated higher stigmatization for “fear of fat” (mean 4.5 [2.5]) and “willpower” (mean 5.6 [1.9]) [45]. Israeli female PTs were significantly more likely than males to have higher AFA total scores (3.4 [1.2] vs. 2.9 [1.1]; p = 0.005), higher “fear of fat” subscale scores (4.8 [2.5] vs. 3.7 [2.5], p = 0.02), and significantly lower BAOPs scores (15.9 [5.3] vs. 18.0 [6.3], p = 0.013) [45].
Goff et al. collected weight stigma measures in a diverse sample of Singaporean medical professionals (Table 3) [58]. The sample included five hundred and twenty-five healthcare providers and students (mean age 31.58 (9.78) y) including, but not limited to, medical doctors, dentists, nurses, psychologists, PTs, and OTs [58]. A total of 129 PTs (clinicians = 67, students = 62) and 57 occupational therapy professionals (clinicians = 26, students = 31) completed the Fat Phobia Scale and the Anti-fat Attitudes Questionnaire [51]. The mean Fat Phobia Scale score for the entire sample of healthcare providers and students was 3.19 (0.20) [58]. The mean Anti-fat Attitudes Questionnaire score for the entire sample was 3.20 (1.25) [58]. There were no differences in the mean scores between students and clinicians for the Fat Phobia Scale, the AFA, or AFA subscales [58]. There were significant differences in the scores based on gender. Men had higher Fat Phobia Scale scores (3.22 (0.20) vs. 3.18 (0.20); p = 0.017) and AFA willpower subscale scores (4.53 (1.88) vs. women 3.85 (1.80); p < 0.001) [58]. Women had higher AFA fear subscale scores (5.54 (2.56) vs. 4.70 (2.60); p = 0.001) [58].
PT students also demonstrate weight bias. Rompolski et al. reported that United States (US)-based PT students (63.5% within the 18–24-year age range; 71.6% female) had a baseline (see Section 4.2) mean ATOP score of 72.9 (15.8) and a baseline mean M-WBIS score of 2.8 (1.3) [59]. The mean ATOP score suggests greater positive attitudes towards those with obesity; however, 21 percent of students had scores consistent with negative attitudes (<60) [59]. The authors interpreted the M-WBIS score as demonstrating moderate weight bias [59]. A total of 115 Israeli PT students (mean age 26.4 (4.9), female = 68) completed the Fat Phobia Scale, the AFA, and BAOPs [45]. The mean Fat Phobia Scale scores (3.6 [0.4], mean AFA scores (3.0 [1.2]) and mean BAOPs scores (18.0 [5.7]) illustrated weight bias within this population [45]. Israeli PT students also demonstrated higher AFA subscale scores for “fear of fat” (mean score 4.5 [2.8]) and “willpower” (mean score 5.3 [2.1]). Female PT students were significantly more likely to have higher AFA scores (3.3 [1.1] vs. 2.8 [1.2], p = 0.039) and AFA “fear of fat” subscale scores (5.3 [2.6] vs. 3.6 [2.6], p < 0.001) [45]. O’Donoghue et al. reported weight stigma in physiotherapy students in the Republic of Ireland [47]. The mean ATOP score was 69.4 (14.3), with 29% scoring below 60 [47]. Students felt that food addiction and psychological problems were more important causes of obesity compared to genetic or metabolic factors [47]. Most students (96%) did not feel it was appropriate to make jokes about people with obesity; however, 40 percent felt that their peers had negative attitudes towards patients with obesity, and 45 percent had observed fellow students making jokes about patients [47].

3.2. Weight Stigma Scores Post Intervention in Physical Therapy Professionals

Two studies assessed changes in weight stigma scores [56,59]. Jones et al. recruited 27 Canadian physiotherapists (female = 22) to participate in an in-person educational seminar on the topic of PT treatment for patients with total joint replacement and obesity [56]. Participants completed the ATOP and BAOPs surveys the day before the seminar and at the conclusion of the session [56]. Among the topics offered during the seminar were presentations on obesity sensitivity, the causes of obesity, bariatric rehabilitation, and strategies to reduce bias and discrimination [56]. The mean ATOP scores decreased from 71.3 (13.7) to 63.5 (15.9) (mean difference −7.8 [95% CI: −1.2, −14.3] (p < 0.001; effect size −1.0)), suggesting a worsening of attitudes toward individuals with obesity [56]. The mean BAOPs scores improved from 17.4 (6.4) to 22.3 (7.6) (mean difference 4.6 [95% CI: 7.0, 2.1) (p < 0.001; effect size 0.76)), suggesting a change in belief about obesity being under one’s control [56].
Rompolski et al. evaluated how participating in an anatomy dissection lab course affected weight bias in US PT students [59]. The experimental group consisted of students who were enrolled in a human cadaver dissection lab versus a control group of US PT students who participated in an anatomy lab consisting of surface palpation, virtual anatomy, and plastic models [59]. Participants completed the M-WBIS and the ATOP and answered open-ended questions. The baseline mean ATOP and M-WBIS scores for the cadaver cohort were 71.5 (16.0) and 2.7 (1.3), respectively, and for the control group, they were 77.2 (14.7) and 3.1 (1.3), respectively [59]. There was no change in the post-scores after the completion of the anatomy lab. Most students reported that it was difficult or that it was time consuming to work with larger donor bodies [59].

3.3. Weight Stigma Scores for Occupational Therapy Professionals

Eight studies reported weight stigma scores for OT clinicians and/or OT students [48,57,58,61,62,63,64,65]. A reflexive thematic analysis and six tools were utilized to determine the prevalence of weight bias in these populations: the AFA, Attitudes Toward Obesity—Prejudicial Evaluation and Social Interaction Scale (AO-PESIS), ATOP, BAOPs, Fat Phobia Scale, and WIAT (Table 4). The study populations consisted of OTs, OT assistants, and students from Australia, Canada, Singapore, and the United States (US) [48,57,58,61,62,63,64,65]. Cross-sectional studies were primarily utilized to survey OTs, OT assistants, and OT students. Each study reported that clinicians and/or students demonstrated attitudes and/or beliefs associated with weight bias.
Leemhuis et al. surveyed 145 members (mean age 42.35 (10.456) y; women = 137) of the American Occupational Therapy Association (OT = 125; COTA = 18; other = 1) [62]. The mean ATOP score was 68.6 (14.3), with 20.7% scoring below 60 (i.e., negative attitudes towards people with obesity) [62]. Participants in this study were asked open-ended questions that were designed to explore potential barriers to treatment for the obese population. Themes generated from the open-ended questions included negative attitudes, a lack of facility resources, safety, and a lack of education [62].
Vroman and Cote recruited 189 OT students (mean age = 24 y; female = 181) from three US-based universities [55]. The AO-PESIS, ATOP, and BAOPs tools were administered to assess weight bias. Before completing the AO-PESIS items, the subjects read a 150-word patient case study and viewed a photo of either an average-weight individual or an individual with morbid obesity [55]. The OT students rated clients with obesity more negatively on the “judgement” and “social distance” subscales of the AO-PESIS compared to average-weight clients [55]. The judgment subscale includes ratings for a patient’s recovery potential, the clinician’s willingness to provide care to the patient, and empathy and compassion for the patient [55]. The social distance subscale includes ratings related to trust and the ability to befriend the person [55]. The OT students demonstrated weight stigma on the ATOP and BAOPs scales. The mean ATOP score for undergraduate students was 72.8 (SD 15.4), and for graduate-school students, it was 73.3 (SD 13.9) [55]. Sixteen percent of OT students scored below 60 (i.e., negative attitudes) on the ATOP [55]. The mean BAOPs score for undergraduate students was 19.5 (6.9), and it was 20 (7.9) for graduate-school students (scores range from 0 to 48; a lower score indicates that one believes obesity is under the control of the patient) [55].
Friedman et al. explored weight bias in OT assistants and students [57,63]. Their first study recruited 58 occupational therapy students (mean age 25.47 (5.09) years; women = 53) from three Midwestern universities who completed the WIAT and a survey [63]. The mean WIAT score was 0.33 (SD 0.38); this score is associated with a slight preference for thin people (range 0.15–0.34) (Table 4) [63]. Most OT students’ scores indicated “preferring thin people” (69%) [63]. A subsequent study by Friedman et al. consisted of 5671 OT assistants and PT assistants (mean age = 26.5 (8.8); female = 4403) who completed the WIAT [57]. The mean WIAT score was 0.50 (SD 0.40); this score is associated with a moderate preference for thin people (range 0.35–0.64) [57]. A majority of OT and PT assistants indicated a preference for thin people (82.4%) [57]. Older individuals had a higher anti-fat bias, whereas females had a lower anti-fat bias [57]. This study did not differentiate scores between professions.
Lunt et al. utilized a novel 24-item questionnaire to identify factors related to occupational therapy treatment for patients who are obese [64]. Eighty Australian OTs completed the survey. Most OTs rated that they had good to excellent knowledge of the causes of obesity. However, barriers were noted, including weight bias [64].
Instead of utilizing an outcome tool (see Table 2), Richards et al. performed a mixed methods study with a novel three-item questionnaire (five-point Likert scale) (quantitative approach) and a reflexive thematic analysis (qualitative approach) [65]. Eleven Australian OTs (mean age 39; range 22–59 years) participated in the study. Three themes were associated with the qualitative interviews: “exploring the client’s needs for weight management, incorporating weight management strategies in occupational therapy interventions, organization of current occupational therapy practice for people with obesity” [65]. OTs rated numerous interventions based on their effectiveness (1–5 scale). Examples include healthy eating advice = 3; physical activity advice = 4; client education = 2; and motivational training = 2 [65].

3.4. Weight Stigma Scores Post Intervention in Occupational Therapy Professionals

Only one study assessed changes in weight stigma scores in OTs post intervention [61]. Forty-two OTs (mean age not provided; professional experience ranging from 0 to ≥15 years) participated in workshops that were developed using the theory of planned behavior [61]. The first portion of the seminar was designed to raise awareness, and the second portion utilized case studies to increase know-how related to OT practice with clients who are obese. Participants completed the ATOP and BAOPs prior to and immediately after the seminar. There was no change in the ATOP scores in either cohort, with mean scores ranging from 67.6 (13.8) to 79.4 (17.3) [61]. There was no change in the BAOPs scores in the first cohort; however, there was a significant change in the scores in the subsequent year (pre = 20.2 (7.6) to post = 31.5 (7.9); p <0.05) [61].

4. Discussion

4.1. Weight Stigma in Physical Therapy and Occupational Therapy Professionals and Students

Previous research has highlighted weight stigma in healthcare professionals; however, the prevalence of bias in PT and OT populations was unknown [16]. This scoping review identified fifteen articles assessing weight stigma in PT and OT clinicians and students. Each study demonstrated explicit and/or implicit bias. Due to the design of the weight stigma measurement tools, the exact prevalence of clinicians and/or students who have weight bias is unknown; however, some of the studies provide insight as to the potential degree of the problem. For example, 24 to 29 percent of physiotherapy students reported negative attitudes towards people with obesity [47]. Over eighty percent of physical therapy assistants and occupational therapy assistants reported that they “preferred thin people” on the WIAT [57]. In total, 16 percent of occupational therapy assistants and 20.7 percent of OTs reported negative attitudes towards people with obesity on the ATOP [48,62]. Almost 70 percent of OT students “preferred thin people” on the WIAT [63].

4.2. Educational Interventions for Physical Therapy and Occupational Therapy Professionals and Students

Three studies were identified that reported assessing weight stigma scores before and after an intervention in a PT or OT population [56,59,61]. Jones et al. found a worsening of attitudes (ATOP scores) toward individuals who are obese after an eight-hour seminar; however, there was an improvement in beliefs about obesity being under one’s control (BAOPs scores) [56]. The type of anatomy lab exposure did not lead to changes in weight bias scores in physical therapy students. Follow-up questioning with those in the anatomy cadaver lab cohort found that a majority perceived it to be difficult to work with larger donor bodies [59]. A workshop designed for occupational therapists reported no change in the ATOP scores; however, the BAOPs scores did improve in one cohort [61]. Mixed results in response to an intervention are not uncommon in healthcare populations [66,67]. Potential limitations associated with the studies include the use of convenience sampling, a lack of randomized controlled studies, and a small sample size.
This scoping review has identified bias in PT and OT student populations; however, there is a lack of research evaluating strategies to reduce bias. The results of this study highlight the need for the implementation of education offerings to allow students to assess bias (e.g., taking the Fat Phobia Scale) and to receive education addressing weight stigma (e.g., how bias impacts one’s health, person-centered communication skills, equipment requirements). Educators should evaluate the impact of applied interventions, ideally utilizing experimental research designs (e.g., randomized controlled trials, quasi-experimental).

4.3. Effectiveness of Interventions to Reduce Weight Stigma in Healthcare Professionals

Interventions may be effective at reducing bias in healthcare professionals [66]. Improved outcomes have occurred after short- and long-term interventions (i.e., one session versus multiple sessions across many weeks) [68,69,70]. Berman and Hegel provided a one-hour workshop to the medical faculty of a rural academic program [68]. The workshop increased faculty awareness about weight bias, and attendees reported that they learned information that could be used to teach students or change the way they practice [68]. Longer training periods have improved bias scores in medical and nursing students. Medical students that received repeated educational experiences during the first, second, and third years of their program had significant improvements in attitudes (Modified Fat Phobia Scale) that were maintained during their four years in the program [69]. A 15-week curriculum consisting of obesity sensitivity training led to significant improvements in ATOP scores in nursing students [70].
Moore et al. published a systematic review and meta-analysis of interventions designed to reduce weight bias in medical and allied healthcare professionals [66]. Similar to the results found in this scoping review, Moore et al. reported reduced bias scores or improved awareness of weight stigma in a variety of disciplines; however, some studies failed to show positive changes post intervention [66]. The results from this review highlight that more research is needed to determine the most effective strategies for reducing bias.

4.4. Strengths and Weaknesses of Current Studies

There are strengths and weaknesses associated with the studies identified in this scoping review. A strength of the studies included in this scoping review is that they reported the rates of bias and/or the perceptions of patients with obesity in samples of PT and/or OT clinicians, assistants, and/or students. Many of the studies utilized a cross-sectional study design. This type of study design is appropriate for determining the prevalence of weight bias. It can be concluded from the available evidence that weight stigma is common in PT and OT populations. What is unknown is when one develops a bias. For example, it is unknown if students possess a bias prior to enrolling in an academic program or if bias is acquired after starting courses. It is also unknown when clinicians develop bias.
A strength associated with some studies is the reporting of the percentage of individuals whose weight bias tests identified stigma [47,57,62,63]. For example, O’Donoghue et al. reported that 29 percent of PT students scored below 60 on the ATOP and 24 percent had negative attitudes on the NEW Attitudes Scale [47]. This information provides context for the severity of the problem (i.e., approximately 1 in 3–5 had bias scores depending on the scale utilized). However, many studies only provided mean scores without identifying the percentage whose scores would be associated with weight stigma [43,45,56,58,59]. Thus, it is unknown in those studies how prevalent bias is within the sample.
Another strength associated with several studies is large sample sizes consisting of participants representing both sexes [43,45,47,57,60,62]. Larger sample sizes consisting of both sexes adequately represent the population studied. For example, Friedman et al. surveyed 5671 OT and PT assistants [57]. However, most of these studies reported scores for their entire sample. A limitation of this statistical presentation is that differences based on sex are relatively unknown. Two studies reported comparisons between women and men [45,57]. In one study, there were some differences identified between sexes (e.g., women had higher AFA scores than men) [45]; however, in the other study, females had a lower anti-fat bias score [57]. Several studies had smaller sample sizes [56,59,63,64,65]. The results from the studies with smaller sample sizes reflect the bias within that group and should not be generalized to a larger sample.

4.5. Recommendations for Future Research

As previously mentioned, PT and OT clinicians and students demonstrate weight bias. Patients that experience stigmatization from healthcare providers are more likely to not access care [22,23,24]. Educational interventions are therefore warranted to reduce explicit and implicit biases. As previously mentioned, studying bias in entry-level students should be considered. This population is easily accessible to academic researchers. Academics partnering across different universities could conduct experimental studies to compare the effectiveness of different interventions. The change in bias scores could be tracked across the course of a curriculum. This may reveal milestones associated with improved scores (e.g., after specific coursework, after participating in a clinical experience, or with general professional maturation). Post-graduation surveys could illustrate changes in bias scores. For example, if bias scores worsened post-graduation, future research could explore potential causes for this negative change. Clinicians also demonstrate bias. Similar research strategies could be applied to therapists and therapy assistants. For example, academics could partner with large hospital settings and conduct studies similar to those performed at the university level.

5. Conclusions

This scoping review identified several studies reporting weight bias in PT and OT clinicians and students. Only three of the fifteen studies reviewed assessed the effectiveness of interventions at improving weight stigma scores (i.e., reducing weight bias) in these populations. Current interventions have demonstrated mixed results. Future studies are needed to determine the optimal intervention strategies.

Author Contributions

Conceptualization, J.B. and K.T.; methodology, J.B. and K.T.; writing—original draft preparation, J.B. and K.T.; writing—review and editing, J.B. and K.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
AFAAnti-Fat Attitudes Questionnaire
ATOPAttitudes Towards Obese Persons Scale
AO-PESISAttitudes Toward Obesity—Prejudicial Evaluation and Social Interaction Scale
BAOPsBeliefs About Obese Persons
FAATFat Attitudes Assessment Toolkit
PTPhysical Therapy or Physical Therapist or Physiotherapist
OTOccupational Therapy or Occupational Therapist
NEWNutrition, Exercise, and Weight management
WIATWeight Implicit Association Test

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Obesities 05 00046 g001
Figure 1. PRISMA flow diagram.
Figure 1. PRISMA flow diagram.
Obesities 05 00046 g001
Table 1. Initial keywords and keyword combinations of literature review search utilizing CINAHL and PubMed.
Table 1. Initial keywords and keyword combinations of literature review search utilizing CINAHL and PubMed.
Keywords or Keyword CombinationsArticles Identified in Initial Literature Search
Weight bias3027
Weight bias OR weight stigma OR fatphobia OR anti-fat bias2389
Weight stigma2086
Weight stigma2077
Anti-fat bias564
Fat phobia291
Weight stigma AND physical therapy39
Weight stigma AND occupational therapy38
Weight bias AND physical therapy 30
Weight bias AND occupational therapy27
Anti-fat bias AND occupational therapy12
Fatphobia AND occupational therapy10
Anti-fat bias AND physical therapy9
Fatphobia AND physical therapy7
Table 3. Studies reporting weight stigma in physical therapists, physical therapy assistants, and/or physical therapy students.
Table 3. Studies reporting weight stigma in physical therapists, physical therapy assistants, and/or physical therapy students.
Author (Year)CountryStudy DesignPopulationSelected Results
Setchell et al. (2014) [43]AustraliaCross-sectional survey256 physiotherapists (mean age 42 (11) y; female = 194) completed the AFA and provided free-text responses after the review of case studiesAFA
Mean score 3.2 (1.1)
Free-text responses to cases of overweight patients generated five themes: “negative language when speaking about weight in overweight patients”, “focus on weight management to the detriment of other important considerations”, “weight assumed to be individually controllable”, “directive or prescriptive responses rather than collaborative”, and “complexity of weight management not recognized”
Setchell et al. (2016) [55]AustraliaDiscourse analysis (inductive qualitative design): data collected during 6 focus groups (4 to 6 participants per group)27 physiotherapists (mean age 39 (range 23–72); females = 18)Four discourses developed from the focus group interviews:
  • “Patients who are overweight are little affected by stigma”
  • “Patients who are overweight are difficult to treat”
  • “Weight has simple causes (diet and exercise)”
  • “Weight is important in physical therapy”
Elboim-Gabyzon et al. (2020) [45]IsraelCross-sectional survey285 physical therapists (mean age 39.6 (10.1) y; female = 223)
115 physical therapy students (mean age 26.4 (4.9); female = 68)		PT clinicians
Fat Phobia Scale mean score = 3.6 (0.5)
AFA mean score = 3.3 (1.2)
BAOPs mean score = 16.4 (5.6)
PT students
Fat Phobia Scale mean score = 3.6 (0.4)
AFA mean score = 3.0 (1.2)
BAOPs mean score = 18 (5.7)
Women (PT clinicians and students) had significantly higher AFA scores than men (p = 0.005; 0.039)
Women (PT students) had significantly higher AFA fear of fat subscale score (p < 0.001)
Women (PT clinicians) had significantly higher AFA fear of fat subscale score (p < 0.002) and lower BAOPs scores than male counterparts (p = 0.013)
Jones et al. (2021) [56]CanadaSingle-group pretest–posttest and an online cross-sectional survey27 physiotherapists participated in an 8 h interactive seminar (intervention) (mean age not provided; females = 22)
383 physiotherapists completed online surveys (mean age not provided; females = 321)		Seminar cohort
ATOP
Pre-seminar mean score = 71.3 (13.7)
Post-seminar mean score = 63.5 (15.9) p < 0.001
BAOPs
Pre-seminar mean score = 17.4 (6.4)
Post-seminar mean score = 22.3 (7.6) p < 0.001
Both groups
ATOP and BAOPs scores were statistically similar at baseline
O’Donoghue et al. (2021) [47]Republic of IrelandCross-sectional survey179 final-year physiotherapy students (mean age 22.7 (2.8) y; female = 125)ATOP
Mean score 69.4 (14.3)
29% scored below 60
Causes of obesity
N = 132 identified food addiction or psychological problems as “very important” or “extremely important” causes
NEW Attitudes Scale
Mean score = 20 (20.5)
24% had a negative attitude toward treating people with obesity
PWBH
40% believed peers had negative attitudes towards patients with obesity
45% reported observing peers making jokes about patients who were obese
Friedman et al. (2022) [57]United StatesCross-sectional survey5671 occupational therapy assistants and physical therapy assistants (mean age = 26.5 (8.8); female = 4403) completed the WIATWIAT
Mean score = 0.50 (0.40)
Majority of COTA/PTA “preferred thin people” (82.4%)
Older individuals had higher anti-fat bias
Females had lower anti-fat bias
Goff et al. (2024) [58]SingaporeCross-sectional525 healthcare providers (clinicians or students; mean age 31.58 (9.78) y)
57 occupational therapy professionals (clinicians = 26, students = 31)
129 physical therapy professionals (clinicians = 67, students = 62)		Scores provided for the entire sample of healthcare providers
Fat Phobia Scale
Mean score = 3.19 (0.20)
Anti-fat Attitudes Questionnaire
Mean score = 3.20 (1.25)
Rompolski et al. (2024) [59]United StatesQuasi-experimental pretest–posttestTwo US-based DPT cohorts (females = 71.6%)
Cadaver (experimental) cohort participated in an anatomy dissection lab using donor bodies
Control cohort participated in an anatomy lab using surface palpation, plastic models, and virtual anatomy		Cadaver cohort
Baseline mean ATOP = 71.5 (16.0)
Baseline mean M-WBIS = 2.7 (1.3)
Control cohort
Baseline mean ATOP = 77.2 (14.7)
Baseline mean M-WBIS = 3.1 (1.3)
No change in scores at the conclusion of the course
Webber et al. (2024) [60]CanadaCross-sectional survey184 physiotherapists (mean age not provided) and 34 physiotherapy students (mean age not provided) (females = 165) completed online surveysFat Attitudes Assessment Toolkit
Positive attitudes toward people who are obese except on the following subscales:
Attractiveness (72% had neutral or disagree scores)
Responsibility (82% had neutral or disagree scores)
Discrimination (38% had neutral or disagree scores)
AFA = Anti-Fat Attitudes Questionnaire; ATOP = Attitudes towards Obese Persons Scale; BAOPs = Beliefs About Obese Persons; NEW = Nutrition, Exercise, and Weight; PWBH = Perceived Weight Bias in Healthcare; PT = physical therapy; WIAT = Weight Implicit Association Test.
Table 4. Studies reporting weight stigma in occupational therapists, certified occupational therapy assistants, and/or occupational therapy students.
Table 4. Studies reporting weight stigma in occupational therapists, certified occupational therapy assistants, and/or occupational therapy students.
Author (Year)CountryStudy DesignPopulationSummary of Results
Forhan and Law (2009) [61]CanadaNonexperimental pretest–posttest42 occupational therapists (mean age not provided; professional experience ranging from 0 to ≥15 years)
Two cohorts (2006 n = 22; 2007 n = 20) participated in a workshop and completed ATOP and BAOPs measures 		After completing the workshop:
ATOP
No change in attitudes (either cohort)
BAOPs
2007 cohort had a significant change post workshop, reflecting improved beliefs
Leemhuis et al. (2010) [62]United StatesCross-sectional survey145 members (mean age 42.35 (10.456) y; women = 137) of the American Occupational Therapy Association (OT = 125; COTA = 18; other = 1). ATOP
Mean score 68.6 (14.3)
20.7% scored below 60
Open-ended questions
(Some) Barriers to treatment: negative attitudes, lack of facility resources, safety, and lack of education
Vroman and Cote (2011) [48]United StatesCross-sectional survey189 occupational therapy students (mean age 24 years; females = 181; undergraduates n = 122)AO-PESIS
Obese clients received a significantly greater negative rating for the judgement and social distance scales compared to those who were of average weight
ATOP
Undergraduates = mean score 72.8 (15.4)
Graduates = mean score 73.3 (13.9)
16% of all students scored below 60
BAOPs
Undergraduates = mean score 19.5 (6.9)
Graduates = mean score 20 (7.9)
Friedman et al. (2019) [63]United StatesCross-sectional survey58 occupational therapy students (mean age 25.47 (5.09) years; women = 53) from 3 Midwestern universities completed the Weight Implicit Association TestWeight Implicit Association Test
Mean WIAT score = 0.33 (0.38)
Majority “preferred thin people” (69%)
Lunt et al. (2022) [64]AustraliaCross-sectional survey80 occupational therapists (0–21 years of experience) completed a novel survey (24 questions utilizing a 5-point Likert scale)Knowledge of factors that cause obesity: 94% rated good to excellent
Knowledge of weight management strategies: 56% good to excellent knowledge of OT role
Conduct occupational assessments and interventions: 74%
Assessments and interventions related to weight management: 23%
Entry-level education related to working with patients of higher weight: 10%
Top barriers to delivering care: lack of training, equipment (access and cost), environmental barriers, and weight bias
Friedman et al. (2022) [57]United StatesCross-sectional survey5671 occupational therapy and physical therapy assistants (mean age = 26.5 (8.8); female = 4403) completed the WIATWIAT
Mean score = 0.50 (0.40)
Majority of COTA/PTA “preferred thin people” (82.4%)
Older individuals had higher anti-fat bias
Females had lower anti-fat bias
Goff et al. (2024) [58]SingaporeCross-sectional525 healthcare providers (clinicians or students; mean age 31.58 (9.78) y)
57 occupational therapy professionals (clinicians = 26, students = 31)
129 physical therapy professionals (clinicians = 67, students = 62)		Scores provided for the entire sample of healthcare providers
Fat Phobia Scale
Mean score = 3.19 (0.20)
Anti-fat Attitudes Questionnaire
Mean score = 3.20 (1.25)
Richards et al. (2024) [65]AustraliaMixed methods
Qualitative: reflexive thematic analysis
Quantitative: 5-point Likert scale		11 occupational therapists (mean age 39 y; female = 10)Three themes associated with qualitative interviews: “exploring the client’s needs for weight management, incorporating weight management strategies in occupational therapy interventions, organization of current occupational therapy practice for people with obesity”
OTs rated numerous interventions based on their effectiveness (1–5 scale)
Examples include healthy eating advice = 3; physical activity advice = 4; client education = 2; and motivational training = 2
AO-PESIS = Attitudes Toward Obesity—Prejudicial Evaluation and Social Interaction Scale; ATOP = Attitudes Toward Obese Persons Scale; BAOPs = Beliefs About Obese Persons; OT = occupational therapist; COTA = certified occupational therapy assistant; PTA = physical therapy assistant; WIAT = Weight Implicit Association Test.
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Brumitt, J.; Turner, K. Weight Stigma in Physical and Occupational Therapy: A Scoping Review. Obesities 2025, 5, 46. https://doi.org/10.3390/obesities5020046

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Brumitt J, Turner K. Weight Stigma in Physical and Occupational Therapy: A Scoping Review. Obesities. 2025; 5(2):46. https://doi.org/10.3390/obesities5020046

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Brumitt, Jason, and Katherine Turner. 2025. "Weight Stigma in Physical and Occupational Therapy: A Scoping Review" Obesities 5, no. 2: 46. https://doi.org/10.3390/obesities5020046

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Brumitt, J., & Turner, K. (2025). Weight Stigma in Physical and Occupational Therapy: A Scoping Review. Obesities, 5(2), 46. https://doi.org/10.3390/obesities5020046

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