# Obesity as a multifactorial disease: Understanding and addressing stigma for holistic management

Francesca Bruno, Claudia Puleo, Amelia Rizzo

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Francesca Bruno, Claudia Puleo, Amelia Rizzo. Obesity as a multifactorial disease: Understanding and addressing stigma for holistic management. Advances in Medicine, Psychology, and Public Health, 2024, 2 (4), pp.266-276. 10.5281/zenodo.14293543. hal-04909407

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# Obesity as a multifactorial disease: Understanding and addressing stigma for holistic management

Francesca BRUNO¹*, Claudia PULEO², Amelia RIZZO³

**Cite this paper as:** Bruno F, Puleo C, Rizzo A. Obesity as a multifactorial disease: Understanding and addressing stigma for holistic management. Adv Med Psychol Public Health. 2025;2(4):266-276.

Doi:10.5281/zenodo.14293543

Received: 12 August 2024

Revised: 20 October 2024

Accepted: 05 November 2024

Published Online: 07 December 2024

¹Department of Cognitive, Pedagogical, Psychological Sciences and Cultural Studies, University of Messina, Messina, Italy.
E-mail: francescabruno.psi@outlook.it ORCID: 0009-0007-1842-2470

²Department of Cognitive, Pedagogical, Psychological Sciences and Cultural Studies, University of Messina, Messina, Italy. E-mail: claudiapuleo23@gmail.com ORCID: 0009-0008-8087-204X

³National Institute of Social Welfare, Medical-Legal Center of Messina, Italy. Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy. E-mail: amrizzo@unime.it; amelia.rizzo@outlook.it ORCID: 0000-0002-6229-6463

*Correspondence

## Abstract

Obesity is a multifaceted disease resulting from the interplay of genetic, biological, environmental, psychological, and social factors. This review delves into the interconnected drivers of obesity, with a particular focus on obesogenic environments, genetic predispositions, and socioeconomic inequalities. It also examines the far-reaching stigma associated with obesity, which intensifies health disparities, undermines mental well-being, and discourages healthcare engagement. Drawing on the latest research, the review highlights integrated strategies that combine personalized medical care, community-driven initiatives, and systemic reforms to address both obesity and its stigma. Special attention is given to structural and legislative measures, educational programs, and early interventions for children and adolescents. The findings underscore the critical need to redefine obesity as a complex health condition rather than a moral failing. By bridging interdisciplinary research, policy innovations, and advocacy, this review calls for a holistic, compassionate, and equitable approach to managing obesity and reducing its associated stigma.

**Take-home message:** Obesity is a complex, multifactorial condition influenced by genetic, biological, environmental, psychological, and social factors. Addressing obesity holistically requires not only medical interventions but also efforts to combat weight stigma, which exacerbates health disparities and psychological distress. This commentary underscores the importance of interdisciplinary strategies, societal reforms, and stigma-reduction initiatives to improve health outcomes and promote equity.

**Keywords:** Interdisciplinary interventions; obesity; weight stigma; weight bias; public health policy.
## INTRODUCTION

Obesity is a multifactorial and complex health condition that cannot be reduced to simplistic explanations of personal behavior or a lack of willpower. Its development is influenced by a diverse range of interconnected factors, including genetics, environmental contexts, socioeconomic conditions, and individual behaviors. Over the past few decades, extensive research has deepened our understanding of obesity, demonstrating that it arises from a dynamic interplay of biological and environmental determinants. Theories such as the thrifty gene hypothesis [1] and energy balance models [2] provide foundational frameworks for understanding the biological predisposition to efficiently store fat—an evolutionary advantage in environments with limited food availability, which now contributes to the obesity epidemic in modern, calorie-rich societies.

The obesogenic environment, characterized by the widespread availability of high-calorie foods, sedentary lifestyles, and urban infrastructure that limits physical activity, plays a central role in driving the obesity crisis [2]. Urbanization and globalization have drastically transformed traditional diets and activity patterns, fostering conditions that promote weight gain while hindering effective weight management. Alongside environmental factors, genetic influences significantly contribute to variations in body weight regulation. Evidence suggests that obesity has a heritable component [3]. Advances in genomics and molecular biology have identified several genes involved in appetite regulation, fat storage, and metabolic rate, further reinforcing the understanding of obesity as a complex interaction between genetic predispositions and environmental influences [4].

Despite this recognition of its multifactorial nature, individuals with obesity frequently face significant stigma, compounding the psychological and social challenges of the condition. Weight stigma encompasses negative attitudes, biases, and discrimination directed at individuals due to their body weight, which is pervasive across society. As noted by Puhl and Heuer [5], such stigma is a source of emotional distress and contributes to poor mental health outcomes, including depression, anxiety, and low self-esteem. Additionally, stigma can discourage individuals from seeking essential healthcare services, thereby reducing the likelihood of receiving effective treatment and support [6]. In healthcare settings, discrimination based on weight is also prevalent, with providers often displaying implicit biases or offering suboptimal care, further perpetuating health disparities [7].

The multifactorial causes of obesity and the stigma it incurs necessitate a holistic approach to its management. Effective interventions must address not only medical and behavioral factors but also the cultural, social, and psychological dimensions that impede progress. Emerging research in public health, behavioral sciences, and policy-making underscores the promise of strategies that integrate individual care with broader societal changes to mitigate both obesity and its associated stigma [8]. Moreover, reducing weight stigma is critical for improving the well-being and health outcomes of individuals with obesity.

This commentary aims to explore the latest scientific insights into obesity as a multifactorial disease, examining both its underlying causes and the stigma it engenders. It will also review current interventions designed to manage obesity while addressing stigma and propose strategies for future research and public health efforts. By synthesizing evidence across multiple disciplines, this commentary seeks to provide a comprehensive overview of the challenges and opportunities in addressing obesity and its associated stigma.

## DISCUSSION

Obesity is a chronic and multifaceted condition stemming from the interplay of genetic, biological, environmental, behavioral, psychological, and social factors (See Map 1). Understanding these interconnected influences is critical for unraveling its etiology and designing effective interventions.

### Genetic and biological factors
Genetic predisposition plays a significant role in obesity, with heritability estimates ranging from 40% to 70% [3]. Genome-wide association studies (GWAS) have pinpointed several obesity-related loci, including the *FTO* and *MC4R* genes, which regulate appetite and energy metabolism [9]. Rare mutations in genes such as *LEP* (leptin) and *POMC* (proopiomelanocortin) have been associated with monogenic obesity, highlighting the importance of genetic factors in severe cases [10].

Epigenetic modifications, shaped by environmental exposures during critical periods like prenatal development, also contribute to obesity susceptibility. For instance, maternal overnutrition or undernutrition can lead to metabolic dysregulation in offspring, a phenomenon referred to as developmental programming [11].

Additionally, hormonal and neuroendocrine pathways play a central role in obesity. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, often induced by chronic stress, can elevate cortisol levels, encouraging fat accumulation, particularly in the abdominal region [12]. Leptin resistance and altered ghrelin signaling further impair appetite regulation, contributing to overeating and weight gain [13].

## Environmental and behavioral factors

The modern environment is a driving force behind the obesity epidemic. The pervasive availability of calorie-dense, nutrient-poor foods, coupled with aggressive marketing, fosters an "obesogenic" environment [2]. Urbanization and sedentary lifestyles reduce opportunities for physical activity, intensifying the imbalance between calorie consumption and expenditure.

Behavioral factors, such as irregular eating patterns, excessive consumption of sugar-sweetened beverages, and reliance on fast food, significantly contribute to weight gain. Another key behavioral risk factor is sleep deprivation, which is increasingly prevalent in modern society. Insufficient sleep disrupts hormonal balance, stimulating hunger and reducing energy expenditure, thereby promoting weight gain [14].

The "Thrifty Gene Hypothesis" suggests that certain genes evolved to optimize survival in environments with limited food availability and pronounced seasonality. These genes, potentially linked to energy-sensing mechanisms like AMPK and mTOR kinases, may now predispose humans to obesity in a world abundant with food and pervasive psychosocial stress. This chronic activation of neuroendocrine systems in today's environment is hypothesized to contribute to the rising prevalence of obesity [15].

Family instability is another critical factor, particularly during adolescence. Research indicates that multiple family transitions from birth through adolescence can increase socio-emotional challenges, especially among girls, heightening their risk for obesity [16].

## Psychological and cognitive factors

Psychological conditions such as depression, anxiety, and chronic stress are closely associated with obesity. Stress, in particular, can influence eating behaviors by increasing cravings for high-fat, high-sugar "comfort foods." These foods offer temporary relief but contribute to long-term weight gain [17]. Emotional eating, a coping strategy for managing negative emotions, further exacerbates caloric overconsumption.

Cognitive factors also play a role. Impaired executive functioning and decision-making can hinder individuals' ability to maintain dietary and exercise regimens [18]. Traits like impulsivity, which are common in individuals with substance addiction, are similarly linked to obesity. Research suggests a positive correlation between impulsivity and food addiction, emphasizing the shared mechanisms between these behaviors [19].

Another significant cognitive risk factor is mental rumination, a process involving repetitive, negative thought patterns. Rumination increases vulnerability to weight stigma and the internalization of discriminatory attitudes, which can perpetuate psychological distress and hinder effective weight management [20].
## Social and cultural determinants

Obesity disproportionately impacts individuals from lower socioeconomic backgrounds, underscoring the significant role of social determinants. Economically disadvantaged populations face substantial barriers, including limited access to affordable, nutritious food options and safe spaces for physical activity [21]. These structural inequities create environments that hinder healthy lifestyle choices and exacerbate the prevalence of obesity. Additionally, cultural norms and traditions shape dietary habits and perceptions of body weight, with some cultures associating larger body sizes with health, wealth, or prosperity, further complicating public health efforts [22].

Social networks also play a pivotal role in the prevalence of obesity. Research suggests that obesity tends to "cluster" within social groups, as shared behaviors and attitudes toward food and physical activity propagate among family, friends, and broader communities [23]. This phenomenon highlights the social reinforcement of lifestyle patterns that contribute to weight gain.

Weight discrimination represents a significant societal issue that perpetuates obesity. Studies indicate that individuals who experience weight-based stigma are three times more likely to remain in a state of obesity [24]. Discriminatory attitudes and behaviors can create psychological and behavioral responses that undermine efforts to manage weight effectively. For example, exposure to stigmatizing or discriminatory content—whether through media or interpersonal interactions—can reduce inhibitory control and increase caloric intake. This underscores the detrimental and counterproductive effects of weight stigma on individuals with obesity [25].

## Interaction of factors: The systems perspective

The multifactorial nature of obesity underscores the necessity of a systems approach to understand its complexity. The interplay between genetic predispositions and environmental exposures often creates feedback loops that reinforce weight gain. For example, individuals with a genetic predisposition to obesity may be more susceptible to weight gain in an obesogenic environment, which in turn exacerbates psychological stress and metabolic dysregulation. These compounded effects highlight the need for interventions that address multiple levels of influence simultaneously.

Disparities in healthcare access and quality further compound the problem, delaying the diagnosis and management of obesity. Untreated obesity frequently leads to comorbid conditions, such as type 2 diabetes and cardiovascular disease, creating a cyclical relationship between the disease and its health consequences [26].

## Consequences of stigma associated with obesity

The stigma surrounding obesity is pervasive and manifests across various settings, including schools, workplaces, and healthcare environments. This stigma not only leads to discrimination but also has profound effects on mental and physical health. Individuals with obesity are often stereotyped as lazy, lacking willpower, or unintelligent [27]. These biases perpetuate social isolation, erode self-esteem, and hinder the ability to engage in health-promoting behaviors.

In healthcare, weight stigma can lead to implicit biases among providers, resulting in delayed diagnoses and inadequate treatment. Patients with obesity may avoid seeking medical care due to prior negative experiences, further exacerbating their condition [28]. Internalized stigma—when individuals adopt societal prejudices about weight—can lead to heightened risks of anxiety, depression, and disordered eating. This cycle of stigma and poor mental health often hinders effective weight management [29].

## Social stigma

Social stigma reflects the negative stereotypes and prejudices directed toward individuals with obesity, often characterizing them as lazy, undisciplined, or lacking self-control. These biases manifest in education, employment, and personal relationships. For example, students with obesity are more likely to face bullying in school, which adversely affects their academic performance and mental health [30]. In the workplace, employees with obesity often encounter biased hiring
practices, fewer promotions, and lower wages, irrespective of their qualifications or performance [31]. The cumulative impact of social stigma reinforces a cycle of exclusion and marginalization, reducing opportunities for economic and social advancement.

Body shape, particularly abdominal obesity, is often associated with personality traits, such as being "lethargic," "greedy," or "selfish" [32]. These stereotypes suggest that social selection may play a role in shaping the biology and societal perception of obesity. In the media, both traditional and social, individuals with obesity frequently face discriminatory portrayals. Such depictions—common even in children's television programs—perpetuate negative stereotypes and reinforce societal biases [33].

## Medical stigma

Weight bias in healthcare settings poses a significant barrier to effective medical care. Providers often perceive patients with obesity as noncompliant or unmotivated [6]. These biases lead to shorter consultations, less thorough examinations, and an overemphasis on weight loss as a universal solution, often at the expense of addressing other health concerns. For instance, patients with obesity are less likely to receive preventive screenings, such as mammograms or Pap smears, delaying the detection of critical health issues [34].

Additionally, younger individuals, those with more severe obesity, and those with chronic conditions are more likely to experience lower-quality, person-centered care (PCC) [35]. Women with obesity face unique challenges, particularly in fertility care, where socioeconomic barriers and psychological stress further hinder access to treatment [36].

## Internalized stigma

Internalized stigma occurs when individuals accept societal stereotypes and blame themselves for their weight, leading to feelings of shame, guilt, and inadequacy. This phenomenon has severe mental health implications, increasing the likelihood of depression, anxiety, and maladaptive behaviors such as emotional eating. Many individuals avoid physical activity for fear of judgment in public settings, further impeding their health goals [37].

For pregnant women with obesity, internalized stigma often arises from discriminatory remarks in medical settings, leading to weight bias internalization (WBI), which compounds psychological stress [38]. Over time, internalized stigma diminishes self-esteem, motivation, and the ability to engage in health-promoting behaviors.

## Impact on health

The psychological toll of weight stigma is profound, often resulting in chronic stress that exacerbates existing mental health conditions. Persistent exposure to weight-based discrimination has been linked to elevated cortisol levels, a stress hormone that promotes weight gain and metabolic disturbances [6]. Stigma also worsens eating disorders, such as binge eating disorder, which is already prevalent among individuals with obesity [39]. This feedback loop between stigma and mental health creates additional barriers to effective obesity management [40].

Obesity is also strongly associated with the development of depression through pathophysiological mechanisms. Inflammatory processes, driven by obesity, contribute to the pathogenesis of depression. Adipocytes and macrophages, including brain microglia, migrate to adipose tissue under obesity conditions, exacerbating systemic inflammation [41].

Weight stigma has measurable effects at the molecular level. For example, exposure to discrimination is associated with elevated levels of C-reactive protein (CRP), particularly among individuals with a BMI in the 25–30 range, reflecting systemic inflammation [42]. Furthermore, weight discrimination may increase the risk of cognitive decline and dementia, suggesting that psychosocial stressors, beyond BMI, can significantly impact brain health [43].

## Barriers to social and community participation

Weight stigma also limits individuals' ability to engage fully in social and community activities. Fear of judgment or discrimination often deters participation in group exercise programs, social events, or even everyday activities such as
shopping or dining out. This withdrawal from public life diminishes quality of life while reinforcing isolation and marginalization [44].

In educational settings, stigma negatively impacts academic performance, particularly among children and adolescents. Coping strategies, such as reducing visibility within school contexts, limit participation in extracurricular activities, creating disparities that affect long-term health and success [45].

### Intersectionality of stigma

Weight stigma frequently intersects with other forms of discrimination, including those based on gender, race, and socioeconomic status. For instance, women are disproportionately subjected to weight-based discrimination compared to men, especially in social and professional contexts [46]. Similarly, individuals from lower socioeconomic backgrounds often encounter compounded stigma, as their weight is erroneously attributed to personal shortcomings rather than systemic barriers, such as limited access to nutritious food and recreational opportunities [21].

Recognizing these intersecting forms of discrimination is critical for developing targeted interventions that address the unique challenges faced by diverse populations. Intersectionality amplifies the negative effects of stigma, making it an even greater barrier to achieving equitable health outcomes.

Stigma associated with obesity permeates every facet of life, exacerbating health disparities and reinforcing societal inequities. Effectively addressing this pervasive issue requires a multifaceted approach, including public education to challenge stereotypes, healthcare provider training to reduce bias, and systemic policy reforms to promote inclusivity. Together, these strategies can foster a more equitable and supportive society.
<figure><img src="image_3.png" /><figcaption>**Figure 1.** Intersectionality of weight stigma and its impact on health and equity.</figcaption></figure>

## Promoting healthy environments

Creating healthy environments is a cornerstone of obesity prevention. Policies that regulate access to nutritious foods, encourage physical activity, and restrict the marketing of unhealthy products are essential for addressing obesogenic environments [47]. Educational campaigns and healthcare professional training can reduce biases against individuals with obesity, fostering more supportive and equitable care. The adoption of neutral, non-blaming language when discussing obesity further helps to diminish stigma and promote respectful communication [48].

## Integrated approaches to obesity management

Effective obesity management requires a holistic, integrated approach that combines medical, behavioral, and psychological interventions. Programs that emphasize nutritional education, psychological support, and regular physical activity have demonstrated sustained success in improving health outcomes [49]. Increasingly, these efforts are complemented by societal interventions that challenge stigma and promote inclusion.
Healthcare professionals are increasingly adopting personalized, patient-centered care models tailored to the needs of individuals with obesity. Multidisciplinary teams, including nutritionists, psychologists, and exercise specialists, are essential for delivering comprehensive support while minimizing internalized stigma that is often reinforced by oversimplified weight-loss advice [50].

Cognitive-behavioral therapy (CBT) has proven effective in alleviating the psychological burden of stigma while supporting weight management goals. Advances in technology have further enhanced access to care through telehealth platforms and mobile applications. These tools provide virtual coaching, behavioral therapies, and community-building interventions that are accessible, stigma-free, and adaptable to diverse lifestyles. Social media-based initiatives focusing on peer support and inclusivity also play a significant role in reducing stigma [51].

## Policy-level interventions

At the societal level, policies promoting size-inclusive healthcare training are gaining momentum. Educating healthcare providers to recognize and mitigate weight bias improves patient experiences and treatment adherence. Public health campaigns are shifting away from weight-focused messages toward broader themes of holistic health, incorporating diverse body representations to reduce stigma [8].

Structural interventions aim to dismantle systemic barriers that perpetuate stigma. Examples include incorporating size-inclusive seating in public spaces and implementing legislation to classify weight discrimination as an actionable offense. Evidence suggests that such measures not only empower individuals with obesity but also help reshape societal perceptions, fostering greater equity [51].

## Community and Advocacy Efforts

Grassroots initiatives and advocacy groups play a pivotal role in reducing weight stigma. Community-based programs that emphasize non-competitive, enjoyment-focused physical activities have shown effectiveness in improving health outcomes and fostering a positive self-image. Advocacy campaigns for equal rights and fair treatment of individuals with obesity challenge societal norms, pushing for systemic change and greater inclusivity.

## Future directions

Emerging research highlights the critical need for interventions targeting children and adolescents to disrupt the cycle of stigma and obesity early in life. Policies that combine anti-bullying measures with health education in schools have shown significant promise in fostering a healthier, stigma-free environment.

Addressing the intersectionality of stigma—where weight bias overlaps with gender, race, or socioeconomic factors— requires nuanced and inclusive strategies tailored to diverse populations [52]. By integrating medical care, education, advocacy, and systemic reform, it is possible to achieve meaningful improvements in health outcomes and reduce the pervasive stigma associated with obesity.

## CONCLUSION

Obesity, as a multifactorial disease, demands a comprehensive understanding that encompasses genetic, biological, environmental, behavioral, and societal factors. The foundational work of Maes et al. [3] and Locke et al. [9] highlights the significant influence of genetic predispositions and hormonal pathways on body weight regulation, while Swinburn et al. [2] emphasize the critical role of an obesogenic environment shaped by urbanization and modern food systems.

Psychological and social dimensions further complicate this landscape. Emotional eating and chronic stress, as outlined by Dallman et al. [17], increase susceptibility to weight gain, while socioeconomic and cultural factors exacerbate health disparities [21, 38]. Weight stigma, as described by Puhl and Heuer [41] and Christakis and Fowler [23], compounds these challenges by fostering discrimination and internalized shame, leading to adverse mental health outcomes and diminished access to healthcare. Structural and interpersonal biases, particularly when intersecting with race, gender, or socioeconomic
status, intensify the barriers faced by individuals with obesity [6,38]. Brewis et al. [7] stress that stigma is not merely a consequence of obesity but an active driver of poor health outcomes, underscoring the urgent need for targeted stigma-reduction strategies.

Innovative interventions, such as telehealth platforms and community-driven programs, have shown promising results in recent studies [8]. Legislative measures to combat weight-based discrimination, combined with educational initiatives to address implicit biases in healthcare, offer pathways for systemic change [51]. Future strategies must prioritize early interventions, particularly those targeting children and adolescents. Research [51] underscores the importance of comprehensive anti-bullying and health education programs in schools to disrupt the cycle of stigma and obesity at its roots.

In conclusion, reframing obesity as a complex health condition rather than a moral failing is paramount [52]. Addressing its multifaceted causes and the stigma it perpetuates is essential to fostering a more inclusive and equitable society. The alignment of multidisciplinary research, systemic policy reforms, and community advocacy, as highlighted in this discussion, provides a robust framework for improving health outcomes and promoting well-being among individuals living with obesity.

**Funding:** This research received no external funding.

**Acknowledgments:** None.

**Conflicts of Interest:** The authors declare no conflict of interest.

**Disclaimer/Publisher's Note:** The Publisher remains neutral regarding jurisdictional claims in published maps and institutional affiliations. Additionally, the Publisher is not responsible for the accuracy, completeness, or validity of the content of scientific articles published herein. This statement exempts the Publisher from any responsibility regarding the content of scientific articles, which is solely the responsibility of the authors and peer reviewers.

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