Overweight and obese medical students had significantly worse overall health and lower body esteem than normal-weight/underweight students, and were more likely to use drugs or alcohol to cope with stress, placing them at elevated risk for stress, which in turn could increase the risk of professional burnout,48 lower professionalism and empathy,49,50 lower academic performance,49,51–53 poor mental health,49,54 substance abuse,55 and suicidal ideation.56 Female students who were overweight/obese also reported less social support and more loneliness than their normal/underweight counterparts, suggesting that these students are more prone to the isolation and lack of support structure that impair health and predict burnout.57–60 Overweight/obese men (but not women) felt a greater sense of mastery, a psychological coping resource. One possible explanation for this finding is that men, but not women, who are overweight/obese must achieve a higher level of mastery than their peers in order to be competitive in medical school. More work is needed to understand these gender differences.

Students who were overweight/obese perceived more stigma, even after adjusting for race, gender, socioeconomic status, and age. Moreover, among overweight/obese students, perceived stigma was almost universally associated with conditions known to increase the risk of stress and reduce the ability to effectively cope with stress. This finding is noteworthy given the documented pressure of medical school and the link between stigma and risk of stress-related chronic diseases.15,61 In addition, evidence that physicians and trainees exhibit high levels of prejudice against individuals who are obese27,62–64 suggests that medical school may be especially threatening and stressful to overweight and obese students. However, first-year medical students who were overweight/obese had similar anxiety and depressive symptoms, self-esteem, and sense of mastery as their normal/underweight counterparts. This may be due to the universally heightened uncertainty that students experience during the first semester of medical school, which may have obscured group differences.

We found high levels of implicit and explicit self-stigma among overweight/obese students, among whom 70 % implicitly associated greater body size with negative words, suggesting internalization of these beliefs. Explicit self-stigma was associated with several stress vulnerability factors, although the strength of association varied among self-stigma components. Fear of gaining weight was strongly associated with each stress vulnerability measure. Dislike of fat people was also associated with greater depression and anxiety and lower self-esteem. The high prevalence of these attitudes suggests that the explicit in-group bias that can protect members of some minority groups may not apply for this group. Furthermore, as medical students and members of a generation exposed to public health messages touting the “war on obesity,” they may be especially likely to view obesity as a dangerous risk factor. This belief, though consistent with experience and social norms, is inconsistent with the need to maintain self-esteem—a conflict with negative implications for health and well-being.

Blaming people for being fat was not consistently associated with stress-related factors. The few associations with blame that reached significance were in a direction suggesting greater resiliency. This is surprising, given evidence that controllability beliefs are predictors of prejudice.65 It may be that the belief that weight is modifiable through willpower reinforces a sense of control over one’s own weight and protects against a feeling of helplessness. Another possibility, consistent with the system justification theory66, is that assimilation to the majority view of the causes of obesity increases one’s sense of belonging in medical school and common group identity with other students. This may also explain why implicit self-stigma was associated with less loneliness and perceived stress. Further study is warranted to examine whether perceived controllability of weight and implicit self-stigma are protective in some cases.

Implicit self-stigma was highly prevalent among overweight/obese students, suggesting that there is little automatic in-group bias in this population. Given the fact that in-group bias may protect self-esteem against the effects of stigma, the strong pro-thin implicit preferences found here are striking. Surprisingly, implicit self-stigma was not associated with worse well-being.

The primary limitation of this research is the cross-sectional nature of these data, which preclude inferences of causality. The focus of the survey on first-year students limits the generalizability of the findings to advanced trainees. However, first-year students represent a critical and vulnerable point3 in the progression toward a medical career, and thus are important to study in their own right. The current findings provide evidence that this population may require supportive services to prevent further degradation of well-being. Longitudinal study is needed to assess whether differences persist throughout medical school, and whether the trajectory of change for other factors differs according to BMI. Although we selected items from two scales that were representative of the concepts measured, we note that using selected items may affect measure validity. Also, many statistically significant associations have small effect sizes, and the clinical significance of these effects is difficult to assess. However, small differences that occur systematically may be meaningful, especially if those differences grow over time. Other limitations include the lack of direct measurement of student health or height/weight. However, the data were collected in a large national sample of medical students using validated measures, and provide novel insights regarding self-stigma and well-being among obese and overweight medical students.

We hypothesized that medical students who were overweight or obese—and female students in particular—have worse physical/mental health, fatigue, self-esteem, social support, and sense of mastery than non-overweight students. We found evidence to support this hypothesis for some but not all factors. We further hypothesized that among these students, those who have experienced more stigma or who are self-stigmatized will have worse outcomes. This hypothesis was supported by the data, with variation in experiences and attitudes associated with each factor. Our findings suggest that stigmatizing experiences may erode these students’ ability to cope with stress.

Medical schools should consider ways to support this group of students. Strategies that foster a non-threatening environment include enforcing zero tolerance of derogatory comments about overweight/obese patients, ensuring that curricula emphasize complex multifactorial causes of obesity, and including obesity and other stigmatized conditions in discussions about bias and disparities in care. To support students, schools could provide counselors trained to identify the effects of stigma on students’ ability to cope with stress, promote student awareness of the effects of stress on physical and mental health, and help students learn adaptive ways to regulate emotions. Additional qualitative research or more systematic information about programs to address the stigma of being overweight would complement the survey results from the present study in a valuable way. Effective strategies and interventions will benefit stigmatized students as well as the overall student body.