Obesity, stigmatization, and mental health: the imperative of a psychosocial and legal approach in Brazil

Obesity is often considered a medical condition, primarily due to its associations with cardiovascular diseases, type 2 diabetes, and various other metabolic comorbidities.¹ However, its psychological impacts and the risk of suicide are frequently overlooked. There exists substantial evidence supporting a bidirectional association between obesity and prevalent mental disorders, including but not limited to depression and anxiety, which both elevate the risk of and are influenced by excess weight.² Epidemiological data indicate that individuals with extreme obesity (body mass index [BMI] ≥ 40) have a high prevalence of suicidal behavior, including suicide ideation and attempts. A German population-based study by Wagner et al. assessed the lifetime prevalence of suicidal behavior, including ideation and attempts, among adults with extreme obesity (BMI ≥ 40).³ The results showed that 33% of women in this group reported suicidal ideation at some point in their lives, and 27% had attempted suicide. Among men, both suicidal ideation and suicide attempt rates were reported at 13%. These data underscore the severity of mental health risks in individuals with extreme obesity. A systematic review by Klinitzke et al., based on more than 3.9 million participants, confirmed the association between obesity and an increased risk of suicidal ideation and attempts, especially among women. These findings demonstrate that obesity cannot be understood solely as a physical health issue, but rather as a condition with significant mental health implications and psychosocial vulnerability.⁴

Beyond clinical symptoms, individuals with obesity experience high levels of social stigma in daily life, healthcare services, the workplace, and educational settings. Global evidence indicates that experiences of weight-related stigma are closely linked to psychological distress, both in individuals seeking obesity treatment and in community settings. These experiences are associated with a wide range of negative psychosocial consequences, including depressive and anxiety symptoms, low adherence to treatment, antisocial behaviors, and inadequate coping strategies.⁵ The internalization of stigma – accepting negative societal messages about one’s weight or mental state – has been linked to increased depressive symptoms, hopelessness, and reduced help-seeking, which are known pathways to suicidality. Furthermore, studies have shown that weight-based discrimination intensifies the relationship between psychological disorders and suicidal outcomes.⁶ Thus, stigma does not act merely as a social phenomenon but as a psychological amplifier of suffering among individuals with obesity. While most data on the prevalence and impact of weight stigma come from high-income countries, recent Brazilian research has highlighted similar concerns. A national cross-sectional study involving 2,560 participants found that 61% of the individuals with obesity had not received a formal diagnosis, which suggests significant internalization of stigma among the Brazilian population.⁶

In response to these psychosocial and mental health challenges, legislative measures are gaining relevance. Bill No. 1786/22, currently under debate in the Brazilian National Congress, aims to combat fatphobia by criminalizing discrimination based on weight. The proposal seeks to equate these acts with other recognized forms of prejudice, such as racism and xenophobia.⁷ This movement represents an institutional response to the suffering of individuals with obesity and the growing scientific understanding of the psychological burden imposed by stigma. Legal protection not only acknowledges the harm caused by discrimination but also paves the way for public health initiatives that integrate mental health care and obesity treatment in a more humane and comprehensive manner. If approved, this law could help reduce discrimination in healthcare, the workplace, and public spaces, foster inclusion, and encourage educational campaigns to dismantle prejudice.⁵

Evidence suggests that public support for obesity-related policies is significantly shaped by the way obesity is framed. A systematic review by Hill et al.⁸ suggests that policies which frame obesity primarily as a matter of individual responsibility tend to reinforce weight-related stigma, while those that acknowledge structural and environmental factors are more likely to reduce weight bias and gain public acceptance. These findings reinforce the importance of adopting legislative measures, like Bill No. 1786/22, that are grounded in a broader understanding of the social determinants of obesity.

Although specific legislation against weight-based discrimination remains limited globally, some jurisdictions have already implemented laws prohibiting discrimination based on body weight or physical appearance. Studies suggested that these measures reduce the psychosocial impacts of discrimination and improve the well-being of individuals with obesity.⁹ For example, the U.S. state of Michigan enacted a law prohibiting weight-based discrimination in the workplace. Additionally, cities such as San Francisco and Washington, D.C., have included similar protections in their local anti-discrimination laws. While studies evaluating the direct impact of such legislation on weight-related discrimination are scarce, research on anti-discrimination laws in other domains – such as mental health – has provided valuable insights. These laws have proven effective in reducing stigma and improving the quality of life of affected individuals. The World Health Organization’s World Mental Health Report 2022 highlights that psychosocial rehabilitation strategies – particularly those incorporating legal protections and anti-discriminatory frameworks – are crucial for reducing stigma, promoting empowerment, and ensuring social inclusion for individuals with mental health conditions.¹⁰ Additionally, a joint position statement by the Brazilian Association of Emergency Medicine (ABRAMEDE) and the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO) emphasizes the need to combat weight stigma in clinical settings, advocating for structural adaptations, specialized training for healthcare teams, and a respectful healthcare environment to address these issues.⁹

Implementing this legislative measure will present challenges, including the need for specialized training for public servants, clear protocols for reporting situations of stigma, and the establishment of effective legal pathways for victims. This situation is likely to stimulate discussion on freedom of expression and the viability of efficient systems for monitoring and enforcing anti-discrimination provisions. Scientific evidence pertaining to obesity, suicidal ideation, and discrimination is accumulating, underscoring the pressing need for proactive measures. Nevertheless, institutional and academic responses have not yet adequately met this demand. A comprehensive and integrated approach that recognizes obesity not merely as a metabolic disorder but also as an indicator of psychosocial vulnerability will be essential to mitigate suicide rates in this population.

Acknowledgments

The authors would like to thank all of our colleagues who contributed to the discussion and refinement of the ideas presented in this letter.

References

• ¹ Hruby A, Hu FB. The epidemiology of obesity: a big picture. Pharmacoeconomics. 2015;33:673-89.
• ² Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67:220-9.
• ³ Wagner B, Klinitzke G, Brähler E, Kersting A. Extreme obesity is associated with suicidal behavior and suicide attempts in adults: results of a population-based representative sample. Depress Anxiety. 2013;30:975-81.
• ⁴ Klinitzke G, Steinig J, Blüher M, Kersting A, Wagner B. Obesity and suicide risk in adults-a systematic review. J Affect Disord. 2013;145:277-84.
• ⁵ Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100:1019-28.
• ⁶ Viola LF, Mandel F, Valerio CM, Bernardini MA, Halpern B. Exploring the perceptions of obesity, health habits, stigma, and eating behaviors in Brazil. Diabetol Metab Syndr. 2025;17:119.
• ⁷ Kirby T. Brazil considers obesity discrimination law. Lancet. 2024;404:1912-3.
• ⁸ Hill B, Bergmeier H, Rodriguez ACI, Barlow FK, Chung A, Ramachandran D, et al. Weight stigma and obesity-related policies: A systematic review of the state of the literature. Obes Rev. 2021;22:e13333.
• ⁹ Von Hellmann RLMG, van de Sande-Lee S, de Melo ME, Messias ACNV, Maia IWA, Lunardi MC, et al. Care of patients with obesity in the Emergency Department: a joint position statement from the Brazilian Association of Emergency Medicine (ABRAMEDE) and the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO). Arch Endocrinol Metab. 2025;69:e240411.
• ¹⁰ World Health Organization (WHO) [Internet]. World Mental Health Report: Transforming mental health for all. 2022 Jun 16 [cited 2025 May 10]. https://www.who.int/publications/i/item/9789240049338
  » https://www.who.int/publications/i/item/9789240049338

• How to cite this article: dos Santos GR, Boaventura B, Baldez DP, da Fonseca NKO, Fopa GT, Lovato LM, et al. Obesity, stigmatization, and mental health: the imperative of a psychosocial and legal approach in Brazil. Braz J Psychiatry. 2025;47:e20254259. http://doi.org/10.47626/1516-4446-2025-4259

Edited by

• Handling Editor:
  Thiago Fidalgo

Publication Dates

• Publication in this collection
  31 Oct 2025
• Date of issue
  2025

History

• Received
  10 Apr 2025
• Accepted
  1 May 2025