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Overcoming Stigma and Bias in Obesity Management

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Last Update: March 10, 2024.

Continuing Education Activity

Weight stigma, defined as the negative attitudes, beliefs, and stereotypes that society holds toward people who are overweight and people with obesity, exists in healthcare settings. Weight bias refers to an individual's attitudes, beliefs, and behaviors towards someone with obesity. In the medical setting, the bias may result in discrimination, decreased access to care, and compromised health outcomes. Interprofessional healthcare team members may not recognize the occurrence or significance of this intentional or implicit bias. Stigma in healthcare leads to individuals postponing necessary medical attention due to fear of judgment or discrimination, delaying diagnoses and treatment.

Weight stigma may also strain relationships between clinicians and patients, hinder communication, and cause patients to comply less with prescribed treatment plans, resulting in suboptimal health outcomes. This activity describes the stigma associated with obesity and its consequences. Participating clinicians have the knowledge and tools to identify, address, and reduce its occurrence and deliver improved patient care.

Objectives:

  • Identify overt and implicit weight stigma and bias in healthcare within patient encounters.
  • Assess how weight stigma and bias negatively affect healthcare outcomes by hindering treatment adherence for patients with obesity.
  • Apply strategies to identify, address, and reduce stigmatizing behaviors in healthcare and design weight-friendly clinical environments. 
  • Implement strategies within the interprofessional team to prioritize well-being, recognizing the multifaceted nature of obesity and its impact on health.
Access free multiple choice questions on this topic.

Introduction

The World Health Organization (WHO) defines obesity as "abnormal or excessive fat accumulation that may impair health." The prevalence has risen exponentially over the last 50 years, and the WHO estimates that more than 650 million adults globally were living with obesity in 2016. A lack of international consensus on whether obesity is categorized as a disease is up for debate. In June 2013, the American Medical Association (AMA) voted to recognize obesity as a disease requiring treatment and prevention, but not all countries agreed. Proponents argue that identifying obesity as a disease leads to better management and fewer complications. Labeling obesity as a chronic disease such as asthma or hypertension promotes a holistic approach that reduces the stigma and discrimination experienced by affected individuals and improves education for healthcare professionals, policymakers, and the general public. Critics argue that labeling obesity as a medical condition may lead to unnecessary interventions and contribute to further stigmatization by reinforcing negative stereotypes and promoting a narrow focus on individual responsibility rather than addressing the complex underlying socio-economic and environmental factors.[1][2]

Obesity is often associated with stigma due to prevailing societal attitudes linking body weight to personal character flaws and a lack of self-discipline. Clinicians may view obesity solely as the result of individual choices, such as poor diet and lack of exercise, rather than acknowledging the multifactorial etiology. Stereotypes and negative assumptions about individuals with obesity can lead to discriminatory attitudes, creating an environment where patients feel judged or blamed. This can reduce the quality of medical care and hinder patient-clinician relationships. Recognizing and challenging these biases is crucial for clinicians to provide compassionate, patient-centered care that addresses the multifaceted nature of obesity and supports individuals in achieving their health goals.  

People who are overweight or obese report experiencing discrimination from an early age in education, at work, and in healthcare, stemming from the stigma associated with the condition. This stigmatization occurs at younger ages than in the past as the prevalence of childhood obesity increases. Commonly held societal beliefs that individuals with obesity are lazy, overindulgent, and lacking in self-control are inaccurate and negatively impact patients.[3][4][5] 

A study from France in 2005 showed that most clinicians knew that being overweight and obese are threatening to health, and 79% agreed that it falls under their scope of practice; however, 30% of respondents expressed negative attitudes towards obese patients. Several Australian, British, and Israeli studies demonstrated similar beliefs. Australian clinicians reported feeling frustrated when treating patients with obesity because they lacked self-motivation and compliance. In a British qualitative study, primary care clinicians held the view that obesity is caused by unhealthy eating and lack of exercise, solely blaming the patient. In Israel, another study showed that 31% of family medicine clinicians judged overweight people as lazier than those of average weight. Surveys have also noted that "difficult" patients, perceived as those with behaviors harming their health, may elicit strong negative emotions.[6][7][8][9][10]

Issues of Concern

Stigma and bias can lead to suboptimal care, and clinicians must be aware of the potentially profound impact of their words and actions, both deliberate and unintentional. An example of overt bias towards patients with obesity is a clinician making derogatory comments or using offensive language about a patient's weight during or after a medical consultation. This includes using stigmatizing terms like "fat," joking inappropriately, or expressing negative stereotypes to colleagues about people with obesity. An instance of unintentional bias is a clinician assuming that a patient's health issues are solely attributed to their weight without thoroughly investigating other potential causes, such as attributing joint pain to obesity without considering other musculoskeletal conditions or assuming a lack of adherence to treatment plans based on body weight alone. This bias is often more subtle and rooted in unconscious societal stereotypes. By addressing these issues, clinicians can promote a more supportive and inclusive approach to patients with obesity and improve health outcomes. 

Biased perspectives can result in inadequate medical care, as individuals may hesitate to seek further help due to a fear of being judged. This can lead to delayed diagnoses and a worsening of other chronic health issues. A small observational study of Irish patients with obesity in 2021 noted that prior experiences of weight bias led to missed or canceled follow-up appointments, as well as an escalation of harmful behaviors related to food and physical inactivity as a response to being subjected to stigmatization. Another example cited was binge or comfort overeating after medical consultations. Clinicians may inadvertently perpetuate stereotypes, such as making assumptions about a patient's lifestyle, likely compliance with treatment, or overall health behaviors. They may attribute all medical issues to obesity and focus solely on weight reduction rather than addressing patients' comprehensive healthcare needs. An example is when clinicians prescribe less pain medication for patients with orthopedic conditions who are instructed to lose weight first. Clinicians may neglect to discuss preventive care unrelated to weight, assuming patients with obesity are less likely to follow their recommendations. A 2024 review of observational studies between 1993 and 2023 noted fewer pelvic examinations and screening tests for cancer and less frequent intensification of diabetes management in patients with obesity.[11]

During the COVID-19 pandemic, obesity emerged as a risk factor for hospitalization, intensive care, and increased mortality. While clinicians may recommend prompt evaluation and treatment, those efforts succeed only if patients seek treatment. Weight stigma is recognized as a barrier to equitable healthcare, and patients with obesity are less likely to access the care they need. During the pandemic, The Lancet reported that many people with both obesity and COVID-19 in the United Kingdom (UK) expressed a sense of shame, a perception that they were less of a priority than others, and a reluctance to seek medical assistance. During COVID-19 lockdowns, "Quarantine-15" gained popularity as a description of weight gain associated with the pandemic. In the UK, a public health campaign from the National Health Service (NHS) in 2020 included the statement that "Tackling obesity would reduce pressure on doctors and nurses in the NHS, and free up their time to treat other sick and vulnerable patients," suggesting that those with obesity were burdening the health care system and putting lives at risk. This message only served to reinforce the stigma surrounding obesity and may have resulted in individuals avoiding much-needed medical care.[12][13][14]

Weight stigma is associated with adverse psychological and physiologic consequences. Patients with obesity may internalize the biases they experience, leading to decreased self-esteem and a reluctance to engage further with the healthcare system. This emotional toll can contribute to mental health challenges and poorer health behaviors, such as binge eating, increased overall food consumption, and decreased physical activity, as well as a physiologic stress response with elevated levels of cortisol and inflammatory markers. These effects are in addition to the already-known chronic health complications of obesity.[15][16] 

Many strategies exist to reduce weight stigmatization and bias in healthcare. The first step is recognizing that being overweight is a sensitive topic, and clinicians must address overall health and well-being, not just the body mass index (BMI). One participant in the previously mentioned patient-perspective Irish study said, "I wish my doctor would see me as a person first who has feelings." A good clinician-patient relationship positively impacts treatment compliance and reduces the likelihood of adverse health outcomes associated with weight bias. Clinicians who use motivational interviewing can encourage positive behavior changes in a collaborative, non-confrontational manner. This approach utilizes reflective listening and open-ended questions to support patients as they develop intrinsic motivation to achieve healthier habits.[17]  

The healthcare team must establish a zero-tolerance policy against stereotypical language, images, or humor that inaccurately depicts patients who are overweight or obese as lazy or lacking in self-discipline. A 2024 cross-sectional study of physicians in training in Turkey reported that nearly half had heard derogatory comments or jokes about patients with obesity during their medical education, and almost a quarter had witnessed a patient with obesity being subjected to discriminatory treatment while hospitalized. Leaders in medical education must challenge these widespread and longstanding biases about obesity and promote a narrative consistent with scientific knowledge. 

In 2020, a multi-disciplinary group of international experts, including representatives from academic and scientific organizations, issued a joint consensus statement for ending the stigma of obesity. They recognized that people who are overweight or obese face social stigma, and their statement condemned the use of language, attitudes, and policies that stigmatize weight and pledged to support initiatives to prevent discrimination in the workplace, education, and healthcare. They advocated for governmental and institutional policies and validated tools such as the "antifat attitudes test" (AFAT) to assess clinical attitudes towards people with obesity.[18] 

One potential strategy to reduce the stigmatization of obesity is increasing clinician empathy through perspective-taking exercises. Obesity simulation suits (OSS) have been used in multiple clinical settings as a teaching tool during simulated patient encounters. Standardized "mock" patients at a German medical school were asked to wear an OSS during a teaching encounter. Students, teachers, and the mock patients were then questioned about the experience. The study concluded that the use of OSS to simulate obesity was convincing. The AFAT was administered after the session and showed that the students demonstrated more bias than the instructors or mock patients. In simulated settings, tools such as the OSS allow learners to discuss sensitive topics such as weight in a safe environment. In another study, a group of nurses and physiotherapists wore an OSS for 2 hours in public. After the experience, follow-up surveys showed more empathetic and less judgmental attitudes towards those with obesity than before the study. In a similar study, nurses reported more positive attitudes about obesity after wearing an OSS. Another tactic in medical education utilizes dramatic readings rather than standard lectures about the medical management of obesity. One study found the medical students who participated in the former group exhibited lower levels of explicit bias when questioned afterward.[19][20][21][22] 

What makes a clinical setting "weight-friendly?" First, the staff must model practices and attitudes that promote inclusivity, respect, and personalized care for individuals of all body sizes. Non-judgmental perspectives foster open communication and trust, and neutral language helps avoid stigmatizing terms related to body weight. Using "patient-first" language, such as "patient with overweight or obesity," is preferred over "obese patient." Patients prefer "healthy weight, overweight, and body mass index" rather than "morbidly obese, fat, and big." Using motivational interviewing and asking for permission to discuss the patient's weight before providing unsolicited advice promotes patient-centered communication and is less threatening for people who feel vulnerable. When primary care clinicians and staff believe they are treating patients with obesity with respect and compassion, their clinics may lack the appropriate equipment and furnishings to create a "weight-friendly" environment. Chairs in the waiting area and examination rooms must be sturdy and accommodate higher body weights. Chairs and sofas without armrests may be more comfortable for larger patients. Accessible, appropriately sized examination tables with steps or stools are necessary. Patients feel less self-conscious when weighed privately on scales designed for weights above 180 kg (400 lb). Other clinical supplies to create a body-positive space include extra-large patient gowns, large blood pressure cuffs, longer needles for phlebotomy, and vaginal specula in bigger sizes.[23] 

Clinical Significance

The disease model views obesity as a complex and chronic medical condition rather than solely the result of personal choices and behaviors. Diet and physical activity play a significant role and are influenced by genetic, environmental, and physiological factors. Obesity is associated with metabolism and hormonal regulation alterations, challenging sustained weight loss. The disease model promotes a medical approach to managing obesity, including lifestyle modifications, medications, and, in some cases, bariatric surgery. In the disease model, obesity is considered a chronic condition requiring ongoing medical intervention rather than blaming the patient for unhealthy habits. Recognizing obesity as a chronic disease like hypertension, diabetes, or asthma enables clinicians to care for patients more effectively. The acceptance of this model by the medical community has influenced approaches to treatment, public health strategies, and research.[24] 

Obesity-related stigma creates barriers to care and increases the likelihood of poor health outcomes. Addressing stigma allows reframing obesity from personal failure to a treatable medical condition. Clinicians and patients can focus on preventing and treating known complications. Obesity increases the risk of cardiovascular diseases, including hypertension, dyslipidemia, stroke, and coronary artery disease, as well as metabolic disorders such as type 2 diabetes and insulin resistance. Obesity predisposes patients to osteoarthritis, back pain, sleep apnea, obesity hypoventilation syndrome, gout, and an elevated risk of certain cancers, particularly breast, colorectal, and endometrial. Clinicians who address the contributing role of obesity in these conditions mitigate the associated health risks and contribute to patients' well-being and quality of life.[25]

Discussing the conditions associated with being overweight and obese is often a more useful approach during an appointment than focusing solely on a patient's weight. An elevated BMI and central adiposity increase the risk of developing type 2 diabetes mellitus (T2DM). Furthermore, a long duration of high body weight is an independent risk factor for T2DM. Planning to screen for T2DM  at a future visit is more productive than merely scheduling a follow-up visit for weight management and is less likely to result in patients who feel they have failed if their weight is unchanged. Recommending guideline-directed screening for obesity-related cancers offers another opportunity to mention excess weight in a non-judgemental manner. Meaningful conversations between clinicians and patients about these conditions ultimately address weight without it being the main topic of the discussion. While patients may be focused on the cosmetic aspects of weight loss, clinicians need to share the health benefits of a lower BMI. As little as 5% weight loss is significant, leading to reductions in chronic diseases, all-cause mortality, and improved quality of life metrics. A weight-friendly clinic helps patients feel comfortable and welcome, encouraging them to return for follow-up visits.[26][27]

Addressing weight-related stigma and biases dismantles barriers and fosters a supportive healthcare environment that can impact the trajectory of obesity-related health issues. Stigma can lead to suboptimal care, delayed diagnoses, unhealthy behaviors, and exacerbate chronic health conditions. Clinicians can reduce stigma by adopting patient-centered communication, motivational interviewing, and zero-tolerance policies against discriminatory practices. By creating inclusive spaces that promote open dialogue and individual autonomy, clinicians can empower patients to manage their health concerns proactively. Patient engagement is fundamental in mitigating the severity and progression of the medical complications linked to obesity. Accepting the disease model of obesity and addressing weight-related stigma ultimately improve clinical outcomes for patients with obesity.[28]

Enhancing Healthcare Team Outcomes

Interprofessional healthcare teams can improve outcomes by destigmatizing obesity and enhancing patient engagement. Recognizing obesity as a chronic disease is essential. Nurses and support staff should ensure a weight-friendly space. Clinicians can employ motivational interviewing techniques. Comprehensive treatment plans may involve lifestyle modifications, medications, and referrals. The team can support zero-tolerance policies against derogatory language and practices. This approach optimizes patient care, promoting positive health outcomes for patients with obesity and related conditions.

Review Questions

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Disclosure: Brittney Ginsburg declares no relevant financial relationships with ineligible companies.

Disclosure: Sharon Daley declares no relevant financial relationships with ineligible companies.

Disclosure: Amy Sheer declares no relevant financial relationships with ineligible companies.

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Bookshelf ID: NBK578197PMID: 35201725

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