A patient walks into your office. His/her BMI is 34. He/She has seen a couple of nutritionists before, tried to lose weight before, and really just doesn’t want to be here.
What do you do?
As we were examining a case study in one of my classes recently, I overheard someone mention that clearly the patient was doing something wrong if he/she couldn’t lose weight. This comment didn’t sit quite right with me, and as I dwelled on this notion that we are entirely responsible for our weight, I thought about how this common misconception has the potential to actually do harm. As today is World Obesity Day, I thought it an apt time to discuss obesity stigma and weight bias in healthcare.
One of the concerns I have studying public health nutrition after three years working in research on lifestyle interventions for weight loss and diabetes prevention is the focus that is often placed on behavior in the approach to obesity. Although behavior clearly plays a large role in weight, there is an increasing body of evidence to suggest that there are many other factors that can impact a person’s weight, and I worry about the potentially stigmatizing effect of focusing primarily on the behavioral factors.
Full Disclosure- While I am not currently overweight or obese, I have struggled with weight in the past. While I don’t recall specific incidents of weight bias in a medical setting, I do remember feeling generally uncomfortable in settings when my weight was addressed.
In 2014, over 1.9 billion adults worldwide were estimated to be overweight or obese, and according to data from the National Health and Nutrition Examination Survey (NHANES), approximately 2 in 3 adults in the United States were considered to be overweight or have obesity. (Flegal, Kruszon-Moran, Carroll, Fryar, & Ogden, 2016; Obesity and Overweight Fact Sheet, 2016) It might be expected that as incidence of overweight and obesity rise, stigmatization of individuals in these weight ranges would decrease; however, this is not the case. Obesity Stigma, weight bias, and weight discrimination remain highly prevalent in The United States. Although weight discrimination is not a new phenomenon, research suggests that the prevalence has increased by 66% over the last decade, and is estimated at rates comparable to the prevalence of racial discrimination in America. (Andreyeva, Puhl, & Brownell, 2008). The prevalence of weight stigma in clinical settings is even more concerning. In fact, a number of studies have suggested that many health care providers have negative stereotypes regarding people with obesity.(Phelan et al., 2015) Weight stigma is sometimes perpetuated by public health messaging and intervention efforts, and there is a growing body of evidence that suggests that weight bias and weight stigmatization pose a substantial risk to patient health outcomes and interfere directly with obesity intervention efforts. As future clinicians, it is important that we are aware of this bias and the potential associated health issues.
Obesity Stigma and Stereotypes
Many of you are probably familiar with the stereotypes surrounding those who are overweight, but may not understand overweight and obesity stigma within the context of disease stigma. Historically, stigma has surrounded many diseases and imposed suffering on those diseased individuals. Disease stigma has occurred when groups have been blamed for their illnesses.(Puhl & Heuer, 2010) Weight stigma is not different. In fact, the basis of weight stigma and weight bias lies on the belief that overweight or obese individuals are responsible for their weight, in other words, excess weight is perceived to be a direct result of only controllable factors such as overeating and lack of exercise. Stereotypes surrounding people with overweight or obesity include: lazy, lacking willpower, stupid, weak-willed, and non-compliant.(Puhl & Heuer, 2009) Because of these stereotypes, which paint obesity as a self-inflicted disease, weight stigma has remained one of the last socially-acceptable forms of bias.
Here’s a video from Yale University with an overview:
Clinical and Public health efforts to label and control obesity may in fact promote the idea that obesity and overweight are self-inflicted and controllable measures, perpetuating stereotypes and exacerbating weight bias in the health field. The high prevalence of obesity has been termed an “obesity epidemic” as well as a public health crisis. One study published in BMC Public Health showed that use of certain language increased stigmatizing attitudes among participants, although the authors admitted that more research on the consequences of this messaging is needed.(Luck-Sikorski, Riedel-Heller, & Phelan, 2017)
Actual efforts to study and prevent obesity are also implicated in obesity stigma. Obesity prevention methods focus primarily on behavioral interventions, which often include caloric restriction and increased physical activity.(MacLean et al., 2009) Focusing interventions solely on individuals’ behavior perpetuates a stereotype that overweight/obesity is caused solely by behavior, and therefore encourages the belief that these individuals are lazy, unmotivated, or lack willpower.(Luck-Sikorski et al., 2017)
How does Bias Impact Health?
It is well known that the stigmatization of certain vulnerable populations has a negative effect on the health of these groups. Public health organizations acknowledge the obstacles and consequences created by disease stigma. Sadly, however, weight stigma has only recently been identified as a concern, and therefore efforts to address this type of stigma are still being developed.
“Weight stigma actually increases the likelihood of unhealthy eating behavior as well as lower levels of physical activity in stigmatized individuals.”
Unfortunately, many health care professionals still believe that stigmatization based on being overweight or obese is justifiable and potentially even useful in motivating lifestyle change among individuals.(Puhl & Heuer, 2010) A number of studies have shown that weight stigma actually increases the likelihood of unhealthy eating behavior as well as lower levels of physical activity in stigmatized individuals.(Puhl & Heuer, 2010) Weight-based stigmatization is also a significant risk-factor in binge-eating behaviors, which often result in increased weight gain. (Wang, Lydecker, & Grilo, 2017) Furthermore, poor treatment and negative experiences with healthcare professionals may decrease desire for individuals to seek out care in the future. Finally, weight bias and specifically weight bias internalization have been associated with increased risk of metabolic syndrome, and increased risk of patient mortality.(Pearl et al., 2017)
What can health professionals do?
I believe that as health professionals, it is critical to examine all the determinants of obesity rather than simply focusing on behaviors. Non-behavioral contributions to obesity may include such things as genetic attribution, access to healthy foods, socio-economic status, or even gut dysbiosis. Although weight is an important topic to broach as a clinician, it is critical that it is done so in a sensitive manner.
Here are some general tips for providers:
- Never blame your patient for their weight!
- Consider the equipment you have in your office. You should have equipment such as blood pressure cuffs to fit any size patient.
- Although not possible in every setting, it may be wise to ask your participant whether it is alright before taking weight and/or waist and hip measurements.
- Be careful not to make assumptions based on weight, such as blaming all health issues on weight.
- Consider using motivational interviewing.
- Focus less on weight loss and more on healthy lifestyle changes
Some Research to Explore
Andreyeva, T., Puhl, R. M., & Brownell, K. D. (2008). Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring), 16(5), 1129-1134. doi:10.1038/oby.2008.35
Bayer, R. (2008). Stigma and the ethics of public health: not can we but should we. Soc Sci Med, 67(3), 463-472. doi:10.1016/j.socscimed.2008.03.017
Flegal, K. M., Kruszon-Moran, D., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2016). Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA, 315(21), 2284-2291. doi:10.1001/jama.2016.6458
Obesity and Overweight Fact Sheet. (2016). Retrieved from: http://www.who.int/mediacentre/factsheets/fs311/en/
Pearl, R. L., Wadden, T. A., Hopkins, C. M., Shaw, J. A., Hayes, M. R., Bakizada, Z. M., . . . Alamuddin, N. (2017). Association between weight bias internalization and metabolic syndrome among treatment-seeking individuals with obesity. Obesity (Silver Spring), 25(2), 317-322. doi:10.1002/oby.21716
Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev, 16(4), 319-326. doi:10.1111/obr.12266
VA, M. (2012). on behalf of the United States Preventative Services Task Force Screening for and management of obesity in Adults: preventative services task force recommendation. Ann Intern Med., 157, 1-32.
Wang, S. B., Lydecker, J. A., & Grilo, C. M. (2017). Rumination in Patients with Binge-Eating Disorder and Obesity: Associations with Eating-Disorder Psychopathology and Weight-bias Internalization. Eur Eat Disord Rev, 25(2), 98-103. doi:10.1002/erv.2499