An important clinical concern for all health-care professionals
It’s often called the last socially acceptable bias.
People with obesity face criticism and discrimination from strangers, educators, employers and media, even family and friends. Often, the critics will defend their words, saying it only comes from a place of concern and is meant with the best of intentions.
Similar scenarios are often played out in doctors’ offices. Significantly, however, researchers who study the effects of weight bias say criticism from a doctor can carry a particular sting for patients with obesity.
“Stigma from a doctor can be so humiliating, shaming, or anxiety-provoking that people will avoid medical care in order to avoid repeating these negative experiences — even at the expense of their own health,” said Dr. Rebecca Puhl (PhD), deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut’s School of Medicine.
What is particularly concerning to Dr. Puhl, a leading researcher on weight bias, are the studies that suggest weight bias in the health-care setting contributes to reduced health-care utilization among patients with obesity, especially for women. She says compared to women of lower body weight, women with obesity are more likely to cancel and delay appointments, and are less likely to seek routine prevention health services, such as cancer screenings.
They are also less likely to experience continuity of care, with one study finding the odds of doctor shopping increased by 19 percent for patients with overweight and 37 percent for patients with obesity, as compared with patients with lower weight. The study also suggested patients with obesity may be much more likely than thinner patients to use the ER to address medical issues that likely could have been resolved in the primary care office.
Dr. Puhl, says bias can play out in a medical encounter in different ways.
“There is some evidence that doctors tend to spend less time in appointments and provide less education about health with patients who have obesity compared to thinner patients,” she said. “Studies have also found some doctors express less desire to help patients with higher weight and have less respect for patients with higher BMIs. All of these findings have implications for patient-provider relationships, and quality of patient care.”
This can be particularly concerning during the COVID-19 pandemic. Dr. Puhl said that because of anticipated weight stigma, patients may be reluctant or hesitant to seek care even if they’re experiencing COVID-related symptoms or risk factors.
“Compared to women of lower body weight, women with obesity are more likely to cancel and delay appointments, and are less likely to seek routine prevention health services, such as cancer screenings.”
The recent Canadian Adult Obesity Clinical Practice Guidelines defines obesity as a chronic disease characterized by excess or abnormal body fat that impairs health. At the population level, obesity is monitored using a simple anthropometric measure called the Body Mass Index (Kg/m2). Based on existing population surveillance studies, the prevalence of obesity in Canada increased significantly over the past three decades. According to the 2015 Canadian Health Measures Survey, 30 percent — or more than one in three adults — in Canada has a BMI over 30 Kg/m2, which meets the population-level screening criteria for obesity and may require medical support if clinically diagnosed with having health impairments associated with their body fat or weight.
Stereotype
Weight bias has long been ingrained in the fabric of society. So, it is of little surprise that health-care professionals bring their own implicit and explicit weight bias into their interactions with patients.
Dr. Puhl says studies have demonstrated health-care professionals and medical trainees can stereotype patients with obesity as lazy, undisciplined and non-compliant with treatment. Some adults with obesity — especially women — say doctors are one of the most frequent sources of weight bias they encounter in their lives.
And this bias does not just manifest itself in personal interactions.
Patients with obesity experience weight stigma every time they are given blood pressure cuffs that are too small, provided gowns that don’t cover them properly, get on examination tables that are too narrow or are forced to stand because waiting room chairs can’t accommodate them. Patients with obesity see all of these events as expressions of social rejection and exclusion.
Dr. Ximena Ramos Salas (PhD), Director of Research & Policy at Obesity Canada, agrees that while obesity can present health issues for patients, weight bias poses its own share of harms. “When a patient with obesity walks into a doctor’s office, assumptions are immediately made about the patient’s health and behaviours. If the patient wants to discuss a concerning medical issue unrelated to their obesity, the doctor is just as likely to dismiss it as a consequence of carrying extra weight.”
She cites the case of Ellen Maud Bennett of Victoria, B.C. Ms. Bennett died in May 2018, just days after being diagnosed with inoperable cancer. In her obituary, she included the following:
A final message Ellen wanted to share was about the fat shaming she endured from the medical profession. Over the past few years of feeling unwell, she sought out medical intervention and no one offered any support or suggestions beyond weight loss. Ellen’s dying wish was that women of size make her death matter by advocating strongly for their health and not accepting that fat is the only relevant health issue.
The issue is so concerning to some health-care professionals that a full chapter on the consequences of weight bias and stigma was included in the recent Canadian guideline on the management of adult obesity. Read more about the Canadian guideline in our article, “Obesity Guideline Addresses Root Drivers.” “This is the first time that weight bias, stigma and discrimination have been included in Canadian clinical practice guideline for obesity, in recognition of emerging and compelling evidence that they represent a significant challenge to practice and policy,” said the authors, which included physicians, researchers, family doctors, mental health experts and people with lived experience.
Despite growing evidence that obesity is a serious chronic disease, write the guideline authors, it is not effectively managed within our current health system. “In general, health-care professionals are poorly prepared to treat obesity,” write the authors. None of the anti-obesity medications available in Canada is listed as a benefit on any provincial or territorial formulary, and none is covered under any provincial public drug benefit or pharmacare program. Wait times for bariatric surgery in Canada are the longest of any surgically treatable condition. Although access to bariatric surgery has increased in some parts of Canada, it is still limited in most provinces and nonexistent in the three territories. Patients referred to bariatric surgery can wait as long as eight years before meeting a specialist or receiving the surgery.
The authors note that society’s continuing narrative of obesity as a self-inflicted condition affects the type of interventions and approaches that are implemented by governments or covered by health benefit plans. Obesity is not officially recognized as a chronic disease by the federal, provincial and territorial, or municipal governments, despite declarations by the Canadian Medical Association, American Medical Association and World Health Organization.
“There are substantial barriers affecting access to obesity care in Canada, including a profound lack of interdisciplinary obesity management programs, a lack of adequate access to health-care providers with expertise in obesity, long wait times for referrals and surgery, and the high costs of some treatments,” state the authors.
Internalized Stigma
Sandra Elia yo-yo dieted for most of her 20s. She would lose a little, gain those pounds back and then some more. “A surefire way for me to gain weight was to go on a diet,” she said. She recognized her doctor was frustrated with her inability to lose weight, but she says it could not begin to compare with the anger she felt with herself.
“My doctor would say, ‘Listen, it’s just a straightforward formula of calories in, calories out.’ And I would feel so stupid because it did seem simple. So why could I not do it? The shame of it all kept me away from all doctors’ appointments for years,” remembers Ms. Elia.
She experienced depression, anxiety, low self-esteem and poor body image. “I felt like I was a loser, I felt broken.” She also engaged in binge eating and avoided physical activity. As a result, her obesity continued to progress.
It is a cycle that Dr. Puhl describes as all too common.
Dr. Puhl said studies have found that weight stigma predicts increased weight gain and obesity over time. “Shaming and stigmatizing people about their weight does not motivate weight loss; it contributes to weight gain. So, there are many reasons why this issue needs to be on the radar, and needs to be adequately addressed, in clinical management of obesity. Weight stigma itself, independent of obesity, is a public health issue.”
“I felt like I was a loser, I felt broken.”
The real culprit, said Dr. Puhl, is a lack of understanding of the complex and multifactorial nature of obesity. “It involves so many factors outside of personal control. I find it helpful to reframe and talk about body weight/obesity as a complex puzzle, where personal behaviour is certainly one puzzle piece. But it’s only one piece, and if we only focus on that single puzzle piece and ignore the other pieces — such as the environment, biology, genetics, etc. — then the puzzle will never be completed or solved. The bottom line is regardless of what you attribute the causes of obesity to, people who have obesity deserve to be treated with dignity and respect.”
Dr. Ramos Salas said she was pleased the recent clinical guideline called upon physicians to create a safe, judgment-free environment where all patients can receive quality health care. “Demonstrating empathy for patients with obesity goes a very long way in making the patients feel heard and respected,” she said.
She suggests that, as a first step in connecting with their patients, physicians reflect on their personal attitudes about body weight. Even the most enlightened, intelligent, and well-intentioned physicians, she said, may harbour bias and express it in subtle ways that they are unaware of. She encourages physicians to make use of the many resources developed specifically for health-care professionals available on Obesity Canada’s website.
The efforts undertaken by one physician to be more mindful of her weight bias was recently shared by a publication produced by the American College of Cardiology. The physician, an orthopedic surgeon, reflected on her attitudes towards her patients with obesity and recognized within herself a strong weight bias. She then developed a strategy to mitigate its effects on her patients.
Before entering an examining room, the surgeon would review the patient’s body mass index. If the patient had obesity, it would turn on a “yellow light,”, so her brain did not get “hijacked” into a decision that may be based on that bias rather than the patient’s condition.
“Weight stigma itself, independent of obesity, is a public health issue”
Dr. Puhl says the growing awareness about the bias and its detrimental effects give her reason to be optimistic. In March 2020, she noted more than 100 medical and scientific organizations around the world signed a consensus statement recognizing weight bias as a significant problem causing significant harm, which needs to be addressed in multiple aspects of our society, including the health care setting.
“This is really the first time the international medical community is speaking with one voice to condemn weight bias, and this is an important step in taking action to address this problem,” she said.
Over the years, Ms. Elia has taken her own action. She is now a food addiction counsellor and is managing her disease well. She says a better understanding of the science of obesity as a chronic disease has led her to be kinder to herself. “When I walk into a room and see cookies, I know my brain lights up in a more intense way than someone who’s been weight-stable their whole life.”
She credits her health improvements to cognitive behavioural therapy, with a specific focus on the stressors that would trigger her to overeat. Two life events saw her regain weight, but she was eventually able to get back on course. “I recognize that it is a lifelong disease. I am never going to be a perfect eater, that is not in the cards. But I understand the importance of connection, of sleep, of support and I am making it a priority to take care of myself.”
