Introduction
People with obesity experience discrimination from an early age that often stems from the stigma associated with the disease. The belief held that people with obesity are lazy, overindulgent, and lack self-control is incorrect and has the potential to negatively impact many aspects of a patient’s life. Therefore, the healthcare team and the larger medical community need to acknowledge the stigma associated with obesity and its implicit bias. Acknowledging this bias and applying methods to decrease the stigma will improve the care of patients with obesity.
People who are overweight and obese experience discrimination in several areas of life, including in the workplace, education, and healthcare.[1] This stigmatization occurs at a very early age, and with the rise in childhood obesity, the discrimination faced by people with obesity is beginning at a younger and younger age.[2] Over the past three decades, several studies have demonstrated that healthcare professionals are not outliers for those stigmatizing obesity. It may serve as a barrier to delivering appropriate and effective healthcare to those with obesity.[3]
A study out of France showed that most general practitioners know that being overweight and obese are life-threatening, and 79% agree that it falls under their scope of practice; however, 30% of providers had negative attitudes towards the obese patients in their care.[4] Several Australian, British, and Israeli studies of physicians demonstrated similar beliefs about people with obesity. Australian general practitioners reported that the most common frustration of treating obesity was the lack of patient motivation and compliance.[5]
In a British qualitative study, primary care physicians expressed beliefs that the condition is caused by unhealthy eating and lack of exercise, leaving the responsibility solely on the patient.[6] An Israeli study showed that 31% of family medicine physicians believed overweight people were lazier than patients who are not overweight.[7]
Issues of Concern
The effects of the stigmatization of obesity on the health of those with the disease have been well documented. Patients with obesity who have felt stigmatized have an increased risk of binge eating disorder, increased food consumption, decreased physical activity, and increased physiologic stress response.[8]
The stigma and, in turn, discrimination impairs the care provided to the patient and the frequency at which a patient seeks care. Being aware of the impact that the stigmatization of obesity has on patients' health may help reframe clinicians' attitudes toward patients with obesity, allowing them to focus less on the weight and more on the diseases with which it is associated. Along with other tools to destigmatize obesity, this reframing may provide better health care.
The stigmatization of obesity is a proven problem for people with obesity and providing optimal health care to those patients. The Joint International Consensus Statement for Ending Stigma of Obesity recognizes that individuals affected by overweight and obesity face a social stigma. The statement aims to condemn the use of language, attitudes, and policies that stigmatize overweight and obesity and pledge to support initiatives to prevent discrimination based on their weight in the workplace, education, and healthcare settings. Reducing stigmatization can be done through concrete policies and some not-so-tangible changes. There are validated tools, such as the antifat attitudes test (AFAT), that can help to assess a health care provider's attitude towards people with obesity. The goal of these tools is to bring awareness and discussion that will lead to positive change in the care of this patient population.[9]
In addition to the previously documented stigma around weight and its impact on the health of those with obesity, the effects of the COVID-19 pandemic present a new area for discussion. Early during the pandemic, the CDC identified obesity as a risk factor for severe COVID-19. The implication of this fact is that people with obesity are vulnerable to biology during the pandemic, and the weight stigma is already acknowledged as a barrier to equitable healthcare. While healthcare workers may acknowledge those with COVID-19 and obesity as being at high risk for severe infection, prompting swift evaluation and treatment, those efforts can only be practical if patients seek treatment. As discussed above, patients with increased BMI are more likely to underutilize or delay healthcare.[10]
This delay in care may negatively impact the individual and potentially have deleterious effects on public health when limiting the spread of cases is paramount. "The Quarantine-15 or the Covid-15" is a term d "scribing the weight gain thought "o inevitably come with the pandemic that has gained widespread popularity with little evidence to support it. What this term does, however, is emphasize body image, focusing on the importance of self-control when it comes to diet and exercise. Messages from recognized organizations have put the responsibility on the individual to reduce their risk of severe COVID-19 infection by losing weight. The UK National Health Service's Better Health initiative aims to reduService'srden to healthcare workers by "tackling obesity" so that it may "free up their" time to treat "her sick and vulnerable patients."[11] This message not only solidifies the stig" surrounding obesity but incorrectly simplifies a disease process that is far from being completely understood.
Strategies to Reduce Stigmatization
Zero Tolerance Policies
One strategy discussed by both the Joint International Consensus and other literature is a zero-tolerance policy for using stereotypical language, images, or humor that inaccurately depicts patients with overweight and obesity as being lazy or lacking self-discipline. Verbalizing a zero-tolerance policy to the health care team will help bring awareness to the issue and improve the culture around treating patients with overweight and obesity.
Perspective Exercises and Emotion Regulation
A potential strategy to reduce stigmatization of obesity is increasing provider empathy through perspective-taking exercises. Use obesity simulation suits (OSS) has been used in multiple clinical settings. The OSS has been used as a teaching tool during standardized patient (SP) encounters. SPs at a German medical school were asked to wear an OSS during an encounter. Students, teachers, and the SPs were then given questionnaires about the experience. The study concluded that the use of the OSS contributed to the realistic perception of a patient with obesity. The AFAT was used and showed that students demonstrated a more substantial antifat prejudice compared to teachers and SPs.[12]
Utilizing tools such as the OSS in educational, simulated settings gives learners more opportunities to discuss topics they may otherwise be uncomfortable with, such as weight. A small qualitative study had seven healthcare professionals wear an OSS for 2 hours in public. Surveys after the experience showed that attitudes were more empathetic and less judgmental towards those with obesity.[13]
A similarly designed study utilized a bariatric empathy suit. Nursing students wore the suit, and when surveyed after the experience to examine the nurses' attitudes towards obesity and obese patients, they reported more positive attitudes toward obese patients.[14] Another tactic to reduce obesity prejudice in medical education utilized standard lectures and dramatic readings. The study assigned medical students to two groups. One attended a one-hour lecture on the medical management of obesity, and the other group participated in a one-hour dramatic reading. Those in the dramatic reading group were found to have lower levels of explicit fat bias.[15]
The hope is for better care by increasing empathy and decreasing bias. Additionally, utilizing the questionnaires and surveys previously mentioned, it is crucial to identify when a bias is present and recognize how this may make providers feel. As discussed above, providers may harbor negative attitudes towards patients they feel to be difficult or noncompliant. A strategy implementing practice in emotion regulation may manage those feelings to deliver better care. This may be in the form of meditation or deep breathing prior to an encounter.
Obesity as a Disease
Another measure is ensuring proper education of the healthcare team on the contributors to patients' weight that are outside of the patient's control.[16] Weight results from the patient's genetics, socioeconomics, and psychology. Children who attributed their increased weight to external causes rather than solely responsible had higher self-esteem than those who believed the contrary. Educating providers on the epidemiology and pathophysiology of weight may allow the conversation between patient and provider to remain on science and literature topics, rather than blaming the patient.
Obesity as a Risk Factor
Discussing overweight and obesity as a risk factor for other diseases allows the patient and provider to focus on weight as being modifiable and treatable, taking the onus off the patient. The hope is this reframing will encourage patients to continue to seek medical care, even when there are setbacks, rather than avoid the doctor because of disappointment they may feel. Discussing the below conditions associated with overweight and obesity may be more appropriate topics for the visit rather than focusing on weight itself.
Body Mass Index (BMI) and central adiposity can predict type 2 diabetes mellitus (T2DM) development. Furthermore, the duration of increased body weight is a risk factor for future T2DM. Discussing the screening for T2DM and its management may serve as reasons for frequent follow-up rather than follow-up for weight alone. The risk of certain forms of cancer is increased in people with obesity, such as colorectal, prostate, and breast cancer. Discussing guideline-directed screening for these conditions may be another opportunity to address weight.
The effects that weight has on the cardiovascular system may be addressed regarding hypertension, stroke, and myocardial infarction, especially in those patients who present wanting to talk about risk reduction. Other conditions that may present an opening for a discussion on weight reduction are precisely those that impair one's quality of life, such as gout, polycystic ovarian syndrome, obstructive sleep apnea, and osteoarthritis, all of which are associated with overweight and obesity.[17] The above examples serve as a starting point for conversations between healthcare providers and patients that ultimately address weight without it being the focus of the discussion.
The Weight-Friendly Clinic Space
As mentioned above, clinicians and staff should be trained to avoid hurtful comments, jokes, or being otherwise disrespectful towards patients with obesity. Using "patient-first" language, such as "patient" with overweight or "obesity," is preferred over "obese patient." Encouraging terms such as "healthy weight," "overweight," and "body mass index" are preferred to terms such as morbidly obese, fat, and large size. Using motivational interviewing rather than providing unsolicited advice may serve as a strategy to implement patient-centered communication, which may be less threatening for patients.[18]
A study published in the journal of Obesity Surgery showed that while primary care providers were supportive in treating co-morbid conditions and attempts at dieting, many did not have appropriate equipment in their offices. Creating a positive office space includes having chairs, sofas, and exam tables that can handle high body weights without tipping or breaking. Having the following tools available in the clinic will also help the patient feel welcomed and avoid embarrassment: extra-large patient gowns, large blood pressure cuffs, extra-long needles to draw blood, large vaginal speculums, weight scales that can measure patients who weigh more than 400lbs and are preferably located in a private area.
Clinical Significance
There is a clear need to combat weight stigma, widespread throughout healthcare globally. An important barrier to treating high weight patients’ obesity is the belief that obesity is simply a consequence of personal decisions of lifestyle and behavior. Starting in 2012, major medical associations began to recognize obesity as a disease, changing the framework for recognition and management of this disease.[19][20]
Obesity is the consequence of genetic and environmental factors that trigger the complex pathophysiology of gut hormones and neuropeptides.[21] Clinicians must first accept obesity as a chronic disease, like hypertension, diabetes, and coronary artery disease, to treat it effectively.
Once a clinician accepts obesity as a chronic disease that must be treated, good patient-clinician communication and cooperation must develop a productive individualized management plan. Using “people-first” language is an important communication statement that prefers terms such as “unhealthy weight” rather than “fat” and “morbidly obese.” Using techniques of motivational interviewing and shared decision-making helps guide the patients towards healthier options and change. While patients may be focused on the cosmetic benefits of weight loss, it is important as a clinician to share the health benefits of lower body weight. As little as a 5% weight loss has significant health benefits, including reductions in most chronic diseases and all-cause mortality and improved quality of life metrics.[22][23] A weight-friendly office space makes the patient feel comfortable and welcome, encouraging them to return for follow-up.
Enhancing Healthcare Team Outcomes
The stigmatization of overweight and obesity negatively impacts the health care provided to patients. Because of this stigmatization, patients are reluctant to seek healthcare, decreasing healthcare visits. The healthcare team's conscious and subconscious biases contribute to the suboptimal care of this patient population. It is the responsibility of all healthcare team members to take whatever steps necessary to ensure the best quality of care is given to each patient. This is only achievable if each healthcare organization aims to end the stigma associated with weight. [Level 4]
The following steps outline ways for the healthcare team to decrease the stigma of obesity and improve the care provided to these patients.
- Step 1: Recognize that obesity is a chronic disease with diverse causes.
- Step 2: Create a weight-friendly space that is sensitive to the needs of people with obesity.
- Step 3: Use motivational interviewing and coaching techniques to set individualized and realistic goals in collaboration with the patient.
- Step 4: Individualize a treatment plan including lifestyle and behavior modification, pharmacotherapy, and referrals to nutrition, psychology, physical therapy, and bariatric surgery when necessary.
- Step 5: Implement zero-tolerance policies for negative language and practices that stigmatize patients with high body weight.
Destigmatizing Obesity and Overcoming Inherent Barriers to Obtain Improved Patient Engagement