Obesity Stigma and Bias

Abstract

Overweight and obesity are escalating in epidemic proportions in the United States. Individuals with overweight and obesity are often reluctant to seek medical help, not only for weight reduction but also for any health issue because of perceived provider discrimination. Providers who are biased against individuals with obesity can hinder our nation’s effort to effectively fight the obesity epidemic. By addressing weight bias in the provider setting, individuals affected by obesity may be more likely to engage in a meaningful and productive discussion of weight. Providers need to be the go-to source for obesity-focused information on new and emerging treatments.

Overweight and obesity are escalating in epidemic proportions in the United States.¹ As the rates of overweight and obesity rise, weight discrimination in America has increased by 66% over the past decade and is equivocal to racial discrimination.^2,3 Perceived provider weight discrimination often causes individuals with overweight and obesity to be reluctant to seek medical help, not only for weight reduction but also for any health-related problems.^4–6 Providers who are biased against individuals with obesity can hinder our nation’s effort to effectively fight the obesity epidemic.^7,8 Bias against those with obesity appears to be socially acceptable and is reinforced by the media.^8–10

In order to effectively facilitate change in weight bias, providers must identify and overcome their own implicit and explicit weight-based biases. Providers are regarded as the go-to sources for obesity-focused information on new and emerging treatments; they also have the responsibility to communicate to patients and the public that obesity is a disease that needs to be addressed in a respectful and compassionate manner. The purpose of this article is to raise awareness of health provider weight bias and stigma and offer strategies that increase sensitivity and compassion to individuals with obesity in an effort to provide the best possible health care.

CONSEQUENCES OF WEIGHT BIAS

Experts suggest that preventing weight stigmatization and bias is essential to effective obesity treatment efforts.^7,8 Shaming individuals with obesity is not an effective tool to motivate them to lose weight because weight-based stigmatization can hamper weight loss outcomes among adults in weight loss programs.^11–13 A research study with women found that individuals who internalized negative weight stigma reported more episodes of binge eating and were less likely to diet.¹³ This finding contradicts the notion that weight stigma and bias encourage individuals to lose weight.¹³

MASS MEDIA AND THE PERPETUATION OF WEIGHT BIAS

Mass media has stigmatized obese individuals.¹⁴ A review of research over the past 15 years related to weight bias in media has reported that many media sources such as animated cartoons, movies, situational comedies, books, weight loss programming, news coverage, and YouTube videos have represented individuals who are overweight and obese in a stigmatizing manner.¹⁴

Mass media has often promoted weight stigma as socially acceptable.^8,10,14 A study that conducted a content analysis of news images found that the majority of images presented portray obese individuals in a negative manner.¹⁰ The media commonly represents individuals who are overweight and obese as headless figures who are inappropriately clothed and eating.¹⁰ A recent study found that positive media images of individuals with obesity had an affirmative impact on reducing weight-based stigmatizing perceptions held by the public.¹⁵

HEALTH CARE PROVIDER BIAS

Health providers need to be aware of the fact that most individuals who struggle with overweight and obesity have often attempted many measures to lose weight.¹⁶ Obesity is caused by many influences such as genetics and environmental factors.¹⁷ Lifestyle changes can be especially difficult in certain environments.

People with obesity often face ongoing weight discrimination and bullying.¹⁴ Research has identified that obesity bias is prevalent in health care settings.¹⁸

A recent study surveyed 358 nurse practitioners (NPs) at a national conference regarding their attitudes and beliefs regarding individuals with obesity. The study found that NPs reported negative beliefs and attitudes toward patients who are overweight and obese.¹⁹ The participants of this study perceived individuals with overweight or obesity to be not as good or successful as others, not fit for marriage, messy, and not as healthy.¹⁹ A British study of 398 nurses found that only 2.3% had provided information to a group related to an intervention for managing obesity.²⁰ This study identified that very few respondents indicated they had training in obesity management and reported they spent 5% of their clinical time in obesity management. This study also found that the nurses’ own body mass index (BMI) was statistically related to their views of obesity; the higher the nurses’ BMI, the lower their negative perception of obesity.²⁰

A survey by Jay et al²¹ with 250 physicians found that 40% reported a negative reaction toward a patient who was obese. This study found that 56% of providers felt they were qualified to treat obesity, and 46% felt they were successful in treating patients with obesity.²¹ The majority of the physicians reported they felt frustrated when treating patients with obesity.²¹ A study with 255 physicians found that those who had a high percentage of patients with extreme obesity were less likely to recommend weight loss medication or bariatric surgery to manage weight.²² However, physicians with greater knowledge in obesity management were more likely to treat patients with weight loss medications or bariatric surgery.²² This study also identified that many physicians reported difficulty with performing physical examinations such as palpating abdominal masses or completing pelvic and breast examinations because of extreme obesity in patients.²²

More than 50% of primary care physicians (n = 620) regarded patients with obesity as “awkward, unattractive, ugly, and non-compliant.”²³ The participants did agree that if their time spent with obesity treatment was compensated properly they would spend additional time on weight management.²³ Research has found that primary care physicians (n = 122) spend less time with obese patients compared with thin patients (mean = 31.13 minutes with normal-weight patients, mean = 25.00 minutes with patients who were moderately overweight, and mean = 22.14 minutes with patients who were extremely overweight).²⁴

It is important for health providers to be knowledgeable about how to provide care that is free of obesity bias and stigma. Extra care must be taken to prepare providers to effectively perform a physical examination on individuals with obesity. Obesity is one of the most prevalent diseases in America, and it is important that providers are competent with all aspects of obesity treatment and management.

PATIENTS’ PERCEPTION OF BIASED CARE

Patients perceive obesity bias. Participants in a study were provided a list of 20 possible sources of obesity bias and asked to rank them in order of frequency. Family members were at the top of the list, and physicians were rated the second most common source of obesity bias.¹² This study did not observe a difference between sexes in relation to the forms or frequency of obesity stigma that they experience. This study also identified that 53% of women with obesity received inappropriate comments from physicians regarding their weight.¹² Younger women with obesity reported more stigma than individuals who were older.¹² Participants from this study also reported that they experienced weight stigma from nurses (46%), dieticians (37%), and mental health professionals (21%).¹²

Eating more was identified as a common coping strategy used to deal with obesity stigma.¹² The majority (79%) of the participants reported using this strategy on more than one occasion to cope; however, 10% reported that they have not used this strategy for coping. Seventy-five percent of participants reported refusal to diet as a coping style related to obesity stigma.¹²

WEIGHT BIAS IMPACTS THE USE OF HEALTH CARE SERVICES

Patients who experience obesity bias from providers may cancel or delay appointments as well as avoid preventative health care and screenings.⁴ One study surveyed 498 women who were overweight or obese regarding their perceived barriers to routine gynecologic cancer screenings.⁵ The women were asked, “Has your weight been a barrier to getting appropriate health care?” In response to this question, 52% responded yes. The percentage of women who reported they delayed seeking health care increased as the BMI increased. These women cited the following reasons for delaying treatment for care: providers expressed negative attitudes, discourteous treatment, weighing procedures that caused embarrassment, uninvited weight loss advice, and examining tables/gowns/equipment too small to be functional.⁵

One study with 216 women found that delays and avoidance of preventive care were associated with their BMI.⁶ The women participants in this study reported that if they gained weight since their last office visit, they avoided making future appointments with their health care provider. They also wanted to avoid being weighed on the provider’s office scale, knowing they would be told by their provider that they needed to lose weight.⁶

Regardless of the reason individuals with overweight and obesity avoid preventive health measures, weight bias and miscommunication between patients with obesity and providers lead to a vicious cycle of bias and worsening obesity and health. Obesity creates health consequences, resulting in an increased need for medical visits. However, bias in health care can lead to negative feelings, avoidance of health care providers, and unhealthy behaviors.^8,11

RESEARCH RELATED TO REDUCING OBESITY BIAS

Many more studies reporting obesity bias have been published than studies focused on obesity bias reduction.⁸ More research is needed in the area of identifying measures and strategies to reduce obesity bias.

One study focused on identifying strategies to reduce weight bias with college students. This study identified that students’ perceptions of individuals with obesity are influenced by the beliefs held by their valued reference group of peers.²⁵ This study also found when participants were provided with information that obesity was a complex disease with multiple causes, such as genetic, biological, and noncontrollable aspects, their negative attitudes decreased.²⁵ Conversely, when the students were given information that obesity is attributed to controllable causes, negative attitudes increased.²⁵

Online educational interventions may be a promising intervention for reducing obesity bias. One study with 258 participants evaluated web-based intervention as a means to change attitudes related to obesity with student teachers and schoolteachers.²⁶ The content of this web-based instruction included the following topics: 1) controversy regarding the etiology of obesity; 2) treatment and health risks associated with obesity; 3) the physical, psychological, and social effects of the obesity stigma; 4) sociocultural pressures to obtain thinness among children and adolescents and the risks associated with weight loss efforts; 5) strategies to help children deal with the social stigma of obesity; and 6) intervention techniques to promote bias-free behavior in the school setting. The participants in the intervention group had improved attitude changes related to obesity. This study also evaluated the effect of the intervention related to the credibility and body size of the online course lecturer. It is interesting to note that participants reported a higher level of improved attitudes when the credible presenter was overweight versus not overweight.²⁶ Online educational interventions may be a promising avenue for reducing obesity bias with providers and students entering all health professions.

To reduce obesity bias, multiple strategies are needed. Providers can serve as a positive influential voice to reduce obesity bias with their interaction and communication with the public, peers, and students. Providers can also play a pivotal role in conveying that obesity is a disease with a complex etiology. Providers can impart to the next generation of providers the importance of eradicating obesity stigma and providing the best possible care to individuals with obesity.

RESOURCES AND STRATEGIES TO REDUCE PROVIDER OBESITY BIAS

Many resources are available to help providers overcome obesity bias including free online resources and online classes that address obesity bias and offer tips to help providers reduce it. There are also specific supportive strategies to lower obesity bias that can be used in the clinical setting.

THE OBESITY SOCIETY

The Obesity Society is an excellent resource for helpful information related to providing the best possible care for individuals who are overweight and obese. They also have helpful recommendations to help providers overcome obesity bias.

How Can Weight Stigma Be Reduced?

Some specific strategies for health professionals are as follows (taken directly from the Obesity Society²⁷:

1. Consider that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity.

2. Recognize the complex etiology of obesity, and communicate this to colleagues and patients to avoid stereotypes that obesity is attributable to personal willpower.

3. Explore all causes of presenting problems, not just weight.

4. Recognize that many patients have tried to lose weight repeatedly.

5. Emphasize behavior changes rather than just the number on the scale.

6. Offer concrete advice (eg, start an exercise program, eat at home, etc, rather than simply saying, “You need to lose weight”).

7. Acknowledge the difficulty of lifestyle changes.

8. Recognize that small weight losses can result in significant health gains.

9. Create a supportive health care environment with large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and friendly patient reading material.

How to Identify One’s Own Bias?

It is also useful to identify one’s own bias. Asking the following questions can be helpful in this regard (taken directly from the Obesity Society²⁷):

1. Do I make assumptions based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?

2. Am I comfortable working with people of all shapes and sizes?

3. Do I give appropriate feedback to encourage healthful behavior change?

4. Am I sensitive to the needs and concerns of obese individuals?

5. Do I treat the individual or only the condition?

ONLINE RESOURCES AND CLASSES FOR PROVIDERS TO REDUCE OBESITY BIAS: RUDD CENTER

The Rudd Center from Yale University, New Haven, CT, has exceptional resources to help providers overcome obesity bias. The Rudd Center also has an 8-module tool kit self-assessment course to help prevent obesity bias with providers. This tool kit would be an excellent addition to NP courses that focus on obesity treatment and management. This tool kit also provides continuing medical education hours. This site has excellent self-assessment tools and guidelines related to the following 8 modules: increasing self-awareness of weight bias, improving provider-patient interactions, overview of weight bias in health care settings, office environment strategies to reduce weight bias, weight bias resources for OBGYN providers, weight bias resources for pediatricians, weight bias resources for bariatric surgery clinics, and resources for overweight patients. See the Table for website information.

Table.

Helpful Resources

The Obesity Action Coalition (OAC) The OAC is a patient advocacy organization focused on improving the lives of those with obesity. In addition to information and advocacy on weight bias, the OAC produces a wide variety of education on obesity and advocates for access to care.	www.obesityaction.org Understanding Obesity Stigma Brochure - http://www.obesityaction.org/weight-bias-and-stigma/understanding-obesity-stigma-brochure People-First Language for Obesity - http://www.obesityaction.org/weight-bias-and-stigma/people-first-language-for-obesity Guidelines for Media Portrayals of Individuals Affected by Obesity - http://www.obesityaction.org/weight-bias-and-stigma/media-guidelines-for-obesity Weight Bias in the Workplace Guide - http://www.obesityaction.org/weight-bias-and-stigma/weight-bias-guides/weight-bias-in-the-workplace-information-for-employers Weight Bias in Healthcare – A Guide for Healthcare Providers Working with Individuals Affected by Obesity - http://www.obesityaction.org/weight-bias-and-stigma/weight-bias-guides/weight-bias-in-healthcare-a-guide-for-healthcare-providers-working-with-individuals-affected-by-obesity Weight Bias Resource Articles: Shame Campaigns - Do They Work? Weight Bias: Does it Affect Men and Women Differently? Weight Bias and Discrimination: A Challenge for Healthcare Providers Combating Weight Bias and Working with Your Healthcare Provider “Fattertainment” – Obesity in the Media Weight Discrimination Understanding the Negative Stigma of Obesity and its Consequences
UConn Rudd Center website: The Rudd Center aims to stop the stigma through research, education, and advocacy. Tool kit modules to help providers or health care students prevent obesity bias. This center has a tool kit that consists of 8 education modules to help providers prevent weight bias: helping without harming in clinical practice. This tool kit would be an excellent resource for providers and would be helpful to include in nursing education curriculum. This site has assessment tools for providers. Rudd Policy Brief Presentations by Dr. Rebecca Puhl	http://www.uconnruddcenter.org/weight-bias-stigma Videos exposing weight bias Continuing medical education course for health care providers to help reduce obesity stigma in clinical settings Online Tool Kit “Preventing Weigh Bias Without Harming in Clinical Practice” Module 1: increasing self-awareness of weight bias. Module 2: improving provider-patient interactions Module 3: overview of weight bias in health care settings Module 4: office environment strategies to reduce weight bias Module 5: weight bias resources for OBGYN providers Module 6: weight bias resources for pediatricians Module 7: weight bias resources for bariatric surgery clinics Module 8: resources for overweight patients Weight Bias: A Social Justice Issue. Weight Discrimination and the Law Clinical Implications of Obesity Stigma Pediatric Obesity and Bullying: Implications for Patients, Providers and Clinical Practice Weight Stigma in the News Media and Public Health Efforts to Address Obesity
STOP Obesity Alliance – Why Weight Guide The Strategies to Overcome and Prevent (STOP) Obesity Alliance released a series of educational videos and website for health care providers as part of STOP’s continued efforts to improve communication with patients affected by obesity. The information is based on STOP’s Why Weight? A Guide to Discussing Obesity & Health With Your Patients, a unique tool designed to help providers build a safe and trusting environment with patients to facilitate open, productive conversations about weight. The materials provide guidance and suggestions on how to initiate conversations with adult patients about weight and health.	http://whyweightguide.org/

Specific Strategies to Help Providers Overcome Obesity Bias

Self-reflection

Providers need to incorporate strategies to help individuals who struggle with obesity by providing compassionate care that is free of bias. It is important that providers take time for self-reflection to identify if one has any personal biases and how to overcome these assumptions in order to provide the best possible care. An excellent way to help with self-reflection is by completing the first module, which includes questionnaires located on the Rudd Center website associated with Yale University (Table).

Supportive Communication and Language

It is important to use supportive communication and language. Emphasize achievable behavior goals rather than weight. Steer away from language that places blame. It is important for providers to choose their words wisely. The least stigmatizing/blaming terms recommended are weight, unhealthy weight, and high BMI.²⁵ The most stigmatizing/blaming words are fat and morbidly obese. The most motivating words are unhealthy weight and overweight. The least motivating words are fat, morbidly obese, and chubby.²⁵

It is recommended that before discussing weight with patients, consider the following language in discussions about weight (J. Nadglowski, Obesity Action Coalition, personal communication):

1. “Could we talk about your weight today?”

2. “How do you feel about your weight?”

3. “What words would you like to use when we talk about weight?”

People-first Language

For years, health care education has stressed the importance of not labeling individuals based on their disease. However, in practice, this people-first principal has not been applied to obesity. It is important to put people first and not to label them by their disease. For example, it is not appropriate to identify an individual as obese but instead identify the individual as having obesity. By labeling someone by their disease, it often dehumanizes the individual, which further contributes to weight bias. It is also important for publications and scholarly writing to reflect people-first language. An excellent resource to help providers with this method can be found in the Table. There are also specific suggestions that can help providers establish a supportive office environment.

Specific Suggestions to Creating a Supportive Provider Office Setting

Supportive Office Environments.

It is also important to create a supportive office environment. It is important that seating areas have wide, sturdy chairs without armrests with an appropriate distance between each chair. One study with providers identified that in their primary care offices, 61.8% of their waiting room chairs were armless.¹⁸ Providers from this study indicated that 53.6% of their offices had extra-large gowns.¹⁸ Gowns need to be large enough to accommodate all sizes of patients. The offices should contain appropriate nonoffensive reading materials. Bathrooms need to be properly equipped with hand rails that comfortably accommodate individuals of all sizes.

Weighing Procedures.

Providers must implement appropriate weighing procedures at the ambulatory care office. It is important that patients are weighed at a private location so that other individuals do not see the patient weighing in. Providers must record weight silently, with no comments or commentary. Facilities need to have scales that can weigh up to at least 500 pounds. A research study with providers reported that 41.7% of their offices have scales that record over 350 pounds.¹⁸ It is also important to have a height meter with the scale to accurately calculate a BMI. It is also recommended that providers ask the patients for permission to weigh them. Hospitals must be equipped with appropriate scales to accommodate all weights and ensure patients are weighed in a private area.

Necessary Equipment.

All health care facilities need to have extra-large adult arm and thigh blood pressure cuffs. Care must be taken to ensure that step stools are sturdy, and wide examination tables can safely accommodate all weights.

CONCLUSION

NPs can make a difference with the obesity epidemic by overcoming any personal obesity bias and discrimination. They can also lead the way by addressing obesity bias in their interactions with the public, peers, and patients. They can strive to become knowledgeable and comfortable with providing evidence-based obesity care that includes the best possible strategies and treatments to help individuals achieve a healthy weight.

The education of current and future health care providers needs to focus on raising awareness of attitudes and bias toward obesity as well as addressing the development of empathy for the patients’ struggles and experiences. Most individuals with excess weight have tried repeatedly to lose weight and many have had previous negative experiences with other health providers regarding their weight. Because of these reasons, there are many suggestions for creating a supportive environment for obese patients in medical settings. NPs need to ensure that offices are properly equipped and supportive for individuals who are overweight and obese.

Providers also need to be aware that bias exists so that educational activities can be integrated into training programs, professional development activities, and media campaigns to ensure all patients are treated with respect and dignity. This will help make certain that individuals with obesity are comfortable and feel supported when seeking medical care and will go a long way to foster a positive health care environment so that providers can have the opportunity to guide patients in effective weight treatment and management.

NPs are a vital force in health care in America. NPs can be change agents in the area of obesity bias. They can also strive to be experts in obesity management and care. Obesity is one of the most prevalent diseases in America and impacts many medical conditions. NPs can lead the way in providing non-biased, high-quality obesity management, treatment, and care. NP education needs to include formal preparation related to eliminating obesity bias and preparing the next generation of providers to excel in obesity management.

Obesity prevention and intervention are public health priorities to improve the overall health of our nation. Addressing and eliminating weight bias and stigmatization are vital first steps to ensuring that patients receive quality care and effective weight treatment and management. By becoming aware of one’s own biases, developing empathy for the experience of patients, and working to address the needs of patients with obesity, health care providers will make strides to make the US a healthier nation.