People who are overweight and obese face many forms of bias, such as weight-based stereotypes, weight discrimination, and fat shaming. Weight-based bias, which is the negative evaluation of one group (in this case, obese patients) and its members relative to another, is alive and well in today’s health care system, reported Gregory Marler, PhD (c), DNP, ACNP-BC, FCCP, during a presentation at the Gerontological Advanced Practice Nurses Association (GAPNA) annual meeting, held September 27-30, 2023, in New Orleans, Louisiana.

An international consensus statement for ending the stigma of obesity, endorsed by over 90 organizations, was released in 2020. It states: “Tackling stigma is not only a matter of human rights and social justice, but also a way to advance prevention and treatment of these diseases.”¹ Examples of bias around obesity in medical professionals include the perception that obese patients are noncompliant, overindulgent, lazy, and unsuccessful, said Dr Marler. In one study of medical students, most students thought obesity was a disease (89%) or caused by behavioral issues (88%). However, 74% thought it resulted from ignorance, and 28% thought people with obesity were lazy.²

This bias negatively affects the approaches to and communication methods around working with patients living with obesity and could be addressed by taking a more holistic approach to the whole patient, rather than focusing narrowly on weight.²

What is the Cost of Obesity?

The medical cost of obesity in 2019 was estimated to be nearly $173 billion.^3,4 “In health care, we see medical spending skyrocketing because of special equipment that we have to use, disease complications that have to be managed, premature mortality, and decreased quality of life, to name a few,” said Dr Marler.

However, the cost of weight bias is also astronomical for patients, with effects going beyond those based on the physical effects of obesity alone. Dr Marler noted that overweight and obese patients often have delayed screening or check-ups, leading to worsening or exacerbation of medical conditions. “The psychological toll that it takes on our patients ― stress, anxiety, and depression is significant. We as health care providers have to be focused on weight bias very mindfully and how it impacts the patient.”

What is ABCD?

In 2016, the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) introduced the diagnostic term Adiposity-Based Chronic Disease (ABCD), which designated obesity as a chronic disease. It is not a diagnosis solely dependent on body mass index (BMI) scores, but rather focuses on “a complications-centric approach that primarily determines therapeutic decisions and desired outcomes.” The intent is to promote overall health, standardize protocols around weight loss and management, and develop evidence-based strategies for optimized patient care, with the goal of improving both individual and population health over time.⁵

Gregory Marler, PhD (c), DNP, ACNP-BC, FCCP

The introduction of this diagnosis “frames the condition of talking about worsening clinical presentations in a context of, yes, BMI, but also those other components. It puts BMI within the context of other disease processes that are going on,” explained Dr Marler. “Historically, we’ve used weight and specifically BMI as the marker of health. Weight is evaluated the minute we’re born, and that assessment goes all the way through the time that our lives end. We follow trends, we fixate on our weight. Whether we are conscious of it or not, weight impacts every aspect of our lives. It can become deeply personal, and internalized.”

Dr Marler further advised that researchers and clinicians “need to get away from using solely BMI…there’s still a lot of ongoing research in that area but there’s not a firm second choice, something that takes into account the whole person. And that’s what the ABCD nomenclature is advocating. That we take in not only the BMI component but the other components of the patient’s health, and contextualize that.”

What are Weight Biases and Weight-Based Stereotypes?

There is an interconnectivity between bias, stereotypes, and discrimination that affects communication and interaction between patients and health professionals.⁶

Bias is the negative evaluation of one group and its members relative to another.⁷
Stereotypes are the generalizations that individuals, in this case, overweight or obese, are lazy, gluttonous, lacking in self-discipline, and unmotivated to improve their health and that they are non-compliant with medical treatment and personally to blame for their higher weight.⁶

Dr Marler offered this example: “We teach students how to focus on patient-centered care. But that work is often negated “because health care providers tell jokes or say derogatory comments [about a patient’s weight].” These comments are sometimes made in front of the patient. “But because [the patient] is intubated or sedated ‘it doesn’t really matter, it’s all for fun’― but it does matter because it creates an air of acceptance, an environment of normalcy.”

How Can Health Care Professionals Manage and Mitigate Bias?

Knowledge is a key factor in identifying and mitigating weight bias, Dr Marler believes. “We have to recognize when we see or when we experience weight bias. We need to keep emphasizing the topic. If we’re not talking about it, if we’re not presenting it on a regular basis at conferences, we tend to forget about it.” Choosing a patient-centered communication style reframes the context of patients’ interactions with medical communication around the patients’ concerns, questions, and preferences, Dr Marler said.⁸

“The upshot of the paradigm shift from the Endocrine Society is really that this is a different way to communicate not only to our patients but about our patients,” he said. The paradigm shift allows clinicians to think about identifying obesity in clinical terms, like stages, providing more context of clinical severity. “We think about weight stigma as general stigma, but it is an internalized bias that impairs not only quality of life, but also [increases] psychosocial disorders, and decreases therapeutic interactions and effectiveness,” Dr. Marler said.

Dr. Marler presented 2 resources to help providers address weight bias in themselves and their practices:

The Rudd Center for Food Policy and Health at the University of Connecticut provides online educational resources for health care providers to reduce weight bias and improve patient care.
The Harvard University Office for Equity, Diversity, Inclusion, and Belonging partnered with the non-profit organization Project Implicit to create a series of free tests for implicit bias.

A comment from the audience provided some real-world context for recognizing weight bias and treating obesity as a chronic disease. In talking with some of her hospital providers regarding bariatric surgeries for obese patients, she reported that their position was that even after surgery, “patients were just going to gain the weight back.” The advanced practice nurse pointed out that they would not make the same comments about heart failure patients or someone with chronic obstructive pulmonary disease (COPD). “We don’t withhold prednisone from someone who has COPD exacerbation. So why are we advancing that mentality for a weight case? By relating weight as a chronic condition, and how we care for other chronic conditions, then we [can eliminate] that stigma.”

Visit Clinical Advisor’s meetings section for more coverage of GAPNA 2023

Source

Marler G. Weight bias in the acute care setting: recognition and mitigation. Presentation given at: GAPNA 2023; September 27-30, 2023; New Orleans, LA.

References

1. Rubino F, Puhl RM, Cummings DE, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020;26(4):485-497. doi:10.1038/s41591-020-0803-x

2. Geller G, Watkins PA. Addressing medical students’ negative bias toward patients with obesity through ethics education. AMA J Ethics. 2018;20(10):E948-E959. doi:10.1001/amajethics.2018.948

3. CDC. Obesity is a common, serious, and costly disease. Centers for Disease Control and Prevention. Published July 20, 2022. Accessed October 6, 2023. https://www.cdc.gov/obesity/data/adult.html

4. Ward ZJ, Bleich SN, Long MW, Gortmaker SL. Association of body mass index with health care expenditures in the United States by age and sex. Plos One. 2021;16(3):e0247307. doi:10.1371/journal.pone.0247307

5. Mechanick JI, Hurley DL, Garvey WT. Adiposity-based chronic disease as a new diagnostic term: the American Association of Clinical Endocrinologists and American College of Endocrinology position statement. Endocr Pract. 2017;23(3):372-378. doi:10.4158/EP161688.PS

6. Weight Bias & Stigma. UConn Rudd Center for Food Policy and Health. Accessed October 6, 2023. https://uconnruddcenter.org/research/weight-bias-stigma/

7. Nadolsky K, Addison B, Agarwal M, et al. American Association of Clinical Endocrinology consensus statement: addressing stigma and bias in the diagnosis and management of patients with obesity/adiposity-based chronic disease and assessing bias and stigmatization as determinants of disease severity. Endocr Pract. 2023;29(6):417-427. doi:10.1016/j.eprac.2023.03.272

8. Hashim MJ. Patient-centered communication: basic skills. Am Fam Physician. 2017;95(1):29-34.

This article originally appeared on Clinical Advisor

Recognizing and Countering Weight Bias in Medicine