Weight Stigma Remains a Barrier to Patient Care

Obesity has historically been regarded as a moral failing, and people with obesity describe being seen as deficient, lazy, and/or undeserving of respect, lacking willpower and self-discipline, and gluttonous. Negative judgments about obesity persist not only in society at large but also in healthcare settings, despite the American Medical Association’s declaration of obesity as a disease in 2src13.

These views contribute to weight bias (negative ideologies associated with obesity), which can lead to weight stigma (discriminatory acts and ideologies targeted toward individuals because of their weight and size).

Ironically, as obesity rates have increased, so have the rates of bias and stigmatization toward individuals of larger body sizes. Paradoxically, research suggested an association between weight stigma and increased food intake, eating without being hungry, emotional eating, binge eating, and long-term weight gain.

Weight bias and stigma in medicine remain a systemic barrier to healthcare, but the medical community is working to address the problem, and there are practical steps physicians can take to make their practices weight inclusive.

Impact of Weight Stigma

Weight stigma in healthcare settings is communicated to patients verbally and nonverbally. Patients reported being “fat shamed,” as described in a recent article in Fortune magazine.

“I always go in [to medical appointments] with my guard up,” one patient said in the article. That patient was told by an obstetrician/gynecologist that she was “too fat” and that the physician couldn’t treat people like her after the doctor tried and failed to insert an intrauterine device.

Nonverbal shaming can include looks of disgust or contempt, discussions that lack warmth, and a demonstrated unwillingness to touch the patient.

Weight discrimination can have serious consequences for patient health. Patients who have experienced weight bias in a medical setting are more likely to cancel appointments and avoid preventive care, which increases their medical risk. For example, women with obesity are less likely to be up-to-date on Pap smears and screening mammograms, often due to perceived weight stigma and lack of appropriately sized examination equipment.

“Weight stigma is a major concern that needs to be addressed in clinical practice and medical education,” Kathleen Robinson, MD, PhD, assistant professor of internal medicine-endocrinology and metabolism, Iowa Carver College of Medicine, Iowa City, Iowa, told Medscape Medical News.

Robinson and colleagues surveyed 395 individuals who were asked about their experiences related to weight stigma and healthcare. Of these, 73 provided narrative responses, some of which included experiences of being shamed.

“We found ongoing tension between the framing of weight as solely a result of personal responsibility vs weight as a multifactorial condition with an array of uncontrollable aspects,” Robinson reported.

“And we found healthcare providers made assumptions about patients based on body size, such as what they were eating or whether they were exercising, and didn’t necessary ask about or acknowledge the patient’s previous experiences with losing weight or what their actual lifestyle was,” she said. Advice was often “trite and dismissive,” rather than addressing the patient’s specific needs and history.

Weight stigma can result in physicians dismissing patients’ non–weight-related concerns, refusing care, or attributing health problems to obesity without considering other causes.

“If a patient with obesity presents with knee pain, for example, it’s all too often attributed to excess weight,” Kasuen Mauldin, PhD, RD, professor and director of the Dietetic Internship Program, San Jose State University, San Jose, California, told Medscape Medical News. “But there are many causes of knee pain, of which mechanical weight-related stress is only one. So, before you attribute the knee pain to the patient’s weight, ask yourself how you would handle the same complaint in someone of lower body weight and size and conduct the same workup.”

Evolution in Thinking

Stigmatizing attitudes in healthcare arise from a lack of education and the mistaken belief that weight is a primary indicator of health.

David Strain, MD, PhD, associate professor of cardiometabolic health, the University of Exeter Medical School in Exeter, England, said the “dogma” he learned in medical training was that obesity “is a pure function of eating too much and exercising too little, so the treatment was simply ‘eat less, move more.’”

He likened this advice to telling a person with lung cancer: “All you need to do is stop smoking.” Smoking is a risk factor for cancer, but the process is more complex. Smoking cessation is one of many interventions, and some nonsmokers also develop cancer, said Strain, who is chair of the British Medical Association’s Board of Science.

In this weight-centric approach to health, lower weight is regarded as healthier than higher weight, Amanda Velazquez, MD, director of Obesity Medicine, Cedars-Sinai Center for Weight Management and Metabolic Health, Los Angeles, told Medscape Medical News. And weight — typically measured as body mass index (BMI) — is generally viewed as being within the patient’s control.

However, obesity isn’t a single entity but a “complex, multicausal, chronic disease with variable clinical phenotypes defined by abnormal or excessive adiposity,” according to a 2src23 consensus statement of the American Association of Clinical Endocrinology (AACE).

The statement expands on the AACE’s previous efforts, including its adoption of a new diagnostic term for obesity: Adiposity-based chronic disease (ABCD). The association recommends complication-centric staging that facilitates personalized interventions. Therapy should include not only percent weight-loss goals but also alleviation of obesity-related complications, rather than weight loss per se. This approach is “consistent with the medical model for treatment of chronic disease and may help reduce weight stigma and weight bias.”

Additionally, the European Association for the Study of Obesity in 2src24 issued a new framework for the diagnosis, staging, and management of obesity in adults to better align with the recognition that it is an adiposity-based chronic disease. The document offers “pillars of treatment” that include behavioral modifications like physical activity, psychological therapy, obesity medication, and metabolic/bariatric procedures.

Like the AACE statement, it noted that BMI alone is insufficient for diagnosing obesity. Instead, it recommends an algorithm for diagnosing and staging obesity based on BMI, fat accumulation, and a clinical component including medical, functional, and mental domains.

A new metric — the body roundness index — has been proposed as a substitute for BMI. But opinions are mixed, and it needs to be validated in additional independent cohorts.

Tips for a Weight-Inclusive Practice

Addressing weight stigma in healthcare involves changing the clinical approach to patients with obesity.

Physicians should focus on helping patients set and work on behavioral goals rather than on losing weight, Mauldin said. “If you go to a financial planner, you won’t be told, ‘Get rich.’ Instead, you’ll be given concrete, practical steps, such as diversifying investments or saving money every month. Similarly, instead of focusing on weight, it’s better to focus on actionable items, such as food substitutions, filling the plate with vegetables, or increasing movement.”

Measuring and discussing a patient’s weight may not always be necessary at every appointment and may perpetuate the weight-centric model — especially when a person is presenting with an unrelated concern, Mauldin said. A weight-centric approach can contribute to the notion that obesity drives all illness, leading to potential neglect of other etiologies.

An alternative model is Health at Every Size, which supports “size acceptance to end weight discrimination and to lessen the cultural obsession with weight loss and thinness,” Velazquez said. It promotes “balanced eating, life-enhancing physical activity, and respect for the diversity of body shapes and sizes.”

Mauldin emphasized that a weight-inclusive approach means treating patients “holistically, in a nondiscriminatory way, in line with the patient’s internal cues, such as whether they’re hungry, and away from weight being just a number on the scale, which is a weight-centric approach.”

Physicians also can address weight stigma by making sure they have equipment that accommodates patients of all sizes.

Experts recommend ensuring that blood pressure cuffs and patient gowns are large enough for patients with overweight and obesity and opting for patient chairs without arms. “Couches or love seats might be a better choice,” Mauldin suggested.

Examination tables, scales, MRI machines, and similar equipment should be able to accommodate individuals of all sizes and weights. And don’t keep the scale in the hallway. “Being weighed in such a public place might be uncomfortable, not only for patients with larger bodies but for other patients, too,” Mauldin said.

Additional tips include having a split lavatory seat and properly mounted grab bars to help the patient get up more easily, floor-mounted toilets and well-supported toilet bowls, urine specimen collector cups with handles, extra-long phlebotomy needles and tourniquets, and a large vaginal speculum.

Broaching a Sensitive Topic

How physicians talk to patients about weight is important in reducing stigma and creating a safe space because weight is a very sensitive topic, Velazquez said.

Strain advises physicians to ask their patients for permission before broaching the subject of weight and to not use the term normal weight, which implies that obesity is abnormal. “Statistics from the US and the UK show that demographics have shifted, and enough people are overweight that it’s no longer abnormal for a person to be overweight. It’s inaccurate, as well as being stigmatizing.”

He also recommends avoiding scare tactics like telling patients they’ll have a heart attack or get diabetes. These statements are “inaccurate because a larger percentage of people living with obesity haven’t had a heart attack or haven’t developed diabetes compared to those who have.”

This negative messaging contributes to a sense of self-blame and shame in people with diabetes or cardiac issues, suggesting it’s “their fault that this happened and they could have made the problem disappear, as if by magic,” said Strain, co-author of a consensus statement on the importance of language in engagement between healthcare professionals and patients with obesity.

Mauldin advises “not commenting on people’s appearance, whether positive or negative. Train your staff not to even say, ‘Wow, you lost weight; you must be doing better,’ or ‘You look great.’”

The AACE’s consensus statement recommends a five-component approach — the “5As” — to inform engagement with patients with obesity surrounding weight-related concerns.

• ASK if you can discuss weight and the health impact of ABCD.
• ASSESS health status and complications.
• ADVISE on treatment options based on the severity of ABCD.
• AGREE on treatment plan and weight-loss goals.
• ASSIST in the continuous process of weight management, with reassessment of goals/treatment options.

Robinson advises “giving patients space to open up and talk about their history of weight before jumping in and offering advice.” If patients report having been stigmatized by previous healthcare providers, “it’s appropriate to express empathy.” She sometimes refers these patients to therapists or counselors who can help not only with past painful experiences but also with addressing internalized weight bias.

Fortunately, Robinson said, “The medical culture around weight is slowly changing, and educating is improving. Most physicians really want to do well by our patients, but we need to continue increasing education about how to support and treat them.”

Velazquez is on the advisory board for Intellihealth and for WeightWatchers and has previously been an advisor to Eli Lilly and Company and a consultant for Novo Nordisk. Strain is the somatic research lead for health for the UK Parliament and has previously served on the scientific advisory board for Novo Nordisk. Robinson and Mauldin disclosed no relevant financial relationships.

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).