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  • Viewpoints

    Shame on us for shaming people with excess weight

    Bias against people with obesity means patients don’t get the medical attention they need. It’s time for medicine to stop stigmatizing excess weight and provide compassionate care to people of all sizes, one expert argues.

    Doctor in protective equipment talks to obese African-American mature lady holding black tablet

    Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

    I learned a painful lesson about obesity during my third year of medical residency.

    I was caring for Jacyln Williams*, a 45-year-old woman with severe obesity, at an outpatient internal medicine clinic in Columbia, South Carolina. I had treated her for three years already, carefully outlining healthy eating plans and physical activity regimens — yet she never lost more than five pounds. Part of me believed she just wasn’t trying hard enough.

    But a chance meeting quickly revealed — and changed — my unconscious weight bias.

    One day, I bumped into Williams at a local grocery. She was warm and friendly, exclaiming, “Dr. Stanford, it is so great to see you!” As I made some small talk, I found myself eyeing her grocery cart, surveying her choices. She noticed my visual assessment and announced, “See, Dr. Stanford, I have been doing exactly what you told me to do.” Indeed, her cart was the picture of healthy eating: a great blend of lean protein, whole grains, fruits, and vegetables. So, what was going wrong?

    Physicians and other health care professionals are among the greatest perpetrators of weight bias.

    I had failed to realize that treating obesity is hardly a matter of just getting patients to eat less and move more. A complex disease, obesity can be fueled by numerous factors, including one’s genes, environment, and the hormones that affect the desire to eat and amount of fat stored. In addition to lifestyle changes, treatments that help address obesity include medications, surgery, and cognitive behavioral therapy, which works to shift attitudes and actions.

    I’m certainly not the only provider who has made problematic assumptions about individuals with excess weight. In fact, physicians and other health care professionals are among the greatest perpetrators of weight bias. The problem has become so pervasive that patients have launched a campaign requesting that they be weighed only when necessary and not at every appointment.

    As providers, we cannot continue to allow excess weight to permeate how we judge the behaviors and worth of patients. Bias is not only disrespectful to our patients — it threatens their health and well-being.

    How weight bias harms patients

    Few providers are immune from bias — whether conscious or unconscious — against people who carry excess weight. A 2021 survey in the United States, Canada, and several other countries found that patients reporting bias from doctors ranged from 63% to 74%. A study of more than 4,700 medical students found 74% exhibited implicit weight bias, and 67% exhibited explicit bias.

    Frequently held stigmatizing notions about people with overweight or obesity include the belief that these individuals are lazy, noncompliant, or lacking in self-control. When these views come from trained medical professionals, they can be tremendously damaging to patients.

    Bias can cause problematic changes in eating, including binge eating and unhealthy attempts at weight control. Bias also leads to a physiological stress response that can have immediate and long-term health effects. Additionally, it often leads to such worrisome results as poorer treatment adherence, avoidance of follow-up care, delay in preventive health screenings, and less effective chronic disease self-management. And the emotional fallout from weight bias includes depression, anxiety, substance use, or low self-esteem — even suicidality.

    Stepping up to address weight bias

    Providers can — and should — take immediate steps to address weight bias in medicine.

    Take the Harvard Implicit Association Test for Weight.

    It takes only around 15 minutes to complete an implicit bias test. All of us have biases, but you won’t know if you have weight bias unless you assess yourself. Let’s identify it so we can fix it.

    Use people-first language for obesity.

    Language matters. Let’s not use stigmatizing language to describe a disease that is already heavily stigmatized in our society. In 2017, the American Medical Association took the bold stance of promoting people-first language for obesity, urging the use of terms like “unhealthy weight” and the elimination of such stigmatizing terms as “fat,” “obese,” or “morbidly obese.”

    Using patient-centered communication also is one of 10 core provider obesity-related competencies created in 2017 by the Strategies to Overcome and Prevent (STOP) Obesity Alliance, of which the AAMC is a member.

    Remember that obesity is a disease. Just like we say “a patient with asthma,” we should say “a patient with obesity” — or we risk reducing a person to their condition. Now consider “morbid,” which implies that death looms. Although persons with obesity have lower life expectancy rates, people with cancer and heart disease do as well. But we don’t call it “morbid cancer” or “morbid heart disease.”

    Learn to treat people with obesity with respect in the clinical setting.

    The Weight Can’t Wait guide from the STOP Alliance is a great tool for understanding how to approach clinical encounters with patients who have obesity. This document — which has been endorsed by 10 major health profession organizations — is a short, accessible, practical guide to effective obesity care.

    Among other guidance, it advises engaging patients who have obesity with respect. For example, a practitioner might say the following during an appointment: “Is now a good time for us to discuss how your weight and health may be affecting each other and how we can work together on it?” It also notes that respect for patients includes ensuring that exam rooms, gowns, chairs, and other office items accommodate people of all sizes.

    Get politically active.

    The Treat and Reduce Obesity Act (TROA) — which would help patients with obesity access appropriate care for their disease — has yet to be enacted even though it was first introduced in Congress in 2013. Many obesity medicine physicians are urging passage of this crucial legislation.

    Two key aspects of the act focus on obesity-related Medicare coverage. First, TROA seeks to provide anti-obesity medication to those who would benefit from it. Currently, Medicare Part D does not allow coverage of these FDA-approved treatments. Why is that? A significant part of the answer lies in implicit biases that reflect the belief that individuals with overweight and obesity somehow don’t deserve pharmacotherapy.

    TROA also seeks to ensure that all patients with obesity receive lifestyle care, such as a consultation with a dietitian. Currently, Medicare doesn’t cover such visits for patients with obesity — but it does cover them for patients with Type 2 diabetes. This is a travesty. People should not have to wait until they develop Type 2 diabetes to receive the dietary guidance they need.

    Improve medical education.

    Medical schools and residencies need to provide in-depth, high-quality education about obesity. Ignorance fuels bias. We need physicians to fully comprehend that obesity is a disease and to understand its pathophysiology, the social determinants related to obesity, and appropriate treatment options, including medications. And they need to know how to counsel patients without shaming them.

    A good foundation for obesity curricula would be to cover the core competencies created by the Obesity Medicine Education Collaboration in 2016, which include communication skills and system-based practice related to obesity. In addition, educators need to assess trainees’ learning to monitor their growth in such areas as empathy and key questions to consider when counseling patients with obesity.

    If we don’t take such steps, we risk perpetuating the weight bias that has plagued the medical community for far too long.

    I don’t know how Williams fared in the long run because I moved out of the area to complete my obesity medicine fellowship. Still, I feel quite sure she never got the best evidence-based care for her disease given that her South Carolina Medicaid coverage was so limited. I hope, though, that the provider who took over her treatment had a better appreciation of the many nuances of this difficult disease than I did when I was beginning my career — and that all future physicians gain the understanding necessary to provide respectful, appropriate obesity care.

    *Not her real name