Improving care for patients with obesity by recognizing weight bias

Ask yourself what you think when you see a person with obesity: healthy, active, motivated? For many people these are not the words that come to mind.

Despite societal progress toward reducing discrimination on the basis of race, gender, disability, and sexual preference, bias related to weight remains common, unchecked, and in many cases, institutionalized. Many people continue to hold feelings of disapproval toward people with obesity, leading to unfair judgment and discrimination. Weight bias is largely based on inaccurate assumptions. The most common and important assumption is that obesity is a completely modifiable condition that an individual can voluntarily control by exercising more and eating less. Despite the lack of any evidence, this belief is prevalent even within the medical profession.

Obesity is an extremely complex condition resulting from many factors. Genetics, epigenetics, adverse childhood experiences, and cultural, environmental, emotional, and physiological determinants all contribute to weight. Attempting to alter only diet and exercise rarely results in sustainable weight reduction.[1]

As physicians, our biases can negatively influence the treatment of patients with obesity.[2] It is important to recognize that although obesity can be associated with a number of medical conditions, many people with obesity are physically fit and metabolically healthy.[3]

We often assume that a person with obesity is inactive, eats poorly, or does not care about their health. Many also assume that all people with obesity want to lose weight and need to be encouraged to do so regularly. Further, physicians often incorrectly attribute patients’ health concerns to their weight, implying that their problems would be resolved if they lost weight, despite many weight-associated conditions also being common in normal-weight individuals.

When we default to weight-loss advice and label patients as noncompliant, we neglect to offer alternative, more realistic recommendations. This leads to patients feeling frustrated, can perpetuate feelings of failure and low self-esteem, and can exacerbate mental health problems.

Some patients may actually stop seeking care entirely. The author of the novel Dietland, Sarai Walker, says, “I have avoided going to a doctor at all. That is very common with fat people. No matter what the problem is, the doctor will blame it on fat and will tell you to lose weight. . . Do you think I don’t know I am fat?”[4]

As physicians who pride ourselves on professionalism and evidence-based practice, we need to become more aware of our assumptions and their consequences.[5] Before discussing the topic of weight, we should request permission and agree on a plan based on the patient’s values and goals, which may not involve weight loss. An individual’s best weight may not align with the traditionally accepted ideal BMI. Focusing on a healthy lifestyle rather than weight is often just as effective in addressing health problems such as hypertension, osteoarthritis, and diabetes. It also avoids adding the credible voice of physicians to the powerful societal pressures leading patients to desperate and sometimes dangerous attempts at weight loss.

Physicians should provide a supportive and sensitive environment to prevent patients with obesity from feeling humiliated or unwelcome. The practice of routinely weighing all patients should be re-examined. Chairs, scales, gowns, and blood-pressure cuffs should be available for patients of all sizes. We must believe our patients when they say they have tried to lose weight. We can remind them that obesity, like most medical conditions, is not their fault, and they should not be blamed any more than those with other diseases like Alzheimer disease or cancer. Obesity is not a choice; if it were, most people would probably not choose it.

Obesity Canada has many excellent resources to assist physicians in learning more about weight bias and providing high-quality health care for patients with obesity.[6]
—Ilona Hale, MD

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This article is the opinion of the Nutrition Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: A meta-analysis of US studies. Am J Clin Nutr 2001;74:579-584.

2.    Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015;16:319-326.

3.    Mann T, Tomiyama AJ, Ward A. Promoting public health in the context of the “obesity epidemic”: False starts and promising new directions. Perspect Psychol Sci 2015;10:706-710.

4.     Kolata G. Why do obese patients get worse care? Many doctors don’t see past the fat. The New York Times. September 2016. Accessed 29 April 2019. www.nytimes.com/2016/09/26/health/obese-patients-health-care.html.

5.    Provincial Health Services Authority. Summary report: From weight to well-being: Time for a shift in paradigms? January 2013. Accessed 24 April 2019. www.bccdc.ca/pop-public-health/Documents/W2WBSummaryReport_20130208FINAL1.pdf.

6.    Obesity Canada. 5As of obesity management, 2017. Accessed 30 March 2019. https://obesitycanada.ca/5as-landing.