Image Credit: World Obesity Federation
Today is ‘World Obesity Day’ and while I’m not a fan of the day, or the framing of body weight as a disease, I applaud them for raising awareness of weight stigma. However, much of the focus is on the way higher body weight is portrayed in the media images and through poor journalism when health care providers are just as likely to perpetuate stigma and bias, so I wanted to share some thoughts on weight stigma in the health care setting. If you’re a health care provider then buckle in – this one is for you. Doctors, nurses, dietitians, nutritionists, therapists, physios, OTs and ANYONE else who comes into contact with patients, listen up, because this is really fucking important.
Fat phobia in the medical community is showing, and it’s not pretty. In fact, it’s really, harmful and damaging. Weight stigma and bias has recently been flagged by the WHO as a public health concern.
Weight bias (a polite way of saying fat-phobia) is ‘negative weight-related attitudes, beliefs, assumptions and judgements towards {fat} individuals’ (side note: I am using fat as a neutral descriptor in the reappropriated sense, not as a derogatory term). Basically, the negative attitudes we have towards higher-weight individuals which are super prevalent in health care.
When these negative attitudes play out in a clinical setting it’s called enacted stigma; all the insidious ways our attitudes and beliefs are expressed in the way we treat (or mistreat) our patients. This isn’t flagrant in-your-face fat jokes, but subtle microaggressions that lead to worse outcomes for the people we are there to care for.
Attitudes can be broken down in two ways;
EXPLICIT attitudes underlying enacted stigma are conscious and reflect a person’s opinions or beliefs about a group. For instance, medical students have been shown to hold the explicit biases that higher wt patients are: non-compliant, lazy, sloppy and lacking self-control, less adherent to lifestyle recommendations and that they are personally responsible for their weight. Not cool.
IMPLICIT biases are subconscious, which is what makes them so dangerous – we’re not even aware we have them. They are things like believing higher weight individuals are lazy, gluttonous, stupid, undisciplined, and worthless. And shocker; both the public and medical doctors have been shown to have strong implicit attitudes about fat people.
A study from Nottingham University (God Bless Judy Swift) found that among a sample of student nutritionists, dietitians, doctors, and nurses only 1.4% of the students had ‘positive’ or ‘neutral’ attitudes towards fat people. That means that 98.6% of future HCPs were starting their career with negative or very negative attitudes about the people they would be responsible for caring for.
What does this mean for the patients? The consequences of weight stigma in health care isn’t easy to measure and there are likely to be immediate and longer-term effects including:
- Higher stress + allostatic load (which increases risk of heart disease, stroke, depression and anxiety)
- Over-attribution of symptoms and problems to weight + subsequent failure to prescribe further diagnostics or consider treatment options beyond weight loss
- Less patient-centered care and communication
- Lower patient ratings of care
- Worse mental health outcomes
- Longer recovery times
- Avoidance of routine and preventative care
And, plot twist, a lot of the negative health outcomes usually attributed to weight may actually be related to weight stigma (at least in part).
And this isn’t happening in isolated cases or to a handful of patients; around 70% of higher weight female patients have reported being shamed by a HCP about their weight; and those are only the ones who actually reported it.
WE HAVE GOT TO DO BETTER.
The way we treat our patients is not simply ‘insensitive’ or ‘unkind’; it’s actively harmful. It actively leads to poorer health outcomes.
In our weight-centric model of health, we prescribe weight loss as the solution to almost everything ignoring that
1) for most people, weight is not a modifiable risk-factor given that around 60% of people fail to lose ‘clinically significant’ amounts of weight, and that almost 80% of weight lost is gained back over 5 years.
2) body weight is defended by a powerful biological system that reacts to a negative energy balance by lowering metabolism and increasing hunger, food preoccupation, and hedonic responses to food making advice to simply ‘lose weight’ ineffective, not evidence based, and stigmatizing (patients internalize failed weight loss attempts as ‘their fault’ as opposed to biology).
And 3) we can improve health behaviours that reduce risk and help manage disease in a number of ways independent of weight loss. By focusing on weight, and asking people to keep doing the same thing they have tried and failed at numerous times before we might inadvertently be pushing people away from making pro-health choices.
So how can we address health concerns without promoting weight stigma?
Do not reduce weight to a ‘simple’ equation. Saying things like “eat less and move more” belies the >100 variables that contribute to weight and contributes to a narrative of individual responsibility.
Consider how you would treat a patient with a ‘normal’ BMI and ask yourself whether you have provided all the same treatment options to your higher weight patient. Have you exhausted the options or just defaulted to weight loss? Some things to consider are medication, further diagnostics, referral to mental health services, group or individual physiotherapy, occupational therapy, podiatry, smoking cessation, gentle (non-diet) focused nutrition (such as plant sterols (added to yoghurt) to reduce cholesterol), mindfulness or similar tools for stress reduction.
Think carefully about how even well-intentioned conversations about weight can be problematic and stigmatising. For instance, imagine how condescending it must feel to be asked “have you ever thought about losing weight?” – in our weight-centric, diet culture, that’s pretty much all anyone ever thinks about. Higher weight patients are likely to have received the message that their bodies are ‘inadequate’ and ‘at risk’ or, even causative of disease; are we naïve enough to think that they have never attempted to lose weight? I’d argue that higher weight individuals are likely to be the most determined dieters making this seemingly innocuous question even more patronizing. The same goes for weight loss leaflets.
Avoid using the terms ‘overweight’ or ‘obese’ – weight is a highly stigmatised trait – biomedical labels add to the stigma associated with being in a bigger body – in fact, research has found that people perceive ‘obese’ to be one of the most blaming, stigmatizing, and undesirable labels for describing weight. Read more about this here. Research has demonstrated that these labels can lead to body image dissatisfaction and poorer psychological outcomes and are unlikely to increase health promoting behaviours. *Just because these terms are not offensive to you, does not mean they are not offensive or stigmatizing to other people*. Ask yourself if you need to tell the patient about their weight – it’s pretty unlikely that they are oblivious. Everyone will have a different preference for describing their body; with my clients I tend to use higher weight – it’s relative and therefore less judgemental. Notice too how patients describe their bodies to you, not just the language they use, but are they conveying a sense of shame or disgust – this could mean they are harbouring their own internalised weight stigma and I would caution you not to collude with that by reinforcing it. A helpful resource is the Appearance Matters podcast from the Centre for Appearance research – a centre of excellence in body image research. The podcast covers different aspects of body image and can be helpful for clinicians and patients alike.
Communicate risk the same way you would to a fair-skinned patient who is at higher risk of skin cancer, or a darker skinned person who is at risk of vitamin D deficiency. You would not tell the person to change their skin colour, but you would explain how you could attenuate that risk, in the same way that lifestyle modifications can attenuate risk associated with higher body weight.
Avoid weighing patients unless medically necessary (i.e. for medication dosage), and even then, blind weigh them. You should also respect the fact that a patient may not want to be weighed or may ask not to have their weight revealed. If weight is an outcome in your setting (which it is in most), is there an opportunity to raise awareness of weight stigma and speak out about the problems inherent in a weight-centric paradigm? This is a great paper to start that conversation.
Be aware of disordered eating; to be clear, do not assume that higher weight individuals have disordered eating, but make sure you screen for subclinical disordered eating, particularly before commenting on a person’s body size or making recommendations about food. This means checking for restrained eating, disinhibited eating, purging (restriction, laxative/diuretics, over exercise), chronic dieting, emotional eating or body image disturbance. Refer to a Registered Nutritionist or Dietitian.
Think how weight-bias may inadvertently impact people at the lower end of the weight spectrum – do you assume that because someone is at lower weight that they aren’t at risk of cardiovascular disease or type 2 diabetes – these patients might ‘fly under the radar’ because the assumption is that these only affect people at the higher end of the weight spectrum.
Check your Implicit Bias Score by using the Harvard tool.
Organise an anti-weight-bias training at your organisation or do a journal club looking at weight-inclusive practice.
Think SUPPORT not STIGMA. Think WELLBEING not WEIGHT. Health GAIN not Weight LOSS.
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