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The Perils of Obesity Prejudices

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One of the most damaging aspects of obesity is the weight bias and stigma that is so pervasive in our thin-obsessed society.

Although modern societies approach prejudices as inherently evil threats to our fundamental human rights, weight stigma largely escapes this view. Indeed, obesity has been called the last socially acceptable form of prejudice, and persons with obesity are considered acceptable targets of stigma.

Weight bias can be overt, as in outright teasing or hostile actions, or subtle. It occurs even in people who are otherwise fair-minded and nonjudgmental -- even in obesity specialists. Rates of obesity stigma exceed nearly every other type of prejudice in our society, and have been increasing over time. Weight stigma has been shown to occur across our society, including in employment, education, the media, health care, and even in relationships, such as family members, parents, and teachers.

One of the most concerning areas of weight bias is in health care providers. Negative attitudes and stereotypes towards patients with obesity have been shown among physicians, nurses, dietitians, psychologists, and medical students. They can play out overtly -- such as not wanting to care for patients with obesity, or more subtly -- such as believing that patients with obesity are noncompliant with treatments.

One common example is refusing to prescribe an obesity medication or offer other treatments, such as surgery, due to the biased perception that the patient doesn't "deserve" it, because they haven't already made sufficient lifestyle changes on their own. Imagine if we refused to treat patients for diabetes, because they haven't already been able to manage their disease on their own.

Studies show that as patient BMI increases, physicians report less respect toward patients and engage in less emotional rapport building. They spend less time in appointments, offer less intervention, and are less likely to offer preventive services and screenings. As you would imagine, this can lead to numerous physical and mental health issues, such as decreased quality of life, increased blood pressure, and lower self-esteem.

What you may not realize is that this type of stigma actually predisposes to unhealthier behaviors and more weight gain. Weight stigma has been shown to increase maladaptive eating and coping behaviors, such as binge eating and emotional eating, and diminish motivation for exercise. Studies have shown that patients who experience judgmental interactions from their physician are less likely to successfully lose weight, and those who experience weight bias are nearly three times more likely to develop obesity over time, compared with persons who do not experience weight bias.

There are several things physicians can do to address weight stigma:

  • First, do no harm. We should become aware of our own implicit assumptions, beliefs and biases about obesity and patients who have obesity. I suggest all physicians take the implicit attitudes test -- my own results shocked me the first time I took it many years ago.

  • Pay attention to language. No one likes being called "fat" or "obese," let alone "morbidly" so. In contrast, using words like "excess weight," "unhealthy weight," or "high BMI" are generally perceived as less stigmatizing and pejorative. Use people-first language (e.g.,"patient who has obesity"), rather than condition-first language (e.g., "obese patient"). These are such small changes, yet they can make a big difference in your interactions with patients, and in patients' healthcare experiences.
  • Learn about the complexity of obesity. I believe much of weight stigma is attributable to a lack of understanding, which leads to outdated beliefs (such as obesity being caused by a lack of willpower), inappropriate assumptions (such as assuming that most people with obesity haven't tried to lose weight -- in one of our studies, 94 percent of those with severe obesity have attempted weight loss, usually multiple times), and unhelpful recommendations (such as the all-too-common advice to "just eat less and exercise more").
  • Practice "obesity medicine," not weight loss. Obesity medicine goes beyond the number on the scale to understand, support, and treat the whole person. Simply focusing on weight or weight loss may have unintended consequences, such as not appreciating the health benefits of moderate weight loss, or not appreciating the benefits of positive health behavior changes that don't show up on the scale.
  • Be an advocate. Challenge weight stigma in the public, in the media, and in your hospital or practice. Whether informally alerting people to stigmatizing behaviors, language, or beliefs, or formally writing letters to the editor or op-ed articles, use your bully pulpit as a physician to set people straight about weight.

  • Most importantly, always aim to treat persons with obesity with the same respect, empathy, and sensitivity that you would offer to any other patient or person.

    This article is also posted on the website of the American Board of Obesity Medicine.

    Dr. Scott Kahan is the Director of the National Center for Weight and Wellness, Medical Director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance, and serves on the Board of Directors for the American Board of Obesity Medicine.