One of the tenets of the Patient Promise is to "identify and guard oneself from potential prejudices against my patient based on unhealthy behaviors, recognizing the often complex origins of these habits." This was based on a growing body of evidence showing that weight bias is growing and adversely affecting the clinician-patient relationship. Recently the New York Times published an article ("When the Doctor is Overweight") that cited research published by Yale's Rudd Center Director of Resarch and Weight Stigma Initiatives and Patient Promise advisor, Dr. Rebecca Puhl. We had the opportunity to catch up with Dr. Puhl and ask her about the issue of weight bias and how we, as clinicians, could become more aware and helpful to our patients.
How did you become interested in the issue of weight stigma in healthcare?
Weight stigma is pervasive in many different domains of our society, and unfortunately health care is one of them. This is an especially important setting to focus on, because we need to ensure that the two-thirds of Americans who are overweight or obese receive quality health care delivered with the compassion and respect that they, like all patients, deserve from health providers. When we look at the evidence documenting negative consequences that people experience as a result of weight bias, whether it be adverse emotional, social, economic, or physical health outcomes, we need to make sure that health care is not contributing to these disparities.
Can you describe the various forms of weight bias (patient to provider, provider to patient, etc), and how much a problem they've posed in healthcare?
Weight bias takes various forms in the health care setting. From providers, we see that health professionals (e.g., physicians, nurses, dietitians, medical students, psychologists) negatively stereotype obese patients to be sloppy, lazy, lacking in discipline and willpower, and non-compliant with treatment. Experimental research shows that as a patient’s BMI increases, physicians report having less respect for the patient, less desire to help the patient, and report that patients are less adherent to medications and more annoying than thinner patients. Additional research indicates that compared to appointments with thinner patients, physicians spend less time with obese patients, have less discussion with them, and admit that they don’t intervene as much as they think they should.
Studies show that patients appear to be aware of these biases, and that stigmatizing experiences in the medical setting can negatively affect health care utilization and contribute to avoidance of health care among obese individuals. As an example, among the heaviest women, as many as 68% report delaying health care services because of their weight, and attribute their decisions to previous experiences of disrespectful treatment and negative attitudes from providers, embarrassment about being weighed by medical staff, and that medical equipment was too small for their body size. The percentage of women who reported these bias-related barriers increased with BMI. Two recent national studies by our team found that even the language that a provider uses to discuss excess weight with patients can have concerning consequences. Specifically, we found that 19% of adults and 24% of parents would avoid future medical appointments if they perceived a doctor had used stigmatized language to describe their weight (or their child’s weight). Furthermore, 21% of adults and 35% of parents would switch doctors if this happened to them.
At the same time, some recent research of ours shows that weight bias is not just one-sided in the patient-provider relationship. Patients, too, hold weight biases toward their doctors. We found that people report more mistrust of physicians who are overweight or obese, are less inclined to follow their medical advice, and more likely to change providers if they perceive their physician to be overweight or obese, compared to non-overweight physicians who elicit significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. This suggests that both patients and providers may be approaching each other with negative biases and stereotypes that can interfere with the patient-provider relationship and the ability to have productive, positive discussions about weight-related health.
Are there other forms of stigma that we can draw lessons from, e.g. smoking?
Smoking is sometimes raised as an example of where stigmatization was effective in contributing to the decline in smoking rates. However, some important distinctions need to be made in making parallels to obesity. Smoking is a behavior, whereas obesity is a chronic medical condition. In addition, much of the success observed in the decline of smoking rates can be attributed to taxes on cigarettes which substantially raised prices, as well as effective media campaigns (such as the Truth campaign) that targeted the tobacco industry, where the stigmatization was focused on the companies that created the toxic product of cigarettes, rather than the people who smoked who were instead often portrayed as victims of a deceptive industry that heavily marketed to them. In fact, effective campaigns like the Truth campaign made a conscious effort not to stigmatize people who smoke. To draw an accurate parallel would be to stigmatize the food industry and the food products created by the industry, rather than the public who consumes their food products. But this is not what has happened.
There seems to be a public misperception that stigmatizing or shaming individuals who are obese will provide motivation or incentive to improve their health and lose weight. But the considerable science on this issue suggests the opposite is true – that this is not an appropriate or an effective tool to address obesity. When children and adults are stigmatized, shamed, or bullied about their weight, they have an increased risk of depression, anxiety, low self-esteem, poor body image, and suicidal thoughts and behaviors. They are also more likely to engage in unhealthy eating patterns (including binge eating, eating disorder symptoms, and maladaptive weight control behaviors), as well as increased food intake, and avoidance of physical activity – all of which reinforce weight gain and impair weight loss efforts.
So if we want to effectively address obesity, we need to support and empower individuals who are struggling with weight, rather than instill stigma or shame. Stigma has been recognized as a known barrier and enemy throughout our history of public health. For example, in the case of HIV/AIDS, the detrimental role of stigma became so evident that national and international health agendas explicitly identified stigma and discrimination as major barriers to effectively addressing the epidemic. There are many other examples throughout history of stigma imposing suffering on groups vulnerable to disease and impairing efforts to prevent and treat those diseases. Obesity is no different, but unfortunately stigmatization of obesity most often goes ignored and unchallenged.
What are specific steps that healthcare providers can implement to reduce weight stigma in healthcare?
Providers can implement a number of strategies to reduce weight bias in health care. First, it’s important for health providers to reflect on their personal assumptions and beliefs about obesity. Do they make assumptions about a person’s character, abilities, or behaviors based on their weight? How do they feel when they work with patients of different body sizes? What stereotypes do they have about obesity? Becoming aware of one’s own personal assumptions can make it easier to recognize communication that might be interpreted by others as biased, even if it’s unintentional.
Although providers may face challenges in their efforts to effectively prevent or treat obesity, their efforts must begin with a conversation with patients about weight and health. Giving careful consideration to the language that they use about weight can help facilitate a productive dialogue, to make sure that patients don’t feel blamed or judged about their weight. Our research has found that patients perceive neutral weight terminology (e.g., “BMI”, “unhealthy weight”) to be more motivating for weight loss and less stigmatizing than words like “fat” or “morbid obesity” when they are used by a doctor. So providers should be mindful of the language they use, and may even want to ask patients what words or language they would feel most comfortable using when they talk about the patient’s weight.
It is also helpful for providers to recognize that many patients who are obese will have already experienced weight bias in the health setting, and as a result may be reluctant or hesitant to talk about weight. Using motivational interviewing techniques can help empower patients in discussions about weight-related health, as can efforts to help patients set realistic goals for health behavior changes (e.g., reducing consumption of sugar sweetened beverages, or incrementally increasing physical activity) without even talking about how much weight a patient may need to lose.
Providers can also implement strategies to reduce weight bias in the physical medical office environment. For example, many patients feel embarrassed, anxious, and ashamed of being weighed at medical appointments, to the extent that some will even avoid health care appointments to avoid getting on the scale. To address this, providers can implement sensitive weighing procedures: making sure that scales can accommodate patients of large size, that scales are located in a private location, that the medical staff person recording the weight does so silently, free of any judgment or commentary, and that the patient is asked for his/her permission to be weighed before the process begins. The American Medical Association has guidelines for other aspects of the medical setting that are important to attend to, such as providing large, sturdy, armless chairs that can accommodate heavier patients, and ensuring that medical equipment is sufficiently large to be functional for obese individuals.
What do you think of The Patient Promise as a way to raise awareness/change behavior among clinicians?
There is an ongoing need to raise awareness of weight bias among health care providers, and The Patient Promise can be an important voice in these efforts. The Patient Promise asks providers to make a commitment to support their patients struggling with obesity, identify and guard themselves from weight prejudices, and to respect their patients, regardless of body size. The more providers who make this pledge, the better equipped we can be to help improve the culture of health care for obese patients and decrease stigma.
How did you become interested in the issue of weight stigma in healthcare?
Weight stigma is pervasive in many different domains of our society, and unfortunately health care is one of them. This is an especially important setting to focus on, because we need to ensure that the two-thirds of Americans who are overweight or obese receive quality health care delivered with the compassion and respect that they, like all patients, deserve from health providers. When we look at the evidence documenting negative consequences that people experience as a result of weight bias, whether it be adverse emotional, social, economic, or physical health outcomes, we need to make sure that health care is not contributing to these disparities.
Can you describe the various forms of weight bias (patient to provider, provider to patient, etc), and how much a problem they've posed in healthcare?
Weight bias takes various forms in the health care setting. From providers, we see that health professionals (e.g., physicians, nurses, dietitians, medical students, psychologists) negatively stereotype obese patients to be sloppy, lazy, lacking in discipline and willpower, and non-compliant with treatment. Experimental research shows that as a patient’s BMI increases, physicians report having less respect for the patient, less desire to help the patient, and report that patients are less adherent to medications and more annoying than thinner patients. Additional research indicates that compared to appointments with thinner patients, physicians spend less time with obese patients, have less discussion with them, and admit that they don’t intervene as much as they think they should.
Studies show that patients appear to be aware of these biases, and that stigmatizing experiences in the medical setting can negatively affect health care utilization and contribute to avoidance of health care among obese individuals. As an example, among the heaviest women, as many as 68% report delaying health care services because of their weight, and attribute their decisions to previous experiences of disrespectful treatment and negative attitudes from providers, embarrassment about being weighed by medical staff, and that medical equipment was too small for their body size. The percentage of women who reported these bias-related barriers increased with BMI. Two recent national studies by our team found that even the language that a provider uses to discuss excess weight with patients can have concerning consequences. Specifically, we found that 19% of adults and 24% of parents would avoid future medical appointments if they perceived a doctor had used stigmatized language to describe their weight (or their child’s weight). Furthermore, 21% of adults and 35% of parents would switch doctors if this happened to them.
At the same time, some recent research of ours shows that weight bias is not just one-sided in the patient-provider relationship. Patients, too, hold weight biases toward their doctors. We found that people report more mistrust of physicians who are overweight or obese, are less inclined to follow their medical advice, and more likely to change providers if they perceive their physician to be overweight or obese, compared to non-overweight physicians who elicit significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. This suggests that both patients and providers may be approaching each other with negative biases and stereotypes that can interfere with the patient-provider relationship and the ability to have productive, positive discussions about weight-related health.
Are there other forms of stigma that we can draw lessons from, e.g. smoking?
Smoking is sometimes raised as an example of where stigmatization was effective in contributing to the decline in smoking rates. However, some important distinctions need to be made in making parallels to obesity. Smoking is a behavior, whereas obesity is a chronic medical condition. In addition, much of the success observed in the decline of smoking rates can be attributed to taxes on cigarettes which substantially raised prices, as well as effective media campaigns (such as the Truth campaign) that targeted the tobacco industry, where the stigmatization was focused on the companies that created the toxic product of cigarettes, rather than the people who smoked who were instead often portrayed as victims of a deceptive industry that heavily marketed to them. In fact, effective campaigns like the Truth campaign made a conscious effort not to stigmatize people who smoke. To draw an accurate parallel would be to stigmatize the food industry and the food products created by the industry, rather than the public who consumes their food products. But this is not what has happened.
There seems to be a public misperception that stigmatizing or shaming individuals who are obese will provide motivation or incentive to improve their health and lose weight. But the considerable science on this issue suggests the opposite is true – that this is not an appropriate or an effective tool to address obesity. When children and adults are stigmatized, shamed, or bullied about their weight, they have an increased risk of depression, anxiety, low self-esteem, poor body image, and suicidal thoughts and behaviors. They are also more likely to engage in unhealthy eating patterns (including binge eating, eating disorder symptoms, and maladaptive weight control behaviors), as well as increased food intake, and avoidance of physical activity – all of which reinforce weight gain and impair weight loss efforts.
So if we want to effectively address obesity, we need to support and empower individuals who are struggling with weight, rather than instill stigma or shame. Stigma has been recognized as a known barrier and enemy throughout our history of public health. For example, in the case of HIV/AIDS, the detrimental role of stigma became so evident that national and international health agendas explicitly identified stigma and discrimination as major barriers to effectively addressing the epidemic. There are many other examples throughout history of stigma imposing suffering on groups vulnerable to disease and impairing efforts to prevent and treat those diseases. Obesity is no different, but unfortunately stigmatization of obesity most often goes ignored and unchallenged.
What are specific steps that healthcare providers can implement to reduce weight stigma in healthcare?
Providers can implement a number of strategies to reduce weight bias in health care. First, it’s important for health providers to reflect on their personal assumptions and beliefs about obesity. Do they make assumptions about a person’s character, abilities, or behaviors based on their weight? How do they feel when they work with patients of different body sizes? What stereotypes do they have about obesity? Becoming aware of one’s own personal assumptions can make it easier to recognize communication that might be interpreted by others as biased, even if it’s unintentional.
Although providers may face challenges in their efforts to effectively prevent or treat obesity, their efforts must begin with a conversation with patients about weight and health. Giving careful consideration to the language that they use about weight can help facilitate a productive dialogue, to make sure that patients don’t feel blamed or judged about their weight. Our research has found that patients perceive neutral weight terminology (e.g., “BMI”, “unhealthy weight”) to be more motivating for weight loss and less stigmatizing than words like “fat” or “morbid obesity” when they are used by a doctor. So providers should be mindful of the language they use, and may even want to ask patients what words or language they would feel most comfortable using when they talk about the patient’s weight.
It is also helpful for providers to recognize that many patients who are obese will have already experienced weight bias in the health setting, and as a result may be reluctant or hesitant to talk about weight. Using motivational interviewing techniques can help empower patients in discussions about weight-related health, as can efforts to help patients set realistic goals for health behavior changes (e.g., reducing consumption of sugar sweetened beverages, or incrementally increasing physical activity) without even talking about how much weight a patient may need to lose.
Providers can also implement strategies to reduce weight bias in the physical medical office environment. For example, many patients feel embarrassed, anxious, and ashamed of being weighed at medical appointments, to the extent that some will even avoid health care appointments to avoid getting on the scale. To address this, providers can implement sensitive weighing procedures: making sure that scales can accommodate patients of large size, that scales are located in a private location, that the medical staff person recording the weight does so silently, free of any judgment or commentary, and that the patient is asked for his/her permission to be weighed before the process begins. The American Medical Association has guidelines for other aspects of the medical setting that are important to attend to, such as providing large, sturdy, armless chairs that can accommodate heavier patients, and ensuring that medical equipment is sufficiently large to be functional for obese individuals.
What do you think of The Patient Promise as a way to raise awareness/change behavior among clinicians?
There is an ongoing need to raise awareness of weight bias among health care providers, and The Patient Promise can be an important voice in these efforts. The Patient Promise asks providers to make a commitment to support their patients struggling with obesity, identify and guard themselves from weight prejudices, and to respect their patients, regardless of body size. The more providers who make this pledge, the better equipped we can be to help improve the culture of health care for obese patients and decrease stigma.
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