Addressing Medicine’s Bias Against Patients Who Are Overweight

According to her obituary, Ellen Maud Bennett had felt unwell for a few years before her death in May 2018. But the physicians Bennett consulted couldn’t see past the extra pounds she carried. If she’d only lose weight, she’d feel better, they told her.

Finally, a physician must have suspected another reason for her malaise, because Bennett was diagnosed with advanced-stage cancer just days before her death at age 64 years.

Bennett, a costume designer for stage and screen who lived in Victoria, British Columbia, expressed a final plea in her obituary: “Ellen’s dying wish was that women of size make her death matter by advocating strongly for their health and not accepting that fat is the only relevant health issue.”

Whether Bennett’s prognosis would have been less dire if she’d been diagnosed earlier isn’t known. But, given the tales told by scores of strangers from around the world who posted their condolences, Bennett’s health care encounters epitomized that of many overweight and obese individuals.

“There is not a single patient with significant obesity who has not experienced weight bias, whether it’s comments from doctors or nurses, the way waiting rooms are set up, or privacy issues,” said Yoni Freedhoff, MD, an obesity specialist at the University of Ottawa. “Weight bias is ubiquitous in society as a whole. Doctors are part of society.”

Weight appears to be the last acceptable bias, because, unlike most other characteristics or conditions, it is one over which individuals are perceived as having control. Losing weight and keeping it off should be (not eating) a piece of cake, this line of thinking goes. And yet, nearly three-quarters of US adults ages 20 years or older are overweight or obese, according to the US Centers for Disease Control and Prevention.

“Our country has placed a huge emphasis on personal responsibility for body weight,” said Rebecca Puhl, PhD, deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. But, Puhl said, that “really oversimplifies the complex causes of obesity and of weight loss and of weight regain.”

“Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity,” concluded the authors of a 2015 review of the empirical literature on weight bias in health care. “There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behavior, and decision-making.”

While a number of studies have suggested that many health care professionals are biased against patients with obesity, evidence about how that bias plays out in terms of patient care and outcomes “is pretty preliminary,” said Mayo Clinic researcher Sean Phelan, PhD, who focuses on the effects of health care professionals’ attitudes toward patients with obesity. Phelan was a coauthor of the 2015 review article.

“There is some evidence showing that physicians tend to spend less time in appointments with patients at a higher body weight,” Puhl said. “Primary care providers have also reported less respect for patients with obesity than those without.”

Weighty Matters
Might weight bias be even more prevalent among health care professionals than among other segments of society? After all, obesity increases the risk of many health problems. Plus, research suggests that health care professionals are less likely to be obese than the general population. Phelan said physicians occasionally rationalize their weight bias by telling him, “I’m also really biased against cancer because I don’t want my patients to have it because it’s bad for them.” The difference is that physicians generally aren’t biased against patients with cancer as well as cancer itself, Phelan suggested.

Because obesity is a health risk factor, physicians feel justified to address patients’ excess weight every chance they get, no matter the reason for their visit, Phelan said. For example, when patients with obesity seek treatment for an earache, some physicians feel the need to remind them that they need to lose weight.

“I don’t disagree that it’s important, but the overwhelming evidence is that by recommending weight loss to your patient in a primary care appointment, when that’s not what they’re there for, does not help them,” he said. “It’s potentially doing harm. Patients who are obese are avoiding that follow-up appointment because they didn’t lose weight, and they said they were going to.”

Starting Early
Weight bias among health care professionals dates back to their undergraduate years, 2 recently published studies suggest. The authors used virtual human technology to see whether the weight of pediatric patients or their mothers influenced assessments made by students with health care majors, such as premed.

In one study, undergraduate participants rated children and mothers with obesity as being less likely to adhere to physician recommendations compared with healthy weight children and mothers.

“We’ve certainly heard from parents…who report interactions with physicians who put a lot of blame on the parent [of obese children],” said University of Florida pediatric psychologist David Janicke, PhD, a coauthor of both virtual human studies.

In the other study, participants rated the pain of pediatric patients with obesity as more likely to be influenced by psychological and behavioral issues compared with the pain of healthy weight pediatric patients.

“These results suggest that interventions targeting weight bias among students and health care trainees may be warranted,” Janicke and his authors concluded. “Future research should begin by examining whether or not participants are actually aware of their own bias.”

Trainees who’ve successfully shed pounds might be more likely to harbor a bias against patients who are overweight than their peers who’ve not had that experience, suggests a 2017 article based on a survey of medical residents and internal medicine residents.

Two-thirds of the trainees reported having successfully lost weight, and 8 out of 10 who had shed pounds said they had maintained their weight loss. Trainees who reported having lost weight and kept it off exhibited more critical attitudes toward patients struggling to manage their weight, the study found.

Educating Trainees
Medical schools devote relatively little attention to the subject of obesity, let alone weight bias, Puhl said.

“If we look at medical school curricula, obesity does not get very much airtime, and that is a problem,” she said. “We need more content…on obesity and nutrition so health care providers understand just how complex body weight is. It’s not just an issue of calories in and calories out. Not only is obesity and nutrition not getting enough attention, but weight stigma is completely off the radar.”

Medical students need to learn how to talk to patients about weight-related health issues, starting with asking their permission to bring it up and not using stigmatizing language, Puhl said. In a study published in 2012 Puhl and her coauthors surveyed a national sample of US adults—about 60% of whom were overweight or obese—about their weight-related language preferences. “Weight” and “unhealthy weight” were rated most desirable, while “morbidly obese,” “fat,” and “obese” were rated as the most undesirable.

A 2015 study reporting survey responses from students at 49 randomly selected US medical schools found that discriminatory behavior by faculty and less positive contact with patients with obesity—often described as “problem” patients—were associated with increased biases against patients who were overweight. These findings suggest that medical schools could reduce students’ weight biases if they made sure that faculty and residents set a better example and they provided opportunities for positive encounters with patients with obesity.

At least a few medical schools have recognized the need to start working proactively toward changing students’ biases against overweight patients.

The University of Pennsylvania is “testing out incorporating more nutrition information into medical training, …which could have implications for helping students understand in a more nuanced way the complexities of weight and eating,” said Rebecca Pearl, PhD, a psychologist at Penn’s Perelman School of Medicine, who conducts weight sensitivity training with medical and nutrition students.

At Johns Hopkins University School of Medicine, researchers embedded an ethics session in a required course, “Obesity, Nutrition, and Behavior Change,” to help improve students’ attitudes toward patients with obesity.

Before the ethics session, 6 cohorts of first-year students had consistently negative attitudes toward patients with obesity, according to a study in the AMA Journal of Ethics.

During the ethics session, students discussed their personal weight struggles and their beliefs about the causes of obesity. They also watched and discussed video clips from the television show “House” that depicted negative attitudes toward overweight patients. In a survey of the 2017 cohort 4 months after the ethics session, 30% of respondents reported that it had helped improve their attitudes toward patients with obesity.

The Mayo Clinic Alix School of Medicine devotes 2 afternoons each year to the topic of nutrition, covering obesity as well as malnutrition, said endocrinologist Manpreet Mundi, MD, who is on the faculty in Rochester, Minnesota. “We really fought hard for this.”

Students learn that it’s much easier to gain weight than it is to lose it, that genetics, the environment, and psychological factors—not simply laziness and a lack of willpower—contribute to obesity, and that being obese doesn’t necessarily affect adherence to treatment. “As that curriculum started to evolve, I started to add components of obesity bias to it,” Mundi said. “We’re trying to have medical students and residents shadow and even work in our obesity clinic.”

Creating a “Safe Space”
Although changing health care students’ and professionals’ negative attitudes toward patients with obesity takes time, relatively simple tweaks, such as moving the scale from the hallway and into a private room, can foster a more welcoming environment.

Mundi said Mayo had remodeled his floor and placed the scale in a hallway. Patients who were overweight began refusing to get weighed. One told him she’d never told her husband how much she weighed, so she wasn’t about to step on a scale in such a public setting. While the location of the scale seems like a relatively simple thing, it wasn’t something he had ever thought about, he explained.

“One of the things we are starting to see now is a kind of recognition that it’s not only patient-provider interactions that we need to think about, but even the office environment,” Puhl said. “Are there sturdy armless chairs in the waiting room? Do they have appropriately sized medical equipment?”

As Mundi said, “if we don’t create a safe space for them...they’re not going to come. We can’t help someone who’s not even coming in.”