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July 7, 2022

Social Stigma of Obesity; How to Manage in a Clinical Setting

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Bias, stigma, and frank discrimination against persons living with obesity are widespread in our society. We are bombarded with ever-increasing direct and indirect messages praising the values of thinness, beauty, and athleticism in social media, fashion, television, movies, sports, etc. This is due to a misunderstanding of the fundamental cause of obesity, where “sloth” and “gluttony” are blamed as character flaws, and those living with obesity are falsely thought to simply lack the necessary willpower to lose weight (1). However, obesity is now robustly recognized as a complex chronic relapsing disease associated thus far with approximately 237 medical complications (including cardiovascular disease, type 2 diabetes, many types of cancer, etc.) requiring lifelong treatment (2).

Unfortunately, healthcare providers are often the source of bias. Sixty-nine percent of women reported that physicians were a source of weight bias, and 52% reported they had been stigmatized by a doctor on multiple occasions in a study surveying 2,400 women (3). Another survey of self-reported attitudes of nurses indicated 31%, 24%, and 12% would prefer not to care for, were repulsed by, and would prefer not to touch patients with obesity, respectively, according to the Obesity Action Coalition(OAC) (3). The results of this are truly disappointing. In the ACTION study, only 55% of patients were given a diagnosis of obesity, and only 24% were given a follow-up appointment out of 3008 patients living with obesity (4). The consequences are hardly benign. Patients may delay or cancel appointments; they will receive no diagnosis and thus no treatment for obesity (despite safe and effective treatments being available), leading to negative health effects and an increased risk of early death (5). Additionally, these negative clinical encounters may lead to patients feeling ashamed and blaming themselves for their weight, i.e., self-stigmatizing, which may further harm a person’s cardiovascular health (6).

The first step in managing the social stigma of obesity in a clinical setting is recognizing that bias against obesity is very real, and it may be direct, but it may also be unintentional and implicit. Healthcare providers must explore the possibility of their own hidden biases against patients living with obesity. Do we think our patients are lazy, eat too much, and have no self-discipline? Have those hidden biases led to stigmatization, expressing the disgrace of patients living with obesity, making them feel that they are of lower social value? Are truly hurtful “anti-obese” comments made, either overtly or as sly comments, verbally or textually in-patient records? Is frank discrimination occurring where we refuse to treat or examine patients with obesity, or are they not treated with the human compassion, dignity, and competence expected of all healthcare providers (7, 8)?

The next step is to replace those biases with the objective medical science known about obesity. Remember the powerful human hormones insulin, leptin, GLP-1, CCK, etc.; the hypothalamic POMC/CART and NPY/AgRP pathways; the adipocyte as an endocrine factory; the brain-gut connection; and realize that the majority of the disease of obesity is not under voluntary control (9). This is just like the “tip of the iceberg” that sank the Titanic, with so much more to be discovered.

We must practice identifying the patient primarily as a human being, not as a disease, by using ”people-first language,” i.e., Mr. X living with obesity, not the obese Mr. X (10). Then recall and bring out the qualities during patient interactions that brought you into healthcare in the first place. Use a non-judgmental empathetic attitude while making appropriate eye contact. Avoid any situations that may bring embarrassment or shame to the patient by doing everything you can to make the patient feel comfortable. Use terminology like “BMI” and “excess weight” rather than “heavy” or “large.”

The clinic staff will also require education on the use of “people-first language” about the disease of obesity and the experience patients may have had with obesity. Patients should be weighed and abdominal circumference measured in a private area only if the patient agrees, and comments about those measures should be avoided. A non-judgmental environment should be the modus operandi of the clinic (11).

The physical environment of the clinic should be optimized as well prior to a patient entering the clinic. This may include handicapped access to the clinic, minimizing stair access only, and available spacious elevators. The entrance to the clinic should be amply wide as well. The temperature at the clinic should be optimized as well, as some patients living with obesity are very sensitive to cold, and warm blankets at times may be invaluable (9).

The waiting room should have bariatric chairs; how many times have patients living with obesity not been able to fit in a small chair? It would be worse if the chair collapses or breaks in a room full of patients. Would a patient ever return if such a negative experience ever happened? All reading materials glorifying thinness, beauty, and athleticism (i.e., implying that patients with obesity are not honored) should be eliminated and replaced with healthy living reading items.

The bathrooms should be equipped with U-shaped open front-split toilet seats as opposed to O-shaped seats, and the toilets should be floor-mounted. Specimen cups with handles are also ideal (2).

The exam room should also be optimized for patients living with obesity to include large adult and thigh blood pressure cuffs; wide bariatric chairs (with or without arms), able to support more than 600 lbs; a wide exam table (that may need to be custom-made) which is sturdy enough and able to support patients living with severe obesity. If the table is not adjustable, a step stool with a handle is recommended (2).

The most inadequate pieces of medical equipment found in many healthcare facilities are scales that are improperly calibrated and are only able to measure up to 300 lbs. A high-capacity, accurate scale, able to weigh in excess of 700 lbs is essential in this day and age.

Primum non-nocere- “first, do no harm” should be at the forefront of healthcare workers treating patients living with obesity, with the goal of improving their quality of life, not worsening it.

Read more about clinical practices in Empowering Patients through Motivational Interviewing.

References: 1. Practical Manual of Clinical Obesity, Kushner, Lawrence and Kumar 2013 2. Obesity Algorithm 2021 3. pdf 4. Kaplan L, et al, Perceptions of Barriers to Effective Obesity Care: Results from the National ACTION Study. Obesity. 2017. doi: 10.1002/oby.22054) 5.; Sutin, AR., Stephan, Y., Terracciano, A(2015). Weight discrimination and risk of mortality. 6. 7. Kirk, S., et al.(2014). Blame, shame, and lack of support: A multilevel study on obesity management. Qualitative Health Research, 24(6) 780-800; 8. Kyle, T. and Puhl, R. (2014). Putting people first in obesity. Obesity. Published online 8 March 2014. doi:10.1002/oby.20727) 9. Obesity Evaluation and Treatment Essentials, Second Edition, Steelman and Westman, 2016 10. Kyle, T. and Puhl, R. (2014). Putting people first in obesity. Obesity. Published online 8 March 2014. doi:10.1002/oby.20727) 11. bias-in-healthcare-a-guide-for-healthcare-providers-working-with-individuals-affected-by-obesity 5-20-18)