Chapter 3 – Obesity
Camilla Curren MD
The Patient Perspective
“You need to lose weight,” “Stop eating so much,” and, “You get bigger every time you are admitted; I guess you just can’t stop eating,” are common pieces of advice and personal observations bestowed upon Mark Collins and Mariah Marsh, two Columbus patients who have experienced bias against obese patients –even as they have fought to resolve this acknowledged medical problem within the recommendations of the medical system. They have not found the remarks, delivered by healthcare providers, to be helpful.
“You can boycott a barber shop or store where the people are rude to you, but you need medical care and cannot boycott the medical establishment,” points out Collins. A patient who has explored every known medical avenue for weight loss, Collins has comorbid conditions caused directly by obesity that compel him to see several different specialists and to attend a few appointments and studies a month just to maintain his current level of health. Sometimes, he admits, he is uncomfortable leaving the house because “people look at me funny,” and so he just does not go to medical appointments or to exercise or PT appointment for his obesity-related orthopedic issues. “Bias has kept me from seeking help I should have and from follow-ups I should do.”
The Last Acceptable Bias?
In fact, bias against people with obesity has been well documented and is nearly pervasive in patients and in society as a whole, including medical trainees and practitioners. This leads healthcare providers to make careless or insensitive remarks that fall below the standard of helpful or actionable patient counsel. 1,3 This finding has led to increased attention to obesity as a medical illness and to multiple types of interventions to decrease students’ and physicians’ expression of bias in medical fields. 1, 2, 8
Bradley Needleman, MD, Medical Director of the Comprehensive Weight Management & Bariatric Surgery Center of The Ohio State University Wexner Medical Center, agrees that obesity is one of the last biases generally treated as if it is acceptable by many in the medical profession. Needleman notes that he has witnessed providers making unflattering remarks about the size of bariatric surgery patients in the operating room in a joking manner and that it is difficult to extinguish this type of behavior. He notes that this bias extends to discrimination against overweight or obese peers, as evidenced by negative evaluations of obese residents by program directors, who may view being overweight as evidence of poor self-care skills. Needleman believes that this discounts the complexity of obesity as a disease, and the multiple factors that go into weight control.
Reducing the Impact of Bias
Some of the most promising interventions shown to reduce expressions of bias against individuals with obesity involved the use of the arts and theater as a springboard to discussion of obesity scenarios. While it did decrease explicit prejudicial behaviors, the use of theater techniques was not shown to increase empathetic interactions between medical students and obese patients.1 Students undergoing only traditional medical lecture-based curricula were more likely, compared to those with added behavioral sciences approaches to the problem, to deliver traditional advice to lose weight to obese patients, and to demonstrate lack of understanding of the perspective or motivations of the obese patient. 1,2
Social Determinants Contribute to Illness
Morbidly obese patients face other obstacles to adequate or commensurate health care, including costs for comorbidities related directly to obesity and a lack of resources that may have contributed to the problem in the first place. While nutritious and low-calorie foods are difficult to obtain in areas with few supermarkets or with limited transportation, they are also more expensive.10 This information is corroborated by Marsh, a health professions student currently on disability for her asthma, a condition worsened by obesity. She is dependent on city buses for transportation and has trouble getting to appointments and has difficulty affording medications and nutritious foods prescribed as part of her overall therapy. So does Collins.
Improving Quality of Care by Reducing Bias
Marsh can cite several instances in which she feels her other medical conditions, including headaches, (which turned out to be pseudotumor cerebri) and shortness of breath (which turned out to be life-threatening asthma) were ignored or misattributed to being “out of shape” by providers. She feels that health care professionals need to be aware of contributors (such as high dose prednisone for asthma and many other medications, such as several antidepressants) that lead to poor weight loss or to weight gain in obese patients who are actually trying very hard to reduce body mass indices (BMI). In addition, she makes a plea for more individualized, patient-centered care that would help the obese patient to be less stigmatized and anxious in health care settings and would help detect other problems, related or unrelated to obesity, and treat them promptly. 4
Marsh’s wishes are echoed in some healthcare literature, which recommends measures such as bias training for medical staff (instruments such as the IAT and zero tolerance policies for BMI-related jokes), using adequate sized office furniture and handicapped equipped venues to avoid awkward physical situations for obese patients, and educating providers on the many and multiple genetic, environmental, biological, psychological and social contributors to weight. 4,7 Providers who understand the interrelated health factors leading to obesity show more positive and comprehensive health care behaviors in managing the health of overweight patients. 4,5 This more comprehensive, personalized information is likely more helpful for their patients than paternalistic messages like “exercise more and eat less.” 6 Subsequently, obese patients treated in a more comprehensive fashion may be more likely to overcome common obstacles and to succeed to a greater degree in weight loss programs and will be less likely to let poor body image or fear of embarrassment preclude their attendance at medical appointments for routine medical care. Routine care is avoided, as Collins suggests, by many obese patients when compared to their contemporaries with a more normative BMI.7
The impact of bias on reducing the prevalence of obesity
Once she attains her degree, Marsh is likely to face the increased stigma of patients against obese healthcare professionals. According to a 2013 study published in the Journal of Obesity, patients viewed overweight or obese physicians with less trust and were less inclined to follow their medical advice and more inclined to change physicians; this behavior persisted regardless of the body mass index of the patient. ³ This finding is in keeping with the high bias against obesity in society at large. 1,7
Research has indicated, in fact, that public policies designed to combat the obesity epidemic will need to combine interventions in social and environmental determinants of health with an emphasis on individual responsibility for weight control in order to be effective and acceptable to the American public. 9