Confronting Weight Bias in the Clinic

This transcript has been edited for clarity.

Holly Lofton, MD: Hi. I'm Dr Holly Lofton. Thank you for joining us for another video in our series about weight management and obesity. Today we have a special topic that is essential to treating patients with obesity. In order to help patients achieve the most success, we need to create a healthy environment in which they feel comfortable. And we can only do that in a situation where all of the providers and staff who interact with patients with obesity are aware of the impact of weight bias. I myself teach residents, students, fellows, and other doctors about the impact of weight bias, so I appreciate your taking the time to learn more about it and how minimizing weight bias in healthcare settings can be beneficial to our patients.

Today I'm joined by two wonderful guests. The first is very near and dear to my heart: one of my patients, Mrs Uta Hershey. We've been working together for such a long time through her weight management journey, and we expect to continue this journey for life. The next special guest I'm being joined by is Dr Rebecca Puhl. Dr Puhl is deputy director of the Rudd Center for Food Policy and Health at the University of Connecticut, where she leads research and policy efforts aimed at reducing weight, stigma, and discrimination. She is an expert on weight bias, has authored over 180 peer-reviewed articles on this topic, and has received multiple national awards in this field. I thank you both for your time. Welcome.

Uta Hershey: Thank you.

Lofton: I'll start with you, Dr Puhl. Can you tell us first what weight bias is and how weight bias can impact the well-being of those with weight conditions?

Rebecca M. Puhl, PhD: Weight bias refers to societal devaluation of people because of their body weight or body size. We live in a society that negatively stereotypes people who have higher body weight. They are stereotyped as lazy, unmotivated, lacking in willpower. And unfortunately, these negative stereotypes give way to societal prejudice and stigma, unfair treatment and discrimination.

Weight stigma is very damaging and harmful to multiple aspects of a person's health and well-being. It can lead to psychological distress, including depressive symptoms, anxiety, poor body image, increased substance use, and even suicidal thoughts and behaviors. And the psychological distress of weight stigma has been documented in both adults and in children. These negative consequences can persist independent of a person's actual weight status. That's important because it tells us that it's not body weight or obesity per se that is leading to psychological distress; it's the stigma of weight that is responsible. Beyond this emotional distress, being stigmatized about weight also leads to worse physical health. Being stigmatized or shamed about one's weight can lead people to engage in disordered eating behaviors like binge eating, unhealthy weight control practices, weight gain, and lower physical activity. And it also increases physiologic stress like cortisol levels and increased risk for metabolic syndrome. All of these can worsen a person's health and quality of life and can even increase mortality risk.

Lofton: I've heard the term "internalized weight bias." What does that mean?

Puhl: Sometimes when people experience weight stigma in their daily lives, when they are exposed to stigma, they become aware of just how many stereotypes there are in our society. People turn those beliefs and stereotypes inward. They blame themselves for their weight status, for the stigma that they are experiencing, and they engage in self-stigma. Why this is important is because we see in research studies that internalized weight bias has the same kinds of negative implications for health that experiences of weight stigma do. Stigma predicts those negative health consequences over and above experiences of weight stigma. We need to be paying attention both to unfair treatment that people are experiencing because of their weight or size, and also how people then interpret those experiences for themselves and how they internalize that bias and put it toward themselves.

Lofton: That's very helpful. I'll move on to a question for Uta. Can you share with us any instances in which you experience weight stigma in social settings or even in a healthcare setting?

Hershey: I think obesity is one of the last acceptable bastions of prejudice and bias. In other words, people feel that they have carte blanche to make comments. This is not just in the family, but also outside, with people that you know or even random people. A neighbor of ours simply said, "It must be difficult for you to be fat and to live your life." This was very hurtful. I'm a creative person, a former fashion executive, and my thinking is always to power around the problems. And that's what I did externally, visibly, with other people. But down deep, I was harboring self-loathing throughout this time, and it made it much more difficult for me to lose weight. In fact, over a 30-year period, I would gain 10 pounds a year — 10 pounds, 10 pounds, 10 pounds — until I was large and unable to really move. And then it was 20 pounds and even 30 pounds. So, how people react with the person does have mostly an internal influence on yourself.

Lofton: Is there a time when you experienced an uncomfortable encounter with a healthcare provider related to your weight that you could share with us?

Hershey: Here is the one major example. I was 52 years old. I needed a colonoscopy. I went to the doctor. He looked at me and said, "You are too obese for me to do it in my office facility, so we'll have to do it in the hospital." And I said, "Sure, let's do it in the hospital." And then he looked at me again and said, "Oh, I'm really not sure I'm going to be able to even do it there." And possibly he was not capable of doing the colonoscopy, but I think the forward movement would have been to seek out a professional who could have done the colonoscopy, who had experience with obese people. I always think that there is a forward path for helping with the immediate needs of an obese person.

Lofton: I give you a lot of credit for being so open, even when you may have felt offended in that medical setting. Were you able to eventually have the procedure performed?

Hershey: I was. My mother passed away from pervasive cancer and I was able to find a doctor who would do this. But it affected my whole approach to how I went about taking care of myself. For about 8 years I did not go to professionals and have procedures done because I was afraid that I would code on the operating room table. I therefore internalized this feeling and thinking, and I did not even pursue bariatric surgery, which was the next natural step for me because I reached the maximum 405 pounds. I think the remedy for someone who cannot treat an obese person is to find a fellow colleague who can help that person and who has the experience. It's understandable that they might want to refer that patient out to someone who has the capabilities to do this.

Lofton: Thank you so much for sharing your poignant experiences. I must say, you're quite brave in continuing to seek out a healthcare provider to care for you in a setting of being told that you might die in the event of a procedure, which could be heartbreaking to hear. So you went to find a surgeon and you had a positive experience. You did well. Dr Puhl, how can weight discrimination in healthcare settings affect patients with obesity, and what are some of the potential consequences for those who do experience this?

Puhl: It's important to recognize that healthcare professionals are not immune to weight bias. We see stigmatizing attitudes of medical professionals that are the same stereotypes that we see in the general population. They also include stereotypes that patients with obesity have poor self-management behaviors or are less compliant with medication and treatment. These kinds of attitudes have been reported by a range of healthcare professionals, including doctors and nurses but also dietitians and mental health professionals, and even students training in professional health disciplines. What we see is that doctors tend to express weight bias at similar levels to the general population. Even if it's unintentional, this can translate to poor communication with patients and reduce quality of healthcare delivery.

For example, compared with their provision of care of patients with lower body weight, when it comes to treating patients with obesity, studies show that healthcare professionals tend to spend less time in their appointments. They demonstrate less rapport with patients. They tend to engage in less patient-centered communication and admit that they don't intervene as much as they think they should. They also report lower respect for patients as their body weight increases.

From the patient side, patients report feeling judged or shamed because of their weight, and receiving disrespectful and insulting comments and insensitive language about their weight — just a general lack of compassion during healthcare visits. This can negatively impact patient care, and it can lead patients to avoid seeking healthcare. We see that adults with higher weight, especially women, are avoiding healthcare because of weight stigma, because of experiences like disrespectful treatment and negative attitudes from their doctors, unsolicited advice to lose weight, or medical equipment that's too small to be functional for their body size, and also from internalized weight stigma — blaming themselves for their weight. People who have experienced weight stigma in healthcare don't want to repeat those experiences. As a result, they delay or avoid seeking healthcare altogether.

Lofton: We know there are many other types of bias that exist in the world, and many people may be victims of multiple types of bias based on gender, socioeconomic status, race, and ethnicity. Can you talk about the intersection of multiple types of discrimination and how that might affect an individual?

Puhl: Yes, this is really important. We know that weight stigma affects people of different racial and ethnic backgrounds, different sexual orientations and gender identities, and different income levels. No one is immune to experiencing weight stigma, and one's cultural or sexual identity is not protective against weight stigma or its harmful impact. But the health consequences of weight discrimination may be elevated in certain minoritized communities, such as Hispanic women or adults with lower income. We also know that obesity-related health disparities exist for racial and ethnic minority groups and sexual minority populations. There's a higher prevalence of obesity in these groups, which places them at higher risk for weight stigma. And so we need to recognize that many people who experience weight stigma are also stigmatized for other reasons — for their racial or ethnic identity, their sexual or gender identity, or another stigmatizing characteristic. For example, among adults with obesity who report weight discrimination, as many as 80% have experienced at least one other form of discrimination. They are experiencing intersectional stigma, multiple forms of stigma. That amplifies health disparities and can negatively affect their mental and physical health. For example, we know that adults who experience both weight discrimination and racial discrimination have a heightened risk for cardiovascular disease. It's really important for healthcare professionals to recognize that patients may be living with multiple stigmatized identities and to really think holistically about how those stigmatized identities can affect their health outcomes and their care.

Lofton: What are some proven effective strategies for minimizing weight bias and discrimination for healthcare professionals who are watching?

Puhl: One thing we do know is that when people attribute the causes of obesity to individual level — characteristics like poor self-discipline or willpower —those attributions increase weight stigma. But in contrast, recognizing the complex etiology of obesity that includes factors beyond an individual's control leads to reductions in weight stigma. That's true for healthcare professionals as well.

Strategies to reduce weight bias in the medical setting need to start with education and recognition of the complex etiology and the pathophysiology of body weight regulation and obesity. But that in itself is not enough. To reduce bias, there also needs to be education and training about weight bias and how it affects patients — training to really increase providers' own self-awareness of personal biases about body weight and how those biases may be communicated to patients. It's also important for healthcare professionals to know what tools to use to improve supportive, respectful, and patient-centered communication. A really big part of this is communication. For example, healthcare professionals can be more supportive to patients by discussing health behavior changes in the context of improving health indices, and non–scale-related victories like improved blood glucose levels and blood pressure and quality of life, rather than focusing only on weight or emphasizing BMI. We need to make sure that physicians are considering the patient's concerns, independent of their weight, and exploring all causes of a patient's presenting problems and using respectful language when talking to patients about weight. Making changes in communication like these can be very helpful in reducing weight stigma in clinical care and providing more supportive and compassionate care to patients of different body sizes.

Lofton: Those are some really helpful strategies. You mentioned earlier having the equipment that can help patients of all sizes feel comfortable, such as not having armrests in the waiting room and having lots of options for blood pressure cuff sizes, making sure that the size and weight limits on equipment are appropriate so patients can feel comfortable in the physical setting while you create the emotional, compassionate setting as well. Are there any other resources that you would recommend for our audience to help them learn more about weight bias and discrimination?

Puhl: Yes. We've developed a number of evidence-based and free educational resources on weight bias; they are available at the Rudd Center website. They include strategies like how to have a discussion about body weight with patients in a way that is supportive and not stigmatizing; what kinds of equipment you can make sure that your office setting has to accommodate people of different body sizes; and how to become more aware of your own implicit bias and challenge some of those assumptions that many people hold.

Lofton: Thank you, Dr Puhl, for sharing those strategies to reduce weight bias in healthcare settings, because we know that this can really help our patients want to address not only weight- but non–weight-related conditions that can improve their longevity and overall quality of health.

Uta, are there any positive experiences of healthcare providers that you can share with the audience? What made those more positive and you more likely to repeat seeing that provider because you felt comfortable with that provider or their office setting?

Hershey: I feel very lucky that all along I had a very supportive GP. She rode the ride with me and continues to be supportive. It is very important to have that general practitioner who can be with you through your journey. The next most helpful doctor was, of course, my bariatric surgeon. I could see that she had the maximum combination of things that I needed to have. One was compassion. One was openness. I felt free to speak about all my issues and worries with her. Part of this was my having decided to open up because I had been closed for many years and trying to solve this tremendous problem on my own. She was there to answer all my questions forthrightly and in a kind and compassionate way. Those two doctors were great standouts in my care and continue to be. And, of course, talking with you every 2 months or so, I find it incredibly important that I have a touchstone person, an expert in the field that I can come to and ask questions.

Lofton: We really tried to share among the medical community so that there are evidence-based improvements in decreasing discrimination related to weight and other factors. One of those is that we use motivational interviewing. To put this simply, this is having an open-ended–question type of conversation with the patient. For example, when I enter the room with a new patient, I know why that person is there; my office door says Weight Management Center. But I want to understand their personal motivation for coming to see me and for having this discussion. So I usually start with, "What brings you here today?" or "Why are you interested in weight management?" And that gives me some insight as to how I can help that patient achieve their goals, especially their non-scale goals. Because the number on the scale is not what the metric is that we're trying to reduce; it's improving the patient's health, happiness, and longevity. And I tell the patient, "I put the scale there because sometimes we need documentation for insurance, but the number doesn't matter to me. I want you to have normal labs. I want you to feel good when you're in a place where you're ready to maintain. We can move from weight loss to weight maintenance. But going forward, know this will be a long process." We want to create a relationship where we both feel that we're moving in the direction that's best for the patient. These are some of the strategies I recommend for providers. Uta, as a patient, is there anything you could share that patients can use to help make these types of conversations more useful?

Hershey: It's important to go back to the doctor that you trust and care about, and also to see this journey exactly as a health journey rather than about how you look on the outside. It is about how healthy you are, and that's very important. To me, it's also important to journal, to write down what happens in your life every day if you can — to know that you are making progress even when sometimes you have hiccups. You can look back on this. I have a book, but you also could do it online, so you're able to see that there is progress. My journey has been 5 years and almost 225 pounds of weight loss, with some ups and downs, and journaling has been helpful. Particularly when I hit rocky roads, I can look and see that overall there is a positive trajectory. I think it's also about time, which is something that hospital administrators have to wrap their heads around: the time that a physician or a medical person can spend with the patient, because sometimes these things take a little bit longer in the office to discuss.

Lofton: Thank you for this amazing insight. We'll definitely utilize those. Audience, you're getting a real treat here.

This has been really wonderful. We have talked about the definition of weight bias and discrimination. Dr Puhl told us how this can affect health consequences across so many different aspects of one's life. Uta shared some of her experiences, both positive and negative, as she's progressed and continues on her health journey, as we call it now. I like that term better. We've given you some resources that you can use to learn more about weight bias, and even some tests that you can do online. There is an implicit-bias test; you can just search that and find it online to test your own implicit or unconscious bias. I encourage everyone to do that. I hope you gain some more information about how being aware of and minimizing weight discrimination and bias in healthcare settings can really help our patients and ultimately make us better providers. Thank you.

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Cite this: Confronting Weight Bias in the Clinic - Medscape - Jan 18, 2024.