Weight Bias, Prejudice, and Stigma in Obesity—Still Among Us and Possibly Worse Than Ever!
BT Online Editor | April 1, 2020
by ADRIAN DAN, MD, FACS, FASMBS
Dr. Dan is Medical Director, Weight Management Institute at Summa Health in Akron, Ohio, and Associate Professor of Surgery at Northeastern Ohio Medical University (NEOMED) in Rootstown, Ohio.
FUNDING: No funding was provided.
DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.
Perspectives is a quarterly column edited by Adrian Dan, MD, FACS, FASMBS, designed to bring attention to current topics and issues pertinent to professionals treating obesity.
Bariatric Times. 2020;17(4):12–13
Prejudice, stigma, and bias toward individuals suffering with a disease? It would seem unimaginable that such callous and insensitive behavior is still existent in 2020. But for patients living with obesity and those seeking medical and surgical treatment to combat it, this type of discrimination is still a pervasive and much- too-common reality.
I was recently asked to evaluate a patient five years post sleeve gastrectomy in the emergency department for symptomatic gallstones, and our discussion took a little detour. We recalled her history of obesity and the results of her bariatric surgery. After a substantial initial weight loss, she regained some of the weight and had admittedly been less than adherent to our recommendations for follow-up visits. “I was ashamed to come see you Dr. Dan…I was ashamed to come see the obesity medicine doctors too…I thought I failed you all.” I paused to reflect, wondering how much of this perceived shame was due to my actions or perhaps those of our bariatric team. I reassured her that obesity is a chronic disease, and that patients should not be ashamed to follow up for care that would help them in the fight against it. As our conversation went on, she confided in me some heart-breaking stories about harassment and dismissal that she endured for decades at the hands of providers, nurses, assistants, and lay members of our community.
While the last half century has certainly brought about remarkable advancements in the realm of social equality, there is still much work to be done when it comes to individuals suffering from obesity. To some, who are not aware of the newly illuminated pathophysiologic roots of this metabolic dysfunction, the condition is still erroneously believed to be a result of poor discipline, lack of will power, and a flaw of character. Others, whose genetic make-up allows them to maintain a healthy weight with little effort, somehow pass themselves off as experts in the root causes of obesity and offer simplistic and unrealistic solutions to ameliorate the condition. Those attitudes have allowed this prejudice to remain one of the last accepted forms of discrimination among those still living with such ignorant insensitivities.
Certainly, surgeons should admit that we often refer to our daily schedule in terms of doing a “gallbladder” or a “bypass” rather than the names of our patients. In doing so, we allow the procedure or disease to define the patient and unknowingly partake in implicit bias. But when asked, medical professionals will often deny any personal bias toward patients with obesity. Studies indicate otherwise, as most of us do hold some implicit bias, and acknowledging the presence of such hidden sentiments is imperative to the admission that a problem still exists.
Society and the media still display explicit biases, and this somehow has remained acceptable and ubiquitous in movies, television shows, and comedy parodies. Societal perceptions remain that obesity is an act, a behavior, and a personal choice reflective of an individual’s virtues and self-control. This allows the media and the entertainment industry to relentlessly make anecdotes and derogatory comments at the expense of patients affected by what is actually a well-defined disease. Some poor nutritional and activity choices might contribute to overweight and mild obesity, but in its severe forms, obesity has genetic and physiologic underpinnings like those of many other conditions. In parallel, it would be unacceptable to ridicule patients with any other diseases, as was unfortunately done with the human immunodeficiency virus (HIV) epidemic in the 1980s. Even in cases when entertainment venues seek to chronicle and document the struggles of patients with obesity, the entertainment measure is mostly attained at the expense of patients. The mark is missed when extreme cases are sometimes showcased, implying that such excessive degrees of obesity must be reached before medical and surgical measures are pursued.
What can we do to tear down our own implicit subconscious, as well as the explicit societal biases? To begin with, person-first language acknowledges the understanding that we are treating individuals afflicted by a disease rather than the disease that affects the individual. Medical professionals must unite in a concerted effort and lead by example to shape new societal norms. This starts with an introspective evaluation of our own personal actions and an understanding of the roots of this highly complex disease. Our patients deserve to be treated with the support, respect, and access to care that patients with any disease should be granted. As the incidence and prevalence of obesity still continue to rise, so must individual champions of this great cause. Sadly, however, and as noted by many who have witnessed the obesity epidemic develop over decades, the resilient stigma and prejudice faced by our patients might now be worse than ever.
by TED KYLE, RPh, MBA
Mr. Kyle is a pharmacist and healthcare innovation professional who serves on the Board of Directors for the Obesity Action Coalition and advises The Obesity Society.
In his commentary, Dr. Adrian Dan makes an excellent point about obesity and weight stigma. These might be the worst of times for patients with obesity and the weight stigma they experience. And at the same time, true to the writing of Charles Dickens, it might be the best of times. How can this be?
Let’s start with the good news. Bias comes in two forms: explicit and implicit. Explicit bias is that nasty stuff we say right out loud. “Can you believe how big she is?” “People with obesity have no one to blame but themselves.” “I’d love to promote you, but unless you can lose some weight and show that you’ve got your life under control, I’d never be able to sell it to management.” These are the kinds of stupid things I’ve heard people say over and over again.
But the good news is that over the last 10 years, that kind of explicit bias is going down. Now to be clear, it’s not gone. But you can’t say things like that anymore and get by with it in polite company. It’s now called fat shaming, and decent people just don’t do that.
How do we know? We know because Harvard’s Project Implicit has been studying implicit and explicit bias in many forms. Last year, they published a paper¹ looking back at how patterns of bias have changed over the last 10 years. They found that explicit bias of all types— including weight bias—had decreased over the last 10 years. That’s the good news.
However, the bad news came when these researchers looked at trends in implicit bias. For sexuality, race, and skin tone, it had decreased over the last 10 years. For age and disability, it had not changed. But for weight, it went up.
While people talk a good game about being more respectful, we have mostly become even harsher in our judgments against people with obesity. We say one thing, and we think another. Sometimes we make those harsh judgments without even really thinking about it.
The obvious question is, what can we do about it? First, we can stop labeling people as “obese.” The problem is the disease of obesity—a complex, chronic disease that’s resistant to treatment. It is not the people who have it, so we should not be labeling them as “obese.” Every one of our patients is a whole person, not just a diagnosis.
But more than that, we need to make sure that we and all our colleagues deal with obesity as the chronic disease that it is. Behavioral challenges are the result of obesity, not necessarily the cause. The cause is genetic, physiologic, and environmental. Behavior change is mostly a tool for coping with it. But when we think of obesity as nothing but a behavioral problem, we put the blame on the patient. And that is how we lose the battle with weight bias.
Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: I. Long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174–192.