Weight Bias in Health Care

I’m often asked my opinion about a diet or a disease is. Who cares what my or anyone else’s opinion is? All we should care about is what the science says. What does the best available balance of evidence published in the peer-reviewed medical literature have to say right now?

Welcome to the NutritionFacts Podcast – I’m your host Dr. Michael Greger.

Did you know that research has consistently shown that healthcare professionals are biased against people classified as overweight or obese? In our first story – we look at how common this problem is.

Described as the last “acceptable” form of bias, weight stigma is the rampant discrimination and stereotyping of overweight individuals. Fifty overweight women were asked to keep a diary of all the times they felt they were being stigmatized for their weight. Over a single week, more than a thousand instances were recorded. An overweight woman may expect to be harassed (such as called names or insulted), run into physical barriers (like unable to fit into public seats), or discriminated against (such as perceived poorer service at restaurants or stores) on average about three times a day. Obese men report three times less discrimination than women of the same size; so, maybe it’s only a daily occurrence for them.
They’re not just being paranoid. Studies using professional actors presenting as job applicants made up to appear overweight with the Hollywood magic of theatrical prostheses were significantly more likely to be discriminated against than when appearing as their normal weight selves. This employment bias was found to be especially prejudiced against overweight women compared to men.
Attitudes can also be explored in surveys. In a comparison of 16 stigmatized social groups, such as homosexuals and homeless people, only drug addicts and smokers were regarded with higher levels of disgust than obese individuals. The researchers did note, however, there was effectively a tie: obese people were “rated just as disgusting as politicians.”
This weight stigma starts surprisingly young. Children as young as three years old describe overweight peers as “mean,” “stupid,” “lazy,” and “ugly.” Then, there was that famous study published back in 1961.
Children in summer camps and schools across a swath of different social, cultural, and ethnic backgrounds in California, Montana, and New York were asked to rank the following images as to who they liked best, including a child in crutches with a brace on their leg, a child in a wheelchair, a child with one of their hands missing, a facially disfigured child, or an obese child. In every population of kids they tested, there was “remarkable uniformity.” The obese child always came in dead last.
That was ages ago, though. But in 2003, researchers published the 40-year follow-up. The study was repeated and…the title of the study gives it away: “The Stigmatization of Obese Children: Getting Worse.” The obese child was liked even less! This parallels trends throughout society, with nearly a 70 percent jump in perceived weight discrimination recorded in national surveys since the mid-nineties.
Attitudes among teachers may not be helping. More than a quarter of teachers and other school staff surveyed felt that becoming obese is “one of the worst things that could happen to a person.” Even parents can be biased, providing less support for college for their overweight daughters compared to thinner siblings. As two prominent obesity researchers commented, “It is a strong prejudice indeed when parents discriminate against their own children.”
What about doctors? One representative national survey found that more than half of physicians viewed obese patients as “awkward, unattractive, ugly, and noncompliant.” About a quarter of nurses agreed or strongly agreed to the statement: “Caring for an obese patient usually repulses me.”
This antagonism can have serious health consequences for those who may need it the most. For example, obese women are at higher risk for developing cervical, endometrial, and ovarian cancers. Yet they are less likely to be screened. Morbidly obese patients only have about half the odds of getting their recommended ¬¬¬pelvic exams. Part of this may be avoidance on the part of the patient, but some doctors just turn obese patients away. The Sun Sentinel polled OB/GYN practices in Florida, and found that as many as one in seven refused to see heavier women––for example, setting weight cut-offs for new patients starting at 200 pounds.
Even doctors who welcome obese patients have been found to give them short shrift. Physicians randomized to receive a medical chart of a migraine patient who was either presented as average weight, overweight, or obese said they would give the obese patient about 28 percent less of their time. And it’s less quality time. Recorded doctor’s visits found physicians tend to build less emotional rapport with overweight patients.
Even obesity specialists profess increasingly explicit anti-fat attitudes. Worsening in surveys taken between 2001 and 2013, obesity specialists described fat people as significantly more “lazy, stupid, and worthless.” Even in the medical literature, you’ll find lines like this, an example from Annals of Internal Medicine: “obesity is an aesthetic crime: it is ugly.”
The good news is that they appear to be able to hide their disdain. In a study entitled “Obese patients overestimate physicians’ attitudes of respect,” despite the negative attitudes doctors harbored towards their obese patients, the same patients expressed their satisfaction with their providers. The researchers concluded, “While physicians may be successfully playing the part, the lack of true respect suggests…the authenticity of the patient–physician relationship should be questioned.”

In our final story today, we ask – how might weight stigma be a vicious cycle?

Although total fasting can dramatically increase blood levels of the stress hormone cortisol––as much as doubling within five days, just dieting alone does not. There is, however, a way stress and obesity could turn into a vicious cycle: weight stigma.
Across thousands of individuals followed for four years, those reporting discriminatory experiences had more than twice the odds of becoming obese. And those who started out obese had more than three times the odds of staying that way, compared to those who started out at the same weight but didn’t experience discrimination. Now, this could be from stress-induced eating on one side of the calorie balance equation, or stigma-induced exercise avoidance on the other.
Obese individuals with more frequent experiences with weight stigma report greater avoidance of exercising in public, feeling judged and embarrassed. These “too fat to exercise” fears may be well-grounded. Strong anti-fat biases have been documented in both fitness professionals and regular gym-goers, which may translate into an unwelcoming environment in fitness centers and health clubs.
Whichever side of the calorie equation that gets tipped, those who experience weight stigma can also end up suffering health consequences independent of any added weight. Those reporting more frequent fat prejudice exhibit higher levels of depression, higher levels of inflammation, and higher levels of oxidative stress, as well as a shorter lifespan. Two studies following a total of nearly 20,000 people both found about a 50 percent increase in mortality risk among those reporting greater daily discrimination. Weight discrimination may shorten life expectancy. Despite these hazards, some scholars advocate for even more fat-shaming.
The President Emeritus of the prestigious Hastings Center infamously advocated for “a kind of stigmatization lite,” using social pressures to compel people to lose weight without resorting to outright discrimination. After all, he argued, what else has the potential to counter the persuasive force of the billions spent in advertising every year by the food and beverage industry? It worked against tobacco. He recalls his own battle with addiction: “The force of being shamed and beat upon socially was as persuasive for me to stop smoking as the threats to my health.” The public health campaign to stigmatize cigarettes turned “what had been considered simply a bad habit into reprehensible behavior.”
When such campaigns have been tried, they have been met with fierce resistance, though. Georgia’s Strong4Life campaign featured billboards of morose-looking obese children with captions like: “Warning: Chubby kids may not outlive their parents” or “It’s hard to be a little girl when you’re not.” The campaign sponsors defended the ads as an attempt to break through the denial in a state with some of the highest recorded childhood obesity rates. It’s only defensible, though, if it works.
Yale researchers found that when normal-weight women are provided with bowls of M&Ms, jelly beans, and chips to snack on after watching clips of stigmatizing material like clumsy, loud, lazy stereotypes getting teased about their weight, they eat about the same amount compared to watching neutral material, such as insurance commercials. But when overweight women watch the same two sets of videos, they triple their calorie intakes after watching the stigmatizing scenes. The researchers concluded, “This directly challenges the notion that pressure to lose weight in the form of weight stigma will have a positive, motivating effect on overweight individuals.” In other words, it could make things worse. Being labeled “too fat” in childhood was associated with a higher risk of becoming obese, compared to children weighing the same who were never told that. But does that mean we should just ignore the elephant in the room? Many doctors apparently think so.
Just as veterinarians have been found to be reluctant to tell people their pets are obese, fewer than a quarter of parents of overweight children report having been told by pediatricians about their child’s weight status. One might think it would be obvious, but a Gallup survey found that parents appear to be “notoriously poor judges of their children’s weight.” Similarly, the percentage of adults who describe themselves as overweight has remained essentially unchanged over the past few decades, despite skyrocketing obesity. All this, Gallup concluded, helps “paint a picture of mass delusion in the United States about its rising weight.”
I think patients have the right to be informed. Those told by their doctor that they are overweight have about four times the odds of attempting weight loss and about twice the odds of succeeding.
Just as smoking physicians are less likely to challenge their smoking patients, overweight physicians are less likely to bring up the subject of weight loss or even document obesity in their charts.
Ironically, overweight patients trust diet advice from overweight doctors more than docs who are normal weight. Unfortunately, primary care physicians appear to have little to offer in terms of specifics. Fewer than half who were surveyed said they provide specific advice to their patients. Just telling patients to “watch what they eat” is unlikely to be particularly helpful, but many primary care physicians may not even get that far. Most physicians said they would spend more time working with patients on weight management if only their time was “reimbursed appropriately.” Maybe we could offer a bonus to refrain from blaming the victim. As one pair of commentators wrote in response to the pro-stigma camp, “If shaming reduced obesity, there would be no fat people.”
I want to end this weight stigma video series with the jaw-dropping findings of a study that I think best illustrates how hard it is to live inside a fat body. If this doesn’t foster sympathy among my medical colleagues, I don’t know what will. Researchers talked to men and women who had lost and kept off more than 100 pounds to tap into their unique insight, having personally experienced what it was like to be morbidly obese and then, on average, 126 pounds lighter. Forty-seven such individuals were interviewed.
They were asked to think back to when they were heavier and make a choice: “If someone offered you a couple of million dollars if you stayed morbidly obese forever, would you have chosen the money? Or would you have chosen to be normal weight no matter what?” Option 1 was, “I would have chosen no money and being normal weight. It would have taken me about a second to decide.” Option 2 was, “I probably would have chosen being normal weight. But the possibility of having that much money would make me think about the choice.” Option 3 was, “I wanted to be normal weight, but I could really use the money. If I could be a multimillionaire, I think I could live with being morbidly obese.” One of the 47 had to think about it, but the other 46 jumped at Option 1. No one chose Option 3. They all said they would give up being a multimillionaire to be normal weight.
If that shocked you, buckle your seatbelts. They were then asked about being obese compared to other disabilities. Normally, when you ask people to choose between living with their own disability or switching to a different one, there is a strong proclivity to stay with their own. For example, even though most people would rather be deaf than blind, blind people prefer to remain blind by a large margin, rather than having sight without sound. They already know how to cope with their own disability, and so there’s safety in familiarity. However, the exact opposite happened when the formerly obese were asked.
Every single one of the 47 said they’d rather be deaf for the rest of their lives than obese. Every single one said they’d rather have difficulty reading, be diabetic, have very bad acne, or heart disease than be obese. More than 90 percent said they’d rather have a leg amputated, and similarly, about 9 out of 10 said they’d rather be blind their whole lives than obese. Obesity appears to be the only handicap where nearly everyone wants to switch, no matter what the cost. To quote one study subject, ”When you’re blind, people want to help you. No one wants to help when you’re fat.”
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