The Impacts of Weight Bias in Health Care

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

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 COVID-19: “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 from 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 you when you’re fat.”

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• Bergendahl M, Vance ML, Iranmanesh A, Thorner MO, Veldhuis JD. Fasting as a metabolic stress paradigm selectively amplifies cortisol secretory burst mass and delays the time of maximal nyctohemeral cortisol concentrations in healthy men. J Clin Endocrinol Metab. 1996;81(2):692-9.
• Nakamura Y, Walker BR, Ikuta T. Systematic review and meta-analysis reveals acutely elevated plasma cortisol following fasting but not less severe calorie restriction. Stress. 2016;19(2):151-7.
• Tomiyama AJ. Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite. 2014;82:8-15.
• Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLOS ONE. 2013;8(7):e70048.
• Vartanian LR, Novak SA. Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise. Obesity. 2011;19(4):757-62.
• Ball K, Crawford D, Owen N. Obesity as a barrier to physical activity. Aust N Z J Public Health. 2000;24(3):331-3.
• Robertson N, Vohora R. Fitness vs. fatness: Implicit bias towards obesity among fitness professionals and regular exercisers. Psychol Sport Exerc. 2008;9(4):547-57.
• Robinson E, Sutin A, Daly M. Perceived weight discrimination mediates the prospective relation between obesity and depressive symptoms in U.S. and U.K. adults. Health Psychol. 2017;36(2):112-21.
• Sutin AR, Stephan Y, Luchetti M, Terracciano A. Perceived weight discrimination and C-reactive protein. Obesity. 2014;22(9):1959-61.
• Tomiyama AJ, Epel ES, McClatchey TM, et al. Associations of weight stigma with cortisol and oxidative stress independent of adiposity. Health Psychol. 2014;33(8):862-7.
• Sutin AR, Stephan Y, Terracciano A. Weight discrimination and risk of mortality. Psychol Sci. 2015;26(11):1803-11.
• Callahan D. Obesity: chasing an elusive epidemic. Hastings Cent Rep. 2013;43(1):34-40.
• Gudzune KA, Beach MC, Roter DL, Cooper LA. Physicians build less rapport with obese patients. Obesity (Silver Spring). 2013;21(10):2146-52.
• Gudzune KA, Huizinga MM, Beach MC, Cooper LA. Obese patients overestimate physicians’ attitudes of respect. Patient Educ Couns. 2012;88(1):23-8.
• Schvey NA, Puhl RM, Brownell KD. The impact of weight stigma on caloric consumption. Obesity. 2011;19(10):1957-62.
• Hunger JM, Tomiyama AJ. Weight labeling and obesity: a longitudinal study of girls aged 10 to 19 years. JAMA Pediatr. 2014;168(6):579.
• Churchill J, Ward E. Communicating with pet owners about obesity: roles of the veterinary health care team. Vet Clin North Am Small Anim Pract. 2016;46(5):899-911.
• Perrin EM, Skinner AC, Steiner MJ. Parental recall of doctor communication of weight status: national trends from 1999 through 2008. Arch Pediatr Adolesc Med. 2012;166(4):317-22.
• Rose SA, Poynter PS, Anderson JW, Noar SM, Conigliaro J. Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data. Int J Obes. 2013;37(1):118-28.
• Pool AC, Kraschnewski JL, Cover LA, et al. The impact of physician weight discussion on weight loss in US adults. Obes Res Clin Pract. 2014;8(2):e131-9.
• Bleich SN, Bennett WL, Gudzune KA, Cooper LA. Impact of physician BMI on obesity care and beliefs. Obesity (Silver Spring). 2012;20(5):999-1005.
• Berry AC, Berry NA, Myers TS, Reznicek J, Berry BB. Physician body mass index and bias toward obesity documentation patterns. Ochsner J. 2018;18(1):66-71.
• Bleich SN, Gudzune KA, Bennett WL, Jarlenski MP, Cooper LA. How does physician BMI impact patient trust and perceived stigma? Prev Med. 2013;57(2):120-4.
• Smith AW, Borowski LA, Liu B, et al. U.S. primary care physicians’ diet-, physical activity-, and weight-related care of adult patients. Am J Prev Med. 2011;41(1):33-42.
• Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment. Obesity Research. 2003;11(10):1168-77.
• Adler NE, Stewart J. Reducing obesity: motivating action while not blaming the victim. Milbank Q. 2009;87(1):49-70.
• Tomiyama AJ, Mann T. If shaming reduced obesity, there would be no fat people. Hastings Cent Rep. 2013;43(3):4-5; discussion 9-10.
• Rand CS, Macgregor AM. Successful weight loss following obesity surgery and the perceived liability of morbid obesity. Int J Obes. 1991;15(9):577-9.
• Wright BA. Sensitizing outsiders to the position of the insider. Rehabil Psychol. 1975;22(2):129-35.

Motion graphics by Avo Media

• candy
• children
• depression
• inflammation
• lifespan
• longevity
• medical profession
• mental health
• mortality
• obesity
• oxidative stress
• weight loss