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The M.D.

Doctors and nurses' weight biases harm overweight patients

Negative reinforcement demonstrably does not work and can discourage patients from seeking future treatment.

December 13, 2010|By Valerie Ulene, Special to the Los Angeles Times

I'm quite thin now, but that wasn't always the case. As a child, I carried around extra weight for many years — and my brothers never let me forget it. They called me "Logs" (as in, my legs looked like them) and "Orca" (as in, I was the size of one). I think "Moo Cow Chunk Chunk" was the one that stung the most.

People who are overweight live with this type of ridicule all the time. "There are pervasive stereotypes that obese individuals are lazy and undisciplined," says Rebecca Puhl, director of research at the Rudd Center for Food Policy and Obesity at Yale University. They're also commonly viewed as mean, stupid and unhappy. A 2008 study in the International Journal of Obesity found that almost 6% of moderately overweight men and women reported experiencing bias because of their size; the rate was 13% for individuals who were obese and 40% for those who qualified as severely obese.

Stigma comes from family members, friends, teachers, employers, classmates, shopkeepers and — more startling and potentially damaging — from healthcare providers such as doctors and nurses.

"Weight bias is a very acceptable part of the medical environment," Puhl says. In 2003, researchers at the University of Pennsylvania surveyed more than 600 primary care doctors and found that more than half viewed obese patients as awkward, unattractive and noncompliant. One-third characterized them as weak-willed and lazy. Even physicians specializing in the treatment of obesity harbor significant weight biases, according to more recent studies.

The problem has been well documented among other types of health professionals, nurses in particular. At least 11 studies focusing on nurses' attitudes toward overweight and obese patients have been published. They consistently show that many nurses harbor negative biases toward these patients and, in some cases, would prefer not to care for them or even touch them.

Doctors and nurses often feel that their weight biases are justified. They — like so many people — believe that obesity is caused almost exclusively by an unhealthful diet and a lack of exercise. In their minds, it's a problem that people inflict upon themselves that could be solved if patients were motivated enough.

Some healthcare professionals actually believe that stigma and shame can be used to help motivate patients to lose weight. Just the opposite appears to be true, Puhl says: "People who are exposed to stigmatizing situations are more likely to engage in unhealthy eating behaviors and less likely to be physically active."

A 2006 report in the journal Obesity examined the ways that women cope with stigmatizing situations involving their weight. Eating was in the top five: Seventy-nine percent of women in the study said they coped with weight bias by eating more food and 75% by refusing to diet. Other studies suggest that exposure to stigmatizing situations increases the likelihood of binge eating.

Humiliating interactions with healthcare providers make many overweight patients reluctant to seek out medical care. Studies show that individuals who are overweight are less likely to get preventive procedures such as cancer screenings. And if they're avoiding the doctor's office, their medical problems are likely to go untreated as well.

Without question, treating obesity is a difficult challenge for physicians. "It can be incredibly frustrating," Puhl says "There aren't a lot of good treatment options."

But what people — healthcare providers in particular — need to recognize is that losing weight isn't just about going on a diet and sticking to it. "Focusing on personal responsibility doesn't work," Puhl says. "There are so many other big contributors that need to be addressed if the problem is to be solved."

Healthcare providers also need to readjust their expectations. Getting individuals who are obese down to a normal weight isn't realistic: Research shows that most people can't expect to lose more than 10% of their body weight and, more important, to maintain the weight loss over time. Instead of viewing that as a treatment failure and growing discouraged with patients, doctors and nurses need to recognize that even relatively small changes in weight represent real progress and can have very important implications for health.

My siblings just wanted to torture me — and that they did. But they, unlike doctors and nurses, weren't under any sort of ethical or professional mandate to be kind. Rather than contributing to the problem of weight bias, healthcare professionals need to try to help eliminate it. They, better than anyone, should understand that obesity has complex causes and requires complex solutions.

A patient who's overweight deserves to be treated compassionately and effectively. It's not just the right thing to do, it's the best approach for successful treatment.

Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.

themd@att.net

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