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Researchers at the Rudd Center for Food Policy and Obesity at Yale University have found healthcare providers are guilty of weight bias

Vol. 9 • Issue 13 • Page 11

The glass door swings open and all eyes turn to the overweight woman pushing her way in to the waiting room.

Wearing an oversized flower-print dress and slip-on shoes that look too small for her wide feet, she presses through the doorway, angling her body as her husband holds the door with one arm and steadies her with the other.

"Oh my God," a mother holding a baby whispers to the 20-something man next to her. "Look at the size of that woman. She must be 300 pounds."

Other patients stare and smirk but avoid eye contact as the obese woman carefully lowers herself into a chair.

As a nurse in this doctor's office, how would you treat this patient? Ask yourself: Would you show her the same respect you give to other patients? Or would you succumb to the widely held stigmas that obese people are ugly, sloppy, lazy, and lacking in willpower and self-control?

Research by the Rudd Center for Food Policy and Obesity at Yale University, New Haven, CT, confirms what many overweight people already know: Weight bias has become increasing common among healthcare providers in recent years.

Why should that be surprising? After all, we live in a media-driven society that constantly bombards us with messages that slim is in and fat is foul. But shouldn't doctors, nurses and other medical professionals be above all the hype? Too often, that's not the case.

"Healthcare providers are not immune to these messages that everyone else sees in the media," said Rebecca M. Puhl, PhD, director of research and weight stigma initiatives at the Rudd Center. "As a result those same biases and stigmas can be communicated to the patient, even if it's unintentional."

A Widespread Problem

In order to stamp out weight bias in healthcare, it's important to first understand the scope of the problem.

In a 2006 Rudd Center survey of 2,400 overweight and obese women, 69 percent said doctors were a source of weight stigma in their lives, and nearly half (46 percent) said they had experienced weight bias from a nurse.

Puhl tells the story of one overweight woman who went to see her gynecologist for help with low libido.

"The gynecologist told her to lose weight so her husband would be more interested," Puhl recalled.

Another obese woman told researchers hospital staff told her she would have to be weighed on a freight scale in the basement because the patient scale couldn't support her.

These, of course, are extreme examples. Most instances of weight bias are far more subtle.

"Making inappropriate comments, smirking, rolling their eyes or other nonverbal ways . all these things can communicate bias," Puhl said.

The Rudd Center suggests nurses examine their own attitudes and assumptions about obese people. Ask yourself: "Am I comfortable working with people of size? Do I make assumptions based on a person's weight? Am I sensitive to the needs of obese patients?"

Also be mindful of the fact the overweight patients probably have been stigmatized by a medical professional at one time or another.

"So, even if you are not expressing bias in your dealings with patients, the chances are they have experienced it elsewhere and are sensitive to it," Puhl said.

Severe Consequences

For obese patients, the desire to avoid bias often leads to delaying or canceling doctor's appointments, mammograms, prostate exams and other medical screenings.

"Overweight people are reluctant to get preventive care, and it's possible they wait until they are more sick than most people would before they seek medical care," said Kelly D. Brownell, PhD, director of the Rudd Center.

Emotional consequences can include low self-esteem, poor body image and even suicidal thoughts. Depression and lack of self-worth can trigger binge eating and avoidance of exercise.

In addition, when doctors and nurses harbor negative attitudes, they are apt to spend less time with obese patients, and the quality of care suffers.

"In a healthcare setting, weight bias can have a significant impact on what happens in the office and also what doesn't happen there," Brownell said.

Behaviors, Not the Scale

Nurses and doctors are in a difficult position. To help an obese patient become healthier, providers have to talk about weight issues in a way that doesn't offend the patient.

Terminology is important, and Puhl suggests asking patients directly how they feel most comfortable about discussing their weight.

"Some patients are fine with the words 'obese' and 'fat,' while others aren't at all," she said.

Providers can ask, "Would it be OK to talk about your health today?"

And that's the key: emphasize "health" rather than the number on the scale, Puhl stressed. "It's a much more complex issue than just being large," she said.

Biological, genetic and environmental factors all play a role in a person's body weight and are often beyond the patient's control.

Marlene B. Schwartz, PhD, deputy director at the Rudd Center, said a good approach is to help patients create an environment in which it's easier for them to eat healthy and be more physically active.

"I don't think the goal should be to hit a target on a scale because that is not what they can control," Schwartz said. "They can only control what they do, and that is to try to be healthier."

Schwartz points out nurses who have struggled with weight themselves can be a positive influence.

"They can tell patients they know what it is like and how difficult it is to stay healthy in the society we live in today," Schwartz said. "They can say, 'I've struggled with these same issues, and here are some of the things I've tried.'"

Don't Blame the Patient

Most obese patients probably have tried to lose weight but achieved only marginal success.

It's easy for medical providers to get frustrated, Brownell said, when their advice and encouragement seems to have gone unheeded. It's important, however, to consider all the circumstances and to not immediately assign blame.

"You can give a person advice to be more active, but they might not have money to join a gym, or they live in an unsafe neighborhood [to exercise outside]," Brownell explained.

Plus, society bombards people with a blizzard of ads and marketing campaigns enticing them to eat. "It's not surprising at all people are overweight," he said.

According to Puhl, research has shown realistically, a loss of about 10 percent body weight can be achieved and sustained over time. So, assigning a goal of 50 percent weight loss is probably setting up the patient to fail.

"As providers, we need to be realistic about what is obtainable and what is not," she said.

The Rudd Center aids medical providers with information and strategies to combat weight bias. Some are simple fixes, such as making sure waiting room chairs and exam equipment are large enough for all patients. It's more difficult, however, to change attitudes, but that also can be accomplished.

"This is not rocket science," Puhl said. "It's about treating all of your patients with respect and dignity, regardless of what they look like.

"It's about respect, dignity and equal treatment."

Jim Kerr is a frequent contributor to ADVANCE.

Overcoming Bias

The Rudd Center for Food Policy and Obesity offers these suggestions to create a supportive medical environment for overweight patients:

• consider patients' previous negative experiences;

• recognize being overweight is a product of many factors;

• explore all causes of presenting problems, not just weight;

• recognize many patients have tried to lose weight repeatedly;

• emphasize importance of behavior changes rather than weight;

• acknowledge the difficulty of making lifestyle changes; and

• recognize small weight losses can improve health.

Make sure the medical office has:

• appropriate medical equipment such as blood pressure cuffs and gowns for large patients

• weight-friendly waiting room with chairs that accommodate larger patients

• appropriate exam room with a wide exam table and a stepstool with a handle

Practice sensitive weighing procedures:

• ask patients for permission to be weighed;

• use sensitive communication;

• weigh in a private location;

• record weight silently, free of judgment/commentary

Identify attitudes by asking yourself:

• Do I make assumptions based on weight regarding character, intelligence, professional success, health status or lifestyle behaviors?

• Am I comfortable working with people of all shapes and sizes?

• Do I give appropriate feedback to encourage healthful behavior change?

• Am I sensitive to the needs and concerns of obese individuals?

• Do I treat the individual or only the condition?

Source: Rudd Center for Food Policy and Obesity

  Last Post: July 6, 2009 | View Comments(1)

As a nurse researcher and Pediatric Nurse practitioner I am amazed on the bias that are obvious in health care. Providers often are not aware of their own bias against overweight children. Body language and the avoidence of discussion about weight in the early years is a form of bias and a disservice to the community. Understanding our own bias may help change behaviors and treatment of our patients and their family

kathleen Falkenstein,  Assistant Professor,  DrexelJuly 06, 2009
Philadelphia, PA


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