How to Challenge Obesity Bias and Stigma in Healthcare

admin April 5, 2023

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This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.

Robert Kushner, MD: Hello. I’m Dr Robert Kushner. Welcome to Medscape’s InDiscussion series on obesity. Today we’ll be discussing obesity bias and stigma, two very important topics. First, let me introduce my guest, Joe Nadglowski, president of the Obesity Action Coalition.

Joe Nadglowski: Thanks, Dr Kushner.

Kushner: Welcome to InDiscussion. Joe, let’s start broad — what is weight bias and what is the difference between bias, stigma, and discrimination?

Nadglowski: Weight bias is simply negative attitudes toward someone based on their body size. And of course, that can lead to worse things, which is stigma. For example, the stereotypes people have around people based on their body size, as well as — and even worse — discrimination, which is taking action based on those. It may surprise your listeners to know that body size is not protected in most places. So, unless you live in the state of Michigan, your employer could fire you today because of your body size, or an apartment could deny you the ability to rent that apartment because of your body size. That often surprises people. Frankly, weight discrimination is one of the things we’re most concerned about. If you are a woman, the most likely form of discrimination you’re going to face in your life is based on your gender, of course, but the second most likely form is going to be based on your weight. It’s important that we actually recognize the impact that weight bias has when it leads all the way to this point of discrimination.

Kushner: You talked about bias when it comes to workplace. Do we see most of it in the media? Is that where we’re most exposed to that kind of problem?

Nadglowski: You see this reinforcement of weight bias all throughout society, but we can pick on the media for a moment. You see it all the time, right? You see the fat jokes on television, late-night talk show hosts or sitcoms, and then you see it in more subtle ways with the imagery that’s used, for example, by our news media, where we often depict people with obesity without their heads — we depersonalize this issue. I don’t believe all bias is intentional. Some of it is very subtle and unintentional, but it is reinforced by the media quite often. We also see it at home, we see it in the workplace, we see it in the doctor’s office, and we see it in lots of places in schools. Weight bias is everywhere. Somehow, when we made obesity bad in this country, we made the people living with obesity bad, and that’s a real challenge.

Kushner: I fear that when we see weight bias so often, we normalize it if it becomes acceptable because it’s everywhere, which is frightening. And I think we really need to change that. What contributes to weight bias in our society?

Nadglowski: I think it is this acceptability that’s out there; you see this constant reinforcement of it. Somehow in our weight-obsessed culture, where thin is considered ideal, we’ve decided as a culture that we’re going to blame and shame people because of their body sizes and think that’s going to help. A lot of that has to do with this lack of education around what actually controls your body size or what controls the disease of obesity. So much of your body size is likely in less control than people think, with pretty significant genetic and environmental causes towards obesity or body size versus just behavior. I think our obsession, especially as an American culture, but even a Western culture around the world, is that somehow we have this ability to control all of these factors ourselves — that this is just about personal responsibility. And unfortunately, that’s not the case. Obesity is much more complicated, in that your body size is much more complicated than that. We have to change some of those attitudes, some of that understanding to really make a dent in weight bias and stigma.

Kushner: You know, as I think back, I think excess body weight or that round shape was always thought to be a sign of affluence. It seems like it’s upside down now. When did it change? Do we know?

Nadglowski: I don’t know if we know an exact time, but I can definitely speak to what you’re talking about there. I mean, in ancient times, if you had wide access to food and therefore you had a larger body, you were considered affluent or successful or whatever it may be. We’ve moved into a time where our environment, in most parts of the world, nearly every part of the world, is we have this overabundance of food. It seems as if this is now stigmatizing people because they can’t control their ability to access this food at any given point. It is likely a modern occurrence, but we’ve seen bias and stigma for hundreds of years, and it will probably take us hundreds of years to actually solve this issue and treat everyone with the dignity and respect that they deserve.

Kushner: I think you have said it affects more women than men. I would think just because of social media and the body perfect — this striving for thinness and so forth. Is that right?

Nadglowski: We definitely see bias impacts women more than men, and we see that in an unusual way. As you know, we study this and there’s thousands of studies on weight bias from all over the world. But when we look at these impacts, we see this predominant impact on women. We see it in their wages; for example, in the US, a woman with obesity earns about 15% less than her normal-weight counterparts. Curiously, if we look at that data for men, that is not the case; men don’t earn differently. In fact, in some ethnic groups, for example, Latino men earn more money than their normal-weight counterparts if they have obesity. And so with men, we see some variations in the data. With women, we see bias quite consistently across the board. Women are much more dramatically impacted and at very early stages; we are not just talking about people with severe obesity — being 100 pounds or more overweight — we see bias even in the overweight category, with women having less than 30 extra pounds on their bodies. That’s particularly troubling. We don’t even start to see bias and stigma in men until they reach that stage of severe obesity, which is 100 pounds or more overweight.

Kushner: You’re talking a little bit about other countries and so forth, and I want to dive into that just a little bit. I know you have done work globally through the Obesity Action Coalition and you’re a leader globally working with other countries to set up an organization like the OAC. Through your lens, is weight bias seen the same in other countries or is this a European and American phenomenon?

Nadglowski: I think our early view was that this was just a European and an American view. As we followed the research, we do see that bias and stigma exist in many other countries as well. In fact, one of the things we often hear from our friends around the world is, “Well, bias and stigma doesn’t exist here.” But then we actually go and talk to the people living with the condition, and they talk about bias and stigma. Now, it won’t surprise me and probably won’t surprise listeners that we see bias and stigma most in younger generations now. The people that are Internet savvy or social media savvy who are probably picking up some of this Western culture around bias and stigma. Maybe it exists less in older citizens of some of those countries around the world, but it is definitely a worldwide problem. In fact, I saw a young researcher do her PhD project recently and [she] was citing studies from nearly every country around the world about examples of weight bias and stigma.

Kushner: Joe, I’m going to ask you to explain two other definitions that I think it’s important for us to know about, and that is the difference between implicit and explicit bias.

Nadglowski: Implicit bias is simply the thoughts you might have. I like to describe this as say, you happened to look out your window right now and you saw a person with a larger body walking by. Your implicit bias is the assumptions and the internal thoughts you might have around their behavior or their character or whatever it may be. Now, explicit bias is when you take that next step and engage in some kind of comment, you make fun of them, you yell out a slanderous term towards them, etc. And I think it’s important that we recognize that implicit bias appears to still be going up around the world when people think about people with larger bodies. Explicit bias seems to be decreasing, which is a good thing, right? We still have work to do around that implicit bias. And for your listeners today, I would really encourage them to think about taking the Implicit Association Test, which is a test offered by Harvard through a place called Project Implicit, where you can actually engage in this exercise to understand if you have any implicit attitudes towards people based on their body size. I’ve actually taken this test hundreds of times and given the test to just as many people. I will tell you that even I still have those attitudes, right? No one scores perfectly on the test. Maybe there’s someone out there and you can message me afterward if that’s the case. But it is really meant to be a tool, right, to say, Hey, I need to work on this. Challenge yourself to see if you are having these assumptions about someone’s character or behavior based just on their appearance.

Kushner: Yeah, I think most of our listeners would be familiar with that, with racial discrimination, right? The implicit bias is because of one’s stature, stage in life, and the color of their skin, and so forth. I think the healthcare providers listening also know about this. There’s been data on when people come to the emergency room — like, how do you treat someone with chest pain if someone’s an African American or a White individual, and we see this same kind of implicit bias. It’s interesting, it extends very clearly to obesity as well.

Nadglowski: When you go to Project Implicit and check it out, there are actually implicit association tests for lots of different circumstances. It is a worthwhile exercise as an individual to go through some of that, to challenge yourself. To be better, more empathetic, and to deliver the best care possible.

Kushner: And we, as healthcare providers, need to be clearly aware and check within ourselves to identify what we’re really thinking and not just what’s coming out of our mouth. It impacts your decision-making and how you may actually treat someone. There’s another definition, which I have become recently aware of, which is just so interesting and concerning as well, and I wonder if you could unpack it for us, Joe, and that’s called weight bias internalization. What is that?

Nadglowski: When people start to internalize these weight bias attitudes, this means they start to believe it themselves. You know this, Dr Kushner, from counseling patients for years, that many times the things patients tell themselves or speak to about themselves when it comes to their own struggles with obesity are some of the worst things that you’ve heard, right? It’s probably worse than what their mom said to them, or their family member said to them, or a previous doctor said to them, and they actually start to believe them. I think this is a key issue here. As a provider, if you hear a patient talking terribly about themselves in terms of these issues or holding a lot of blame and shame around these issues, it’s a trigger or sign for you that they need more help. It’s something that you should say, Wait a second, maybe I do need to send this patient to some counseling around these issues. We’re working on tools to better understand how to help patients cope with this weight bias internalization, but since this concept is so new, we don’t have evidence-based tools yet. There’s still work to be done. I would challenge folks, if you know someone living with obesity, ask them to talk about what they say to themselves. Ask about what they say to themselves when they look in the mirror and things like that. You can find out how much they’ve internalized. That’s why it’s important to remember that your words matter, right? Your actions matter as a provider, because a patient may take those words and then ultimately internalize them in a way that they live with those words for the rest of their lives, and it does real harm over the long term.

Kushner: I’ve seen this depicted in figures as a vicious circle as well, to augment what you’re saying, where you tell someone they’re not worthy enough and they’re not good enough, they’re not acting on what they ought to be doing to take care of themselves, which makes them feel more stress, which increases cortisol, increases inflammation, which then can lead to either hypertension or diabetes and make them feel bad about themselves. They don’t want to be seen in public so they’re less physically active; they’re sheltering at home. That’s what we mean by that vicious circle. It’s really, really quite unfortunate. I think we as healthcare providers need to remember — you said it best — words matter and how what you are saying is interpreted. Joe, I want to stay with the healthcare system. We’re kind of getting into that area now and you mentioned it a little bit earlier. Bias is seen in the workplace, in the media, and also sadly in the healthcare system. What do you hear from members of the OAC and others on how healthcare providers have treated them and, equally or more importantly, how it has affected them in their interaction with the healthcare provider?

Nadglowski: Most of us who live with obesity have likely had a negative experience with our healthcare provider about our body weight. A lot of times, again, I think it is the provider unintentionally engaging in harm. I can share my own personal experience. I still remember this from when I was 20 years old. I was actually at an allergist of all things, having my skin tests done for allergies, and the allergist just walked in for a second as the nurse was doing that, and he looked at me and said, “Joe, you know, you could lose 20 pounds.” He shook his finger at me, turned around, and walked out of the room. You might say, Well, okay, that was obvious. I knew I needed to lose 20 pounds. But it is the interaction; while you told me something, you didn’t offer me any advice or any real skills to be able to move forward. Of course, that is a more subtle example. A lot of our members will talk about their doctors berating them or calling them names or not even having a chair where they could sit because the chairs were too small to accommodate their frame. These things really last and they harm people. I will tell you, in my own circumstance, it’s taken me years to overcome this. I don’t like to go to the doctor because I think my doctor is going to shame me about my body weight again and not actually offer me real advice to move forward. I would really encourage providers to think about their words, to recognize that people who live in larger bodies, who may in many cases have obesity, likely have had a bad experience. You’ll have to overcome that. I know, Dr Kushner, [that] you spend a lot of time training our next generation of healthcare professionals around this. I’ve seen your art, right, of how you engage with a patient. You watch for signals of something that you can tell is bothering them. Likely it was based on something that’s happened in the past from a previous healthcare provider. You pick up on that and you talk to them about it. In fact, I’ve seen a lot of healthcare providers engage in all kinds of tactics to try to use this conversation with the patient, including apologizing to their patients for what may have been past bad experiences with other healthcare providers, and say, “You know, we’re going to have a different kind of conversation about your body size. This is going to be one based on science, on empathy and compassion, not one based on blame and shame.” And I think that really sends a signal. I will tell you, your patients do want to talk about this. There’s no one who lives in a larger body, who is struggling with obesity, who doesn’t want to address it. They just don’t want to be shamed and blamed for it.

Kushner: So well said, Joe — thanks for bringing that up. It’s probably worth also mentioning this concept of “people-first” language, you know, not labeling people. And what I mean by that, of course, is rather than saying you have “an obese patient” or “a diabetic patient” or “epileptic patient”. We never say “cancerous patient” — that even sounds silly, but it’s the same theme. And to change it to “a patient with obesity.” What made me think of that, Joe, is you said “those of us living with obesity” — write it as a disease, rather than “those of us who are obese.” Words matter. And that’s just another good example of good communication. Joe, I want you to spend just a little bit talking about what the OAC is. I introduced you as president, and you and I had an opportunity to work together for well over a decade on the board, at some point, helping with the virtual meetings every year. But tell our listeners what the OAC is and, probably most importantly, how you could become a member and support the OAC.

Nadglowski: The Obesity Action Coalition, OAC for short, is the patient advocacy organization in the obesity space, and we formed now nearly 18 years ago after a legislator stood up at a meeting on obesity and said, “I’m asked every day to do something about the obesity epidemic, but it’s always by a healthcare professional or a public health official. It’s actually never by someone who lives with obesity themselves.” And so OAC was created to fill that gap. We spend a lot of our time focusing on this issue of weight bias. But we also focus on other issues such as access to care. For example, if you woke up this morning and said, today’s the day I want to do something about my obesity, we want to make sure your insurance covers those services. And then we also spend a lot of time providing support and offering balanced educational resources for people living with obesity. There’s a lot of snake oil and malarkey out there, and we want people to understand what the evidence base is when it comes to obesity care. And so more about OAC can be found on our website at obesityaction.org. And we would encourage all healthcare providers who might be listening to this podcast today to join as a member, but also encourage your patients who actually are living with obesity to join us, because that’s really why we’re here, to be a voice of all the people living with obesity.

Kushner: I highly recommend that; it’s actually one of the most delightful activities I’ve been involved in is working with the OAC. It’s really a way of giving back. There’s nothing more heartening than to work with our patients. We serve our patients; that’s why we go into the healthcare field. But to actually work alongside patients, to be on the board with them, to participate in meetings with them is so insightful and rewarding as a healthcare provider. Joe, I wonder if you could just quickly end up here today with maybe some tips for healthcare providers. You mentioned a little bit before, but maybe just to touch on once again, what are the key tips that healthcare providers should do to confront potentially their own bias and turn that around?

Nadglowski: I think everyone should start by taking that implicit association test to make sure they understand that they do have these attitudes. Again, don’t beat yourself up about having those attitudes. We don’t want to blame and shame you if you have attitudes of blame and shame. That’s not the goal here. It’s a good place to start to educate yourself and then really check yourself, right? Think about the next time you see someone in a larger body. Ask yourself, what assumptions do I have? Then challenge those assumptions. One I like to remind folks to challenge themselves about is if you see someone who walks by right now and they weigh 400 pounds, you have to be careful making a judgment about their health. If you don’t know them, you don’t know if a year earlier, they weighed 500 pounds, and they’ve done something remarkable and maintained a 100-pound weight loss. We have to make sure we check our assumptions. I would also ask everyone, when you engage with people living with obesity, to ask them about past bad experiences. I know it’s sometimes challenging to deal with some of the emotions and the complications of this, but it is worth acknowledging that your patients have had bad past experiences and you might be a real tool for them to be able to overcome them. Finally, I would just encourage everyone to challenge bias when they see it. We talked about doing this as a doctor in your office, right? How about in public? If you see a news article that uses stigmatizing language or doesn’t talk about obesity as a disease, challenge it as a healthcare professional. You can be a real resource in your community to help us create better attitudes around obesity. We’re only going to stop stigma and bias if we challenge it. I’ll take one person at a time saying, “You know what? It’s time to stop blaming and shaming people and start treating them with dignity and respect.”

Kushner: Thank you, Joe. Today we’ve had Joe Nadglowski, president of the Obesity Action Coalition, discussing obesity bias and stigma. It’s been a real treat, Joe. I think all our listeners really benefited from your insight, knowledge, and guidance about what to do about changing stigma in obesity. Everyone who works with individuals living with obesity will benefit from your advice. Thank you for joining us. This is Dr Robert Kushner for InDiscussion.