Weight Bias in Healthcare: An Opportunity for Action

Leigh Richards, B.S. with a major in nursing, Class of 2021

In 2013, I found myself the recipient of some alarming news regarding my cervix. I returned a voicemail from my gynecologist and found out that I had an abnormal exam and that a biopsy would be needed to determine whether this abnormality was cancerous. With a family history of cancer in mind, I made the biopsy appointment and anxiously awaited the date. I told no one other than my partner at the time and when she offered to accompany me, I declined because it felt like too much fuss. The morning of my biopsy, I put on my business casual office clothes and packed my lunch for the day. I had scheduled the procedure for early enough in the morning to be on time for work afterwards, and had responsibilities at my nonprofit job that needed my attention. I was ready to be a good patient and productive member of the workforce, and made great pains to avoid making my anxiety surrounding this appointment anyone else’s problem.

I arrived at my gynecologist’s office before sunrise on a Tuesday, and the biopsy went mostly as planned. My ankles were only just out of the stirrups when my doctor removed her gloves, looked me up and down, and asked if I had ever considered weight loss surgery. Stunned, I said I had not. She offered to give me some brochures and a referral to the hospital’s obesity clinic. Of course I was lying- as a woman who has been fat (a term I prefer over “overweight,” “plus size,” and most other euphemisms) my whole life, I semi-regularly spend hours researching the many complications associated with bariatric surgery to see if maybe it is worth a try; I have thus far decided that it isn’t. However, in the cold clinic room where my provider had just finished performing a minor but highly invasive procedure, this question flooded me with embarrassment. My sense of pride at “keeping it together” was replaced with shame, followed by anger at the very body that I was attempting to take care of. She had not asked about my activity level or nutritional intake, nor had she chosen a remotely appropriate time to suggest I get a risky, invasive and unrelated surgery. While my biopsy results came back fine, it took four years for me to gather the nerve to schedule a follow up exam.

Six years later, I am a sophomore at OHSU’s School of Nursing. I am learning from my instructors about the importance of earnest questioning, active listening, and fostering holistic health promotion when providing care to patients. I am learning to not make assumptions about people’s health or health literacy based on my own biases. I am learning more about how healthcare has systemically failed many different patient populations, and I am learning about how to weave awareness of these inequities into my practice as a clinician. Related, I also know now that recent evidence shows little correlation between body size and risk of cervical cancer (Poorolajal & Jenabi, 2016). One 2018 longitudinal study did find an increased risk of cervical cancer among participants classified as overweight or obese and attributed it to an under-diagnosis of cervical pre-cancer, but posited that this was likely due to a failure of current screening equipment and/or technique to adequately serve its clinical purpose among patients with large bodies (Clarke, Fetterman, Cheung, Wentzensen, Gage, Katki, et al., 2018).

If evidence wasn’t informing my provider’s practice, why did she find it appropriate to comment on it at such a time and in such terms? I don’t have an explicit answer to this question, as only that provider can know for sure. However, as a patient who also has institutional access to multiple scholarly databases, I can look to the research to fill in some blanks. A 2015 review of literature concerning the impact of weight bias and stigma on care for patients with obesity found that a). many healthcare providers hold “strong negative attitudes and stereotypes” about these patients, b). these attitudes influence multiple aspects of care including clinical judgment and decision-making, and c). that the impact of this influence can reduce quality of care despite best intentions of the providers (Phelan, Burgess, Yeazel, Hellerstedt, Griffin, & Ryn, 2015). Yet another study published this year found that among a group of nursing, social work, and education students, nursing students had the worst attitudes about obese people (Darling & Atav, 2019). Furthermore, a 2017 quantitative systematic review found that the experience of weight stigma is associated with multiple adverse physiological and psychological outcomes including elevated cortisol and oxidative stress levels, eating disturbances, depression, anxiety, and more (Wu & Berry, 2017). While my experience with my provider in 2013 may seem unique to some, it is one instance of a much larger problem. If we as future clinicians have greater awareness of our own attitudes about people of size, it might be possible to reduce the impact of weight stigma on our patients and improve some of these outcomes. I believe it is our job to break down what can be a hostile environment for those in our care. We must not put our patients in the position of feeling shamed out of healthcare, and thus shamed out of caring for their bodies.

In six years, I have also learned to advocate for myself as a fat patient. I defer being weighed “unless medically necessary” (it has yet to be). I know when receiving medical advice that includes the phrase “lose weight” to ask the provider what they would suggest a thin person with the same conditions/symptoms do. I have also found a team of providers who do not regard me with suspicion when I tell them that my primary reasons for staying active are stress management, controlling my type 1 diabetes, and maintaining heart health. They do not argue with me when I say that I am not interested in losing weight, because they see that I am an active participant in my health and am capable of making an informed decision about it. They do not view my body size as a problematic behavior waiting to be scolded, surgically removed, or yes- even motivationally interviewed out of me. They assess whether or not I am healthy by invoking the very skills that I am learning in my bachelor’s level nursing curriculum. They regard me as a whole person rather than as a constellation of terms used by the media and researchers alike to describe people with my body type (“staggering,” “epidemic,” “crisis”).

The size of a patient’s body shouldn’t impact the care that they receive, but research shows overwhelmingly that it does. As clinicians, it is our obligation to be aware of how our biases against this and many other segments of the population can and do cause harm. A challenge I would like to make to my colleagues at OHSU is to think critically about our perceptions of people of size, especially those with additional intersecting identities that predispose them to further bias from healthcare workers (e.g., racism, classism, transphobia and homophobia).

How do those perceptions influence our compassion and care?

Do we see our fat patients as individuals, or do we see them as a monolith?

Do we view having a small body size as a moral imperative, something that we are owed by our patients?

How much of our treatment of patients of size is informed by data, and how much is informed by bias?

And finally, what are we actively doing (individually and collectively) to ensure that we are providing high quality care to patients of all sizes?

 

References

  • Clarke, M. A., Fetterman, B., Cheung, L. C., Wentzensen, N., Gage, J. C., Katki, H. A., … Schiffman, M. (2018). Epidemiologic Evidence That Excess Body Weight Increases Risk of Cervical Cancer by Decreased Detection of Precancer. Journal of Clinical    Oncology, 36(12), 1184-1191. doi:10.1200/jco.2017.75.3442
  • Darling, R., & Atav, A. S. (2019). Attitudes Toward Obese People: A Comparative Study of Nursing, Education, and Social Work Students. Journal of Professional Nursing, 35(2),     138-146. doi:10.1016/j.profnurs.2018.07.009
  • Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & Ryn, M. V. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews,16(4), 319-326. doi:10.1111/obr.12266. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381543/
  • Poorolajal, J., & Jenabi, E. (2016). The association between BMI and cervical cancer risk. European Journal of Cancer Prevention, 25(3), 232-238.     doi:10.1097/cej.0000000000000164
  • Wu, Y., & Berry, D. C. (2017). Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. Journal of Advanced Nursing,74(5), 1030-1042. doi:10.1111/jan.13511. https://www.ncbi.nlm.nih.gov/pubmed/29171076

11 responses to “Weight Bias in Healthcare: An Opportunity for Action

  1. Important topic, and an exceptionally well-written article. I appreciate your insight and willingness to share such a personal experience in the name of helping us all recognize this bias.

  2. Thanks for having the courage to share your experience and working to challenge us all to be better, more compassionate providers!

  3. thank you Leigh for sharing a very personal experience to help others understand our own bias’. Very good article, you need to go for your masters degree.

  4. This is beautifully written, and such an important thing to bring to the attention of caregivers. I am also a plus sized person, and as a patient I can tell you for certain that the fear of discrimination or mistreatment by physicians is equal to the reality. It took me years to get accurate diagnoses, and to find physicians that don’t punctuate solutions with “lose the weight”. Health comes at every size!

  5. I really appreciate the perspective of your article. I think bringing these biases to our attention is the first step in overcoming our prejudices. Nice work!

  6. THANK YOU! So so so much for writing about this. I’m so grateful. I have an upcoming appointment with a new pcp, and am braced for this conversation, but being hit with it at such a vulnerable moment is inexcusable. I know some great nurses who are well-educated on this topic, but I would love to see more health professionals really push themselves to understand this. If I recall, from the OHSU Diversity and Inclusion workshop that I went to, it is a bias that is also put on to overweight (or fat, as I also prefer to be called) providers.

  7. Leigh.

    I found your essay, personal expressions and references supporting your experience and concerns refreshing and helpful. As someone who requests that all patients considering elective lower extremity Orthopedic surgery allow us to gather Body Mass Index data, I would request your advice. I do so, because level of BMI and particular thresholds are clearly associated with relative risk and important outcome metrics for numerous common procedures. Might you suggests some approaches that would help my MA and research team convey the medical necessity of this sensitive area for data gathering?

    Thank you

    Dennis Crawford
    Professor
    Orthopedic Surgery

    1. Thank you for sharing your thoughts and struggles with implementing evidence based bias free care. I conduct research in weight bias and would be happy to share with you some practices around implementing bias free care. Feel free to email me at najjar@ohsu.edu

  8. I recently went to my doctor and felt like the only issue they saw was my weight, not the several other health issues I have that did not get addressed at all. The only thing that my provider addressed was How I should lose weight.

  9. Thank you so much for writing this article! As a person who is fat, I’ve also experienced bias in healthcare first hand. I take care of my body, eat a balanced diet, exercise daily, and have even had weight loss surgery but I am still “obese” according to BMI charts. None of my habits seem to matter or are even taken into account when discussing unrelated health issues with certain providers. In one instance, while following up with my then PCP for a sprained ankle, she scolded me for my weight and told me that I should be exercising more frequently. Never mind that my chart showed I’d already registered for physical therapy, nor had she asked about my current habits or activity level. When asking her how best to do that with a sprained ankle, she rolled her eyes and said I’d have to wait until the ankle had healed. The shame and anger I felt after that visit made it difficult to want to continue seeking medical advice. Whenever I have to find a new doctor, my first concern is that they will not take me seriously and this is a direct result of the anti-fat bias I’ve repeatedly experienced from healthcare providers. We need to do a better at treating every patient with respect, compassion, and active listening.

  10. Thank you Leigh for having the courage to speak up about an important problem that has gone relatively undetected in our healthcare community. I can tell you as a researcher on weight bias that the bias is very pervasive in healthcare and beyond. Unfortunately, your experience is not an isolated one, as you can see from the response posts and in the literature, there are thousands of stories of patients shamed and blamed for their weight. The spotlight on obesity in the last couple of decades have added to this problem where Healthcare Providers (HCPs) are untrained and not prepared to work with patients of varying weights and sizes. Most of the evidence is showing that HCPs either stigmatize patients they feel should lose weight, or they ignore the patient who is asking for help with weight loss. In fact, most HCPs are quick to make recommendations before appropriate and adequate assessment when it comes to weight. You have made important recommendations related to listening to patients and treating them with respect and compassion. We need to continue to develop evidence based practices related to bias free care for patients and training of weight management skills for all HCPs.

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