With regard to diseases, including obesity, we physicians like to think that “they” (the patients with the disease) are the problem and “we” (the physicians) are the solution. But our attitudes toward obese patients may make us part of the problem regarding their care.
The recent forum sponsored by AAOS Now on “Obesity, Orthopaedics, and Outcomes” focused primarily on the medical issues associated with overweight and obese patients. Comorbidities, intraoperative management, and impact on outcomes for several orthopaedic specialties (spine, trauma, pediatrics) were among the topics covered. In addition, the impact of value measurements as a potential barrier to orthopaedic surgery for the obese patient was covered.
Overlooked, however, was the impact of physician attitudes toward obese patients and the importance of language in discussing weight issues with patients. Even physicians who see themselves as skilled communicators may inadvertently err, as S. Terry Canale, MD, reported in his recent editorial (“A Fat Nation Needs to Be in Motion,” May 2013).
Weight bias and stigmatization are pervasive in our society. Consider the terms that have been used to describe obese people—indulgent, stupid, lazy, ugly, unhappy, sloppy, weak-willed, lacking self-discipline, having poor personal hygiene, and lacking personal responsibility and control. Studies have found an antifat bias among physicians, family members, employers, college admission personnel, and educators; it occurs in jury selection and adoption proceedings. Indeed, antifat bias is as pervasive among physicians as it is in the general population.
The impact of weight bias
Among physicians, weight bias is directed not just toward obesity as a medical condition but also toward people who are obese. Although physicians may not be aware of their own bias, patients certainly are. Physicians are the most prevalent source of bias and stigmatization—ranked first by women and second by men. More than half (53 percent) of overweight and obese patients have reported inappropriate comments about their weight from physicians.
Weight bias, especially toward women, is greater among men, which may be problematic in a field such as orthopaedic surgery, which is more than 90 percent male. The ethnic/gender adult group with the highest prevalence of obesity is the African-American female; this group also self-reports the greatest prevalence of discrimination due to weight.
Physicians report that they respond most negatively to the following diagnostic conditions (in decreasing order): drug addiction, alcoholism, mental illness, and obesity. Physicians also report that they believe seeing obese patients is a great waste of their time, viewing these patients as annoying and noncompliant.
Such attitudes are shaped early; residents often think that patients whose afflictions are perceived as a consequence of their own behavior are less worthy of care. Medical students mention obese patients as a main target for derogatory humor, often initiated by residents and attending physicians.
When confronted with bias toward obesity, patients may adopt undesirable coping mechanisms. Maladaptive responses to weight stigmatization include the following: eating more (including binge eating), refusing to change their eating habits, avoiding exercise, and even cancelling future appointments with physicians or neglecting to obtain necessary health care.
Antifat stigmatization compromises health care. Studies have found a correlation between increasing body mass index (BMI) and appointment cancellation. Women with a BMI greater than 55 kg/m2 report that their weight is a barrier to getting appropriate health care. Obese patients may fail to seek care or keep an appointment for fear of disrobing or being weighed.
What can be done to improve our care of obese patients? As an organization, the AAOS should consider conducting a member survey to reveal unrecognized bias against obesity. Several previously developed instruments are available, including the following: Implicit Association Test, Person Perception Study, ATOP (Attitudes Toward Obese People), and the Fat Phobia Scale.
Audiovisual programs to reduce obesity stigmatization have proven to be effective for medical students; a similar program could be used with AAOS members.
Although the children’s rhyme says “words will never hurt me,” words do hurt. Derogatory remarks about patients should be avoided, especially in the presence of students and house staff. Antifat bias begets more antifat bias when this behavior is learned by medical students and residents from their faculty role models.
Similarly, physicians must make patients aware of their weight problem in a caring and compassionate manner. In his editorial, Dr. Canale noted that he’s “still ducking,” despite what he considered a “pretty empathetic” question: “In my estimation, I feel that you may be struggling with your obesity. How does that fit with what you are thinking?” In fact, studies show that patients prefer the terms “weight,” “weight problem,” and “unhealthy body weight” and respond negatively to “chubby,” “fat,” “fatness,” “obesity,” and “excess fat.”
In any efforts to publicize the health risks associated with obesity, the challenge is to grab attention without stigmatizing the individual. Stigmatization and shock do not work in the context of obesity and have caused the lowest intent to comply.
It’s true that, in some cases, shock campaigns are effective; examples include the “This is your brain on drugs” effort by the Partnership for a Drug Free America and the “OMG” antitexting while driving campaign by the AAOS. But similar efforts have not been well received in efforts against obesity.
The public service campaigns that have had a positive impact include the “5-a-Day” (encouraging eating servings of fruits and vegetables each day), “My Plate” by the U.S. Department of Agriculture, and First Lady Michelle Obama’s “Let’s Move” campaign. All focus on healthy habits and avoid use of offensive terms.
According to Rebecca M. Puhl, PhD, and Kelly D. Brownell, PhD, both of the Rudd Center for Food Policy & Obesity at Yale University, “There is clear and consistent scientific literature showing pervasive bias against overweight people. It is logical that bias begets discrimination. … Overweight individuals can be reluctant to seek medical care … because they will be scolded or even humiliated. The hope is that care of obese individuals will improve as bias decreases.” Physicians should treat obese patients with the same respect, support, and concern as patients suffering from any chronic disease.
For a copy of the AAOS Now Forum agenda book on “Obesity, Orthopaedics, and Outcomes,” email email@example.com
Joseph J. Gugenheim, MD, is a member of the AAOS and The Obesity Society. He can be reached at firstname.lastname@example.org
- Puhl R, Brownell KD: Bias, discrimination, and obesity. Obes Res 2001;9(12):788-805.
- Hebl MR, Ruggs EN, Singletary SL, Beal DJ: Perceptions of obesity across the lifespan. Obesity (Silver Spring) 2008;16(Suppl 2):S46-S52.
- Puhl RM: Campaigns that help and hurt, in Obesity 2012, Annual Scientific Meeting of the Obesity Society. San Antonio, TX, 2012.
- Puhl RM, Brownell KD: Confronting and coping with weight stigma: An investigation of overweight and obese adults. Obesity (Silver Spring) 2006;14(10):1802-1815.
- Greenleaf C, Martin SB, Rhea D: Fighting fat: How do fat stereotypes influence beliefs about physical education? Obesity (Silver Spring) 2008;16(Suppl 2):S53-S59.
- Puhl RM, Heuer CA: The stigma of obesity: A review and update. Obesity (Silver Spring) 2009;17(5):941-964.
- Andreyeva T, Puhl RM, Brownell KD: Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring) 2008;16(5):1129-1134.
- Frank A: Futility and avoidance: Medical professionals in the treatment of obesity. JAMA 1993;269(16):2132-2133.
- Sabin JA, Marini M, Nosek BA: Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One 2012;7(11):e48448.
- Puhl RM, Andreyeva T, Brownell KD: Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in America. Int J Obes (Lond) 2008;32(6):992-1000.
- Teachman BA, Brownell KD: Implicit anti-fat bias among health professionals: Is anyone immune? Int J Obes Relat Metab Disord 2001;25(10):1525-1531.
- Wear D, Aultman JM, Varley JD, Zarconi J: Making fun of patients: Medical students' perceptions and use of derogatory and cynical humor in clinical settings. Acad Med 2006;81(5):454-462.
- Pantenburg B, Sikorski C, Luppa M, et al: Medical students' attitudes towards overweight and obesity. PLoS One 2012;7(11):e48113.
- Wiese HJ, Wilson JF, Jones RA, Neises M: Obesity stigma reduction in medical students. Int J Obes Relat Metab Disord 1992;16(11):859-868.
- Bacon JG, Scheltema KE, Robinson BE: Fat phobia scale revisited: The short form. Int J Obes Relat Metab Disord 2001;25(2):252-257.
- Wadden TA, Didie E: What's in a name? Patients' preferred terms for describing obesity. Obes Res 2003;11(9):1140-1146.
- Puhl RM, Peterson JL, Luedicke J: Parental perceptions of weight terminology that providers use with youth. Pediatrics 2011;128(4):e786-793.