The most recent estimates by the Center for Disease Control indicate that obesity is present in up to 41.9% of adults living in the United States, with a prevalence of severe obesity reaching 9.2%. Consequently, healthcare providers and healthcare systems in general will often interact with and provide care to individuals with obesity. However, weight stigma is common within the healthcare system, often presenting as a poorly equipped healthcare environment, and insufficient proficiency in communicating with and examining individuals with obesity. Most concerning, however, is how anti-obesity bias leads to stereotyping with premature closure and over-attribution of disease when treating patients with obesity. These factors can lead to discrimination and inequity in delivery of healthcare to individuals with obesity and result in healthcare avoidance by these patients. This chapter examines discriminatory practices affecting healthcare delivery to individuals with obesity and discusses approaches to address them.
TopIntroduction
The World Health Organization defines obesity as an “abnormal or excessive fat accumulation that presents a risk to health.” It is typically defined as a body mass index (BMI) of 30kg/m2 or higher (World Health Organization). Obesity is multifactorial, with contributions from genetics, underlying disease, medication use, mental disorders, lifestyle and socioeconomic factors (Hill et al., 2013; van der Valk et al., 2019). The prevalence of obesity among adults in the United States (US) has increased from 13% in the 1960s to 41.9% in 2017 (Centers for Disease Control and Prevention). At a population level, obesity is associated with type 2 diabetes, cardiovascular disease, osteoarthritis, steatohepatitis, and certain cancers (Bluher, 2019). Globally in 2017, high BMI was associated with 4.7 million deaths and 165.6 million disability-adjusted life years lost (Dai et al., 2020).
The rise in obesity rates has been paralleled by an increase in weight stigma (Andreyeva et al., 2008). Weight stigma is the “social devaluation and denigration of individuals because of their excess body weight, [which] can lead to negative attitudes, stereotypes, prejudice, and discrimination” (Rubino et al., 2020). Approximately 40-60% of individuals with obesity experience weight teasing or discrimination (Prunty et al., 2020; Puhl, Lessard, Himmelstein, et al., 2021). Weight stigma manifests widely in multiple domains including the media, educational settings, interpersonal relationships, workplaces, and the structural environment (Alimoradi et al., 2020). The media often portrays individuals with obesity as disheveled, unorganized, undesirable, or as the appropriate subjects of humor (Eisenberg et al., 2015; Karsay, 2019). Social media outlets serve as forums for stigmatizing and misogynistic sentiments related to weight (Chou et al., 2014; Jeon et al., 2018; Wanniarachchi et al., 2022).
Similar to what is seen in society at large, weight stigma in healthcare is common. Physicians often hold negative or stereotypical attitudes toward patients with obesity. These biases may be explicit or more subtle or implicit (Foster et al., 2003; Harvey & Hill, 2001; Puhl & Brownell, 2001). Other healthcare professionals and trainees also manifest such attitudes, including nurses, medical and nursing students, dietitians, and psychologists, further contributing to an environment that is hostile to people with obesity (Budd et al., 2011). As we explore later, healthcare practitioners and trainees often do not understand the etiology or complexity of obesity, and how to treat it (Budd et al., 2011; Butsch et al., 2020; Foster et al., 2003; Katz et al., 2022; Metcalf et al., 2017). This may contribute to reluctance to care for people with obesity, and pessimism about their adherence to therapy and potential for weight loss success (Amy et al., 2006; Wigton & McGaghie, 2001). Furthermore, lack of knowledge and bias may lead to cognitive errors, such as over-attribution of disease to obesity, and premature diagnostic closure.