Q&A: ‘Fatness’ as a measure of health perpetuates negligent medicine, weight stigma

Stigmatization of patients with obesity can affect access to quality health care as well as their comfort and trust in practitioners, while also perpetuating misdiagnosis and “negligent medicine,” researchers and nutritionists report.

“Weight stigma is our negative beliefs and stereotypes based on a person’s weight, size or shape that impacts the kind of care they are getting,” Beth Rosen, MS, RD, CDN, owner of Beth Rosen Nutrition and director of nutrition and dietary services for GI OnDEMAND, told Healio. “It affects a broad spectrum of people with gastrointestinal diseases because it is not necessarily the disease state that brings on stigma as much as the body size of the patient.

“It is important to know that there is not one GI disorder, or any chronic illness for that matter, that only impacts people in larger bodies.”

Empirical evidence has shown that drivers of weight gain are complex, although misconceptions lead many to believe it is within a person’s power to control their body weight through lifestyle modifications.

“This belief reinforces negative stereotypes of people living with obesity, including laziness and lacking willpower,” Adrian Brown, PhD, RD, senior research fellow at the University College London Center for Obesity Research, and colleagues wrote in eClinicalMedicine. “Assumptions that weight is under voluntary control misleads public health policies, confuses messages in popular media, undermines access to evidence-based treatments and compromises advances in research.”

In a 2016 meta-analysis, Spahlholz and colleagues reported the prevalence of perceived weight discrimination was 19.2% among patients with class I obesity and 41.8% among patients with class II obesity. Further, a 2018 U.K. survey from the All-Party Parliamentary Group on Obesity revealed 88% of patients with obesity reported stigmatization, 42% felt uncomfortable talking to their provider about weight and only 26% reported being treated with respect from providers when seeking advice.

“People living with obesity who report weight bias in the health care setting have less trust in their providers, are less likely to access health care screening and services, have poorer outcomes and are more likely to avoid future health care,” Brown and colleagues wrote. “Indeed, research has reported that due to weight stigma experiences, women living with overweight or obesity delay routine cancer screening, which is compounded by 83% of physicians being reluctant to perform an examination on women living with obesity.”

Healio spoke with Rosen about the harmful effects of weight stigma in patients with GI disorders, how to best care for stigmatized patients and advice for speaking in weight-neutral language.

Healio: How can weight stigma be harmful to a patient’s dietary intervention for their GI condition?

Rosen: The major issue with weight stigma when it comes to GI health is that it can lead to misdiagnosis and inadequate care. If a patient with a bigger body walks in and the practitioner recommends weight loss to treat their disease state, that is negligent medicine.

Weight loss is not a health behavior, and the recommendation can further stigmatize the person who is already stigmatized, in addition to not getting the care that they need. In a weight-inclusive or weight-neutral model, patients are given treatment options for their disease, regardless of their body size.

There is a lot of evidence to show that weight bias influences the attitudes of practitioners, including how patients are diagnosed, treatment options and whether a client will follow the recommendations, or be “compliant,” with whatever they are told to do. I have seen where patients are recommended a fad diet to lose weight, rather than given a referral to a registered dietitian to implement a dietary intervention for that specific disease state.

Healio: How often does disordered eating occur in this patient population?

Rosen: If you are working with people who have GI disorders, you are working with people who have eating disorders, disordered eating or maladaptive eating. Approximately 98% of patients with eating disorders have functional GI disorders. In most cases, the eating disorder comes first, but for a few disease states where people are either afraid to eat or restrict their food intake because they blame food for their symptoms, maladaptive eating can be triggered.

It is important for GI practitioners to know that everyone who walks in the door may have disordered eating and should be screened for an eating disorder, because it is so prevalent. Refer those patients to eating disorder professionals to treat this first before the GI issue. In some cases, the GI issue may dissipate with the healing of the eating disorder.

Healio: How can providers and other medical professionals combat weight stigma?

Rosen: Implicit bias fuels weight stigma. The first step is to acknowledge that we all have it, and the second step is to get training to minimize it. Many resources for assessing and combatting implicit bias exist online; Harvard University has a project called Project Implicit and the NIH has a program where they offer tools to improve your implicit bias and remove some of that stigma away from body size.

It is also important that practitioners start to practice weight inclusive care by focusing on behaviors to improve health rather than “lose weight,” which might be more movement, better sleep hygiene, stress management or change in diet. You can do all those things without losing weight and still find improved health outcomes.

The other big one would be to move away from BMI as a measure of health, because it is so flawed. People exist in all shapes and sizes. We are all born different, so it makes sense that we grow differently.

Healio: What is the best way to care for a patient who has experienced this kind of stigma?

Rosen: Look into the patient-centered care model, which includes three tenants: One is communication, two is partnership and three is health promotion. None of those have to speak to weight.

Listen to a client’s experience and acknowledge that their experience was harmful for them. Sometimes just saying, “I believe you” is enough to have a client feel comfortable with you. It is also important to note that part of communication is consent, like asking a patient, “Can I touch you?” or “Is it okay if I take your blood pressure?” or “Would you like to be weighed today?” And if the answer is no, we honor that.

An example of partnership is giving them options to improve their health, asking their opinion and having a discussion before implementing care. And finally, health promotion via health behaviors. Again, weight loss is not a health behavior, but what can we do to promote health based on what might be controllable factors.

Healio: What advice would you give medical professionals for maintaining neutral language when discussing weight?

Rosen: If they have to talk about body size, avoid using terms like “obese” and “overweight.” As I mentioned, “obese” is pathologizing language that denotes you are body sick if it is bigger, and that is not necessarily the case; every size body gets every kind of disease. And then also avoiding the term “overweight,” because it denotes that there is a specific weight that you should be, and if you are not, your current weight is wrong.

Bodies vary — there is no “right” weight based on height. Your right weight is your natural weight; it is where you land when you do not restrict and when you are not mindlessly overeating because of restriction. It is where your body settles when it is not messed with by yo-yo dieting or weight cycling. Unfortunately, a lot of people do not know where that is, because they have not had the opportunity to just live in their bodies without being impacted by stigma to make it smaller.

The language I suggest using with a patient with a bigger body, if you have to discuss their weight at all (again, if it does not speak to their health, there is no reason to talk about it), is, “Let’s talk about your fruit and vegetable consumption,” or “Have you heard about a Mediterranean style diet?” or “We know from research that having a plant-forward diet helps reduce the risk for liver disease — is this something that interests you?”

We also have to take into consideration other determinants of health because, although diet and exercise impact us, so do genetics, access to care, socioeconomic status and weight stigma.

Healio: What else is important for our readers to know about this topic?

Rosen: First and foremost, using fatness as a measure of health perpetuates weight stigma. Size diversity exists and from research we know that diets are neither sustainable nor safe. We need to stop prescribing them.

There will always be fat people, but if we reduce bias, we can have fat people who seek care when they do not feel good, we can have fewer eating disorders, and hopefully, less harm will be done.

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