“Well, it’s kind of his fault, right?”
“If she wasn’t so lazy ...”
“That patient is so undisciplined.”
As young physicians, we’ve been shocked to hear other doctors use these phrases when referring to patients of higher weights. Indeed, while the medical community has taken steps in recent years to recognize and combat biases based on sexuality and gender identity, age or race, weight bias remains frustratingly widespread among American physicians. Not simply prejudicial and offensive, such ignorant attitudes jeopardize the health of patients across the country.
This is not a problem because heavier Americans are necessarily unhealthy. BMI does not offer a perfect assessment of health, and being overweight does not guarantee illness.
Doctors fail patients when they conflate weight and health, believe their patients to be lazy or noncompliant or avoid discussing the topic altogether.
Doctors use data every day in their profession, and yet they have been slow to accept the data on weight bias and wellness. A 2018 Drexel University study on health care avoidance showed that one’s body mass index (BMI) was correlated with weight stigma, increased body shame and rising health care stress. And a 2012 survey of almost 2,500 U.S. women found that 69 percent reported feeling stigmatized by their doctors and 52 percent endured recurring fat bias.
This is not a problem because heavier Americans are necessarily unhealthy. BMI does not offer a perfect assessment of health, and being overweight does not guarantee illness. However, excess body weight can play a role in the development of many health conditions, including coronary artery disease, stroke and type II diabetes. Nearly 5 percent of cancers in men and 10 percent of cancers in women (excluding most skin cancers) have been attributed to excess body weight.
But weight stigma can cause patients to avoid the doctor, meaning such conditions won’t be addressed or discovered. This status quo, in which patients are stigmatized and offered poor health care by a biased physician workforce, is unacceptable.
In February, an editorial in The Journal of the American Medical Association (JAMA) described weight bias as the “last acceptable bias” among health care practitioners. In surveys of primary care doctors, more than 50 percent report viewing patients who are obese as “awkward, unattractive, ugly, and noncompliant.” Too often, medical students find it socially acceptable to mock patients who are obese.
Public health research has repeatedly demonstrated that Americans perceive obesity negatively because they attribute extra weight with personal failure. These anachronistic views persist despite extensive scientific work that has shown that there are clear genetic and environmental factors that often contribute to obesity.
Meanwhile, research has shown that doctors spend less time with patients who are obese. They are also more reluctant to perform pelvic exams or educate patients who are obese. And they may fixate on a patient’s weight, thereby overlooking crucial symptoms. The February JAMA editorial describes the case of Ellen Maud Bennett, who experienced fatigue for years before her death. Doctors at every visit advised her to lose weight. In the process, however, they missed the true reason for her malaise: advanced-stage cancer.
Some doctors may argue that pressuring patients about their weight is simply their way of trying to motivate them to be healthier. But this logic doesn’t make a lot of sense. Research shows that doctors are ill-equipped to provide evidence-based advice to help patients lose weight. Most physicians have not been trained to provide nutrition counseling. Moreover, many physicians recommend diets, despite the fact that studies show that 95-98 percent of efforts to lose weight through dieting alone do not succeed. With half of American adults preoccupied with their weight, added stigma from health care providers can act as a chronic stressor and lead patients to skip appointments and binge eat.
Throughout medical school, we learned how to challenge a diverse range of implicit biases. But we received little to no education on the topic of weight bias and stigma. In an era when over 70 percent of American adults are considered overweight or obese, this oversight is simply inexcusable.
We need new anti-weight bias curriculums that strive to educate medical students and physicians about the complex interaction between weight and overall health, the nonvoluntary genetic and environmental factors that contribute to the development of obesity, and the ways in which physician biases harm patients.
Evidence has shown that such a curriculum can be successful. However, many of the studies that examine these programs have followed medical students for short periods of time. Those studies that have followed students long-term have shown that weight biases can re-emerge. This means medical schools and residency programs must weave these teachings throughout their curricula.
As with sexuality and gender identity, age or racial biases, the path forward to combat weight bias in the medical community will be arduous and slow. But that does not mean we should abandon the cause. With plenty of research demonstrating the negative impact physicians’ weight biases have on patients, American physicians can and must do better.