Batterham, Rachel L

English

UCL Discovery

Weight stigma in healthcare settings is detrimental to health and must be eradicated  Rachel L Batterham1,2,3†  1. Centre for Obesity Research, University College London, London, UK 2. Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital NHS Trust, London, UK 3. UCLH Biomedical Research Centre, National Institute of Health Research, London, UK  †Email: r.batterham@ucl.ac.uk  A large body of indisputable evidence shows that a certain treatment, commonly advocated by all healthcare professionals for a highly prevalent chronic medical condition, is associated with detrimental effects on health and an increased risk of mortality. This ‘treatment’, which needs eradicating from healthcare settings, is weight stigma.   Obesity is a highly prevalent, complex medical condition, characterised by excess body adiposity that impairs health and leads to premature mortality. Empirical evidence has shown that the drivers of weight gain are complex and that the human body is hard-wired to resist weight loss. The chronic nature of obesity and its detrimental impact upon health has led multiple professional bodies and countries to recognise obesity as a disease. Despite the scientific evidence, there is still a commonly held belief that a person’s body weight is purely within their control, and that obesity is a choice that can be easily reversed by eating less and exercising more. This misconception leads to negative stereotypes of people with obesity, portraying them as lazy, gluttonous, lacking in willpower and intelligence, and thus driving weight stigma and discrimination.  There is now indisputable evidence that weight stigma has a detrimental impact on health. Weight stigma is associated with disordered eating, sleep disturbance and exercise avoidance, even after controlling for BMI1. Experimental studies show that exposure to weight stigma leads to increased energy intake, particularly of energy-dense foods1. These behavioural changes may explain why adults and children who experience weight stigma tend to gain weight and have an increased risk of transitioning from overweight to obesity  than people who have not been exposed to weight stigma2. Weight stigma also increases the risk of psychological problems including depression, anxiety, substance abuse and suicidality, particularly when people internalise sizeist attitudes and self-stigmatise3.  Laboratory experiments show that when participants were exposed to a  weight stigmatizing scenarios, their cortisol levels and calorie consumption increase compared to non-weight stigmatizing conditions1. Moreover, individuals with overweight and obesity who experience weight discrimination have higher circulating levels of C-reactive protein and a greater likelihood of abdominal obesity, type 2 diabetes mellitus and metabolic syndrome compared with those who do not experience weight discrimination1. Similarly, adolescents who experience weight stigma are more susceptible to developing obesity, type 2 diabetes mellitus and cardiovascular disease in later life than those who have not3. There are also potential transgenerational implications to weight stigma, as women who experience pregnancy-related weight stigma have an increased risk of gestational diabetes mellitus than those who have not4 . However, what is most concerning is the 58% increase in all-cause mortality in people with overweight and obesity who experience weight discrimination compared with those who do not5.  Weight stigma and discrimination are pervasive and experienced by 20–40% of people living with obesity3. Counterintuitively, healthcare professionals (HCPs) are some of the most common perpetrators of weight stigma. This stigma can be perpetuated by a wide range of HCPs, such as medical students, general practitioners, hospital students, nurses, dietitians, psychologists and exercise therapists3. Negative attitudes of health practitioners towards patients with overweight or obesity include stereotypes that these patients are lazy, unintelligent, lack self-control and willpower, are personally to blame for their weight and are noncompliant with treatment3. Whether explicit (that is, conscious opinions and beliefs about a stigmatised group) or implicit (automatic and subconscious beliefs), these attitudes interrupt the healthcare process. A commonly held misconception amongst HCPs is that weight stigma can be an effective tool to encourage weight loss. However, as outlined above, this belief is incorrect and weight stigma is more likely to lead to weight gain2.  Many of the studies reporting weight stigmatisation by HCPs are over a decade old. Surely the situation has improved in light of new scientific evidence? Unfortunately, two new studies published in the last year suggest the opposite.  One 2022 cross-sectional study of people with overweight and obesity in Israel (where obesity is recognised as a chronic disease), found that  59% of participants reported frequent experiences of disrespectful approaches in medical appointments, including insulting, insensitive and judgmental comments 6. 58% of participants reported that these comments came from a wide range of HCPs. 49% noted receiving suboptimal treatment related to excess weight and 29% reported that medical equipment was unsuitable for people with overweight6. Similarly, the first multinational investigation of associations between weight stigma and healthcare experiences across six western countries (Australia, Canada, France, Germany, the UK and the US), reported that two-thirds of all participants enrolled in a weight management programme experienced weight stigma from doctors7.  Implicit weight bias amongst HCPs can affect the level of support, care and empathy that people with obesity receive. HCPs spend less time in appointments with patients with overweight and obesity, provide less education about health compared with thinner patients and have less respect for people with a higher body weight 3. There is also evidence that patients with obesity are more vulnerable to therapeutic inertia8. Patients who report having experienced weight bias in the healthcare setting have poor treatment outcomes3. Health practitioners tend to over-attribute medical symptoms and problems of patients with overweight or obesity solely to their weight, missing the opportunity for early diagnosis and treatment for the underlying disorder 3. Concerningly, physicians report being reluctant to undertake pelvic exams in higher-weight patients, even though these patients have increased risk of endometrial and ovarian cancer compared with people without overweight or obesity9.   Perceived weight stigma during medical visits is associated with poor relationships between patients and healthcare providers, poor adherence and increased likelihood of avoiding future healthcare interactions 3. Previous experience of weight stigma in healthcare is associated with avoidance of age-appropriate cancer screening, which can lead to delays in breast, gynaecological and colorectal cancer detection 10.  On World Obesity Day 2020, a Joint international consensus statement for ending the stigma of obesity was published3. This consensus statement included key recommendations for healthcare institutions These recommendations included incorporating formal teaching on the causes, mechanisms, and treatments of obesity into standard curricula for all HCPs. The consensus statement additionally recommended that professional bodies develop methods to certify knowledge of weight stigma, its harmful effects and stigma-free practice skills among healthcare providers. Furthermore, medical institutions should provide appropriate infrastructure and equipment for the care and management of people with obesity.   However, despite the undisputable evidence of the detrimental effects of weight stigma in healthcare settings, these recommendations are not being implemented. Whose responsibility is it to drive these changes through? I would argue that everyone involved in healthcare has a responsibility. Through education, we need to reframe the public narrative of obesity so that it is coherent with the scientific knowledge and ensure that medical facilities and equipment are appropriate for people of all sizes. Weight stigma is a social justice issue that needs to be acknowledged not only by the recipient but also by witnesses, otherwise they become complicit bystanders. Is the solution to adopt a policy of zero tolerance to weight stigma across all healthcare settings, highlighting the detrimental health impact and social injustice of weight stigma? To continue to ignore the evidence and do nothing is unethical. Action must be taken to eradicate weight stigma from all healthcare settings.  References  1 Wu, Y. K. & Berry, D. C. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs 74, 1030-1042, doi:10.1111/jan.13511 (2018). 2 Jackson, S. E., Beeken, R. J. & Wardle, J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity (Silver Spring) 22, 2485-2488, doi:10.1002/oby.20891 (2014). 3 Rubino, F. et al. Joint international consensus statement for ending stigma of obesity. Nat Med 26, 485-497, doi:10.1038/s41591-020-0803-x (2020). 4 Nagpal, T. S., Tomiyama, A. J. & Incollingo Rodriguez, A. C. Beyond BMI: Pregnancy-related weight stigma increases risk of gestational diabetes. Prim Care Diabetes 15, 1107-1109, doi:10.1016/j.pcd.2021.07.002 (2021). 5 Sutin, A. R., Stephan, Y. & Terracciano, A. Weight Discrimination and Risk of Mortality. Psychol Sci 26, 1803-1811, doi:10.1177/0956797615601103 (2015). 6 Sagi-Dain, L., Echar, M. & Paska-Davis, N. Experiences of weight stigmatization in the Israeli healthcare system among overweight and obese individuals. Isr J Health Policy Res 11, 5, doi:10.1186/s13584-022-00518-9 (2022). 7 Puhl, R. M., Lessard, L. M., Himmelstein, M. S. & Foster, G. D. The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLoS One 16, e0251566, doi:10.1371/journal.pone.0251566 (2021). 8 Alessi, J. et al. Diabetes and Obesity Bias: Are We Intensifying the Pharmacological Treatment in Patients With and Without Obesity With Equity? Diabetes Care 44, e206-e208, doi:10.2337/dc21-1294 (2021). 9 Adams, C. H., Smith, N. J., Wilbur, D. C. & Grady, K. E. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 20, 45-57, doi:10.1300/J013v20n02_04 (1993). 10 Phelan, S. M. et al. The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey. J Gen Intern Med 30, 1251-1258, doi:10.1007/s11606-015-3266-x (2015).   Competing interests  R.L.B. is a trustee of the Obesity Empowerment Network UK, a trustee of the Association for the Study of Obesity, a committee member of the British Obesity and Metabolic Surgery Society, a committee member of the National Bariatric Surgery Registry and a special advisor for obesity for the Royal College of Physicians.  

Weight stigma in healthcare settings is detrimental to health and must be eradicated

https://discovery.ucl.ac.uk/10155005/2/Batterham_Weight%20stigma%20in%20healthcare%20settings%20is%20detrimental%20to%20health%20and%20must%20be%20eradicated%20.pdf

Weight stigma in healthcare settings is detrimental to health and must be eradicated

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