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Recognizing and Eliminating Weight Stigma and Bias in Health Care

Learning Objectives
1. Discuss how to address internalized bias in patients with obesity
2. Identifying personal biases as well as bias in staff members
3. Explain the importance of person (or people) first language
4. Recognizing obesity as a trauma-based disease
1 Credit

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Audio Transcript

Intro: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. In this episode we'll be hearing from obesity, medicine specialist and OMA clinical education director Dr Nicholas Pennings. Joining him is Joe Nadglowski, president and CEO of the Obesity Action Coalition and the speaker at the OMA 2022 Spring Summit. Today our experts discuss weight bias in health care, treating internalized bias in patients with obesity, identifying our own biases as well as bias in staff members, the importance of person-first language, and recognizing obesity as a trauma-based disease. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.

Nicholas Pennings, MD: I recall a patient visit with a middle-aged female patient where she tearfully recounted an incident as a teenager walking through a mall when a total stranger made a derogatory comment about her size along with a reference to a snouted animal. Even though the incident occurred almost 3 decades prior, the emotional trauma persisted. She stated that she continues to run this traumatic experience through her mind and finds herself repeating the fat-shaming name over and over again. Weight bias remains an unacceptably acceptable form of discrimination within family, society, and health care professionals. Hi, I'm Dr Nick Pennings, chair of family medicine at the Campbell University School of Osteopathic Medicine and executive director of clinical education at the Obesity Medicine Association. With me today is Joe Nadglowski, President and CEO of the Obesity Action Coalition. Joe presented a lecture titled “Stop Weight Bias: Understanding Weight Bias in Health Care” at the OMA 2022 Obesity Summit. Welcome, Joe.

Joe Nadglowski: Thanks for having me.

Pennings: So weight stigma and bias are terms that are commonly used together, but they have different meanings. What is the difference between stigma and bias?

Nadglowski: So bias really is that negative attitude that people have, that inherent attitude that people have towards people with obesity. And then of course, stigma can be, as you act upon it, what behaviors you take to actually act on those attitudes. And you know, I listen to your opening comment here about that patient whose story you described, and I will just remind the listeners today that that those of us who struggle with obesity, these activities, whether it's bias, stigma, discrimination because of your body size, being made fun of because of your body size, they live with you forever. And I actually relate very personally to the person that you described in those opening comments, because I still remember the first time a doctor ever talked to me about my weight and how much they stigmatized me because of it. And it's something that lives with you forever. Even though I do this every day and I work on this issue every day, it's something that is very, very difficult to overcome. Your words really do matter when it comes to addressing obesity.

Pennings: And they can be very sharp and piercing when they occur and stick with you as it did in this patient. And that was something that you experienced, as well, as you hear very frequently in the line of work that you do?

Nadglowski: Absolutely, and what I would just encourage anyone who is talking to someone about their obesity is to recognize they've likely had these negative experiences in the past. Look for those signals. Look for the signal that someone has started to internalize these attitudes to shame themselves, and if they are, talk to them about it. And honestly, if it's something you're not comfortable with doing, then refer them to mental health support to get that. I think oftentimes in order to want to care for ourselves when it comes to our obesity, we first have to love ourselves and we have to overcome these kind of internal biases that we called internalized bias that people have absorbed over all the years. And it's not just health care professionals—it's the person walking down the street, as you described, it could be from the media, it could be from a family member. There are a lot of sources of this bias and it is probably, if you're a young person with obesity, probably the biggest challenge you actually face when it comes to your obesity. You know obesity is a chronic disease, right? It's a progressive disease, so when you're young, oftentimes it's the social and the psychological side of this that's the hardest to deal with. The physical, the cardiometabolic issues, they come with time, but early on in your life it is actually living with the stigma, living with the bias, living with discrimination you face that is the hardest part of living with obesity.

Pennings: And you mentioned something in the about patients internalizing that bias, and I see that a lot and it's a challenging situation to deal with. What kind of things do you recommend health professionals do to address patients that are being very stigmatizing or biased towards themselves?

Nadglowski: Yeah, again, I think it's important that first of all, any health care provider, and obviously if you're an obesity medicine physician, a patient's coming to you to get obesity counseling or receive medications, et cetera. But if you're a primary care provider, first thing you should do is you should always ask a patient for permission to talk about their weight. And you would say, “Well, Joe, obesity is a chronic disease. We don't ask permission to talk about other chronic diseases.” But in in many ways obesity is a trauma-based condition as well, right, because of these past bad experiences. So using a kind of a trauma-informed lens around this chronic disease model actually is a good way to start those conversations. So always ask permission.

And by the way, if a patient resists, say, “Well, I appreciate that and I will respect your decision. Just know whenever you are ready we are going to have an evidence-based, stigma free conversation about your weight and I'm here to have that conversation with you when you're ready.” And of course, many of them will change their mind in that moment and actually talk to you. But if not, hopefully they come back to you at some point in the future. But again, if you see someone, they're using terminology to describe themselves in a very negative way, they're beating themselves up excessively about this, I would actually offer the advice I offered anyone when they see someone engaging in bias and stigma, and that's actually to step back and say you know what? Let's reset your understanding about obesity. Let's talk about what obesity is and what obesity isn’t. And obesity is a complex condition that is not just about personal failure, and this is about biology, this is chemistry, not choices. Whatever terminology you choose to use when you describe obesity, start there. Teaching people that obesity is complex makes them less likely to engage in bias and hopefully less likely to stigmatize themselves about their weight.

Pennings: I agree. As I go into the biology of obesity with patients, I often do see them starting to look at things differently when we talk about how whenever you calorie restrict, no matter what size you are, as soon as your calorie restrict, your hunger signals go up, your satiety signals go down, and you're going to be hungry. And that's going to be challenging to overcome, especially on a long-term basis.

Nadglowski: Yeah, and I think it's important that patients understand that this is, again, this is biology, right? And then it takes just a little bit of time by provider, probably more time than the average primary care provider has to counsel someone around these issues, but it's important that you have those conversations. Again, society has always told us this is all our own fault when we struggle, and the reality is, our health care provider's job is to actually change that conversation and talk about how this is really hard. The reality is addressing obesity is hard, and we're going to support you in the journey and there's going to be ups and downs. However, if something doesn't work out, that's not your fault. That is because the treatment's not the right one from you, and we'll move you on to the next treatment and find one that does work.

Pennings: And that is the ideal, but the reality is health care…weight bias is very common in health care. So what should health professionals be looking for as a source of bias that they might have in their own beings or in their office that they're not even aware of?

Nadglowski: Yeah, so I think I think every person and especially our health care providers need to stop and ask themselves, “Am I sensitive to the needs of people living with obesity?” And you may be doing this in very unintentional ways, right? You may not realize that the seating in your office won't accommodate someone of a larger size, and that's sending a signal right away that maybe this isn't the right person for me to talk to, because they don't even have the right kind of furniture.

I would also really encourage you to train your staff around this subject of bias. One thing I hear all the time is offices will get a newer new receptionist to greet patients as they come in and then a patient will come in, and they'll say you know, “Patient X, Dr so-and-so is really going to be able to help you.” And then suddenly you see the patient deflate. Well, what they don't know, because they're a new receptionist, is that patient's been coming for years and Dr so-and-so's already have helped them lose a tremendous amount of weight. But they don't meet society's ideal about body size, and therefore that person just thinks that all that work I've done for the last couple of years and all the way I've managed to lose already is not success just because of one innocent comment from a staff person. So it's important that we train across the board, that you not judge someone based on their body size. Someone could walk into the room where we're talking right now and weigh 400 pounds. And if you don't know them, you can make no judgement based on their health because of their body size, because you don't know if a year earlier they weighed 500 pounds and they've done something remarkable, which is maintain 100 pound weight loss. So we have to be very, very careful by judging obesity just on appearance, right? It's important that if we're going to talk about obesity that we do an honest look at someone's health and where they are in in their status in life.

Pennings: I agree it's very important that your staff be aware of those things. You don't want them yelling down the hallway that, you know, the large cuff didn't fit, can you get me the super-sized one, you know? And comments that would be negatively perceived. And also teaching our staff about people-first language. What is people-first language and why is it important?

Nadglowski: Yeah, so people-first language, person-first language sometimes it is referred to, is the typical language we use to describe someone who has a disease. So you would always say, for example in cancer, that a patient has cancer. You would never say they're cancered or they're cancerous, right? But no, the person has cancer. But with obesity we have had this unfortunate tendency to use the word obese. And so really, person-first language is eliminating the word obese from your vocabulary, so you would say “a person living with obesity” or “a person with obesity”. And by the way, be careful. There's other things that you can do to try to be partially people-first language, but then make mistakes. So you would never say “a patient suffering with obesity” because not everyone who lives in a larger body suffers, right? So we have to be careful about applying some of these negative terminology in this.

And this slips into places all the time, and in fact, if you take a look at journals and/or, you know, textbooks around obesity, you're going to see the word obese used pretty commonly and I really would encourage anyone listening today to spend the time to actually work out the vocabulary in your head that you never have to use it again. And you can't just do it with your patients, you’ve got to do it with everyone. Like commit to using it. And I will admit, it took me two years to work that word out of my vocabulary. And I still remember the last time I used it incorrectly in a sentence because I hadn't built my sentence structure in my head to say how someone develops obesity. I said becoming obese instead of developing obesity and because I hadn't thought of the structure in my mind to have that sentence. But it was a concerted effort on my part. Especially someone who's been around as long as I have where you, you're kind of, I've been doing this for 17 years so we have a lot of bad language that we have to work out of our vocabulary. But it is doable and I would encourage everyone to again just eliminate that word obese.

Pennings: And we still see it a lot in the medical literature. Even publications coming out today still use that terminology. What are you doing to try to help change that and create better awareness of that term?

Nadglowski: Yeah, so we have actually asked lots of the medical journals to commit to using person-first language. In fact, me and a couple of my colleagues are actually engaged in a research project right now. We're actually looking at the major medical journals to see how often they use person-first language for obesity, say compared to how often they use it for diabetes, which is really something…another area where you've seen probably more progress than we've seen in obesity. We know the old term diabetic is now being replaced with person with diabetes, right? And they've had more success there, so we're doing some comparisons there.

The other area we have to fix—and this is the nature unfortunately of our health care system—is some of the coding systems that we use to code obesity in your electronic health records still use that old non-person first language. And so we are actually working with the authorities both at the World Health Organization that originally developed those codes and then of course, as it moves to the United States with the Department of Health and Human Services as they come forward, to see more person-first language being used there. I will say one great area of really positive news we saw, it was about…it was a little over two years ago now, the Centers for Disease Control actually put on their obesity website their commitment to actually commit to person-first language when it comes to obesity. And so we're starting to see some progress among researchers. It will take a little more time, but slow and steady when it comes to that. I've been relatively pleased with the amount of content we've seen, at least from government agencies and some of the medical journals. We still really struggle in the media, right? You're rarely going to see a newspaper article that doesn't use word obese, and they often argue that's because of word count because it takes two words to say it instead of one word. But I think with more pressure and with more providers starting to use the right kind of language, we'll see the media change over time, as well.

Pennings: That's a pretty weak excuse.

Nadglowski: Yeah.

Pennings: Yes, I agree. You know, when it comes up, “morbid obesity due to excess calories,” it's really a revolting description of obesity diagnosis. So where are you in changing that? Is that something that we're close or we can hope to see sometime soon? What are your expectations around that?

Nadglowski: Yeah, so again I started 17 years ago, morbid obesity was the terminology or morbidly obese terminology used very commonly, and honestly I do see that terminology disappearing. We've even seen the surgeons begin to use severe obesity instead of morbid obesity. And I will say that in ICD 11, which is the next version of codes that come forward, you see these descript[ions[, the word morbid dropped from a descriptor on that. And curiously, they actually even changed the second part of that sentence, which you mentioned was, you know, “morbidly obese due to excess calories.” Now it will actually be, “obesity due to energy imbalance,” right? So I think that is actually, even that is less of a judgment in its terminology, so we've seen progress there. But I will say there's probably an opportunity in the short term for listeners—and they should pay attention to OMA's future newsletters—because there is actually an effort going on right now not to wait until ICD 11 comes out, which will still be 3, 4, 5 more years in the US depending on how long it takes to get rolled out. But there is a there is actually an effort being led right now to actually ask HHS not to wait that long when it comes to these codes around obesity to make those language changes now. And so I just encourage your listeners to stay tuned because we will have more information and probably an opportunity for them to act from an advocacy standpoint in the coming months.

Pennings: That's great, that's great. You know, like all forms of bias, weight bias takes a heavy emotional toll on patients and a number of studies have looked at some of the health consequences of weight bias. Can you tell us about some of those studies and what they found looking at the impact of weight bias on patient care?

Nadglowski: Yeah, so the one reality is if you're a person like myself who lives with obesity, the studies are pretty clear—you know, you unfortunately go to the doctor less often. You engage in less preventative care. And a lot of this is believed, of course, that well when I go to the health care provider or the doctor, they just make fun of me or they give me a hard time, and so therefore I'd rather not get stigmatized that way, so therefore I don't go anymore and the consequences of this is pretty substantial. Actually, you know if you look at the data, people with obesity on average spend less time in their doctor's appointments than someone without obesity. And really, I think how that goes is of course me as a patient, I don't want to talk about it and my health care provider maybe doesn't want to ruffle my feathers or worry they're going to embarrass me so they don't talk about it. So it's a really quick visit, but as you know, we have to talk about this. And I think for me what, again I would encourage, is any health care provider ask permission and then take this from a nonjudgmental approach. Take the disease approach, that obesity is a complex disease approach, and talk to your patients about it. Take that blame and shame away from them, and I think… And it'll take time and it'll be hard, but I think your patients deserve that kind of better care.

Pennings: I think it is important to ask and, but it's also important not to have that “don't ask, don't tell” kind of mentality either and both parties are just trying to get in and out of the room as quickly as possible. And really, if a patient is ready to touch upon an issue that is often affecting so many aspects of their health care, but doing it in that unbiased way because it can make the problem worse, not better, right, just being told that you know all these health consequences are because of your weight and then leaving it at that just shames the patient and makes them feel worse.

Nadglowski: Absolutely. I think this—and again my first experience with my health care provider was him walking in the room while I was having allergy testing done, he was pricking my back and he looked at me and my shirt was off obviously, and he wagged his finger at me, “You know you could lose 30 pounds,” and he turned around and he walked out of the room, right? I mean, and I'm like, of course Doc, I know I can lose 30 pounds, but you know you telling me doesn't do anything, right? But talk to me about how we can do this together, and I think that's… If you have a conversation with your patients about “Yes, I know this is hard and I know it could be a sensitive topic, but this is not about judgment. This is about us working together. Not me just telling you to lose weight, but us actually working together to do it.” Your patients want to engage in those conversations. I have yet to meet someone who struggles with their obesity—they could be the loudest member of the fat acceptance or fat liberation movement as they call themselves now—I guarantee you at some point in their life they've tried to lose weight. So they just need better support in doing it, right? And I think that's what a good patient provider relationship can do when you when you have this in a nonjudgmental way.

Pennings: You know, a patient if they come in and their blood pressure is high. maybe 160 / 100, no physician would say, “I want you to lower your blood pressure by 40 points before your next visit” and then walk out of the room, right? And that's no different than telling a patient to lose weight, but not giving them any of the tools or resources to be able to do that.

Nadglowski: Absolutely agree, and I think it happens so often, right? I think—in fact you know we have a large campaign, OAC does, my organization, where we…it's called the Your Weight Matters Campaign where we encourage people to go have a conversation with their health care provider about their weight. No matter what their body size status is—just go have a conversation. We actually studied those people and I think 70% of them, even though we gave them the tools to say, “Here's how you have a better conversation,” 70% of them still said “my doctor just said go lose weight,” right? They didn't actually give them the necessary support to do that, and so we're trying to change that. I know OMA is trying to change that, as well. So first of all, help those patients ask the right questions, but also help the providers have the right kind of training so they feel comfortable actually having these conversations. Because obesity, treating obesity's hard, right? It's not, it's not as simple as unfortunately the public thinks it is, or the media thinks it. This is, it takes some training both on the on the patient side and the provider side to have good conversations.

Pennings: So what are some of the other key initiatives that the Obesity Action Coalition is taking on to combat weight bias in society? And how can health professionals learn more or become more invovled

Nadglowski: Yeah, so we are engaging and challenging bias when we see it and so we have a very large campaign called the Stop Weight Bias campaign. So it's StopWeightBias.org, you just visit that website and it features some real patient stories and some public service announcements that now appear on television all across the country. In fact, I think we had. $12 million worth of donated ads last year, which is pretty remarkable. This, I think these PSA's have really appealed to people and struck a chord right? So people want to have this conversation about let's not stigmatize people, let's give them the help that they need. And for those listening today, I will tell you that the most important thing you can do as a provider is to challenge--actually, even as a person—is to challenge bias when you see it. Unfortunately we let bias slide too often, right? We let, you know, the newspaper make a comment that's wrong. Or we let the newscaster make comment or wrong, or the late night talk show host make a joke and not reply to it. It's time for us to speak up, and again, I just want to encourage around tactics here though: so we are not going to shame and blame people into not engaging in shame and blame, right? We don't want to be just as bad as the people who are engaging in these activities, so I would start from that message of education, say “Hey, can we talk about this in a different way? And here's why.” Talk about the complexity of obesity, the biology of obesity and then, if possible, include some real people with the lived experience, which—people who have plenty of patients if you're treating obesity, but you can also come to OAC and we can help identify folks for you as well—who can say, “Look, okay, you heard it from the science and the and the evidence side and the biology side. Let's hear from the lived experience side. And really, let's talk about this in a much more comprehensive way, in a way that will, ultimately, you know, benefit more people to seeking better health.”

Pennings: That's great. So lastly, when discussing obesity with health professionals, what's your favorite bit of advice?

Nadglowski: Yeah, so my bit of advice with health care providers themselves is to just go back and take a look at your entire practice and say where is the gaps, right? Where could bias slide through in this process? And again, you know a lot of times providers will come to me and say, “well, I'm I think I'm having personally having really good conversations with patients, but they're not coming back or they come back once or twice and they don't come back and what's going on?” And I would challenge you to go back and actually take a look at your entire practice again because it may not be you that's the problem. It could be your MA or your nurse or the janitor, or someone who parks the cars, or r whatever it may be at your facility. Don't just think about this as just you as the provider themselves.

And again I think the other thing that all providers should be doing is just ask permission. Of course, obviously, if you're running, even if you're running an obesity management clinic, why not? Why not say, “Okay, I know you've come here to see me you know, to talk about your obesity, but it's okay we talk about this, right? I want to make sure you're here because you want to be here and you want to have this conversation.” I think it's a great way to, just to again, acknowledge that there may have been some trauma in the past around this issue and start off with a level of respect. And again, I know we don't do that for blood pressure, and we don't do it for cancer, we don't do for those other things, but you're likely have not been traumatized in the past because of those other conditions, and so therefore just start with that. Show dignity and respect, but take a hard look at your overall practice, right? And even if you're in obesity medicine, I think it's worth every once in a while just saying, you know what, we're going to step back and take a look: where's bias sneaking in? And if you identify this place as fixing, if you don't see any, that's great. Then just you know, reconvene and do it again the year following, just to make sure, especially as we turn over people so frequently in health care.

Pennings: I agree. You know, increasing self-awareness is such an important part as you grow in a medical practice, and we need to be constantly aware of our words, our actions, our office setting. So many things influence patient care so maintaining that self-awareness is important.

Well, thank you for being with us today and you can see Joe Nadglowski's full lecture on the Obesity Medicine Academy called Stop Weight Bias: Understanding Weight Bias in Health Care. Thank you for being with us again.

Nadglowski: Thank you, sir.

Outro: [outro music] Thank you for listening to this episode of Obesity: A Disease. For more information about Obesity Medicine podcasts and other valuable resources from the clinical leaders in obesity medicine, please visit www.obesitymedicine.org\podcasts. If you enjoyed this episode and want to listen regularly, head over to iTunes where you can subscribe, rate, and leave us a much appreciated review. The views expressed in this episode are those of the host and guest, and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please join us again for our next episode of Obesity: A Disease.

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© 2022 Obesity Medicine Association. All Rights Reserved.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Participation Statement: Upon completion of this activity, learners will receive a Participation Certificate.


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