Is the Obese Patient Welcome in Your Office?

Stigma and bias against obese patients are pervasive in our culture.  Part of this likely stems from the fact that obesity is perceived as a choice arising from personal responsibility or lack thereof.  Obese persons experience stigma and discrimination in many aspects of their lives.  This includes socially, in the work place but most disturbingly in the health care arena.

Health care based bias against obese patients can be overt.  Take for instance, Ida Davidson, the Shrewsbury Massachusetts woman who, upon presenting to her primary care physician for a second visit, was told that she could no longer be a patient at that office because she weighed more than 200 lbs.

Often times though, the bias is more subtle.  Obese patients frequently identify physicians and other health care providers as significant sources of bias against them.  This is substantiated by studies that reveal that physicians, nurses and even medical students harbor conscious or subconscious biases against the obese patient.   Adjectives such as weak willed, lazy, stupid, awkward, unattractive, ugly and noncompliant, have been used by health care providers to describe obese patients. 

A Johns Hopkins study noted that physicians have lower respect for patients with higher BMI than patients with lower BMI.  Physicians who have more respectful attitudes towards patients,  share more medical information and have more positive effects during encounters compared with patients for  whom they have less respect.  Patients desire a respectful relationship with their physicians and may avoid seeking health care if they perceive lack of respect.   Doctors tend to be less empathetic and form less of a bond with obese patients.  Women are more likely to be subjected to bias and stigma by physicians at a lower BMI( approximately 27) when compared with men  (BMI of approximately 35).
Bias may also include attributing the patient’s symptoms,  irrespective of their presentation to their weight making the obese patient feel invalidated and unheard e.g. the patient who presents with a sore throat but gets a lecture about his/her weight. 

The bias may include more tangible things such as seating that is either not safe or accommodating of the obese patient, scales with limited weight capacities, gowns that do not fit and blood pressure cuffs that are too small.  These overlooked, but easily fixable, aspects of the health care environment can potentially make a profound impact on the comfort and psyche of the obese patient.

Joseph J Gugenheim, MD wrote….”our (physicians’) attitudes towards obese patients may make us part of the problem regarding their care”.  Given that two out of every three American adults are obese or overweight, we could be potentially providing a disservice to a large proportion of our patients.

Being aware of the bias that we each bring to the patient – physician encounter can also help the health care professional deliver better care to the obese patient.  As noted in the Obesity Society piece, asking the following questions can be helpful in this regard:

    • Do I make assumptions based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?
    • Am I comfortable working with people of all shapes and sizes?
    • Do I give appropriate feedback to encourage healthful behavior change?
    • Am I sensitive to the needs and concerns of obese individuals?
    • Do I treat the individual or only the condition?

      One of the first steps in assuring that obese patients are comfortable in our offices is to offer staff members training in obesity sensitivity.  The patient visit may be sabotaged long before you set foot in the exam room, by an unthinking comment from a receptionist or nurse.   Our obese patients are likely quite aware that there is a problem with their weight and feel physically and psychologically vulnerable in a physician’s office, likely having had a negative experience with the health care system before.

      Listen to, and validate your patient’s concerns.  Evaluate their complaints just like you would with a normal weight individual; do not assume that their weight is the problem.

      Congratulate and praise patients for making healthy changes no matter what the scale says.  The Diabetes Prevention Study has shown that small amounts of weight loss can have a disproportionately large impact on health.  Do not overlook the 20 pounds the patient has managed to lose just because they are carrying an excess of another 50 lbs.  Further, the patient who has not yet shown a significant weight change, but is making incremental behavior changes (e.g. eliminating sodas, increasing physical activity) needs encouragement and recognition.
      Recognize the complex nature of obesity and the multiple phenotypes.  Offer patients concrete advice – e.g. limit eating out to 2 meals per week versus you need to lose weight. 
      Create a supportive health care environment with large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and patient friendly reading material.

      Maintain an excellent patient-doctor relationship.  The patient should not feel that the quality of the physician – patient relationship is contingent on their weight loss or lack thereof.

      Puhl, RM, Brownell, KD.  Bias and discrimination and obesity.  Obesity Research 2001; 9: 788 – 905.

      Gudzune, K, Beach MC, Roter, D, Cooper, L.  Doctors build less rapport with obese patients.  Obesity  2013; 21 (10):2146 – 2152.

      Gugenheim,J.  Physicians’ attitudes and weight bias.  Aaos.org/news/aaosnow/jun13/clinical7.asp

      Foster, G, Wadden, T, Makris, A, Davidson, D, Swain Sanderson, R, Allison, D and Kessler, A.  Primary care physicians attitudes about obesity and its treatment.  Obesity Research 2003; volume 11 issue 10 pp 1168 – 1177.

      Bagley, CR, Conklin D, Isherwood, RT, Pechiulis DR, Watson, LA.  Attitudes of nurses towards obesity and obese patients.  Percept  Mot  Skills 68: 954

      Huizinga, M, Cooper, L, Bleich, S, Clark, J, Beach MC.  Physician respect for patients with obesity.  Journal of General Internal Medicine Nov 2009 Vol 24 Issue 11 1236- 1239

      Obesity, Bias and Stigmatization.  www.obesity.org/resources-for/obesity-bias-and-stigmatization.htm