The Clinicians' Guide on Talking to Patients About Obesity

Obesity and Stigma: The Joint International Consensus

As obesity rates grow in adults, so does an obesity bias in physicians. Now more than ever, we need weight-inclusive care. And the first part of that puzzle is changing the conversation—using words that give patients agency and help them achieve optimum health.

With Rebecca Puhl PhD, Elena Christofides MD, FACE, and Scott Isaacs MD, FACE, FACP

Obesity Bias

More than 1 in 3 Americans have been diagnosed with obesity. Yet, to be called obese remains so stigmatizing that most patients who want to lose weight for medical reasons would prefer their health care practitioners not use that word to describe them, even in a medical setting.

 

Why? Patients with obesity experience stigma and discrimination about their weight long before they have a conversation about it with their clinician. Research shows that this continuous experience makes them less likely to receive medical care and can cause physical and psychological harm. The incorrect but pervasive idea that people who are obese have brought it upon themselves, and the accompanying accusations of laziness, overeating, and lack of willpower have also been shown to influence public health policies and access to necessary medical treatments for the condition and its comorbidities.

The Joint International Consensus Statement on Obesity and Stigma

As a result of the enduring stigma and discrimination patients with obesity face and their grave consequences on patients' health and ability to receive adequate medical care due to well-documented bias within the medical community, 36 of the world's leading obesity experts recently published their "Joint International Consensus Statement" in the journal Nature Medicine. They found overwhelming evidence that:

  • Many health care professionals hold negative attitudes about obesity, including stereotypes that affected patients are lazy, lack self-control and willpower, are personally to blame for their weight, and are noncompliant with treatment.
  • Adults and children who experience weight-based stigma are more likely to avoid exercise and physical activity, and to engage in unhealthy diets and sedentary behaviors that increase the risk of worsening obesity.
  • Quality of health care is adversely affected by weight-based stigma.
  • Fear of prejudice and internalized weight bias cause direct and indirect harm to patients with obesity, as they are less likely to seek and receive appropriate treatment for obesity or other related conditions.
  • The idea that the causes of obesity depend on patients’ faults, such as laziness and gluttony, provides the foundation for stigma against obesity.
  • Popular expressions such as ‘energy in versus energy out’ or ‘calories in versus calories out’ are misleading because they inaccurately imply that body weight and/or fat mass are solely influenced by the number of food calories ingested and the amount of energy burned through exercise. This narrative is not supported by evidence and provides a foundation for stigmatizing views that blame patients’ lack of willpower for their obesity.
  • The idea that obesity is a 'choice' is a misconception, inconsistent with both logic and scientific evidence showing that obesity results primarily from a combination of genetic, epigenetic, and environmental factors.
  • There is a widespread assumption, including among many medical professionals, that voluntary lifestyle changes, such as diet and exercise, can entirely reverse obesity over long periods of time, even when severe. This assumption runs contrary to indisputable scientific evidence demonstrating that voluntary efforts to reduce body weight activate potent compensatory biologic responses (for example, increased appetite and decreased metabolic rate) that typically promote long-term weight regain.
  • Medication and metabolic surgery are not ‘easy ways out’ but evidence-based, physiologic approaches to treating obesity and type 2 diabetes, given their ability to influence underlying mechanisms of energy and glucose homeostasis.
  • There is objective evidence that in many patients obesity presents the typical attributions of a disease status, which include specific signs and symptoms, distinct pathophysiology, reduced quality of life, and increased risk of complications and mortality.
  • Although prevailing evidence supports a rationale for obesity to be defined as a disease, as recognized by leading worldwide authority bodies and medical associations, current diagnostic criteria for obesity, only based on BMI levels, are inadequate to accurately diagnose obesity.

Practitioners who do not necessarily specialize in obesity should also educate themselves on the complex causes of body weight regulation to avoid communicating the unhelpful and scientifically invalid message that patients should lose weight without support or additional therapies such as weight loss medications. Adjunctive pharmacotherapies have been repeatedly proven to increase the percentage of body weight patients dealing with obesity are able to lose, at an average of 5-7.5% with medication, while diet and exercise are only likely to cause weight loss of 2-3% in a person who has obesity and has tried to lose weight unsuccessfully in the past.

"Obesity specialists who have the correct information and know how metabolism works are treating obesity like they would any other health condition, by offering patients all of the treatments available to them and discussing their options with them based on their specific history of weight loss and gain," says obesity specialist Scott Isaac MD, FACE, FACP. "But other primary care physicians and health care practitioners who may not have the same training are often unintentionally coming from a problematic moral or disciplinary mindset where they are telling patients it's their fault that they can't lose weight." 

"One of the shifts that clinicians need to make to better treat patients with obesity is to stop leaving the treatment to the patients themselves and instead treat it the same as we would any other disease," says diabetes and metabolism expert Elena Christofides MD, FACE. "If you had a patient with lung cancer, you wouldn't withhold cancer treatments from them and just wait for them to quit smoking. That would be considered cruel and unethical. But the way many clinicians treat patients with obesity is cruel and unethical in the same way because their bias dictates that those patients should only undergo proven treatments for their disease, such as medication and surgery, after they have failed at diet and exercise. Why would you withhold treatment from a patient and send them home to treat themself? It doesn't make any sense.”

A large step away from obesity bias, and toward treating obesity as you would any other condition, is to avoid suggesting it is the patient's problem to solve themself and resist oversimplifying the causes. “This shift in the language clinicians use in conversations with their patients has been demonstrated in our studies to be a key component for effective stigma reduction," says Rebecca Puhl PhD, a professor at the Rudd Center for Food Policy and Obesity at the University of Connecticut, as well as the author of many recent studies about obesity bias, including the comprehensive review"What Words Should We Use To Talk About Weight? A Systematic Review of Quantitative and Qualitative Studies Examining Preferences for Weight-Related Terminology," recently published in the journal Obesity Reviews. "It's also effective to educate health care providers and trainees about the complex etiology of obesity; that it is clearly not just about a lack of willpower or motivation." 

“Clinicians should approach obesity as they would any other patient dealing with any other disease or condition of equal severity and present the patient with all of the options that could help them, including medication and surgery,” says Dr. Christofides. "It is a more holistic approach that recognizes there are many facets that contribute to a patient's health, including body weight and metabolism."

"Health care providers should not assume patients with obesity can lose a significant amount of weight using diet and exercise alone," says Dr. Isaacs. "Be honest with the patient about how much weight they are likely to lose by making lifestyle changes versus how much more they could with medication. Let the patient decide if their treatment plan will integrate weight loss medication to help them reach their goals. Don't make that decision for them any more than you would for any other patient with a serious medical condition."

It is very common for patients with obesity to change their behavior, and their health indices will improve, but they do not lose weight. Assuming that because they have not lost weight they were not really trying or complying with the plan that was set out is a stigmatizing assumption that gets made, and it is also not giving those patients concrete support and strategies to bring about more substantial change. “Using terminology like 'excuses,' or suggesting that patients dealing with obesity have cheated on their diet or that they're not telling the truth about sticking to a weight loss plan because they haven’t lost weight, or implying that they're noncompliant is not only counterproductive to supporting patients dealing with obesity, but it has also been shown to be scientifically inaccurate,” says Dr. Puhl.

The 36 obesity experts who published their "Joint Consensus International Statement" in 2020 also created the following pledge to help other clinicians better serve their patients with obesity and provide them with care without stigma or bias in 2021. 

The Clinicians' Pledge To Eliminate Obesity Bias and Stigma

To Recognize

  • Individuals affected by obesity face a pervasive form of social stigma based on the typically unproven assumption that their body weight derives primarily from a lack self-discipline and personal responsibility.
  • Such portrayal is inconsistent with current scientific evidence demonstrating that body-weight regulation is not entirely under volitional control, and that biological, genetic, and environmental factors critically contribute to obesity.
  • Weight bias and stigma can result in discrimination, and undermine human rights, social rights, and the health of afflicted individuals.
To Condemn
  • The use of stigmatizing language, images, attitudes, policies, and weight-based discrimination, wherever they occur.
To Pledge
  • To treat individuals with obesity with dignity and respect.
  • To refrain from using stereotypical language, images, and narratives that unfairly and inaccurately depict individuals with obesity as lazy, gluttonous, and lacking willpower or self-discipline.
  • To encourage and support educational initiatives aimed at eradicating weight bias through dissemination of current knowledge of obesity and body-weight regulation.
  • To encourage and support initiatives aimed at preventing weight discrimination in the workplace, education, and healthcare settings.

To Acknowledge

  • Prevalence of weight bias and stigma in the media, healthcare, education, and workplace
  • Psychologically and physically harmful effects on individuals
  • Impact on access to care and research
  • Biological mechanisms of weight regulation in physiology and disease
  • Clinical evidence of uptake and barriers to access of available treatments
  • Mechanisms of body-weight regulation and energy homeostasis

How can clinicians put this pledge to eliminate obesity bias and stigma in medicine into action? It starts with motivational interviewing...

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