News & Analysis

Medical News & Perspectives

Addressing Medicine’s Bias Against Patients

Who Are Overweight
Rita Rubin, MA

A
ccording to her obituary, Ellen Maud
Bennett had felt unwell for a few
years before her death in May 2018.
But the physicians Bennett consulted
couldn’t see past the extra pounds she car-
ried. If she’d only lose weight, she’d feel bet-
ter, they told her.
Finally, a physician must have sus-
pected another reason for her malaise,
because Bennett was diagnosed with ad-
vanced-stage cancer just days before her
death at age 64 years.
Bennett, a costume designer for stage
and screen who lived in Victoria, British
Columbia, expressed a final plea in her
obituary: “Ellen’s dying wish was that
women of size make her death matter by
advocating strongly for their health and
not accepting that fat is the only relevant
health issue.”
Whether Bennett’s prognosis would
have been less dire if she’d been diagnosed
earlier isn’t known. But, given the tales told
by scores of strangers from around the world
who posted their condolences, Bennett’s
health care encounters epitomized that of
many overweight and obese individuals.
“There is not a single patient with sig- rector of the Rudd Center for Food Policy and patients with obesity. Phelan was a coau-
nificant obesity who has not experienced Obesity at the University of Connecticut. thor of the 2015 review article.
weight bias, whether it’s comments from But, Puhl said, that “really oversimplifies the “There is some evidence showing that
doctors or nurses, the way waiting rooms complex causes of obesity and of weight loss physicians tend to spend less time in ap-
are set up, or privacy issues,” said Yoni and of weight regain.” pointments with patients at a higher body
Freedhoff, MD, an obesity specialist at the “Many healthcare providers hold weight,” Puhl said. “Primary care providers
University of Ottawa. “Weight bias is ubiq- strong negative attitudes and stereotypes have also reported less respect for patients
uitous in society as a whole. Doctors are about people with obesity,” concluded the with obesity than those without.”
part of society.” authors of a 2015 review of the empirical lit-
Weight appears to be the last accept- erature on weight bias in health care. Weighty Matters
able bias, because, unlike most other char- “There is considerable evidence that such Might weight bias be even more prevalent
acteristics or conditions, it is one over which attitudes influence person-perceptions, among health care professionals than among
individuals are perceived as having control. judgment, interpersonal behavior, and other segments of society? After all, obe-
Losing weight and keeping it off should be decision-making.” sity increases the risk of many health prob-
(not eating) a piece of cake, this line of think- While a number of studies have sug- lems. Plus, research suggests that health care
ing goes. And yet, nearly three-quarters of gested that many health care professionals professionals are less likely to be obese than
US adults ages 20 years or older are over- are biased against patients with obesity, evi- the general population. Phelan said physi-
weight or obese, according to the US Cen- dence about how that bias plays out in terms cians occasionally rationalize their weight
ters for Disease Control and Prevention. of patient care and outcomes “is pretty pre- bias by telling him, “I’m also really biased
“Our country has placed a huge empha- liminary,” said Mayo Clinic researcher Sean against cancer because I don’t want my pa-
sis on personal responsibility for body Phelan, PhD, who focuses on the effects of tients to have it because it’s bad for them.”
weight,” said Rebecca Puhl, PhD, deputy di- health care professionals’ attitudes toward The difference is that physicians generally

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aren’t biased against patients with cancer as
well as cancer itself, Phelan suggested.
Because obesity is a health risk factor,
physicians feel justified to address pa-
tients’ excess weight every chance they get,
no matter the reason for their visit, Phelan
said. For example, when patients with obe-
sity seek treatment for an earache, some
physicians feel the need to remind them that
they need to lose weight.
“I don’t disagree that it’s important,
but the overwhelming evidence is that by
recommending weight loss to your patient
in a primary care appointment, when
that’s not what they’re there for, does not
help them,” he said. “It’s potentially doing
harm. Patients who are obese are avoiding
that follow-up appointment because they
didn’t lose weight, and they said they were
going to.”
Starting Early
Weight bias among health care profession-
als dates back to their undergraduate
years, 2 recently published studies suggest.
The authors used virtual human technology
to see whether the weight of pediatric
patients or their mothers influenced assess-
ments made by students with health care
majors, such as premed.
In one study, undergraduate partici-
pants rated children and mothers with obe-
sity as being less likely to adhere to physi-
cian recommendations compared with
healthy weight children and mothers.
“We’ve certainly heard from par-
ents…who report interactions with physi-
cians who put a lot of blame on the parent
[of obese children],” said University of
Florida pediatric psychologist David
Janicke, PhD, a coauthor of both virtual
human studies.
In the other study, participants rated
the pain of pediatric patients with obesity
as more likely to be influenced by psycho-
logical and behavioral issues compared
with the pain of healthy weight pedi-
atric patients.
“These results suggest that interven-
tions targeting weight bias among students
and health care trainees may be war-
ranted,” Janicke and his authors concluded.
“Future research should begin by examin-
ing whether or not participants are actually
aware of their own bias.”
Trainees who’ve successfully shed
pounds might be more likely to harbor a bias
against patients who are overweight than
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their peers who’ve not had that experi-
ence, suggests a 2017 article based on a sur-
vey of medical residents and internal medi-
cine residents.
Two-thirds of the trainees reported hav-
ing successfully lost weight, and 8 out of 10
who had shed pounds said they had main-
tained their weight loss. Trainees who re-
ported having lost weight and kept it off ex-
hibited more critical attitudes toward
patients struggling to manage their weight,
the study found.
Educating Trainees
Medical schools devote relatively little at-
tention to the subject of obesity, let alone
weight bias, Puhl said.
“If we look at medical school curricula,
obesity does not get very much airtime,
and that is a problem,” she said. “We need
more content…on obesity and nutrition so
health care providers understand just how
complex body weight is. It’s not just an
issue of calories in and calories out. Not
only is obesity and nutrition not getting
enough attention, but weight stigma is
completely off the radar.”
Medical students need to learn how to
talk to patients about weight-related health
issues, starting with asking their permis-
sion to bring it up and not using stigmatiz-
ing language, Puhl said. In a study pub-
lished in 2012 Puhl and her coauthors
surveyed a national sample of US adults—
about 60% of whom were overweight or
obese—about their weight-related lan-
guage preferences. “Weight” and “un-
healthy weight” were rated most desirable,
while “morbidly obese,” “fat,” and “obese”
were rated as the most undesirable.
A 2015 study reporting survey re-
sponses from students at 49 randomly se-
lected US medical schools found that dis-
criminatory behavior by faculty and less
positive contact with patients with obesity—
often described as “problem” patients—
were associated with increased biases
against patients who were overweight.
These findings suggest that medical schools
could reduce students’ weight biases if they
made sure that faculty and residents set a
better example and they provided opportu-
nities for positive encounters with patients
with obesity.
At least a few medical schools have rec-
ognized the need to start working proac-
tively toward changing students’ biases
against overweight patients.
The University of Pennsylvania is “test-
ing out incorporating more nutrition infor-
mation into medical training, …which could
have implications for helping students
understand in a more nuanced way the
complexities of weight and eating,” said
Rebecca Pearl, PhD, a psychologist at
Penn’s Perelman School of Medicine, who
conducts weight sensitivity training with
medical and nutrition students.
At Johns Hopkins University School of
Medicine, researchers embedded an ethics
session in a required course, “Obesity,
Nutrition, and Behavior Change,” to help im-
prove students’ attitudes toward patients
with obesity.
Before the ethics session, 6 cohorts of
first-year students had consistently nega-
tive attitudes toward patients with obe-
sity, according to a study in the AMA Jour-
nal of Ethics.
During the ethics session, students dis-
cussed their personal weight struggles and
their beliefs about the causes of obesity.
They also watched and discussed video
clips from the television show “House” that
depicted negative attitudes toward over-
weight patients. In a survey of the 2017
cohort 4 months after the ethics session,
30% of respondents reported that it had
helped improve their attitudes toward
patients with obesity.
The Mayo Clinic Alix School of Medi-
cine devotes 2 afternoons each year to the
topic of nutrition, covering obesity as well
as malnutrition, said endocrinologist
Manpreet Mundi, MD, who is on the fac-
ulty in Rochester, Minnesota. “We really
fought hard for this.”
Students learn that it’s much easier to
gain weight than it is to lose it, that genet-
ics, the environment, and psychological fac-
tors—not simply laziness and a lack of will-
power—contribute to obesity, and that being
obese doesn’t necessarily affect adherence
to treatment. “As that curriculum started to
evolve, I started to add components of obe-
sity bias to it,” Mundi said. “We’re trying to
have medical students and residents shadow
and even work in our obesity clinic.”
Creating a “Safe Space”
Although changing health care students’ and
professionals’ negative attitudes toward pa-
tients with obesity takes time, relatively
simple tweaks, such as moving the scale
from the hallway and into a private room, can
foster a more welcoming environment.
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Mundi said Mayo had remodeled his
floor and placed the scale in a hallway.
Patients who were overweight began
refusing to get weighed. One told him
she’d never told her husband how much
she weighed, so she wasn’t about to step
on a scale in such a public setting. While
the location of the scale seems like a rela-
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tively simple thing, it wasn’t something he
had ever thought about, he explained.
“One of the things we are starting to
see now is a kind of recognition that it’s
not only patient-provider interactions
that we need to think about, but even
the office environment,” Puhl said. “Are
there sturdy armless chairs in the waiting
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News & Analysis
room? Do they have appropriately sized
medical equipment?”
As Mundi said, “if we don’t create a
safe space for them…they’re not going to
come. We can’t help someone who’s not
even coming in.”
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