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MGH

Published On October 7, 2019

CLINICAL CARE

Seeing Past the Scale

Obesity expert Fatima Cody Stanford looks at how physician bias around weight causes harm to patients.

Do doctors have a weight problem? Studies show that physicians, no less than members of the general population, show a marked bias against people who carry extra pounds. In the examination room, such attitudes can cause real harm, as physicians tend to spend less time with these patients and can overlook their non-weight-related symptoms. Fatima Cody Stanford is an obesity medicine physician at Massachusetts General Hospital and researches the effects of bariatric surgery and weight loss medications on adults and children. She also studies how bias against people who are overweight can shortchange patients, and how physicians can begin to see—and treat—the whole person.

Q: How can weight bias affect a patient’s health?

A: People who report that they have experienced bias about their weight are more likely to develop type 2 diabetes and metabolic disease. They are more likely to binge eat and less likely to exercise. Patients who feel they’ve been “fat shamed” have an increased risk of depression, anxiety and low self-esteem. And when these shaming behaviors come from a physician, the patient is more likely to avoid seeking medical care in the future.

Even when physicians don’t shame patients for their weight, their bias can show up in other ways. One patient went to her primary care provider with joint pain, but the physician wouldn’t send her to an orthopedist because obesity was assumed to be the culprit. The patient ended up having a huge cancer in her hip. Sometimes all we see is the obesity.

Q: Your research shows that weight bias is particularly harmful to children. Why?

A: The health effects of weight stigma accumulate over a lifetime. It shapes patients’ lifelong relationships with health care, which they see as a system that accuses them but doesn’t help them. Parents also report that they feel blamed, which can lead to families missing medical appointments.

Q: Why does bias persist in medicine?

A: We do a good job of learning about diseases that may result from weight gain, such as diabetes and sleep apnea. But most of us don’t learn enough about obesity itself to perceive it as a disease, even though the American Medical Association classified it that way in 2013. Instead we tend to think of obesity as a behavior or a character flaw, something that can be solved solely by eating less and exercising more. When weight loss doesn’t happen, we jump to the idea that patients are not adhering to treatment plans.

Q: How does it help to think of obesity as a disease?

A: It changes the idea that a patient is the primary or only contributor to obesity. When we see obesity as a disease, we take the time to learn about the complexity of its contributing factors, such as genetics, psychosocial factors or environmental toxins. It means that we take more seriously the current interventions for weight loss, such as bariatric surgery or medications, which my research shows are effective.

In a survey I published in 2015 in the International Journal of Family Medicine, we found that primary care doctors don’t feel they have the knowledge to treat obesity medically, especially in recommending bariatric surgery. There’s a particular squeamishness on the part of pediatricians. But I’ve had patients who had surgery at 15, and their metabolic profile, their weight status and their outlook on life completely changed. We are able to place several obesity-related diseases in remission when we acknowledge obesity and treat it as a disease. If someone comes into my office with poorly controlled type 2 diabetes and dangerously high blood sugar, it would be medical malpractice for me to let that patient go home with the mantra to just “eat less and exercise more.”

Q: How can doctors advise weight loss without seeming to be biased?

A: Using people-centric language helps. Patients are not obese; they have obesity. In some cases it can be severe, but not “morbid”—which is a loaded term. Be direct with your patients but acknowledge that they are human beings who deserve respect. Give them the license to express who they are and why they struggle with their weight. Just withhold the judgment.