Weight stigma is a significant problem in our society. Patients with overweight or obesity often feel judged by their appearance by those with whom they have never spoken. They are viewed as lazy and without motivation leading to assumptions of their inability to perform other duties including in a professional environment. This sounds harsh because it is. It is also a common story that I hear daily in my office as an obesity medicine physician.
Obesity bias is defined by individuals' social devaluation and denigration due to their excess body weight, leading to negative attitudes, stereotypes, prejudice, and discrimination. This behavior leads patients with overweight or obesity to develop a poor view of themself and avoid social interactions including seeking medical care. Researchers identify two types of stigma – self-devaluation and fear of enacted stigma. Self-devaluation is “the internalization of negative beliefs about oneself and association with negative characteristics due to the stigmatization.” Fear of enacted stigma is “the fear that others will have unfavorable attitudes and engage in ridicule, bias, or discrimination towards the individual.”
Patients with obesity are often afraid to be seen and live with self-judgement as well as external judgement leading to an inherent distrust of others. The medical community is not immune in this problem and patients with obesity often feel that all their ailments are blamed on their weight. Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. Physicians must focus specifically on the 2nd half of that statement. While weight and mechanics are an important consideration, we must remember to treat the patient as a whole and consider all other potential etiologies for disease while maintaining that excess weight is only one factor to be considered.
Osteopathic physicians learn to approach patients as a body unit where inherently structure and function are interrelated. Excess adipose tissue is associated with increase risk of cardiovascular disease, metabolic syndrome and some cancers. It is important but it is not the answer to all questions. This is always a consideration but when we ignore other potential etiologies, patients will get hurt. We will miss diagnoses.
Physicians should not ignore someone’s body mass index (BMI) but it is not our patient’s defining characteristic. Recently the term metabolically healthy obesity (MHO) emerged in medicine to acknowledge that the presence of excess adipose tissue by definition is not always an immediate threat. We must determine if that adipose tissue is causing effects that pose a risk to health. It is understood that metabolically healthy obesity can become unhealthy and this is why we must consider it as a chronic disease. We must monitor our patient’s metabolic markers and ensure conditions such as triglycerides, LDL, insulin, glucose, liver enzymes and inflammatory markers are not showing signs of metabolic syndrome. Physicians must be prepared to have these conversations with patients in an informative but sensitive manner. We know that clinically significant weight loss (CWL) is defined as at least a 5% reduction in weight from the baseline level and associated with improvements in cardiometabolic risk factors, such as beneficial changes in lipid profile and insulin sensitivity (1). Now we also know that this weight loss helps prevent self devaluation and further encourage lifestyle changes leading to positive outcomes.
Weight, specifically excess adipose tissue, matters when it imposes a risk to the patient. We can not deny this. What we can improve is they way we speak to patients leaning more on teaching and support with clear expectations of when this adipose tissue might become a problem. We can explain that consistent movement and resistance training will help decrease these risks but frequent check-ins with a trusted physician are necessary. We must help patients with overweight and obesity to feel comfortable in our offices. This is why physicians that specialize in obesity medicine must be on the forefront of education to our fellow physicians.
Like most chronic diseases, there is a considerable mental health component with obesity. This is often overlooked, and instead medical professionals claim non-compliance and lack of motivation.
A research study (2) followed 162 participants in the context of weight loss intervention in a group setting over a 2-year period with assessments at 6, 12, 18 and 24 months. Unfortunately, the study group was not very diverse including mostly Caucasian women aged 18-70 with a BMI between 30 and 50 kg m2. Feelings of self-devaluation were not predictive of weight loss but were noted to decrease as weight decreased. This shows that as patients adopt a less stigmatizing stance towards themselves, they maintain greater consistency with their intervention leading to more weight loss. How do we translate this to practical applications in medicine? We adopt health coaching to encourage mindfulness and acceptance. Physicians should acknowledge any negative self-talk and encourage rephrasing to positive self-talk. We help to create a supportive environment and build positive communities to support each other. This study did not find an association between baseline levels of self-devaluation and weight loss meaning it is not a barrier to treatment success. It is helpful to gauge this level in the beginning of one’s journey but it should not be used as a judgement of who and who will not be successful.
This study did not find that weight loss had any effect on fear of enacted stigma. This suggests that if one feels they will be judged for their weight then these feelings do not change even if they experience clinically significant weight loss. This is an area where our medical community needs to make significant changes. Hopefully the medical community can be a gateway to help instead of another barrier to care.
(2) Weight Self-Stigma and weight loss during behavioral weight loss intervention. Obesity Science & Practice.
(1) Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice. Int J Obes Relat Metab Disord. 2005;29:1153–1167.