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WEIGHT BIAS

Obesity is associated with multiple medical and psychological comorbidities and often under-recognized problem is that of weight-related stigmatization, which can lead to unfair treatment, prejudice, and discrimination. Are you guilty?

You are listening to ReachMD XM157, The Channel for Medical Professionals. Welcome to The Clinician's Roundtable. I am Dr. Leslie Lundt, your host and with me today is Dr. Rebecca Puhl. She is director of Research and Anti-Stigma Initiatives at the Rudd Center for Food Policy and Obesity at Yale University, where she is also a research scientist. Dr. Puhl is responsible for identifying and coordinating research and policy efforts aimed at reducing weight-bias and improving the quality of life of children and adults affected by obesity.

DR. LESLIE LUNDT:

Welcome to ReachMD, Dr. Puhl.

DR. REBECCA PUHL:

Thanks for having me.

DR. LESLIE LUNDT:

Dr. Puhl, what actually is weight bias?

DR. REBECCA PUHL:

Weight bias generally refers to negative attitude towards the person because he or she is overweight or obese such as stereotypes that they are lazy or lacking in willpower and this can be manifested in different ways, so for example verbal teasing or name calling or the derogatory remarks are very common towards obese individuals. This can also include physical bullying and aggression. They can include relational victimization, which means being socially excluded or ignored and it can also include overt forms of discrimination, so things like not being hired for a job or being denied a promotion or even being defined lower wage is because of one's weight and also it can really emerge in a variety of ways.

DR. LESLIE LUNDT:

Lower wages just because you are overweight.

DR. REBECCA PUHL:

That’s correct, there is actually a number of studies now that have followed large samples of obese individuals for many decades and what they find is that obese woman earn about 6% less than thinner women for the same work performed and obese man earn about 3% less than thinner man and this is after controlling for a number of associated demographic variables that might otherwise account for those findings.

DR. LESLIE LUNDT:

I am a little puzzled that obesity seems to becoming the norm in our society, that I would expect the discrimination to be lessening. Is that happening?

DR. REBECCA PUHL:

You know one would think that as obesity rates increase that people would become more accepting or more tolerant, but in fact we are seeing the opposite trend. We are seeing that attitudes are actually becoming worse.

DR. LESLIE LUNDT:

How does this compare with other biases like gender bias, race bias in the country?

DR. REBECCA PUHL:

Well, you know, we have actually recently studied this question. We looked at a nationally representative sample of American’s and we compared the prevalence of weight discrimination with discrimination experiences based on race and gender and other characteristics and what we found is that weight discrimination is very common and the prevalence rates are actually very close to race and gender and in fact among women, weight discrimination is actually more common than racial discrimination and so this really tells us that this is a legitimate social problem that we need to be paying attention to.

DR. LESLIE LUNDT:

Well certainly, the country’s attention has been on race and gender bias with the election this year and just thinking about it, we have not really had an overweight candidate. Have we?

DR. REBECCA PUHL:

We haven't and you know it's interesting that you bring that up because there were some interesting Internet discussions that were going on, asking if people would still vote for the current candidates if they were obese and I think that, you know, weight bias can trickle in even on that level as well.

DR. LESLIE LUNDT:

How does weight-based stigmatization affect eating behaviors in obese patients?

DR. REBECCA PUHL:

Well, unfortunately, weight bias can often lead to unhealthy eating behaviors. So, for example, what we know from research is that overweight girls and boys who experience frequent weight teasing are more likely to engage in unhealthy weight control or binge-eating behavior as compared to their peers who aren't teased in. Among adults, we see the same kind of thing, that often times people cope with weight bias by engaging in unhealthy eating behavior. As an example in one of our own studies, we surveyed over 2400 overweight and obese women and we asked them, you know, how you cope with weight bias when you experience it and almost 80% of people reported that they coped by eating more food and 75% reported they coped by refusing to diet and I think it's really important to kind of highlight these points because there are some perceptions that weight bias might have a positive function of motivating people to engage in healthy-eating behaviors or to lose weight, but in fact what we are seeing is the opposite, that it can really have a detrimental impact on eating and might even reinforce obesity.

DR. LESLIE LUNDT:

So, this should be something we should bring up with our patients, especially as we try to treat the obese diabetic patient.

DR. REBECCA PUHL:

Absolutely, I think you know, it is really critical for providers to be aware of bias and to be recognizing that it is an experience that is probably happening to their patients even on a daily basis in different settings.

DR. LESLIE LUNDT:

Are we as health professionals guilty of weight bias?

DR. REBECCA PUHL:

Ya, unfortunately Yes. You know, weight bias is very common in healthcare settings and overweight and obese patients often confront stereotypes and negative attitudes from their own providers and the science that has examined this is really quite tiring because studies actually survey different groups of providers about their own attitudes including, you know, physicians, nurses, medical students, dietitians, and providers are very willing to admit that they believe their obese patients are lazy and lacking in self-control and are noncompliant and <_____> than a bunch of other different stereotypes and I think, you know, it's really telling that this is a socially acceptable bias in our culture.

DR. LESLIE LUNDT:

If you are just joining us, you are listening to The Clinician's Roundtable on ReachMD XM157, the Channel for Medical Professionals. I am Dr. Leslie Lundt, your host and with me today is Dr. Rebecca Puhl from Yale University. We are discussing weight bias.

Dr. Puhl, has your group looked at this in their research setting about health professionals being guilty of weight bias?

DR. REBECCA PUHL:

We have. We did a recent study a couple of years ago where we surveyed over 2400 obese individuals and we gave them a list of about 20 different sources of potential weight bias including, you know, family members, colleagues, employers, various health providers and they were asked how often each type of individual, what the source of weight bias in their own life and what we found is that doctors were actually the second most frequent source of weight bias that they confronted. So, I think, you know, it is surprising how common this is and you know not surprisingly patients are reporting that they feel that they are disrespected by their physicians, that they are reluctant to seek healthcare as a result and you know we really need to look at how biased attitudes, you know, impacts the quality of care provided to obese patient.

DR. LESLIE LUNDT:

I just don't hear professionals talking about this.

DR. REBECCA PUHL:

I think there is certainly more awareness of it. Certainly, at our center, we get calls from providers all over the country, who are starting to see this become a problem among their staff and colleagues and who are looking for educational resources and I think, you know, one of the reasons some people might not be talking about it, is that it really is an accepted part of many clinical settings because this is a bias that is so acceptable and I think a lot of times negative attitude stem from perceptions about the causes of obesity that people are complaining for their weight and therefore deserving of negative attitude.

DR. LESLIE LUNDT:

Are any ages especially vulnerable to this bias?

DR. REBECCA PUHL:

People of all ages can experience weight bias, but we know that youth and children are especially vulnerable and they often encounter verbal teasing by peers and bullying and victimization and you know, I don't think it is surprising that peers are frequent critics of obese children and in fact what we are seeing is that negative attitudes in kids begin as early as preschool around 3 years old and what the studies are showing is that preschoolers are reporting that their overweight peers are mean, that they are stupid and ugly and lazy and a whole bunch of negative adjectives and these unfortunately just become worse as kids go through school. You know, they really are vulnerable targets to bias and stigma.

DR. LESLIE LUNDT:

What can an individual healthcare provider do to decrease their own weight bias?

DR. REBECCA PUHL:

Well, I think, there are a number of things. I think the first is to recognize that none of us are immune to society's negative attitudes towards obese people and to really look at once own belief and attitudes about weight, and I also think that there is a number of things that providers can do in their clinical practice to try to address this. So, I think the first is recognizing that we know many patients have experienced bias with previous providers and so we need to really approach patients with sensitivity, and we often need to make sure that we have got accurate information and accurate understanding about the cause of the obesity that, you know, this is really caused by a complex interaction of genetic, environmental, biological factors and to make sure that we don't have automatic assumptions about the causes of obesity that reinforce negative stereotypes. Also, you know, there are a couple of other things that we tend to highlight when we are speaking with providers about this. It's really important to be aware of how we talk about weight with our patients. Sometimes, words or terms that we use may come across as being perjured of even if we don't intend them to be. So, I often encourage providers to really ask patients how do they feel most comfortable talking about their weight and to make sure that as providers we're communicating the same. I think also one other things that obese patients feel quite a lot of anxiety about is getting weighed on the scale. It's a very embarrassing and shameful procedure for many people to the degree that studies show that obese patients are actually avoiding healthcare because they don't want to get weighed and so as providers we need to really recognize that this is a very difficult experience for many people and we need to make sure that we have our scales in private locations of the office, that we record their weight with sensitivity and that we make it as comfortable as we can for them.

DR. LESLIE LUNDT:

My theory is that we tend to be polarized on this issue that either we are overtly biased and negative and disruptive to patients or we completely ignore it and we don't want to talk about their weight because we don't want them to be embarrassed, we don't want to be embarrassed and certainly.

DR. REBECCA PUHL:

I think, you're right.

DR. LESLIE LUNDT:

In psychiatry, that has been a huge problem that most psychiatrists don't weigh their patients and especially with some of the side effects now with medications in psychiatry, we have to weigh our patients, but we are uncomfortable doing that.

DR. REBECCA PUHL:

I think, you are right. I think that there are a lot of legitimate challenges for providers, who are working with obese patients and I think that there is a fine line that needs to be addressed about being sensitive and yet not judgmental and making sure that we address this issue that is important with our patients, but not in the way that feels like unsolicited judgment or advice and it is a difficult balance to achieve.

DR. LESLIE LUNDT:

What can we do in the culture to help?

DR. REBECCA PUHL:

I think in the culture, we need to challenge weight-based stereotypes. For example, in the media, there are very negative portrayals of obese and overweight characters in television and in film, and we really need to replace these negative portrayals of obese persons with more positive examples so that we can communicate the message that, you know, people can be successful and accomplish goals regardless of their body size and I think we also have to make sure as a culture that we understand that body mass index is not necessarily an indicator of health, that there are many individuals, who are very thinner who don't struggle with their weight who actually are unhealthy as well and so we need to make sure we have a broader understanding about that. I think as a culture, you know, we need to consider enacting legislation to protect individuals from weight-based discrimination. You know, gender, race and number of characteristics have been protected for some time, but unfortunately it remains socially acceptable to discriminate against individuals if they are overweight or obese. What happens is that we send a message to society that it's okay to stigmatize people because of their weight and I think that just re-enforces ongoing blame and bias.

DR. LESLIE LUNDT:

Any resources for listeners who may want to learn more about this?

DR. REBECCA PUHL:

I would definitely encourage people to visit our web site, which is www.yaleruddcenter.org. We have a number of resources for healthcare professionals including actually a new CME that has been launched by our center and approved by the Yale Medical School here for free CME credit.

DR. LESLIE LUNDT:

Fantastic, well thank you so much for being in our show today.

DR. REBECCA PUHL:

Thank you.

DR. LESLIE LUNDT:

We have been talking about weight bias with Dr. Rebecca Puhl, who is director of Research and Anti-Stigma initiatives at the Rudd Center for Food Policy and Obesity at Yale University.

I am Dr. Leslie Lundt your host and you have been listening to The Clinician's Roundtable on ReachMD XM157, The Channel for Medical Professionals. If you have comments or suggestion, please call us at (888 MD-XM157). Thank you for listening.