Fat Bias in the Medical Profession

'Fat Bias': A Barrier to the Treatment of Obesity

Tarayn Grizzard Photo by Jeff Cleary

In this brave new century, it is less likely than in the past that people will hear a shockingly sexist remark in the workplace, a blatantly racist comment on TV, or a pointedly anti-Semitic statement anywhere in a public forum. This relative dearth is a wonderful statement on the progress that has been made since the dark days of the turn of the last century when such comments were commonplace and acceptable. In fact, between political correctness, dawning rationality, and a litigious society, there seem to be few prejudices left that are considered socially appropriate to act upon.

Of those remaining biases, fat bias is perhaps the most prominently featured in media, work, and social life in the U.S. The size, shape, romantic prospects, and eating habits of obese people are the focus of many a comedy sketch and movie plot (last year's upsettingly successful Shallow Hal, for instance), and they are a source of insult and torment on the playground and in the boardroom. This phenomenon has been so widespread that prejudice against obese people has been called "the last socially acceptable form of prejudice" by some scholars.

This discrimination occurs despite nearly one fourth of Americans being obese according to federal guidelines on body mass index (BMI). Obese and overweight individuals typically report marked discrimination in daily life with teasing, slurs, petty violence, and isolation. A study attempting to quantify this stigmatization showed that of nearly 1,000 men and women enrolled in weight-gain prevention programs, 22 percent of women and 17 percent of men reported discrimination and prejudice related to their size. The mistreatment was positively associated with BMI. Other research has shown that excess body weight is associated with discrimination. A study of 57 subjects before and after surgery for morbid obesity reported significant prejudice and discrimination at work, within the family, and in public places prior to surgery and little or no discrimination after surgically induced weight losses of 100 lbs. or more.

A Health Care Gap

Within the social schema of obesity-related discrimination, one of the most consistently documented arenas has been health care, with substantial evidence for the presence of "fat bias" among health care workers. In a survey of nurses, 28 percent reported repulsion at the sight of an obese person, while another survey of 438 Michigan physicians showed that obesity was the fifth most negative patient characteristic. The American Academy of Family Physicians surveyed 324 members and found that 39 percent believed that obese patients were lazy, and two thirds thought that obese patients lacked self-control. Other surveys of physicians' attitudes showed that physicians often described their obese patients as "weak-willed," "ugly," and "awkward."

A majority of candidates referred for gastric bypass surgery reported being treated disrespectfully by their physicians because of their weight. Ill treatment of this type has been linked to delays or avoidance of medical care by obese women, in particular; 12.7 percent in one survey reported avoiding or delaying medical appointments because of weight-related concerns such as stigmatization.

Such discrimination within the medical community is particularly damaging due to the health effects of obesity and a subsequent increased need for medical attention. The well-known increased incidence of chronic progressive diseases such as diabetes mellitus, osteoarthritis, and cardiovascular disease in obese people make delays and avoidance of care dangerous. Obesity-related conditions result in 300,000 deaths per year in the U.S. according to the American Heart Association, many of which could be prevented with weight loss and proper medical management. The inadequate treatment of these diseases also adds a significant burden on the health care system. The management of obesity-related medical conditions made up 9.4 percent of U.S. health care expenditures in 1999. The social and fiscal costs of obesity on society--and on the individual--are enormous, and these costs are compounded by negative attitudes toward obese people among health care workers.

Consequences of Inadequate Care

Despite the high cost of obesity, it is often undertreated, possibly colored by physician biases with an ensuing impact on clinical decision-making and health care. The prevalence of childhood obesity is rapidly increasing, with one out of five children being considered obese today. Childhood obesity has been associated with increased rates of diabetes, cardiovascular disease, and adult obesity. However, a recent study of pediatrician referral patterns for failure to thrive/underweight and obesity at the University of Colorado found that pediatricians who referred children for nutritional work-ups referred mostly mildly underweight children and severely obese children. This suggests that moderately obese and overweight children may not be referred for medical treatment until their health status has deteriorated to severely obese. This problem with insufficient treatment is only compounded by the relative lack of reimbursement for pediatric obesity. One study found that only 11 percent of pediatrician-ordered treatments for obesity were reimbursed, particularly when Medicaid was the third-party payer.

Adults face similar problems with inadequate weight-control counseling. In a telephone survey of 12,835 obese U.S. adults, it was found that only 42 percent had been counseled about weight loss by a primary care physician in the past year. Those counseled were significantly more likely to report attempts at weight loss than those who were not. These statistics were in line with an unpublished 1995 National Ambulatory Medical Care Survey in which physicians reported counseling obese patients about weight reduction during 56 percent of general medical visits. This inadequate counseling is particularly problematic because initiation of the more successful therapies for weight loss typically must begin in the primary care setting. Without the advice of physicians, patients may not be aware of the dangers of their excess weight or of the most effective ways to treat them--and may not receive the behavioral and psychosocial support of any clinician should they choose to attempt weight loss.

These issues with inadequate treatment point to a common problem in philosophy, that is, that many physicians view obesity as a primarily behavioral problem as opposed to a medical disorder. In the face of mounting evidence to the contrary, this philosophical position on obesity has remained and continues to impair clinical decision-making, often resulting in prolonged ill health in obese patients--with disastrous consequences for the individual and for society on the whole. In order to ameliorate the effects of societally condoned biases in medical practice, obesity must be actively taught as a biological construct--a medical disorder--to best help patients and the health of our nation.

Obesity sensitivity should be emphasized in medical school classes and in residency training programs, with the purpose of making the medical environment comfortable for obese patients. Formal education on proper, National Institutes of Health-regulated treatment algorithms for treating obesity and counseling obese patients should be mandatory in residency and in medical school. Creating formal constructs to teach students and residents how to deal appropriately with obese patients and provide them the best care possible would begin to override the medical establishment's bias against them and, one hopes, to eradicate the deleterious effects of this highly popular bias.

2002
--Tarayn Grizzard, a third-year medical student at HMS

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.