Dismantling Weight Bias Towards Overweight Patients in Healthcare

Weight bias towards overweight patients is a prevalent form of discrimination present in healthcare today. These patients routinely receive unfair treatment, weight-focused diagnoses and shaming from healthcare providers. This causes psychological and physiological stress for the patients and a hesitant attitude toward accessing healthcare. The weight bias problem exists in almost every aspect of the healthcare system and is present in most countries.

This paper focuses on dissecting this issue in Ontario healthcare using the Systemic Design Toolkit. It starts by framing the system, followed by listening to the actors involved. Influences and root causes are investigated to understand the system. The paper then moves toward defining the desired future for the issue, followed by ideating solution spaces using leverage points. At the end, an innovative strategic solution model is proposed, and a transition roadmap is provided to demonstrate the implementation plan. Interviews, surveys and workshops are the primary methods of research used to investigate the issue.

Findings indicate the rampant presence of weight bias among family medicine practitioners in Ontario healthcare with sources of the issue rooting back to a societal fear of fatness. The ultimate desire for patients is revealed to be a better, more understanding relationship with their doctors, which can be achieved through diagnoses beyond high weight, treatments beyond weight loss, and an approach that looks beyond their body size. Four solution spaces are proposed and then narrowed down to provide the most meaningful and feasible path forward. A new collaborative solution model is presented with a ten-year roadmap that requires constant efforts and partnerships with different stakeholders in the system.

Weight bias, or stigma, is the unfair treatment of individuals based on their weight. Despite being highly pervasive in our society, very few efforts have been made to address it. This is in contrast to other forms of discrimination, such as those with regard to race, class, gender, and sexual orientation, which have the support of official laws and policies (Ramos Salas et al, 2017). Research and social policy on weight bias and discrimination lag far behind, to the point where negative attitudes based on weight have been labeled as the last acceptable form of discrimination (Brownnell et al, 2005, p. 1). In healthcare, weight bias exists commonly in the treatment of fat individuals. Fat individuals are labeled as overweight or obese, both identities given to patients using the Body Mass Index (BMI) tool. Moreover, those who are labeled as obese are presumed to be unhealthy with an increased risk of major diseases such as cardiovascular issues, diabetes, strokes, and cancer. However, BMI is a flawed measure of health, as many recent research studies are starting to indicate, so much so that the CDC (Center for Disease Control and Prevention) in the U.S. puts up this note on their web page, which contains information on obesity:

Test Your Understanding

At an individual level, BMI can be used as a screening tool but is not diagnostic of the body fatness or the health of an individual. A trained healthcare provider should perform appropriate health assessments in order to evaluate an individual’s health status and risks. If you have questions about your BMI, talk with your healthcare provider. (Center of Disease Control and Prevention, 2020)

Nick Trefethen, Professor of Numerical Analysis at the University of Oxford, summarized many of the limitations of BMI in an opinion piece he wrote, stating that “the body-mass index that we count on to assess obesity is a bizarre measure. We live in a three-dimensional world, yet the BMI is defined as weight divided by height squared. It was invented in the 1840s, before calculators, when a formula had to be very simple to be usable” (Carey, 2019). Not only that, the BMI was developed to measure the body of a Caucasian man. It is a health metric resulting from decades of research mostly conducted on Caucasian people (Firger, 2017). Therefore, it is not an accurate measure of health for people of other ethnicities and races.

Despite this research, the use of BMI and the resulting overweight or obese diagnoses from health practitioners result in the biased care of millions of fat people. Weight bias presents itself in various forms within a healthcare setting. Biased providers, including doctors, specialists, nurses, and staff, exude/exhibit judgemental attitudes (Fruh et al, 2016). Diagnoses for the same diseases differ between thin and fat patients, where the latter are almost always ordered to lose weight as the treatment. The effects of this stigma result in these patients feeling alienated and humiliated. They are prone to being at risk for low self-esteem, depression, and lower quality of life (Phelan et al, 2015). Many leave the doctor’s office feeling like a failure and blaming themselves for their poor health, even if they pursue healthy choices. This results in high levels of stress hormones that have several long-term physiological health effects, including heart disease, stroke, and anxiety (Phelan et al, 2015). Ironically enough, obesity is considered a risk factor for these illnesses.

Perhaps one of the most concerning negative consequences of weight bias for fat patients is their avoidance of accessing healthcare, especially preventative healthcare, due to their being embarrassed by their weight (Phelan et al, 2015). Studies have documented a decrease in the use of healthcare services associated with an increasing body mass index. This includes reduced rates of routine breast and gynecological cancer screening tests among overweight individuals when compared to individuals whose body mass index is classified as normal (Alberga et al, 2019). In fact, the avoidance of preventive healthcare by fat individuals is what possibly contributes to the increased overall health risks linked to obesity, as expressed by the medical community (Brownell, 2005, p. 4).

With so many repercussions at play, including increased mortality risks, the stakes are high. Reducing weight bias in healthcare is crucial to the well-being of millions of patients. The dichotomy of all fat patients leading unhealthy lives and all thin patients leading healthy lives is an antiquated form of thinking that should be eliminated. This requirement for a weight bias reduction strategy led to the research question that this project seeks to answer: How might we reduce weight bias and improve healthcare for overweight patients?

However, following a review of the literature and how past interventions differed in the United States and Canada, it was determined that the strategy and tactics cannot be universal. Consideration of the differences in the governance process, health insurance model, and the sheer scale of the problem cannot be managed in the scope of one study. Therefore, the practical decision of narrowing the scope and focusing on the province of Ontario was made, leading to the primary research question being:

How might we reduce weight bias and improve healthcare for overweight patients in Ontario?

Additionally, the following set of sub-questions was listed to help guide the research:

•  What can the patients, physicians, healthcare institutions, and policy-makers do to make weight bias reduction possible?

• What forms of interventions have already been proposed? What are the results of these interventions? Have they been successful?

• How biased are the current healthcare providers in Ontario?

• What is the current diagnosis process and treatment experience for overweight patients in Ontario?

• How are patients currently handling weight bias in their healthcare journey? What strategies do they use?

Discussion Question: What attitudes towards “obesity” does a doctor need to demonstrate in order to convey to patients that their coping strategies are not being judged?

Purpose

This project aims to propose a solution model and roadmap that can be viewed as a starting point for active efforts in Ontario.

In the current weight bias research landscape, few intervention strategies have been proposed to foster change. Researchers agree that any further research in the field should involve individuals living with obesity in all aspects of the research process, including design, methods and knowledge dissemination (Alberga et al, 2016). This paradigm was closely followed in this research study through the types of primary research conducted, which will be revealed in the next sections.

Another prominent tactic that researchers have proposed is sensitivity training for healthcare providers, including existing professionals and current students (Alberga et al, 2016). An example of this tactic is the Balanced View program based in British Columbia. It is an evidence- informed resource designed to reduce weight bias and stigma among medical professionals, mental health professionals, allied health professionals and public health professionals across the province (Balanced View, 2015). Multi-faceted and collaborative approaches have also been recommended for reducing weight bias. Researchers insist that the government, private sector and others need to work together to fund and provide more rigorous solutions (MacLean et al, 2009).

Nationally, there has been minimum progress made. The 2020 Canadian Obesity guidelines have taken a new direction and have called for a shift in focus to the root causes of obesity rather than weight loss alone. That means doctors working with patients are asked to understand the context that underlies the issue, which could include genetics, trauma and mental health issues. The advice by Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons also pushes healthcare providers to recognize any bias they may have against overweight patients — such as assuming they lack willpower or are non-compliant (The Canadian Press, 2020).

Currently, in Ontario, there are no active interventions implemented; however, some dialogue exists. In 2019, at the Ontario Public Health Convention, a panel discussion was held to discuss the role of public health in addressing weight bias and how to promote healthy lifestyles without stigmatizing the overweight population. Toronto Public Health was one of the panelists participating in this talk. Their intervention proposition included approaches such as ensuring all public health messaging or images used in resources and communications should focus on health and well-being instead of weight. They should acknowledge the role of individual and social determinants of health. They should be inclusive of all shapes and sizes and not exacerbate negative stereotypes of individuals with obesity (Hambleton & McColl, 2019).

While there are plenty of strategies proposed, with some progress being made; there is no explicit action being taken on a daily basis. The unfortunate emergence of the COVID-19 pandemic further introduced a plethora of issues to the Ontario healthcare system, pushing the goal for tackling weight bias to the backburner.

However, complications from weight bias have not paused. Obesity rates continue to rise, along with biased care for fat patients. Clearly, the current protocols of treating fat patients are not working; otherwise, we would have seen positive change through statistics and qualitative patient-centric research.

The pandemic will end, albeit with lasting effects and changes, and we need to be prepared to put healthcare weight bias reduction back on the high priority list.

This project will aim to have that game plan ready.