by Sean Phelan, PhD

Obesity is one of the most strongly and regularly stigmatized conditions. With the exception of a handful of other important studies, we have little knowledge of how that stigma affects the quality of medical care that patients with obesity receive.

In our paper, the “Impact of Weight Bias and Stigma on Quality of Care and Outcomes for Patients with Obesity,” we reviewed previously conducted research from various academic fields and disciplines to explore how weight stigma may affect patients.

We also proposed a model whereby, in addition to the direct impact of obesity on physiological health and chronic disease outcomes, obesity may also impact an individual’s health through two related processes:

1. Stereotypes about individuals with obesity affecting clinical decision-making; and
2. Provider bias and cues in the clinic environment triggering a stress response in patients with obesity that negatively affects the quality of communication, and consequently, adherence to recommendations and utilization of follow-up care.

There is strong evidence that most health care providers hold strong implicit and explicit weight bias against patients affected by excess weight and obesity. In addition, stereotypes about people with obesity that are endorsed by some health care providers include “lazy,” and “weak-willed.”  These factors can combine to influence provider behavior in a few ways:

  • Providers tend to communicate less warmly with patients they believe will not be adherent to treatment recommendations. This is a belief that may be more common about patients with obesity.
  • On average, primary care providers report respecting patients with obesity less than other patients. This behavior can affect communication and information giving, resulting in physicians giving less time to patients with obesity, and spending less time educating these patients about their health.
  • Some physicians may over-attribute other health conditions and symptoms to obesity, and they may also consider different treatment options than they would with other patients.
  • There is evidence that patients can detect implicit bias, and are less satisfied with care provided by a doctor who demonstrates high implicit bias.

In addition, patients with obesity may experience “stereotype threat” if they perceive that they are being treated differently or judged because of their weight. Stereotype threat is a response to stress that occurs when we become aware that we are being viewed in a stereotypical way. Regularly being weighed and discussing weight-loss might have the same effect, especially if not done in a patient-centered environment and in an empathetic way.

The surroundings in a healthcare environment, also referred to as “clinic cues,” may also cause stereotype threat. For example, medical equipment, gowns, exam tables, or waiting room chairs that are not accessible or large enough may signal to a patient that they are “unusual” or “unexpected,” and can then create stereotype threat for the patient.

Experiencing stereotype threat or feeling stigmatized can have a number of effects on a person. The initial response to stress is unpleasant and can impair a patient’s ability to communicate effectively with their doctor, as well as their ability to process and recall new information. This could ultimately reduce a patient’s ability to stick with their treatment plans, and result in them avoiding follow-up care. The increasing exposure to stress also has many negative effects on health and well-being.

Strategies to reduce stigma and stereotype threat among patients have not received a great deal of attention, but we identified several strategies that could be tested as ways to improve care and outcomes for patients with obesity.

These strategies include:

  • Educating health care providers about weight bias and the effect that is has on patients, and asking them to examine their own biases and beliefs.
  • Providing physicians with training and resources to reduce their own stress may help them reduce the likelihood that implicit biases “hijack” their behavior, and instead they are able to provide patient-centered and compassionate care to all their patients equally.
  • Clinics providing training in evidence-based communication strategies for behavior change, such as motivational interviewing, and working to ensure the continuum of care includes adequate referral resources for obesity treatment.

Much more research is needed to understand the full impact of weight bias on healthcare providers, patients and the public health field as a whole. With this research, we will be able to develop and test interventions to improve the quality of patient-centered care for patients with excess weight and obesity, to ensure effective and compassion care is received.

About the Author:

Dr. Sean M. Phelan is an Assistant Professor of Health Services Research at the Mayo Clinic in Rochester, MN. Dr. Phelan is a core faculty member in the Mayo Research Program on Equity and Inclusion in Healthcare, where his research program is focused on reducing health disparities and improving health care quality and outcomes for patients with obesity, as well as patients from other stigmatized and marginalized groups. He is also a consultant on diversity and equity issues with Partners in Equity and Inclusion. Dr. Phelan can be reached at [email protected] or [email protected].