by Melinda J. Watman, BSN, MSN, CNM, MBA
“Order exists because a system of beliefs and sentiments held by members of a society sets limits to what those members can do.” — James Q. Wilson
As a clinician and former individual affected by obesity, I have the advantage (or disadvantage) to have seen and experienced weight bias from “both sides of the fence.” Because of this, I want to discuss these things from the healthcare provider perspective to try to understand why even caregivers, whose first concern is to “do no harm,” so commonly harbor this bias and what can be done to change it.
Let me preface my remarks by saying my intent is not to single out healthcare providers. Negative reactions toward individuals affected by obesity are equally common and destructive among the U.S. population as a whole. But, I choose to focus on healthcare providers because I am one and can speak from experience.
The roots of weight bias run deep. From the time we are children, we learn fat is “bad” and thin is “good.” There are numerous studies substantiating this with children as young as three years old. Therefore, it should not be surprising that weight bias is also exhibited by those affected by obesity as well. Clearly, it is almost impossible to avoid the influences of these beliefs.
Consider the following effects of obesity prejudice, all of which are supported in the medical, mental health and social welfare literature:
Unlike children in the schoolyard, most adults may not deliberately set out to inflict pain, despite many of us bearing witness to people acting on their negative feelings. The general attitude of society is those affected by obesity are “fair game” for overt expressions of dislike, contempt and derogatory “humor.” What further sets the treatment of those affected apart is the acceptance of expressing bias in their presence – after all, it is only a “joke.”
Rebecca Puhl, PhD, and Chelsea A. Heuer, MPH, from the Yale Rudd Center for Food Policy and Obesity recently published a review of the literature on weight discrimination and stigmatization, titled “The Stigma of Obesity: A Review and Update.” Their results highlight some important and alarming findings. Unlike discrimination and prejudice against other social groups, weight discrimination has increased 60 percent throughout the last decade. Given this statistic, it is not surprising that many, perhaps most, healthcare personnel share some portion of these feelings. Like anyone else, we are part of a society which condones disapproval of those affected by obesity.
One of the first steps in reducing prejudice is to recognize it in ourselves. Once done, it is impossible to go back to “not knowing.” At which point, each of us who finds this prejudice in our hearts can be far more conscious of the ways in which we express ourselves. While we may not always be able to change how we feel, we can change how we act, which is where we have the opportunity to reduce and eliminate weight discrimination.
There are strong, repeated findings that individuals affected by obesity are viewed by a large portion of healthcare providers as awkward, unattractive, noncompliant, sloppy, weak-willed and lazy. Healthcare providers are not immune to harboring these same views – the U.S. population, as a whole, tends to be correlated strongly with the same views. For the most part, many believe those affected by obesity have brought their problems on themselves and should be able to “handle” it on their own.
Interestingly, studies also show healthcare providers overwhelmingly feel inadequate in treating obesity. Many in our community feel discomfort in even discussing weight-related issues and lack deep knowledge on effective ways to manage the problem. It has certainly been my experience that healthcare providers can become quite frustrated (often self-critical) if they are ineffective. Those feelings are hard to live with. Perhaps there is some connection between weight prejudice and our frustration when we attempt to embark to place our patients on various weight-loss therapies, unfortunately so often with little long-lasting success.
My hypothesis is, under these circumstances, that it can be tempting to “blame the victim.” Indeed, in our society, such would hardly be the only example of blaming the victim and we all know the harm that can cause. Regardless of the reactions patients affected by obesity elicit in us, we owe it to them to provide the same level of care, compassion, interest and concern as we do for any other patient with a chronic disease.
Unfortunately, there is reliable evidence that many healthcare providers do not consider obesity a disease. So let’s take obesity out of the equation and simply look at the diseases often accompanying it – type 2 diabetes, hypertension, cardiovascular disease – which we can treat. If these patients are avoiding care as a result of well-founded fears of humiliation and stigmatization, we are actually “causing harm.” These are the very patients we should be acting aggressively to enhance the availability of and access to ongoing care. It is hard enough to convince patients to remain diligent about their healthcare. We certainly don’t want to be one of the causes that push them away.
So where does this leave us? It would be wonderful if healthcare providers could simply flip a switch and no longer harbor weight bias or behaviors resulting from it. Given this is an unrealistic expectation, how do things improve?
Step one – Increased self-awareness
Step two – Change our behavior toward our patients affected by obesity and hope our heart follows
Next, there’s a great deal known about obesity. Since it may become the nation’s leading health problem, it is important for us to recognize what we know and what we don’t know about the problem. Being willing to discuss obesity in the same open, compassionate and helpful manner as is done for patients with cancer or mental illness would be a huge step forward. Extending these changed behaviors beyond the healthcare setting to our family and social life would set examples for others less conscious of the consequences of their actions.
As the quote at the start of this article says, society shapes what is acceptable and what is not. We have the ability to change how we conduct ourselves, if not totally then partially. It is for us to make the choice. We need to be leaders in changing how those affected by obesity are treated both medically and socially.
About the Author:
Melinda J. Watman, BSN, MSN, CNM, MBA, spent years in clinical practice and recently founded “THE F WORD FAT tiny word, BIG impact,” a company that provides educational seminars to organizations on understanding, managing and eliminating weight bias and discrimination.
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