Confronting Weight Bias in Health Care

During my first job as a therapist, I often had to treat patients at different site locations to fill my 40 hours per week. There were several facilities who needed help frequently, so I would float out to those buildings for any new patients or supervisory notes. One day, I entered one of these facilities, and every single therapist looked at me with the same pitying expression. The rehab manager asked me to step into her office. “I’m so sorry to put you in this position. One of the new patients on your schedule today is a really large man. His BMI is 103. It took 12 people to move him from the stretcher into the bed last night. Obviously it’s not safe for you to do any mobility with him by yourself, so let me know when you’re planning to see him and the whole therapy team will come with you.” I cringed inwardly, and probably outwardly too. I remember feeling overwhelmed and out of my league. Was this even a safe situation? How was this person managing at home?

After reviewing his chart, I went to meet him by myself. I introduced myself as his PT, and I could tell as he sized me up that he was feeling at least as nervous as I was. He waskind, and we had an easy rapport. I asked him the usual history questions, and about his hospital stay. “I feel much better now, especially since I showered last night.” I froze. “You took a shower?” “Yeah, it was awesome. I just don’t feel clean after a bed bath.” I clenched my jaw to keep it from dropping and searched my brain for the right words. “So……how did you get to the shower?” He shrugged. “I walked, and my wife helped me set up the shower chair.” WHAT?!?! 12 nurses and EMTs physically lifted this man from the stretcher into his bed WHEN HE COULD WALK?!?! I laughed out loud. As it turns out, no one considered asking him if he could stand or transfer, so he just let them struggle through the moment.

When I brought him in to see the therapy gym by myself, people looked at me like I was the hulk. But I didn’t need superhuman strength to treat him, I just needed to ask him the same questions I ask all my other patients, and actually listen to his answers, rather than arriving at some foregone conclusion before I even got to know him. It was an extreme situation, but it illustrates today’s point well. In the health care system, we use weight as an acceptable form of discrimination, as though we can learn all there is to know about a patient if we see them walk in the door and they don’t match our ideal “healthy” body type. We are all responsible for confronting our own biases, but this is one instance where the root of these biases is multifaceted.

Let’s start with BMI, which I am required to report for all my patients in order to be reimbursed by most insurances. Body mass index was invented by Adolphe Quetelet, a Belgian astronomer and mathematician, in the early 1800s. He also founded phrenology, which is long known for being discriminatory pseudoscience. His goal was to identify characteristics of l’homme moyen, or the average man, and he used BMI as one of these characteristics. These characteristics were later used as a scientific justification for eugenics – systematic sterilization of people whose body characteristics were considered to stray too far from the “ideal man”. In the early 1900s, life insurance companies in the United States began using BMI to decide how much to charge prospective clients. In the 1960s, physicians began using the measure as a proxy to represent a patient’s health status. In the 1970s, Ansel Keys compared several measures to determine health and obesity, and he determined that BMI was easiest, most cost effective, and least inaccurate – correctly identifying “obesity” about 50% of the time. In 1985, the NIH changed their definition of obesity to include BMI ranges, and then in 1998, the NIH changed their definition to make the threshold for medially diagnosable obesity much lower. In 2011, a study showed that BMI accurately identifies less than 50% of “obesity” in black, white, and Hispanic women.

In summary, we are using a measure from the early 1800s, invented by an astronomer to justify eugenics, in order to provide and prescribe medical care in the United States in 2022. Aside from being medically inaccurate and wildly biased against people of color (since the astronomer from Belgium only used Western European males in his calculation of averages), focus on BMI places too much emphasis on weight in general. Weight is primarily genetically determined – it is almost as heritable as height, and is more heritable than heart disease. It is not a great indicator of health. And, over-focus on weight combined with our biases against overweight are hugely problematic in establishing a functional patient/provider relationship.

Research[1] shows that primary care providers spend 28% less time with overweight patients, and are more likely to report their encounters as being a “waste of time”. Additionally, providers over-attribute symptoms to weight, versus considering other diagnoses or treatments aside from just recommending weight loss. This attitude is recognized by patients, who then avoid clinical care in order to avoid judgment, shame, and poor outcomes. These two behaviors cycle together to result in worse health outcomes for heavier patients and an eroded patient/provider relationship.

This is not inevitable. Providers can work on educating themselves to decrease bias, we can better educate students about actual data concerning the diagnosis and treatment of overweight, and providers can make changes to their clinics to indicate non judgment. The study I cited above recommends the following steps for creating a better patient/provider relationship and an environment more conducive to making ALL patients feel comfortable seeking medical care:

1) increase provider empathy through perspective-taking exercises

2) alter perceived norms regarding negative attitudes and stereotypes

3) encourage provider instruction and practice emotion regulation to foster positive affect

4) assess implicit attitudes

5) educate providers on genetic, environmental, biological, psychological and social contributors to weight gain and loss

6) reduce focus on body weight and instead on healthy behaviors

7) adopt patient-centered communication strategies

8) provide chairs and equipment that can be used by all patients

9) adequate referral sources for behavior change counseling

The above study did not indicate HOW providers and medical facilities should carry out these steps, but intentionally trying to make all people feel comfortable and welcome is a step in the right direction. In my experience, provider biases against overweight are actively passed down to medical students. During my therapy education, I was excited for the lecture on physiology of obesity, as I had taken a semester long course on this topic in undergraduate. I understood obesity to be a complex issue, in which we would really need to utilize the biopsychosocial model of health care. Instead, our professor proceeded to lecture us about calories in vs. calories out dieting, and told some rambling story about “the awkward fat friend” in a music video. If this is the actual professional education we are providing to students (never mind the cultural messages we receive daily), it’s no wonder the bias against people with overweight is so pervasive in the medical community.

It is normal and inevitable that we all have unconscious biases. It is not inevitable to act on them, and it is certainly not inevitable to utilize biased and nonscientific measures in medical care to make medical decisions, or to make decisions about payment for medical treatment. Compassionate care works to make ALL patients feel heard and welcome. It is critical to believe people when they tell us about their experiences, and if their experiences challenge our expectations, then it is OUR responsibility to alter our expectations by practicing perspective taking, educating ourselves, and asking more people about their experiences. No one should avoid medical care because they are afraid of being judged, and we should never ask 12 people to carry someone who is perfectly capable of walking.

[1] https://onlinelibrary.wiley.com/doi/10.1111/obr.12266. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity