Episode 100: Clinical Conversations: Advocacy Series - Weight Bias and Stigma

Welcome to obesity a disease. The official obesity medicine association podcast exploring the many facets of the disease of obesity. Obesity a disease podcast is brought to you by the obesity medicine association a clinical leader in obesity medicine. A young female student came to see me for evaluation for the treatment of obesity and the course of her encounter I asked if she had experienced stigma and bias from healthcare providers in the past. She related that she always struggled with her weights and once when she was visiting her pediatric endocrinologist for thyroid disorder the provider told her that she was fat and that if she didn't lose weight she wouldn't have any friends. She was at the delicate age of 15 and this was a devastating set of comments for her. She actually proceeded then to engage in some risk taking behaviors, unhealthy eating patterns in order to lose weight and gain friends. She did eventually realize that this self-destructive course was not a good direction for her and got her life on a better path. When she was 18 at the last visit with this pediatric endocrinologist she confronted him about what he had said and how devastating it was to her. Her weight was lower at the time and his comment was well you lost weight so when I said work I'm not going to change what I say which also was a very devastating thing to hear. I think the story exemplifies of how destructive shaming comments can be on patients and how misguided some health professionals are about obesity. Hi I'm Dr. Nick Pennings, Chair of Family Medicine at Campbell University School of osteopathic medicine and Executive Director of Clinical Education for the Obesity Medicine Association. I have with me today Vicki March and D and Kate Varney Dio who are Obesity Medicine Specialist and today we're talking on a special podcast series on advocacy for obesity treatment and this session will be on weight bias. Dr. March if you just tell me a little if you want to tell the audience a little bit about yourself. I'm an internist I've been practicing for over 30 years and in the early 2000s became particularly interested in obesity medicine became boarded in obesity medicine and recently transitioned from doing internal medicine and obesity medicine to exclusively obesity medicine about two three years ago. I direct the Comprehensive Weight Loss Program at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania and I serve on the advocacy committee of the Obesity Medicine Association. That's great and Dr. Varney. I am Dr. Kate Varney I am a obesity medicine physician and primary care physician. My primary force certification is a family medicine and that's where I kind of started our practice of obesity medicine and then have transition now into working a lot with patients after very ectic surgery and also in an academic setting I'm the obesity medicine director at UVA Health in Charlottesville, Virginia and so I work with medical students and residents trying to teach them about obesity medicine and kind of bridge the gap that education gap that we don't get in our training initially. I have been on the Obesity Medicine Association Advocacy Committee for the last four years with Vicki all four years like something about that committee that just kind of derives you in right like doing good work but we've been working for the last four years you know trying to bring awareness to various areas in the advocacy space with related to obesity. And one of those key areas is weight bias and stigma that we see in healthcare and in other settings and what I gave was just one example and I'm sure you all have examples of yourselves of patients who've had similar experiences. What other ways do you see stigma and bias entering in the healthcare encounter? I think bias is a really it's really interesting I think we've become a lot more aware of bias recently but I always found the issue of implicit bias kind of problematic because implicit bias is kind of things that you're like they're kind of you're not even aware of right so things that you've you know your life experiences that have kind of shaped your attitude and in judgment to where people but sometimes you're not even aware of them versus implicit bias which is just overt you're aware of it and you know those things actually harm patients and so I think that as healthcare providers I think that it's really important that we not only work toward you know addressing our own implicit bias but also or explicit bias but also asking for feedback from our peers to what what have you seen that I could do better right but I really love your your intro story because I think that kind of sets the stage with you know the young woman in the in the chronology office because I always use an example with my patients about you know obesity is a really complex disease and it's not just eat less exercise more there's all these other factors that go into it and I just imagine I say what what would you think if you walked into a doctor's office and you know you know the doctor is looking at your labs and saying wow your your thyroid labs indicate that you have hypothyroidism like you have a low functioning thyroid which can make it easier to gain weight right so well here's these labs you know you have hypothyroidism you need to eat less exercise more right like no like we wouldn't do that a good good physician and provider would say here here is this medication and in addition we're going to correct this hormonal issue and then in addition to that here's some other techniques that we could use diet exercise things that can kind of offset you know the change in your resting metabolic rate or and so it's just it's it's you know I think using examples like that with your peers and your patients really help bring to light you know how how many biostinks this is how they're in the kind of field of obesity well I can give a really good there's so many examples I run into this all the time implicit and explicit bias against people who have obesity but one really stark example is the bias against the use of anti-obesity medications the way the media talks about how if you go off the medicine you regain the weight as if this is such a surprising and unusual thing but when you go off statins your cholesterol goes back up when you go off anti-hypertensives your blood pressure goes back up if you go off medications to control diabetes your blood sugar goes up so why would obesity a chronic progressive disease be any different and yet it is treated differently and I use that example over and over again when I speak to patients and even then I get the sense that they still are self-planning so it takes multiple and speaking to other physicians as well and other providers it takes multiple times I'm saying the same thing over and over to people before I feel that I feel like that it just sink in so that's another very important example yeah I think that example exists for patients and themselves too they feel like they're cheating if they're taking a medication or they're not doing you know they're weak-willed and and not have enough confidence and believe in themselves and blaming themselves because they have to take a medication in a core to control something that they perceive they should just be able to do on their own and I think that sort of reinforces that what are some other kind of examples of how bias enters the health professional setting say in the office setting well one thing that I see over and over again is I'll have a patient come in multiple people will do this and say I didn't want to come in today because I gained weight and I was bad this last month I was terrible I was bad I had no willpower I was lazy and they self-blame and almost cancel appointments if they are not going if they're not doing things according to the way they think I think they should do they are afraid of disappointing me if their weight goes up who doesn't come down or even comes down and it's only a quote only a few pounds they feel terrible about that so and often I've had people tell me about other shaming things they've experienced at other physicians offices I've had people who've lost 10% of their weight 20% of their weight 15% of their weight they'll go to their PCP or to a surgeon who will still berate them for not losing enough you know for for saying you've only lost this much weight and making you feel bad about the accomplishments they have achieved right or somebody comes in for the first time And their weight is still there be a month. still fairly high and the provider says, well, you really need to start losing weight. And maybe they've lost 50 or 100 pounds even before coming in there. You know, you need to kind of know where they're at before you start judging what they need to do. Yeah. And I think of like overtly just avoiding healthcare providers, right? Like so there were studies during COVID that showed that patients with obesity, some studies out of Europe that showed that patients with obesity, they thought that that contributed to the way of care and early intervention and COVID treatment, which you know might have, you know, you know, looked a little bit like, you know, obesity patients with obesity had, you know, higher complications, right? Well, was that because they were coming in later and presenting later because they were just trying to avoid at all? There was also, there was, there's a study back in 2015 that cited at least five other studies that showed that, you know, it demonstrated about 20% higher risk of non-adherence with the patients. So not fallen through the appointments, not doing the treatment that you want just based on kind of a combined explicit and implicit bias that they had experienced in the past with healthcare providers. And part of that is the tendency for healthcare providers to blame all their problems on their weight, right? And so if for my blood pressure is high and, you know, my weight is up, I don't want to go and hear, you know, well, if you didn't, if you didn't weigh so much, blood pressure wouldn't be so high. Is that something you see as well in the healthcare profession? Yes, of course. But also it must be emphasized to patient-sized things that, you know, you tell them, yes, you have high blood pressure and yes, this might be related to your weight and it's possible that losing weight and becoming healthier in general might help you control your blood pressure. So I don't think it is important not to dissociate some comorbidities from obesity at the same time, not blaming everything on weight and not making the person feel bad for having these conditions, you know, because as Kate pointed out, it is very important to realize the complexity of obesity in the organ systems that it can affect, but at the same time being kind to people, affirming what they have done, affirming that this is about their health, not just about the number of a scale, that body composition is important, as important, fitness is important, the whole wellness route. Another thing though that about wellness is that a lot of another example of prejudice is that a lot of companies and also insurance companies offer a wellness program for people. At the same time, they do not cover treatment for obesity. They will say, oh yeah, we have some wellness classes, we have some weight management classes, but they do not have treatment for obesity. They use this as almost an excuse or a cover for not treating obesity as a disease and putting it in the category of wellness when it's actually separate from wellness. It's associated, you want to be well, but it is a disease and has to be treated in the disease category. And a lot of companies, insurance companies use this wellness method as an out. I mean, it had a situation of a patient that the insurance company would cover the anti-obesity medication, but they wouldn't cover the diagnosis of obesity, which doesn't make any sense at all. I'm sorry Kate, go ahead. What were you going to say? I kind of think of it like Vicki's example is kind of a parallel scenario. It was kind of like, we could think about like lung cancer, right? Like a patient has lung cancer and the insurance company will cover a smoking cessation program, but not the chemotherapy to treat the cancer or the surgery to cut out the volumine tumor. So it's just that we have this, you know, the underlying thing is, here is this either implicit or explicit, explicit bias that we think that obesity, even as up to 20% of healthcare providers, they recently surveyed, think that it's basically a willpower thing. It's a character flaw. It's an issue with lifestyle only and, you know, totally dismissing these other genetics and, you know, other medications and all these other factors, socioeconomic things that can plan, which is really, it's crazy for me as a healthcare provider because we're some of the most, we're supposed to be some of the most educated people in society, right? But we're just completely dismissive of all this evidence that's out there. Right, people with obesity are treated differently. They're treated differently than other other patients with respect to medications. I think, for example, when it comes to a medication like to epiromate, the phantom endopiromate combination, it's subject to REMs, you know, where risk evaluation and management strategies. But it's not if you're using to epiromate for migraine or using it for seizure disorder, but people with obesity have different criteria than more stricter criteria. So I think it's an example of any other areas that you can think of where you see people with obesity being treated differently in the healthcare system. Very much so. So it can be according to what your insurance is, what your income is. If a person in Pennsylvania, right, just this past January, Medicaid in Pennsylvania started covering anti-obesky medications. But before that, it didn't. A Medicare does not cover it at all, ever. It's excluded from Medicare. Some insurance companies have allowed it and then they disallowed it. And we've, there have and also prejudice against off-label use of some of these medications. As physicians and other healthcare providers, it's legal and perfectly fine and very common to use medications off-label. An example is to appear made, which by itself can cause weight loss in some people. That we use metformin or to appear made off-label to treat obesity. That's common. We do it. Nobody cares. Nobody makes a fuss. But all of a sudden, some providers are getting threatening or intimidating letters from insurance companies if they're using ozemic, sorry, to use the brand name, somagletide off-label. Because there is another medication that is somagletide that is okay to use for obesity. But the same medicine with a different brand name is not committed and people are getting by insurance companies and people are getting threats about this is a fraud. Be careful of this being fraudulent. It is not fraudulent. It's normal. It's normal behavior for healthcare providers to use medications off-label and all of a sudden they're being intimidated from using these because they're for treatment of obesity. All right. And so there are and access to care is different too. So we see a higher obesity rates in those with lower socioeconomic status. And at the same time, we see less access to medications, less access to care in those so that there's a growing disparity there in those populations. And our attitudes toward patients, it really spills over and people can see we see this in our patient satisfaction surveys, whether they be talking about in office or hostile equipment. For example, I had a patient, I can't remember exactly what their weight was, but I'm here in Virginia and we didn't have a MRI machine that would fit this patient. So we had to have this patient travel two hours away to a veterinary facility at a university that had a vet program where they used the MRI for cattle and horse. I mean, how does that make a person feel that I have to go two hours away to get an imaging that is used for animals, right? Like that it's so demeaning, right? And that that just the disrespect that they feel, you know, it's, you know, I only learned of this recently and I've been working in the advocacy space for a while now, but I only learned at a conference a couple weeks ago that Michigan only, there's only one state in the United States that has a law to declare weight as a protective category against discrimination. Like I that it's unbelievable to me that we can there there's no law that states don't have this law. So right now it's Michigan, but I I heard that New York City is passing a law that should go into effect in October and November. So but that it's just it's a little mind blowing to me that we can, I always say that I feel like obesity bias is the last socially acceptable bias that's prevalent, you know, even we have so much, you know, we're doing so much for our LGBTQT population, which makes up, you know, a smaller percentage of the United States, whereas, you know, this despite having this really high prevalence of overweight and obesity here in the United States, I mean 70% of people, people either have overweight or obesity, yet they're still actively discriminated against. And that's, I just, I find that just, that's one of the things that I find the most worrisome with bias against obesity. Well, it even comes to things like blood pressure cups, exam tables, having to climb up on an exam table, stress test machines, other types of imaging equipment, chairs and waiting rooms, weighing people in front of other people, having scales that don't have the correct capacity. These are things that are prevalent in many hospitals and provider offices. There are some places that are trying to be compliant to be able to reduce some of the bias against obesity by having some of the proper equipment, but it's not at all universal. Even within my health system, there are some places which require it and other places which don't. And all this healthcare bias and societal bias has an impact on the patient. So the patient starts to think of themselves and shames themselves. They think of themselves in a negative light. They're biased towards themselves. How do you deal with that? How do you deal with that mindset with patients when you see them blaming themselves for their issues? Well, very, very often I will remind them that this is a physiological, complex disease, and none of this is their fault. I affirm everything positive that they're doing, things that they dismiss. I will point out are very important changes. I talk about gray areas and trying not to be all or nothing because there's a lot of all or nothing behavior and perfectionism and then giving up without being perfect. And so I, and I think what that does is my goal is to make them feel better after the appointment and when they first come into the appointment. And I think that a lot of times the body language will change and I can tell that I've made that kind of a difference in their feelings at the moment, those momentary bad feelings and that when they leave, they may feel motivated to continue along a healthier path. But I think people can get very discouraged and give up if they have the negative views. And there's so many, there's so many examples of bias, you know, we have pages and pages that when we're preparing for this, we're like, oh yes, and this and this. And we actually cut out so much of it, you know, to try to give us the biggest bang for the buck. But just, you know, when you see a bias, you know, stand up against it, right? And like call it out, be an advocate, be loud about it. And I think that leads to the second part for even with patients, but also health care providers, education, education, education, right? Like before I went back and cut my obesity training, you know, we were not taught these things, health care providers, you know, I hear, you know, I hear some kind of sensational, you know, podcast people say like, your doctors have been lying to you about, you know, and I'm like, we weren't lying to them. We just weren't taught and we were unfortunately influenced by what we know. And so the last 10 years of obesity research has just exploded in a way that we know what obesity is and what it's caused from and how we can treat it. And so health care providers, in and of themselves, number one, there's been, you know, there was a big study that we're often citing, you know, obesity doctors talk about that, that physicians, all physicians receive less than 10 hours of medical education out of thousands of lecture hours that we have on nutrition, obesity, and treatment, right? I don't remember having a single lecture about that, you know, 13, 15 years ago. So I had to go back and get this education and just wow. And you know, it's, it's, it's, you kind of get, once you get out into your practice, when you start to become an endocrinologist or a gastroenterologist or whatever your field is, you kind of really, you know, focus on that area and you have to, it's, it's all that you can do to stay up on the data in your own area, right? So expecting people to actively seek out physicians during their busy schedules and they're overloaded, they're burned out to actively go out and learn this in this other field, right? Is, is probably not that realistic. So it's our job for the people that do know this stuff to go out and educate, educate, be out on social media platforms, be doing talks in your community, be doing talks to your professional peers and educating them on this. You know, when, when Vicki and I go to conferences, you know, even, you know, we, we have, we're less, there's in the United States people that went back and got this obesity training, obesity medicine specialist, American board of obesity medicine physicians only make up less than 1% of all physicians, right? And so when we go to these conferences and we hear these things, we're still like, wow, we learn something new every day. So it's, it's about education and we need to really get out there and start educating more people as much as we can. And at these conferences, you'll hear other physicians go, wow, that's amazing physicians, right? Like, right? So they don't know and we can't expect them to know what they don't know. So that's our job to get out there and start educating. And I think that's something that's been very important, you know, within the OMA, that's our mission. That's what we've been looking to do. I've been fortunate to be able to incorporate obesity medicine into the curriculum for the past 10 years at my medical school. And really, it's been great to be able to, to do that and now see it just growing and recognizing and it's important. So I agree, you know, educating physicians and other healthcare providers is really key to expanding and the care of obesity and making sure that patients are being treated effectively for obesity. Vicki, maybe comment a little bit about educating patients and where they can learn about obesity and learn about stigma and bias and try to overcome some of those challenges. Yeah, well, the same, you know, I think one by one, when you talk to patients, you talk about their individual journeys with their weight and their struggles and what's difficult and be encouraging to them at all visits to have my office, the people I work with, my team be aware of the complexities of obesity. So they are respectful toward patients. I think we always have to work very hard on the language we use with our patients. There's been some many papers and studies showing that there are certain words that people do not like to hear and different ways of approaching patients so that they are more comfortable. So words like obese are hated by people who have obesity, using the word weight is much more neutral and much more acceptable to people. So examples like that in active listening, some motivational interviewing techniques are important to learn to speak with people who have problems that are, that they might feel ambivalent about, that they might have sensitivities about to make them feel more comfortable and be on a more collaborative level with people. So I think it's not so much a lot of people who have obesity know a tremendous amount about obesity because they've lived with it for a long time. But I think it's the way we engage in our conversations with patients. That is the most important. The way we speak to them, a rapport we develop, a collaborative approach, what are they willing to do, where are they coming from, what have they done already. I think that is a very important thing so that you develop a longitudinal relationship with people so that they feel comfortable with you and they will continue to come back for long term follow-up. Another thing to educate people on is that it isn't just about losing weight, it's about maintaining the healthy lifestyle so that the weight will stay off, which is very, very difficult because of the body's defense of the higher weight and educating people about the importance of long term care, the importance of staying on medication and continuing lifestyle change and needing to have accountability and support for that in the medical field. Perhaps a specialist, perhaps a PCP, but it is not something that actually has an end date. When I talk to patients about obesity or about their weight and you know, do it in a non-judgmental and a non-threatening or a way that is more patient centered, I find that they get more and more comfortable talking about it as we move along where they don't feel like they're being judged. And I also emphasize the importance that my most important role is as a health provider is when you're struggling, when your weight is going up, when you're having difficulty. And that's often when people try to avoid seeing healthcare because they're afraid they're going to be judged and ashamed for any problems that they're having, but I emphasize that's where you need me the most. I think most of them are. The fact that it's such a heterogeneous disease and so many causes, each person is an individual. And so what you tell one person and what you discuss with one person, what they're willing to do, what they want to do, what they have done, what their body is capable of doing. It differs from person to person. So you can't just give the same advice to every person. It has to be individualized. And you really have to spend a lot of time listening. And if you want people to disclose things like eating disorders, which people are very full of shame about, it has to be a very non-judgmental, careful listening approach. That's great. Okay. Well, I'd like to thank you for participation. in this discussion today. I think there's some really important topics that we touched upon. And more that we could talk to touch upon, but hopefully this will get a message out that will change people's thinking about patients with obesity and be able to more effectively and more compassionately treat patients who are struggling with this disease. - Thank you for listening to this episode of Obesity, a disease. For more information about obesity medicine podcasts and other valuable resources from the clinical leaders in obesity medicine, please visit www.obesitymedicine.org/podcasts. If you enjoyed this episode and want to listen regularly, head over to iTunes where you can subscribe, rate, and leave us a much appreciated review. The views expressed in this episode are those of the host and guest and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please join us again for our next episode of Obesity, a disease.