Bias and Stigma Hinder Effective Obesity Treatment
Bias and stigma against patients living with obesity impairs treatment and contributes to poor health, according to a consensus statement on the subject.1
“We felt strongly that we need to establish a baseline for the discussion around obesity, and recognized the need for consistent language,” says Anthony G. Comuzzie, PhD, CEO of The Obesity Society.
Clinicians should avoid using stigmatizing language when discussing the disease of obesity. “Such behavior contributes to the continuation of the bias and stigma surrounding the disease, leading to a reluctance for patients to seek the help needed to effectively address this serious medical issue,” Comuzzie says.
The Obesity Society recommends that “every person with obesity should have access to evidence-based treatment.” This is the most important part of the entire statement, according to Deborah Horn, DO, MPH, medical director for the UT Center for Obesity Medicine and Metabolic Performance in Houston.
“Yes, let’s work on prevention to decrease the burden of obesity in the future for our communities and our countries,” Horn says. “But we must also provide treatment to the individuals living with obesity now.”
Bias and stigma surrounding obesity mirrors the way mental health was viewed. “This has improved dramatically; now, patients seek care, and healthcare providers feel confident delivering care for mental health,” Horn says. “We desperately need the same paradigm shift in obesity care.”
There is a sense that patients can control obesity with sheer willpower. “People sometimes blame [patients] with obesity, and people can blame themselves,” says Daniel Bessesen, MD, professor of medicine in the division of endocrinology, metabolism, and diabetes at the University of Colorado Anschutz Medical Campus.
There is a need to treat patients living with obesity respectfully. Bessesen argues clinicians’ mindset has to change to view obesity as a biological problem.
Bias and stigma directed against patients living with obesity is a major deterrent to care, asserts William Dietz, MD, PhD, chair of the Strategies to Overcome and Prevent (STOP) Obesity Alliance and director of the Summer M. Redstone Global Center for Prevention at George Washington University’s Milken Institute School of Public Health. Part of that comes from the presumption, by physicians and also family members, that obesity is the patient’s fault. Dietz recommends providers begin with a question, such as: Is it OK if we talk about obesity? If the patient concurs, physicians can follow other questions, such as: How concerned are you about your weight? What have you tried to do about it? What can you do about it?
“We are moving away from a hierarchy of care where a primary care provider tells the patient what they ought to do. The more appropriate alternative is shared decision-making,” Dietz says.
Options might include intensive behavior changes, with a review of diet and physical activity, pharmacological therapy, and bariatric surgery. “But each of those steps requires that the patient decides what they want to do, in consultation with the primary care physician,” Dietz stresses. “It’s a stepwise approach to therapy.” There are some other ethical issues surrounding obesity treatment:
• Few patients who meet criteria for anti-obesity medications receive them. “All individuals should have access to anti-obesity medications,” Horn asserts.
Currently, Medicare does not cover any anti-obesity medications, and Medicaid coverage varies by state. Some individuals receive some degree of coverage with employer-provided insurance, but it varies. “Can you imagine if Medicare failed to cover diabetes, hypertension, or heart disease medications? We would find that unacceptable as a society,” Horn says.
Some of the medications are highly effective and well-studied, but remain unaffordable. “Drugs that cost over $1,000 a month are far out of reach for many people,” Bessesen laments. “We’re in a place where people who have the money can get high-quality medication, and people without money can’t.”
Lack of coverage for obesity visits with a healthcare provider, for safe and effective FDA-approved medications, and bariatric surgery is “fundamentally based on bias and stigma,” Horn argues.
• Some providers sell products or nutritional supplements of questionable value. “Obesity has long been left to be treated by unproven therapies, vitamins, minerals, products advertised on infomercials, fad diets, and quick-fix exercise programs,” Horn says.
If patients do not receive good options from their primary care physicians, they are more likely to turn to alternative, unscrupulous sources for help. “It’s a whole cottage industry,” Bessesen observes. “What’s driving that is patient demand and the opportunity for people to profit.”
• Some providers are prescribing anti-obesity medications online. The problem is not the medications, necessarily; some are safe and efficacious. The problem is patients living with obesity believe they need to turn to online providers in the first place.
“If you have diabetes, you don’t look online for someone to send you insulin. Why are we doing this [for obesity]?” Bessesen asks.
• Some providers refuse to prescribe anti-obesity medications until the patient proves they can stay on a diet. “We don’t do that with diabetes or blood pressure medication,” Bessesen notes.
• Some providers do not bring up anti-obesity medications. If the patient requests these drugs, providers discourage them, instead arguing weight loss drugs are harmful. “That’s not an honest representation of the medications,” Bessesen says.
• Physicians often do not bring up the topic of obesity at all. The ethical concern is patients go untreated. “Then, this serious, chronic, progressive disease goes unchecked, advances, and increases the risk of so many other diseases,” Horn says.
For certain providers, they are uncomfortable bringing up the topic. Many do not know how to treat obesity. Regardless of the reason, says Dietz, “it’s unethical not to diagnose the disease when it’s present. If somebody has high blood pressure, we wouldn’t think of not diagnosing it.”
1. The Obesity Society. Consensus statement on obesity. Jan. 31, 2023.
The industry is moving away from a hierarchy of care where a primary provider tells the patient what they ought to do. Instead, the model is moving toward shared decision-making.
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