One size fits all? Conversations with patients on bariatrics

Over the past few years, the term epidemic has been re-catapulted from the history books into modern day society and one could argue it is almost exclusively associated with the COVID-19 pandemic. However, many other epidemics are still prevalent in society and worryingly on a projectile trajectory. According to the World Health Organisation,¹ worldwide obesity has nearly tripled since 1975.

In 2016, more than 1.9 billion adults worldwide, 18 years and older, were overweight and of these over 650 million were obese. 39 million children under the age of 5 were overweight or obese in 2020 and over 340 million children and adolescents aged 5-19 were overweight or obese in 2016. It may be alarming to know that most of the world's population live in countries where being overweight and obesity kills more people than being underweight or malnourished.

At the forefront of the obesity epidemic, obesity bias and stigma (or fat-shaming as it is also known) is an under-recognised and widely prevalent barrier to optimal care of the obese patient, and can even be present among primary care professionals.

What is weight bias?

Internalised weight bias is defined as holding negative beliefs about oneself due to weight or size. These internalised negative self-beliefs can be bolstered by external influences such as others’ negative attitudes towards, and beliefs about, a person because of their weight. These negative attitudes may be manifested by stereotypes and/or prejudice towards people who are overweight. Believe it or not, medical professionals are not always an exception to this.

For most patients, seeing a doctor is most definitely not their idea of fun, but it most definitely is not supposed to be fear-inducing. However, for many overweight or obese patients, interacting with the healthcare system (and the ever-present weighing scale) can be extremely daunting. Patients who feel they are experiencing obesity bias from healthcare professionals may cancel or delay appointments as well as avoid preventative healthcare and screenings. Sometimes doctors can be guilty of holding negative attitudes, both explicit and implicit, about patients with excess weight. This weight bias could potentially lead to delays in care and other downstream health consequences as seen in the following case study.

Case study

Mr A, a patient living with obesity, twisted his right ankle whilst out for a walk one evening through a muddy field. Mr A attended his GP, Dr H, who examined him and advised he had a soft tissue injury. Mr A’s symptoms worsened over the next two weeks and he returned to Dr H, who advised Mr A that the strain he suffered whilst out walking and the pain associated with it were greatly exacerbated by the fact that he was grossly overweight. Dr H weighed Mr A and advised that he needed to lose a significant amount of weight, and this would alleviate the pain he was experiencing.

Four weeks later, Mr A, frustrated and feeling like Dr H was discounting his symptoms, presented at the Emergency Department in his local hospital in worsening pain. An x-ray of his ankle revealed a displaced posterior malleolus fracture, which required surgical treatment.

Mr A and his wife made a complaint to the practice, as he felt that Dr H had been discriminatory against him by attributing his symptoms to his weight. The complaint was discussed as a practice and a Significant Event Analysis undertaken to ensure that lessons were learned from this case. Dr H provided an apology in writing to Mr A and followed this up with a meeting with Mr and Mrs A.

Mr A went on to pursue a clinical negligence claim against Dr H, alleging that failure to diagnose the ankle fracture had led to a delay in surgical treatment and unnecessary pain and suffering. It was also alleged that Mr A had experienced psychological distress as a result of Dr H attributing his symptoms solely to his weight. An expert witness report, provided for Mr A, concluded that Dr H had breached his duty to Mr A by failing to refer him for an x-ray when his symptoms did not settle within a reasonable timeframe. It was stated that had the patient been referred for an x-ray sooner, the fracture would have been diagnosed and possibly would have been undisplaced, which may have meant that surgery could have been avoided.  The case was settled for an undisclosed sum.

How can healthcare professionals avoid weight bias and stigma in practice?

Approaching the subject of weight can be extremely difficult to navigate in everyday life, let alone in a healthcare setting. Asking for permission from a patient to discuss their weight is always a good start. Psychologically speaking this makes patients feel more in control of the conversation and its direction from the offset. Questions such as “Could we talk about your weight today?” or “How do you feel about your weight?” are always good conversational ice breakers when discussing weight. Asking the patient what words feel comfortable for them when discussing their weight will further alleviate any discomfort felt during the conversation for patient and doctor alike.

If the patient declines to discuss their weight doctors should respect that decision. A good tip to navigate through the potential “uncomfortableness” of a patent declining to discuss their weight issues is to end the conversation by letting the patient know that you are available to discuss the issue whenever they feel the time is right for them.

When discussing the topic of weight with patients, it is important for doctors to choose their words wisely and steer away from any language that places blame. Stigmatising or blaming words such as fat, morbidly obese and chubby should be replaced with words such as weight, unhealthy weight and high BMI. Adopting a people first language principal is important in terms of not labelling a patient by their disease. For example, it is not appropriate to identify an individual as obese but instead identify the individual as having obesity. By labeling someone by their disease, it often dehumanises the individual, which can further contribute to weight bias.

Below are some helpful practical strategies healthcare professionals can adopt in their day to day to practice:

• Recognise the complex etiology of obesity and communicate this to colleagues and patients, thus dispelling the stereotype that obesity is solely attributable to personal willpower or lack thereof.
• Consider that, although weight may be contributing to a patient’s symptoms, there may be other causes.
• Ensure that overweight and obese patients presenting with symptoms are afforded proper and adequate assessment and/or specialist referral to rule out all causes of presenting problems.
• Be mindful that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity.
• Recognise that many patients have unsuccessfully tried to lose weight repeatedly.
• Discuss holistic approaches to weight loss with the patient including behavioral and lifestyle adjustments, ensuring to not focus solely on the number on the scale.
• Offer constructive concrete advice or suggestions such as advising he patient to take up an exercise program or eat at home, etc., rather than simply saying, “You need to lose weight”.
• Acknowledge the difficulty that patients living with obesity may have with adapting new lifestyle changes.
• Emphasise to patients that even small weight losses can result in significant health gains.
• First impressions count so consider creating a supportive health care environment from the offset. Implementing large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and friendly patient reading material in the waiting area may be helpful in reducing patient anxiety prior to a consultation.
• Researching reputable patient advocacy groups within your local community or nationwide and encouraging patients to engage in such support groups is another way to ensure a patient leaves a consultation feeling informed and supported.

One online group, The European Coalition for people living with obesity (ECPO) was initially established in 2013, to help the European scientific and clinical community better understand the patient experience. The group regularly hold online workshops for patients and clinicians alike encouraging open and frank conversations around the topic of obesity bias and stigma in healthcare settings.

A very useful online tool healthcare professionals may consider using to assist in overcoming obesity bias is The Rudd Centre’s 8-modue tool kit self-assessment course. The toolkit is designed in to help clinicians across a variety of practice settings with easy-to-implement solutions and resources to improve delivery of care for overweight and obese patients. The resources range from simple strategies to improve doctor-patient communication and ways to make positive changes in the clinical environment, to profound ones, including self-examination of personal biases.

To summarise, healthcare professionals can make a huge difference with the obesity epidemic in the UK by initially striving to overcome any personal obesity bias and discrimination they may hold within themselves. They can also lead the way by addressing obesity bias in their interactions with their patients. By becoming knowledgeable and comfortable providing evidence-based obesity care, they can make a big difference to the way patients manage their own health.

The education of current and future health care professionals should focus on raising awareness of attitudes and bias toward obesity as well as addressing the development of empathy for patients’ struggles whilst living with obesity. Doctors should be mindful of the fact that most individuals with excess weight are very much aware of their weight and will have tried repeatedly to lose weight. Many of these patients may have had previous negative experiences with other health professionals regarding their weight. These reasons should be important factors for creating a supportive environment for obese patients in medical settings to ensure all patients are treated with respect and dignity. This will help ensure that patients living with obesity are comfortable and feel supported when seeking medical care and will go a long way in ensuring that healthcare professionals can have the opportunity to guide patients in effective and tailored weight treatment and management.

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