How Our Own Biases Are Blocking Progress Against Obesity

| March 1, 2019

A GUEST Message from Ted Kyle, RPh, MBA

Mr. Kyle is a pharmacist and healthcare innovation professional who serves on the Board of Directors for the Obesity Action Coalition and advises The Obesity Society on advocacy. At Conscienhealth.org/news, he publishes a widely-read daily commentary that reaches an audience of more than 15,000 thought leaders in health and obesity.


Dear Readers,

After three decades of trying to overcome the growing prevalence of obesity, it’s plain to everyone that we’re not making the progress we need. Surgery is a safe and effective tool for improving the health and lives of people with obesity and its complications. But only a tiny fraction of the people who could benefit actually do. Partly that’s because of poor access to care, and partly it’s because of unrealistic fears. Another big factor is friends, family, and even healthcare providers that discourage patients from opting for surgery. 

Access to other evidence-based options is no better. Health plans find many ways to limit utilization of intensive behavioral therapy. Obesity medications are few and poorly covered by pharmacy benefit plans. Many people who get good care must pay for it out of pocket. Many more simply can’t afford it.

Why is this true? Advocates for obesity care will tell you that bias is the biggest stumbling block. The public, payers, and healthcare providers generally assume—falsely—that obesity is a condition that people choose for themselves, and likewise, if people want it bad enough, they can simply reverse it through willpower. Why pay for something that people have done to themselves? The simple solution is free—better habits.

There are two forms of bias—implicit and explicit. Implicit bias is automatically activated and tends to be more unconscious, influencing individual behavior without clear awareness. Explicit bias is within conscious awareness and influences outward behavior in an intentional manner. 

Explicit bias. A recent and vivid example of explicit bias displayed by a healthcare provider can be seen in an article Medscape recently published and then retracted.2 Editor-at-Large Dr. George Lundberg, a board-certified pathologist who served as editor of the Journal of the American Medical Association for 17 years, wrote with contempt about seeing “so many really fat people shoveling down large quantities of free breakfast food.”

He was writing about recent travels to rural America. In his travels, he observed people with obesity staying at the mid-range hotels and then described them eating “anti-nutritious garbage.” In addition, he noted that he “never saw one person exercising.”

Finally, he tied it all together by saying, that life is short and maybe he should just “join the crowd and pig out” on root beer floats and banana splits.

This kind of explicit contempt for people based on their physical size is less acceptable than it was only a few years ago. We’ve seen it in our own research at the Obesity Action Coalition (OAC), and Harvard researchers recently documented a decline of explicit bias, too.3

It took only about a week for Medscape to retract Lundberg’s commentary after I wrote a rebuttal with Drs. Caroline Apovian and Amanda Velazquez. The OAC and a host of activists had also called upon Medscape to retract it. Responding to an outcry on social media, Editor-in-Chief Eric Topol called Lundberg’s words despicable. 

Clearly, explicit fat shaming won’t fly anymore without a protest.

Implicit Bias. A subtle, implicit bias from people who are genuinely committed to obesity prevention is that people with obesity are a lost cause. We heard this recently from a senior leader from the Centers for Disease Control and Prevention (CDC) at a congressional briefing on the state of obesity.1 We must emphasize prevention over treatment, she told us, because it can have a bigger impact. It seems that implicit bias allows policymakers to discount the lives of people with obesity.

Implicit bias is very much a different story. That same Harvard study, which found a decline in explicit weight bias, conversely documented a rise in implicit bias. In fact, this trend was sharply different from every other form of implicit bias the study measured. Bias against people based on race, skin tone, age, disabilities, and sexual orientation have all declined over the last decade, but implicit bias against heavier people has grown stronger.

This shows up everywhere we turn. It shows up in stigmatizing images used to depict people with obesity. Usually these images consist of headless bellies and buttocks. Following the retraction of the Lundberg commentary, Medscape used such an image for an obesity story which it swiftly removed upon hearing objections. Elsewhere, though, these images are very common—even from bariatric professionals. People who use them seem not to realize how dehumanizing they are. 

Implicit bias also shows up in the language that journals use to describe people with obesity. American Medical Association (AMA) Style and AMA policy call for “people-first language” in writing about people with disabilities and chronic disease.4 Articles about “the diabetics” or “the disabled” are rare, but articles about “the obese” are relatively common. Such language is a tell—it gives away the fact that many healthcare providers regard people with obesity less humanely than they regard people with other diseases. 

The list of implicit forms of bias is quite long and includes myriad ways that clinics fail to accommodate people with obesity. Seating, gowns, and medical equipment are often too small. Thus, the message is clear: you don’t belong here. Unsurprisingly, people with obesity avoid healthcare as a result. Far too often, it’s humiliating.

Impact on Policy and Research. The false assumptions that fuel bias provide an excuse for making access to care either difficult or impossible. Often, patients begin to internalize the stigma and believe they don’t deserve respect. This makes health outcomes even worse for them and leaves them hesitant to challenge discriminatory policies and practices.

Likewise, bias has an impact on research. When people are convinced that obesity is purely a behavioral problem, resources go to repetitious studies of behavioral factors that have long been known to have little effect on obesity.5 For example, we have a long string of studies to show a correlation between diet soda and excess weight, even though a causal relationship is unlikely. Many studies repeatedly suggest that skipping breakfast correlates with excess weight gain, but controlled studies have shown this not to be a cause-and-effect relationship.

Meanwhile, studies of obesity physiology, medical treatment, and surgical treatment are harder to fund and are greeted with more skepticism. 

In short, the implicit bias that obesity is mainly the result of bad behavior is widespread. This bias hobbles everything about our response to obesity—from research to prevention, treatment, and policy. 

In this issue of Bariatric Times, Dr. Paul Davidson and Pam Davis, both active advocates for obesity care, present an in-depth look at weight bias among healthcare providers, even among those dedicated to treating obesity. The title of their article, “We have met the enemy and it is us,” provides thought-provoking insight to facilitate an inward look at how our internal biases affect our actions which, in turn, has a profound effect on patients, quality, and growth. Davidson and Davis conclude:

“It is time we as healthcare providers routinely make the argument for people with obesity to be treated with respect and without bias. We must conquer the enemy within, and it begins with self-awareness, conversation, and education.”

I couldn’t agree more. If we wish to make more progress, we will have to overcome weight bias and obesity stigma. Mitigating bias in the healthcare environment is a good place to start.

Sincerely,

Ted Kyle, RPh, MBA

References

  1. On the Hill. The State of Obesity. Robert Wood Johnson Foundation; March 5, 2019. https://www.stateofobesity.org/stories/on-the-hill/. Accessed March 5, 2019.
  2. Lundberg GD. Retracted—All is lost and I have no hope: the obesity epidemic. Medscape. February 15, 2019. https://www.medscape.com/viewarticle/908358. Accessed March 5, 2019.
  3. Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: I. Long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174–192. Epub 2019 Jan 3. https://journals.sagepub.com/doi/10.1177/0956797618813087. Accessed March 5, 2019.
  4. American Medical Association House of Delegates approves resolution to help destigmatize obesity [news release]. Denver, CO: Obesity Medicine Association. June 13, 2017. https://obesitymedicine.org/ama-destigmatize-obesity-resolution/. Accessed March 5, 2019.
  5. Casazza K, Brown A, Astrup A, et al. Weighing the evidence of common beliefs in obesity research. Crit Rev Food Sci Nutr. 2015;55(14):2014–2053.

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