Conveying Empathy: Why Are We Still Struggling?

by Tracy Martinez, RN, BSN, CBN

Background
There are an estimated 93 million Americans who are obese and an estimated 12 million suffering from morbid obesity. This life-threatening disease in and of itself affects one’s mobility and quality of life, and creates social stigmas.[1] Studies suggest a considerable increase in this disease among all groups regardless of age, ethnicity, and socioeconomic background.[2]

Some of the most alarming statistics are in our children, predicting an even graver future. The proportion of obese and overweight children and adolescents in the United States nearly doubled in the 1980s alone, and the numbers continue to rise.[3,4] Unfortunately, many, if not most, of our patients who suffer from morbid obesity have endured a lifetime of loneliness, discrimination, and self blame. Why is this still true? As you read this article, reflect on the statistics that still remain in today’s day and age, and why these stigmas still exist.

When Do Obese Biases Begin?
Latner and colleagues[5] conducted a study in children’s attitudes toward obesity. They found that children as young as six years of age describe silhouettes of a child with obesity as lazy, dirty, stupid, ugly, a cheater, and a liar. This bias carries over into adulthood. In another study, college students rate their peers with obesity as warm and friendly; however, they also rate them as unhappy, lacking self confidence, self indulgent, and undisciplined compared to nonobese peers.[6]

Black-and-white line drawings of a normal-weight child, a child with obesity, and children with various handicaps, including missing hands and facial disfigurements, were shown to a variety of audiences. Both children and adults rated the child with obesity as least likable. It is unfortunate to observe that this prejudice extends across races and across rural and urban populations and, saddest of all, exists among the obese themselves.[7] Drawing an even grimmer picture of discrimination against this population, data suggest that these biases and discriminatory attitudes can be activated and subsequently conveyed without intention or conscious awareness.[8]

One of many misunderstandings about those who suffer from the disease of morbid obesity is that the population has a high prevalence of psychological illness. On the contrary, studies of severely overweight persons conducted before they underwent bariatric surgery have shown that there is no single personality type that characterizes the severely obese. This population does not report greater levels of psychopathology than the average weight-controlled population.[9] However, in our program’s population, the prevalence of depression is quite high (80%), which is not surprising in a society that is overtly cruel to individuals with obesity.

The medical field itself is not immune to the very biases that these patients face. Alarmingly, a survey of nursing attitudes toward the obese population reported that nurses believed that the people with obesity most likely have issues with anger and that they were lazy and overindulgent.[10] Hospitals should be a safe haven for patients, but unfortunately this is not always the case.

Healthcare professionals contribute to the culturally driven attitudes. In one study, mental healthcare professionals were asked to evaluate identical case histories with corresponding photographs of either normal or women with obesity. The women with obesity were rated significantly higher on agitation-impaired judgment, inadequate hygiene, inappropriate behavior, intolerance to change, stereotyped behavior, suspicion, and total psychological dysfunction.[11]

In another study, clear and consistent stigmatization—and in some cases discrimination—can be documented in the following three important areas of daily life: employment, education, and healthcare. Among the findings, 28 percent of teachers in one study said that becoming obese is the worst thing that could happen to a person; 24 percent of nurses said they are “repulsed” by obese persons; and parents provide less college support for an overweight child than for a thin child. There are also suggestions, but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas.[12]

Many patients have shared their experience in weight loss attempts and the disappointment with each failure. This sadness deepens when their primary care physician conveys disappointment in them with their failures. As one patient told me as he first sought care for bariatric surgery, “I am a wounded bird. I need help; be gentle with me.”

Failure in long-term weight loss may be the outcome, but efforts to lose weight are not. It has been estimated that Americans spend close to $33 billion annually on weight loss attempts. According to the Obesity Action Coalition (OAC), in 2000 the cost of obesity was more than $117 billion, and in 2003 Americans spent an estimated $75 billion in weight-related medical bills.

Our society (both medical and nonmedical) frequently demonstrates the belief that if patients ate less and exercised more, they could control their weight. In other words, patients choose to be obese. The fact is that morbid obesity is a disease of multifactorial origin that is strongly associated with genetic predisposition. Studies of twins have shown that two-thirds of the variations in body weight can be attributed to genetic factors.[13]

Another study demonstrated that when professionals whose careers emphasized research or the clinical management of obesity, even they have very strong weight bias, indicating a pervasive and powerful stigma. Understanding the extent of anti-fat bias and the personal characteristics associated with it will aid in developing intervention strategies to ameliorate these damaging attitudes.[14]  These attitudes pervade individual relationships and interactions, and larger dynamics within various societal realms.

Quite possibly, the most outrageous example of discrimination was when Blue Cross/Blue Shield of Tennessee required an IQ test for those seeking bariatric surgery to treat their morbid obesity.

Many researchers have worked diligently to demonstrate that bariatric surgery pays for itself in less than three years. What other surgical procedure pays for itself? What other surgical procedure is asked to justify such a thing?

Why is it that our patients continue to jump barriers to get an insurance approval in an effort to treat their life-threatening disease? Even when this surgical treatment is shown to be immensely successful in treating and resolving virtually all associated comorbidities—70 percent or more?[1] The general public would be outraged if an insurance company denied surgery to a patient suffering from pancreatic cancer, which never pays for itself, and has a minimal chance of success and resolution. Despite Medicare acknowledging obesity as an illness, some, if not most, healthcare givers are not aware of this determination. Likewise most healthcare givers do not understand the genetic predisposition to this disease.

Why are we still struggling? Maybe we are the reason.
Despite our ongoing empathy training classes, nursing in-services, and creation of an “obesity-friendly environment” in our hospitals, we all know that bias and discrimination are prevalent, even within our own programs. Caregivers are taught to practice sensitivity and nonjudgment, but do they truly convey compassion free of prejudice because they are told to or because they understand that this is a disease and not a moral shortcoming?

Change begins with us as leaders in the field to educate the public of this deadly disease that kills nearly 400,000 individuals per year. But it is equally—if not more—important to ensure that healthcare providers fundamentally understand that this life-threatening disease is a predominantly genetic disease.

Until this understanding is shared by the majority, the patients we seek to help will still endure discrimination, public cruelty, social stigma, limited healthcare, and loneliness.

Change your words—change the attitudes
Our patients are not “morbidly obese” patients; rather, they are patients who suffer from morbid obesity. They are not the disease—they suffer from a disease. We don’t say “the ovarian cancer women,” so why do we say “the morbidly obese women?” Think about it; reflect on your choice of words. If we don’t change our choice of language, how can we expect others to change theirs? Review all your presentations, program materials, brochures, websites, and other related materials to change the language.

Do not hide your bariatric unit by labeling the signage as “surgical unit.” Bariatric units are in existence to treat the disease of morbid obesity. We do not hide the obstetrics unit, cardiac unit, or oncology unit. All units treat medical conditions. If you do not have your units properly labeled, ask for new signage to include bariatric services.

Encourage colleges to think of one’s body mass index (BMI) as the fifth vital sign. Approaching one’s weight data in this way helps decrease the embarrassment that so many of our patients have felt with an office body weight check. Calculating one’s BMI allows the healthcare provider to educate the patient about health risk in a “medical” approach rather than through an embarrassing interaction. BMI may be the most important piece of data to assess one’s health.

Surgeons do not simply perform weight loss surgery—it is much more that that. Using the words bariatric or metabolic surgery describes the surgical procedure and specialty best and again takes away the “cosmetic” overtone.

When advertising, stress the health benefits of bariatric surgery. Rather than the common “Patient X has lost 110lbs.,” used in advertising, emphasize the health benefits of treating this disease.

Summary
Discrimination and bias still exist in treating morbid obesity, despite years of research and publications explaining the pathophysiology of this disease. The disease of morbid obesity affects one medically, economically and physically, but it is the psychological impact that can be the most devastating to ones life. Suffering from a disease that is full of misunderstandings and biases can be demoralizing. Changing our language and practices as discussed in this article may be beneficial in increasing the acceptance of morbid obesity as a disease, not a lack of restraint and gluttony. Change begins one action at a time.

A Lonely Disease

We begin our support groups in numerous ways. In one particular support group we hosted, I asked patients to state their names and the most significant comorbidities from which they no longer suffered. As we went around the room, individuals beamed as they stated all the comorbidities that no longer controlled their lives, including not needing a CPAP, a walker, insulin injections, or hypertension medications.

The last patient in the group to speak was a 52-year-old gentleman who held a prestigious position as CEO of a small software company. He hesitated, deep in thought, before responding, “You know, I suffered from diabetes and sleep apnea, but the worst comorbidity I suffered from was loneliness.” This is one of the effects of obesity that, while not clinically based or even measured psychologically, has major negative impact on our patients in everyday living.

Societal Ignorance

A patient of mine shared a story that is hard to believe. She was having her two grandchildren visit for Easter vacation and was at the grocery store preparing for their arrival. As she was in the market shopping, a woman she had never met before walked up to her, proceeded to remove a box of cookies from her cart and said, “Honey, you don’t need this… look at yourself.” This is the type of societal ignorance and disregard for feelings that many of our patients can attest to experiencing.

References
1.    Obesity Action Coalition website; www.obesityaction.org.
2.    Lanz P, House J, Lepowski J, et al. Socioeconomic factors, health behavior and mortality. JAMA. 1998;279:1703–1708.
3.    Ogden Cl, Flegal KM, Carroll D, et al. Prevalence and trends in overweight among US children and adolescents 1999–2000. JAMA. 2002;288:1728–1732.
4.     Freedman DS, Khan LK, Serdula MK, et al. Trends and correlates of Class 3 obesity in the United States from 1990 through 2000. JAMA. 2002;288:1758–1761.
5.    Latner JD, Stunkard AJ, Wilson GT. Stigmatized students: age, sex, and ethnicity effects in the stigmatization of obesity. Obes Res. 2005;13:1226–1231.
6.    Tiggerman M, Rothblum ED. Gender differences in social consequences of perceived overweight. Sex Roles. 1998;18:75–86.
7.    Bessenoff GR, Sherman JW. Automatic and controlled components of prejudice toward fat people: evaluation versus stereotype activation. Soc Cogn. 2002;18:329–353.
8.    Stunkard AJ. Wadden TA: Psychological aspect of human obesity. Am J Clin Nutr. 1992;55:5245–5325.
9.    National Institute of Health Consensus Development Conference Panel: Gastrointestinal Surgery for Severe Obesity. Ann Intern Med. 199;115:956–961.
10.    Maroney D, Golub S. Nurses attitudes toward obese persons and other ethnic groups. Percept Mot Skills. 1992;75:387–391.
11.    Young LM, Powell B. The effects of obesity on clinical judgments of mental health professionals. J Health Soc Behav. 1985;26:233–246.
12.    Puhl R, Brownell K. Bias, discrimination, and obesity. Obes Res. 2001;9:788–805.
13.    Stunkard AJ, Froch TT, Hrubic Z. A twin study on human obesity. JAMA. 1986;256:51–54.
14.    Schwartz M, Chambliss H, Brownell K, et al. Weight bias among health care professionals specializing in obesity. Obes Res. 2003;11:1033–1039.
15.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery ; a systematic review and meta-analysis. JAMA.2004;292(14):1724–1737.

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