by Gabrielle Cooper, UNC Medical Student and 2022 CEED Summer Research Fellow

It is time to examine the root cause of the stigma physicians hold against patients in larger bodies. The anti-fat bias that many physicians hold and its negative impact on the care patients with higher weight receive has been well-described in the literature. Providers have been shown to assume patients in larger bodies are nonadherent to treatment or do not care about their health (Street et al., 2007). Providers may demonstrate less respect for patients with higher weight (Huizinga et al., 2009). Patients in larger bodies may be less inclined to seek medical care including cancer screenings (Drury & Louis, 2002). Furthermore, patients who face weight stigma are more likely to experience anxiety, depression, and higher physiological markers of stress (Wu & Berry, 2018). The question that needs to be confronted is where is this stigma derived from and how are providers being trained to care for these patients? Of note, the term “obesity” is associated with substantial stigma and has been replaced with alternative language (Puhl, Peterson & Luedicke; 2013).

A growing number of studies are demonstrating that medical students hold anti-fat bias. In a study of 310 medical students at Wake Forest University, 72% of students shared explicit preference for thin people, yet 67% believed they did not have any preference (Miller et al., 2013). In a similar study, 74% of medical students from Robert Wood Johnson School of Medicine demonstrated implicit bias against people with higher weight (Phelan et al., 2014). The same study showed that bias increased throughout the students’ medical education. In a study at the University of Pennsylvania, medical students surveyed after taking gross anatomy lab described larger bodied cadavers as “difficult”, “unhealthy” and “disgusting” (Goss et al., 2020). Working with larger bodied cadavers contributed to the students’ perceptions of large bodies as being unhealthy. In a study of 76 third- and fourth-year medical students from the DC area, students treating a simulated patient with shortness of breath were more likely to treat patients with higher weight with lifestyle recommendations and patients with lower weight with medication (Persky & Eccleston, 2011). It may be that medical students enter medical school with these biases; however, it is important to analyze how medical students are being trained. Are medical school curricula contributing to these biases?

I have personally experienced being taught that higher weight is synonymous with disease. Lecturers and textbooks list increased weight as a risk factor for many clinical pathologies without explaining a direct causal link. When working through practice cases on cardiac, renal, or respiratory diseases, the physical exam will usually list a BMI above 30 kg/m². These manufactured practice patients often engage in other unhealthy behaviors such as smoking, drinking excessive amounts of alcohol, or living a sedentary lifestyle. The association we are taught is clear: increased weight causes disease. Additionally, these practice cases are demonstrating an association between having a larger body and not caring about one’s health. Although I am speaking to my experience at one medical school, anti-fat bias is pervasive in medicine (Lawrence et al., 2021).

How can medical schools train clinicians to provide quality care for patients in larger bodies? A few studies have tried to implement short trainings targeted at addressing bias towards patients with higher weight. One study took 45 first year medical students through a one-day intervention where physician experts in nutrition and weight management discussed factors contributing to weight gain, weight bias, and challenges patients in larger bodies face. The results showed some decrease in bias after the intervention, but not to a significant degree (Nestorowicz & Saks, 2021). In a larger study of 1,795 medical students across 49 schools, students who witnessed discrimination by faculty against patients with larger bodies had greater anti-fat attitudes. In the same vein, students who witnessed positive interactions between providers and patients with larger bodies had less anti-fat bias (Phelan et al., 2015). Finally, at the University of Wisconsin School of Medicine, students participated in a workshop discussing weight stigma. After the workshop, students were more likely to believe factors contributing to weight included access to care, stress, and social environment (Niemi et al., 2022). These studies display the potential for medical schools to impact students’ perceptions of patients with higher weight. It is time to change how medical providers are trained to care for patients in larger bodies. Programs should avoid listing BMI in practice cases and assess when is (and when it is not) appropriate to state weight as correlating with or causal of disease. There is a need for overarching change in the rhetoric surrounding weight in medical school curricula to address disparities in care provided to patients in larger bodies.

References:

Drury CA, Louis M. Exploring the association between body weight, stigma of obesity, and health care avoidance. J Am Acad Nurse Pract. 2002 Dec;14(12):554-61. doi: 10.1111/j.1745-7599.2002.tb00089.x.

Goss AL, Rethy L, Pearl RL, DeLisser HM. The “difficult” cadaver: weight bias in the gross anatomy lab. Med Educ Online. 2020 Dec;25(1):1742966. doi: 10.1080/10872981.2020.1742966.

Huizinga, M.M., Cooper, L.A., Bleich, S.N. et al. Physician Respect for Patients with Obesity. J GEN INTERN MED 24, 1236–1239 (2009). https://doi.org/10.1007/s11606-009-1104-8

Lawrence BJ, Kerr D, Pollard CM, Theophilus M, Alexander E, Haywood D, O’Connor M. Weight bias among health care professionals: A systematic review and meta-analysis. Obesity (Silver Spring). 2021 Nov;29(11):1802-1812. doi: 10.1002/oby.23266.

Miller DP Jr, Spangler JG, Vitolins MZ, Davis SW, Ip EH, Marion GS, Crandall SJ. Are medical students aware of their anti-obesity bias? Acad Med. 2013 Jul;88(7):978-82. doi: 10.1097/ACM.0b013e318294f817.

Nestorowicz S, Saks N. Addressing Bias Toward Overweight Patients: a Training Program for First-Year Medical Students. Med Sci Educ. 2021 Apr 6;31(3):1115-1123. doi: 10.1007/s40670-021-01282-2.

Persky, S., & Eccleston, C. P. (2011). Medical student bias and care recommendations for an obese versus non-obese virtual patient. International Journal of Obesity, 35(5), 728-35. doi:https://doi.org/10.1038/ijo.2010.173

Phelan SM, Dovidio JF, Puhl RM, Burgess DJ, Nelson DB, Yeazel MW, Hardeman R, Perry S, van Ryn M. Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study. Obesity (Silver Spring). 2014 Apr;22(4):1201-8. doi: 10.1002/oby.20687. Epub 2014 Jan 9.

Puhl, R., Peterson, J. & Luedicke, J. Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. Int J Obes 37, 612–619 (2013). https://doi.org/10.1038/ijo.2012.110

Street RL Jr, Gordon H, Haidet P. Physicians’ communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor? Soc Sci Med. 2007 Aug;65(3):586-98. doi: 10.1016/j.socscimed.2007.03.036.

Wu, Y-K, Berry, DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018; 74: 1030– 1042. https://doi.org/10.1111/jan.13511

2002. Implicit anti-fat bias in healthcare: An initial evaluation of an intervention to challenge medical students internalized fatphobia and improve competency in weight-related training.