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- [00:03]
A
Welcome to this special two part series of Diabetes Core Update where we are going to discuss weight bias and stigma. This is really important because weight bias and stigma permeate the experience of living with obesity. It leads to measurable adverse outcomes and when it is present in healthcare interactions, it affects all of the subsequent care that a patient receives. I'm your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. This special series of Diabetes Core Update is sponsored by Lilly. Joining us for today's episode is one of the top researchers in the field, Dr. Rebecca Pearl, PhD. Dr. Pearl is an Associate Professor, Director of Research, Department of Clinical and Health Psychology, College of Public Health and Health Professions at the University of Florida. Welcome Rebecca.
- [01:13]
B
Thank you so much for having me here, Rebecca.
- [01:16]
A
The American Diabetes association is in the process of developing and publishing the Standards of care for the management of obesity. The first part of the standards to have been published is the section on weight stigma and bias which was presented at the scientific sessions this past June. I was there, I listened to the presentation and I was happy to see that first that the standards are now coming out and they're being published in portions at a time. And I noticed that you were listed as a collaborator, that you're part of the professional practice committee for the standards and in fact some of the articles that you are author on were included as references. Let's start our podcast off with the basics. Can you define for us what weight bias and stigma is and why it is so important that it was the first part of the American Diabetes Association's Obesity Association Standards of Care to have been released?
- [02:24]
B
Yes, absolutely. It was such a privilege to be a co author on those standards of care related to this topic of weight bias and stigma. For anyone who's not familiar with these terms, we define weight bias usually as negative attitudes towards someone on the basis of their body weight or size. Weight bias can affect people of all sizes across the weight spectrum, although most often we are thinking about people with a high body weight who are typically the most affected by weight bias. And in line with weight bias, we see these negative prejudicial attitudes toward people, especially with a high weight, and negative assumptions or stereotypes about them and about their internal characteristics just based on their outward appearance or their weight. So some of the common stereotypes that people might be aware of are assumptions that someone is lazy or lacks self control or discipline because of their weight. And there's also a lot of blame that's placed on people for being perceived as unable to control their weight, in part because of a widespread misconception that weight is entirely within an individual's control, which we know is not true. And so when we have all these negative attitudes and stereotypes and blame, that's really what drives weight stigma. And weight stigma we often define as a societal devaluation of someone on the basis of their weight or size. And I can talk more about what this actually looks like, but those are kind of how we're thinking about these terms in research and in clinical care. To answer your second question, I was so appreciative that the American Diabetes Association's Obesity association did decide to lead with this section on weight bias and stigma, because I think it really sets the tone for the rest of the guidelines. And it sends a message that any approach to treating obesity has to start with treating all patients with dignity and respect, and emphasizes the importance at the outset for healthcare professionals to be aware of potential biases that they may have. So. So that they are not inadvertently leading to stigmatization or negatively affecting patient care.
- [04:48]
A
Yeah, and it's so important. And we would never think of having any sort of adverse attitudes about anyone else with a chronic disease. And yet there's this continued misunderstanding as you alluded to, that obesity is either a choice, a decision, a lack of will, whatever you want to put to it, without the recognition that it is a chronic disease. Just like hypertension, high cholesterol or diabetes, people don't wake up in the morning, go, boy, I wish I had one of these. But that it is something that some of us get have and some of us don't. You used a term, devaluation. Can you explain a little more what that term means?
- [05:50]
B
Yes. So by devaluation I mean believing that someone has less worth as a person because of their weight or size. And we know that these kinds of messages can really be internalized by people who are facing negative treatment or judgment from others because of their weight. So something that I've been very interested in is self directed stigma or internalized weight stigma, which is when people with a high weight are aware that they are viewed and treated negatively by society and start to absorb those negative messages and apply them to themselves and end up having lower self worth because of their weight. So we know that there are so many messages out there that give the impression or that send a message that people are less worthy, are less competent, are just less able to do things, whether that be in a work environment, a school environment. We hear this from family members. So sending that message that in Some way people are lacking because of their weight. And we know unfortunately that very understandably those messages can really be absorbed and can affect people's self worth and self esteem.
- [07:09]
A
Yeah, and even hearing you say that, I get this just sad feeling because we would never want to make someone feel less of themselves. And you said we send these messages, what does that look like? How do we send those messages?
- [07:29]
B
Yeah, these messages can be sent in both subtle and very blatant ways. Broadly in society media messages and the way that weight is talked about in news stories often really emphasizes the phrase personal responsibility or this idea that people should be able to control their weight. And if they're not able to control their weight, then that means they are irresponsible or somehow a bad person because of that. We see this in popular media in terms of negative portrayals of people with the high weight. Social media certainly is a huge outlet for these messages of blame and shame related to weight. Oftentimes we know from research and also from anecdotal evidence for sure, but it's been documented in many, many research studies that people often face criticism from family members because of their weight, maybe sometimes well intentioned comments about weight, but delivered in a way that does not feel supportive or, you know, loving or positive, and instead feels very critical or blaming. We know that people with a high weight face discrimination in education settings, in employment settings, and in healthcare settings. So those experiences of being teased or bullied or denied opportunities, denied promotions, denied jobs, that also sends that message that someone is not as worthy or doesn't have as high value as someone else with a lower weight. And then there are also ways in healthcare settings especially where these messages can again often inadvertently be conveyed to patients. So, you know, jokes about weight or any kind of derogatory language unfortunately does happen in healthcare settings, even when patients are young children. I've heard many anecdotes from patients about kind of their first exposure to weight stigma, being in a healthcare office when they were a child, and the first time that someone raised a concern about their weight and it done in a way that made them feel like they were bad as a child. But even for adults, the kinds of questions sometimes that healthcare professionals can ask about eating habits or activity habits can feel accusatory. Assuming that someone is eating unhealthily or not exercising just based on their body size or their body mass index or bmi, assuming that weight is the cause of all of a patient's health system health symptoms or health problems, or denying them care for certain kinds of procedures based on BMI alone without considering other health metrics or doing a full health history or other kinds of comments about needing to work hard or have self control to manage their weight or other kind of dismissive messages about their weight or their appearance. Patronizing advice of like, well, have you thought about eating less or moving more? Which of course anybody you know is, is aware of those kinds of strategies and not appreciating how complex weight is. So those are just some examples of the kind of everyday ways that people face these kinds of messages and that they can come specifically in healthcare settings.
- [10:45]
A
Yeah, and you know, there's both, I guess, explicit bias and implicit bias. And I'm going to ask you in a minute to tease that out. But as you were talking, I was thinking of just a recent story that a friend of mine shared going to a doctor and she was very upset because she shared with me that and this is someone who is a registered dietitian, so someone who knows what they're doing. And the doctor said, you realize that you need to lose weight. Now I'm sure the person was well intentioned that you know, this is information they wanted to share. But wait, you know, that had a sting to it because clearly this individual was well aware of health issues around weight and then shortly afterwards said some version of what you just said, which is, you know, you just need to eat less and move more and here's a hint, eat less carbs and without asking anything, either permission to talk about things, which we'll talk in a little while, or having any sense of what this individual, who is very knowledgeable, had already tried. And so what you're saying really resonates and is far, far too common, often by well intentioned individuals. Can you help us tease out the difference between explicit bias and implicit bias?
- [12:30]
B
Sure. So implicit bias is typically thought of as attitudes that may be outside of our conscious awareness, whereas explicit bias is more of our conscious known attitudes and beliefs. And there's different ways of measuring this in the research and we know that both can have an impact on patients and can seep into interactions. I appreciate you sharing that patient's story and unfortunately that is a very common experience. And the patient you described, their profession was in dietetics. But even without that, our patients are experts in weight management often. Right. Because they've been dealing with it throughout their whole lives. They often know far more than the doctor does about, you know, different diet plans and recommendations. And they've done, you know, done those different things many times. And so I agree with you that that assumption of going in that the patient doesn't know what they're supposed to be doing, supposed to be doing, is really off putting. Unfortunately, there's also very blatant experiences that can affect patients too. I'm thinking about multiple patients I've talked with who went to healthcare offices that did not have high capacity scales in the office. And this really speaks to the importance of also making sure that an office environment is set up to be safe and comfortable for people of all sizes and accessible. So I've had more than one patient tell me stories where they did not have an accessible scale in the office and they had to go out to the loading dock of the building to step on a freight scale in order to get their weight. And so when I talked before about devaluation of just thinking how dehumanizing that is and how humiliating and why would any patient want to ever return to that doctor's office or any doctor's office ever again after an experience like that? So that might be something where, you know, it's not necessarily true that the staff or the providers there had explicit bias toward patients, but just, you know, missed or had maybe some implicit biases or didn't think about the ramifications of not making sure that their equipment was accessible for everybody.
- [14:56]
A
Yeah, and we're going to talk in a little while about consequences. But boy, you're that story. Why would you go back there and then you miss all sorts of opportunities for health care, not just around care of, of obesity, but preventive health care and everything else. What does the current evidence tell us about the prevalence of weight bias among healthcare providers? Because all of us as individuals think that we are without bias.
- [15:29]
B
Right? And unfortunately we're all wrong because bias is part of being human. So all human beings have biases. That's part of how our brains work. And healthcare professionals are no exception to that. So we know that the short story is weight bias, both implicit and explicit, is pretty highly prevalent across many different kinds of healthcare professionals, including people who specialize in research and treatment on the topic of obesity. So just having education or knowledge about a topic does not necessarily inoculate us from having some of those deep seated attitudes or biases that can pop up. We know also that these biases start early in health care training. So they've been documented among first year medical students or other kind of pre service health students and then continue throughout the profession. There's some evidence that weight biases may differ across different types of specialties. Like there was a relatively recent paper showing slightly lower levels of weight bias in primary care physicians compared to physicians in other specialties like orthopedic surgery. But overall, we know that no one is immune to having these biases. I will also add that there are some studies that compare negative attitudes among healthcare professionals toward patients with a high weight or obesity compared to patients with other marginalized identities or from other historically marginalized groups, and often find more negative attitudes toward patients with a high weight or obesity compared to those other groups.
- [17:12]
A
So there's no question that it is morally wrong to have attitudes that are unkind and untrue toward another person or another group of people. The question I'll ask next, though, is, does that have consequences? It's wrong, but are there consequences to those attitudes?
- [17:38]
B
Yes, definitely. So you're right. Ethically, we want to make sure that we're not having biases, especially that affect patient care. But this is a social justice issue. But it is also a public health issue because we have really strong evidence across decades of studies that are observational, experimental, longitudinal, time and time again, documenting the harms to health that comes from experiencing weight stigma from other people and internalizing that weight stigma as well. So we know that experiencing or internalizing weight stigma is linked to worse mental health outcomes, including higher levels of depression, anxiety, eating disorder, risk factors, as well as substance use and suicidal thoughts and actions, especially among youth. Weight is one of the leading reasons for bullying and teasing among youth, and so it's not surprising that this has a huge impact on youth mental health, including suicidality, eating disorders, et cetera. And then there are also a number of physical health outcomes that have been tied to experiencing or internalizing weight stigma, which is important to emphasize because even now, there still can be some pushback against the idea of reducing stigma for weight and obesity, because people think that stimulus stigma can motivate people to engage in healthy behaviors and lose weight, and are concerned that if people feel too good about themselves, I guess, that they won't be motivated to engage in healthy behaviors. And over and over again, we see the exact opposite of that, that experiencing or internalizing weight stigma is linked to more unhealthy eating behaviors, including disordered eating, avoidance of physical activity, especially when people are concerned about their bodies and how other people may be judging them. In physical activity environments, we see things like increased risk for cardiovascular diseases and other chronic diseases that are linked to stress. And there's many, many studies that really, I think, compellingly show that weight stigma, like other forms of stigma, is a form of chronic stress. And when people are under stress, they tend to cope with stress, often by engaging in behaviors that undermine health, like eating more unhealthy kinds of foods. And they also have physiological reactions to that stress. So heightened inflammation, changes in cortisol, immune dysfunction. Right. All these things that we know contribute to chronic disease and that also influence appetite or things that would affect affect behavior. And there's actually several studies, big longitudinal studies, showing that people who experience weight discrimination are more likely to gain more weight over time compared to those who don't. And with these studies, I do want to emphasize that the researchers control for factors like BMI or other health factors that could explain these relationships. So it's really isolating the effects of stigma beyond any effects of weight or BMI or other kind of weight related metrics. It's isolating the effects of stigma on these health outcomes. So weight stigma exacerbates or further contributes to any kind of physical health outcomes that we know are also tied to obesity and diabetes and other related diseases. Overall, we know that this undermines engagement and health promoting behaviors. And then there's also research looking specifically at people who are actively trying to lose weight or to manage their weight and showing that weight stigma undermines those efforts as well and other efforts to manage chronic diseases. So it contributes to worse mental and physical health related quality of life.
- [21:39]
A
So when you say for people who are actively trying to lose weight, what sort of actions lead to those negative consequences?
- [21:51]
B
Yeah, so the kinds of things that we hear would be first, just anytime anyone faces negative judgment or discrimination, that can be a stressor. Right. And so when people experience those interpersonal interactions, a very common coping response to that kind of stress is to eat more unhealthy foods or to have thoughts that are discouraging. Right. So any kind of negative interaction or criticism someone gets about their weight could lead to thoughts like, well, what's the point? Or when people internalize those negative experiences, they may start to apply those negative stereotypes to themselves. So if they're getting messages from other people that I'm lazy, I'm no good, I have no self control, they can start to believe those kinds of messages. And when people believe that they don't have self control or that they're lazy, that leads to all sorts of negative emotions. Right. That can lead to behaviors to cope with those negative emotions like avoiding physical activity or eating unhealthy foods, and also can lead people to give up on the kinds of goals that they may have because they don't feel like they are capable of doing it or don't have confidence that they can follow through on those goals.
- [23:07]
A
Yeah. So let's move now from we've talked about the problem, how common bias and stigma is, how large the consequences are. Let's now shift towards solutions. Most of us are well intended clinicians do what they do in order to help patients. And we know we have bias. Some of it is explicit, some of it is implicit. What are some of the ways that we can address this in order to diminish it?
- [23:43]
B
Yes, that's a really important question. And I will also add, especially related to healthcare settings, that when patients face negative judgment or criticism or stigma in healthcare settings, it also leads them to avoid healthcare settings which, as you said, said before so well, that leads to missed opportunities for early intervention or for preventative care. And also because weight bias can negatively affect patient care, it can affect decision making and all sorts of things that can then affect that patient's well being. That's another way in which weight stigma affects health through a healthcare provider. So healthcare professionals in particular, I think it's so important to have that responsibility to be aware of our biases and to make sure that they're not affecting patient care and awareness really is that first step. So doing the honest work of self reflection to ask yourself what assumptions you might make about patients with a high weight or what attitudes you have about people who struggle with their weight or even about your own weight and how that may be affecting how you view patients. And really pausing to ask yourself how weight may be affecting decision making, especially if weight is not the presenting problem that a participant is coming in or excuse me, a patient is coming in for. You know, asking yourself if you'd give the same kind of treatment or guidance to someone in a smaller body. And then seeking out opportunities to educate yourself and to learn more if you feel like you aren't as familiar with experiences of weight stigma or with obesity treatment recommendations. Listening to the stories of people who have struggled with weight to better understand their experiences and educating yourself about obesity, its etiology and causes and its treatment, their initial steps. I can talk more about other practical things.
- [25:43]
A
Yeah, I'd like us to, because I agree with you that the first step is awareness. Second step. I love your suggestion about reflection. I think in every part of life we benefit from pausing and reflecting on how do we do today. Right. Because none of us are perfect and how can we be better tomorrow? What mistakes did I make today? Because we do, and with good intentions, we strive to not repeat the same mistakes too many times. Right. We try to Grow and learn. And then there also are practical strategies sometimes that we can use to facilitate carrying out things that help us do that. What are some strategies?
- [26:33]
B
Yes, well, you mentioned one earlier which is asking permission. So asking permission before weighing a patient and then being respectful if they say that they do not want to be weighed or they do not want to talk about weight, that can actually open up a conversation about why they may not want to be weighed or talk about weight. That's important to have in order to build that relationship with the patient. Other strategies include being careful about the language that's used related to weight. There are lots of different preferences about weight related language and it likely will differ depending, you know, patient to patient. But generally it's recommended to use people first language when talking about weight and obesity and to ask patients what kind of terms they prefer when talking about weight. Using patient centered communication skills, things like reflective listening, motivational interviewing, and also when talking about weight and health, really trying to focus more on health behaviors and overall health rather than focusing so much on weight itself. Because ultimately patients cannot control their weight. They can't snap their fingers and change their weight. They can change behaviors that then can trickle down and maybe affect weight and also also affect overall health. I also absolutely want to emphasize that it's important to avoid making decisions about patient care based on BMI alone. There's been a lot more conversation about this and a lot more change in terms of guidance. But we know that still BMI is often used inappropriately to deny patients care, or you know, used without really getting a full assessment of a person's weight history, of their full health history, and using other health metrics. And then last, as I alluded to earlier, making sure the office is set up for people of all sizes. So having high capacity scales, making sure the chairs are comfortable for people in larger bodies, having blood pressure cuffs and gowns in appropriate sizes, these are some of the the ways that really just convey that message that everybody is welcome in an office setting. And above all, treating patients as a human being first and focusing on their overall well being beyond just seeing the number on the scale or seeing their weight.
- [29:04]
A
Yeah, clearly very important. Let me ask you a question, something I've always believed, which is if we lead with curiosity rather than telling people what to do, asking them about their thoughts and what they have tried first, done first, where they would like to go next. I realize it might be simplistic, but is that a useful strategy?
- [29:34]
B
Absolutely. I love that of leading with curiosity rather than lecturing, because that really Shows that you're not making assumptions that you're gathering information first using those open ended kinds of questions. Even something as simple as saying what are your eating habits like? Or what do you do for physical activity? Rather than more accusatory sounding questions like do you eat a lot of junk food? Right. So that subtle difference can really make it a big difference. And really, you know, approaching things collaboratively, right. Of working with the patient, figuring out based on their needs and their goals and their motivations, what may be the best path forward. Going back to their objective data, like their blood work and test results, but also the kinds of things that are important to them, like having more energy to run around with their kids or their grandkids. And having that collaborative relationship can really go a long way to support someone through any kind of health behavior goals they might have. And again, respecting also if someone does not want to lose weight or does, you know, feels too overwhelmed to make those big behavior change goals, still showing that you're on their side and there for them if they want to revisit it in the future.
- [30:56]
A
One of the tenants of primary care is we're always here for people when they come back and it isn't always the right time in someone's life to make a big change now. Right. We go through different stressors at different times and we can't take care of all the stressors at once. On the other hand, if we're non judgmental, we're here when, when you need me, please come in and I'm here for you. I want to focus now for a few minutes on the first part of a visit because that's a critical opportunity when we as a clinician bring up weight as an issue. And there's no question that trust is a critical component of healthcare. And fundamentally, when any of us go to see a clinician, we're vulnerable. We're also afraid. And that's particularly true when we're discussing things that we're sensitive about. And weight is one of those things. And so when we begin to talk about weight with a patient, there's a high likelihood that right at that juncture we can either facilitate a relationship of trust or interfere with that. Any thoughts about how to navigate that critical juncture?
- [32:15]
B
Yeah, well, starting with asking permission, and this can be phrased in something like, you know, I've noticed that since the last time you were here, you've gained X amount of weight. Is it okay if we talk about your weight today? And if someone says yes, then you can follow up with These more open ended questions, exactly as you suggested of getting their sense of how they're feeling about their weight. So how is this weight for you? How are you feeling about your weight and your health right now? So these kind of broader open ended questions to see what the patient says and where they take things. And all throughout checking in of is it okay if we talk about options for losing weight or for changing eating habits or physical activity, giving a suite of options. Right. Of we could talk about X, we could talk about Y. What sounds best to you? So really making it collaborative, checking in with the patient rather than simply kind of giving or only lecturing or laying out a ton of information without checking in as you go with the patient. And also I think it's important to build trust to make sure that you're following up as well. Right. So it's not just a one time conversation, but showing that you're invested in them as a person and in their care. So when that conversation comes to an end, also having a plan for when's the next time that person can come in to talk about what you've discussed and maybe follow up on this or needs a referral for other kinds of treatment related to helping with their weight. So showing that it's not just an afterthought to talk about weight one time if they really are invested in changing their health behaviors or managing their weight, of giving that indication at the outset that you're there with them through the long haul.
- [34:13]
A
That's a really good point. Because with management of weight, as is true of any chronic disease, it's not only what you do at this visit, but that it's almost like compound interest. What we do increases over time and the effect of what we do as long as we're there and we stay at it. My last question to you, Rebecca, is around something completely different, which is policy. And does weight bias and stigma, in your opinion, also affect policy decisions? Things like insurance coverage for medications?
- [34:53]
B
I believe that weight bias and stigma does affect these kinds of policy decisions. You know, with insurance coverage there are of course other factors that are cited like cost. But it is also hard to avoid the notion that, you know, there is this general belief that people should be able to manage their weight on their own without comprehensive care. This is a widely held belief, especially among people who don't understand the complexity of weight and obesity. And we would never say that for other kinds of health conditions like hypertension or diabetes or even for, you know, diseases that are extremely costly to give treatment for. You think about Cancers. Right. We would never say that, you know, as kind of on a moral level that people don't deserve care even because it's expensive. And there's also a conflation or a misconstrual of medications, for example, for weight management with cosmetic treatments or viewing these as a vanity issue. Certainly we've heard a lot about this in the media and discussions about the GLP1 medications which really I think is do as a disservice to people who have a real medical need for this. And I think among the public and among policymakers, there might be a misunderstanding that these medications are for vanity instead of for the real life saving, you know, health benefits that we know that they have. So when people have this belief that people with obesity or with a high weight should just be able to lose weight on their own, that they don't require comprehensive care, that's going to reduce the likelihood that they would be supportive of coverage or providing interventions to manage obesity.
- [36:39]
A
And I like the way that you put it, reduced the likelihood that things are never binary and our attitudes affect the way we weight different decisions and often without even realizing it, which is a point you made earlier. We're, we're about out of time. Rebecca, do you have any final thoughts for our listeners?
- [37:03]
B
I think we, we covered a lot of really important information for, for people to know. I guess as someone who really cares all a lot about self stigma among people who internalize those negative messages, I think it is useful for healthcare professionals to be on the lookout for that. If they hear their patients speaking about themselves in a really cruel, unkind way, blaming themselves, there are those small moments for intervention to just give that little bit of extra validation and encouragement and kindness that that can go a long way.
- [37:37]
A
I think that's so important. Dr. Rebecca Pearl, thank you so much for joining us.
- [37:41]
B
Thank you so much for having me.
- [37:44]
A
And most of all, as always, thanks to our listeners. Thank you for joining us on this first of a two part series on weight bias and stigma. This special series of Diabetes Core Update is sponsored by Lilly. We thank you for listening to the American diabetes association. I'm Dr. Neal Stolnick. Until next time, stay safe and keep learning.