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Obesity, Stigma, and Discrimination
Definition/Introduction
Obesity, a complex medical condition, has reached epidemic proportions in the United States (US). The National Health and Nutrition Examination Survey (NHANES) conducts height and weight assessments on a representative sample of Americans to gauge its prevalence. A study by Hales et al reported that between 2013 and 2016, the prevalence of obesity stood at 36.5% for men and 40.8% for women.[1] This prevalence has been on the rise since the 1970s, and it is projected that by 2030, nearly 48.9% of adults in the US will be obese.[2][3] Individuals with obesity face increased risks of morbidity and mortality due to health conditions such as diabetes, hypertension, hyperlipidemia, coronary artery disease, respiratory illness, and other comorbidities.[4][2] Obesity also significantly impacts healthcare expenditure, with direct medical costs for obese adults estimated at more than 200 billion USD annually in the United States.[5]
Diagnosing and Understanding Obesity
Body mass index method
Obesity is defined by the body mass index (BMI), which is calculated by dividing a patient's weight (in kilograms) by the square of a patient's height (in meters).[6] Based on an individual's BMI, obesity is classified in the table below.
Table. Obesity Classification
| BMI of 18.5 to 24.9 kg/m2 | normal |
| BMI of 25.0 to 29.9 kg/m2 | overweight |
| BMI of 30.0 to 34.9 kg/m2 | grade 1 obesity |
| BMI of 35.0 to 39.9 kg/m2 | grade 2 obesity |
| BMI of >40.0 kg/m2 | grade 3 obesity |
Waist circumference
Another method to define obesity is measuring waist circumference. In men, obesity is defined as having an abdominal waist circumference of ≥40 inches; in women, it's ≥35 inches.[7]
Percentage of body fat
Obesity can also be diagnosed based on the percentage of body fat. Generally, a body fat percentage of ≥30% in men and ≥35% in women is used as the cut-off value for diagnosing obesity.[8] However, it's important to note that there is a lack of consensus on these values.
Other diagnostic methods
While various other methods exist to diagnose obesity, BMI remains the most widely used due to its accessibility, cost-effectiveness, and reasonable reproducibility.
Challenging Stereotypes and Bias
Unfortunately, the rising rates of obesity have led to the emergence of harmful stereotypes and biases targeting people who are obese.[9] Society has wrongly associated obesity with laziness, irresponsibility, and a lack of self-control. This perception persists despite the recognized influence of genetic, socioeconomic, and environmental factors in the development of obesity. These attitudes have fostered a damaging stigma, resulting in prejudice and discrimination against those affected. Addressing this issue requires dispelling misconceptions and creating an environment of empathy and support for individuals of all body sizes.[10][11]
Issues of Concern
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Issues of Concern
Understanding Weight Stigma
Weight stigma refers to individuals' social devaluation and denigration due to their excess body weight, leading to negative attitudes, stereotypes, prejudice, and discrimination.[12] This issue has escalated, with a two-thirds increase over the past decade.[10] Remarkably, its prevalence now rivals discrimination based on race and age, yet it lacks comparable legal and social safeguards.[13] Addressing weight bias is crucial to establishing equitable protections and creating a more inclusive society that upholds the rights and dignity of individuals, regardless of their body size.
Despite the global prevalence of obesity, individuals with obesity often face discrimination and mistreatment in settings like schools, workplaces, and healthcare facilities. A study by Carr et al noted that those with a BMI of 35 or higher are more likely to experience institutional and employment discrimination.[14] Concerns about weight-based victimization in school children have also been raised.[15] Similarly, a large-scale study comprising 13,996 individuals across various countries found that at least 66% of those experiencing weight stigma also encountered it from healthcare providers.[16] Another study involving 1697 individuals with a BMI >25 reported suboptimal treatment in 48% of cases, with more than 50% noting insensitive and judgmental comments from various healthcare professionals.[17] Research has shown primary care providers spend less time during office visits with obese individuals as they view them as noncompliant patients.[18] A healthcare professional's weight bias impairs their ability to offer support and empathy to these patients, compromising their overall health care.[19] This discrimination in healthcare can deter patients with obesity from seeking healthcare services, affecting overall healthcare resource utilization, including preventive and screening care.[20]
Disease stigmas result from misconceptions and biases that exacerbate the suffering of individuals with these conditions, such as HIV and AIDS. The media highlights these attitudes by depicting thin actors as popular and kind, while overweight actors are often rude, aggressive, and unpopular.[21] The media, educators, and health professionals must be informed and properly educated about the harmful consequences of weight stigma to reduce weight discrimination. The stigma and prejudice towards obese persons significantly impact adverse physical and psychological outcomes.[22] It's crucial to recognize that despite substantial evidence linking obesity to genetic and environmental factors, it is still commonly perceived as an individual-level problem.
Clinical Significance
The current belief is that labeling an individual obese will motivate weight loss.[23] However, research has consistently shown that weight stigma has severe and lasting physical and psychological consequences for this group.[22][9][24][25][26] Individuals with obesity tend to internalize this stigma, reducing confidence in their ability to lose weight.[10] Children and young adults with obesity often face weight-based bullying and discrimination, making obesity the most common cause of youth experiencing such mistreatment in school.[22][27][28]
Weight stigma is also associated with an increased risk of depression, anxiety, suicidal thoughts, and low self-esteem.[29] Weight stigma negatively impacts individuals' eating patterns[30] with one study demonstrating that exposing overweight or obese individuals to weight stigma increased their calorie consumption.[25][26] These negative psychological and behavioral effects, including more frequent binge eating and reduced physical activity, put obese individuals at a higher risk for cardiovascular disease, diabetes, and stroke.[31]
When obese patients experience weight bias in a medical setting, they are more likely to cancel appointments and avoid future preventative health care, ultimately increasing their medical risks and healthcare costs.[19][27] Weight-based discrimination and stigmatization are linked to lipid and metabolic dysregulation, glucose metabolism issues, and elevated markers of inflammation, leading to an elevated 10-year cardiometabolic risk and increased morbidity.[32] One study even suggests that weight-based discrimination might result in a 60% increase in mortality among individuals, although the exact mechanism is unclear.[33]
Weight stigma affects healthcare access and outcomes for obese individuals. Some studies have demonstrated elevated C-reactive protein levels (indicating systemic inflammation) in individuals with perceived weight stigmatization.[34] There has also been evidence suggesting obese women are less likely to be up to date regarding screening procedures such as Pap smears and mammography.[35] This is often due to embarrassment, perceived weight stigma during clinical visits, the lack of appropriately sized examination equipment, and poor patient-provider communication. These factors can lead to delayed cancer diagnoses, increasing morbidity and mortality.
Weight bias and stigma are troubling, influencing perceptions and resource allocation for crucial obesity-related research. This unfortunate reality has resulted in chronic underfunding, hindering the advancement of knowledge in this field.[36] As a result, there has been a rise in cardiovascular diseases, highlighting the consequences of allowing weight bias to persist.
Even interventions like weight loss surgeries are not immune to societal bias. One study revealed that individuals undergoing weight loss surgeries face more negative judgments compared to those who lose weight through diet and exercise alone.[37] This disparity in perception highlights a reluctance to provide universal coverage for surgical weight loss options.
Nursing, Allied Health, and Interprofessional Team Interventions
Addressing Weight Stigma in Healthcare Settings
In the healthcare sector, it's crucial for professionals to confront weight stigma and acquire a comprehensive understanding of obesity. When discussing the need for weight loss, healthcare providers should consider not only biological factors but also environmental influences.[27] An effective approach involves educating patients about adopting a healthy lifestyle, emphasizing components like a balanced diet, regular exercise, sufficient sleep, and stress reduction.[10] Moreover, healthcare professionals should enhance the physical and social environment to facilitate better patient care. This involves effective communication and creating clinical settings that accommodate patients.[38]
Healthcare providers must also be mindful of the language they use when interacting with patients. Research indicates that terms like obese, fat, and morbidly obese can have negative outcomes, whereas referring to patients as individuals with obesity or specifying the grade of obesity can yield more positive results.[39] Another essential aspect to focus on is overall health and behaviors rather than just weight. To further improve interpersonal interactions and avoid embarrassment for obese patients, clinicians should ensure their physical environment includes office chairs that are armless and large enough to seat overweight patients and provide large gowns and medical equipment such as larger blood pressure cuffs and scales.[38]
Utilizing the 5 As Method
In primary care settings, the 5 As method (ask, assess, advise, agree, and assist) offers a nonjudgmental framework for obesity counseling. This approach involves asking patients for permission to discuss weight, assessing their readiness for change, evaluating key metrics like BMI, waist circumference, and obesity stage, providing advice on associated health risks, shifting the focus toward behavior rather than just weight, setting realistic weight-loss expectations and treatment plans, and assisting patients in identifying and addressing barriers. It's essential to recognize obesity as a chronic, relapsing disease throughout this process.[40]
Advocating for Public Policy
In addition to generating awareness, a pivotal strategy for combating weight bias involves advocating for the implementation of robust public policies.[41] These policies should unequivocally denounce weight-based discrimination and take a proactive stance against bullying and cyber harassment targeting individuals with obesity. These policies should span various domains, including education, employment, healthcare, and public spaces, ensuring protection against unjust treatment for individuals with obesity. Engaging in open dialogues is vital to garner support, dispel misconceptions, and highlight the detrimental impact of weight bias on individuals' mental and physical well-being.
Nursing, Allied Health, and Interprofessional Team Monitoring
To bring about meaningful change, we must take a 2-pronged approach: first, we need to increase awareness to reshape how society perceives obesity, and second, we must push for legislative reforms that provide concrete protections. By adopting this approach, we can work towards creating a fairer and more inclusive society where individuals with obesity are treated with respect, receive support, and are empowered to succeed without the burden of unfair bias or discrimination.
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