Facing obesity stigma in healthcare

The need to address obesity stigma in healthcare settings was highlighted on World Obesity Day. Niamh Quinlan reports 

Obesity stigma is the “negative related attitudes, beliefs, assumptions and judgements in society that are held about people living in large bodies”, according to researcher with the RCSI’s obesity research and care group, Ms Niamh Arthurs (BSc, MSc). 

This stigma or bias can be expressed implicitly, explicitly or is internalised. It potentially affects everyone, according to Ms Arthurs, including those working in healthcare and patients. 

“In the general population, about 44 per cent have internalised obesity bias,” Ms Arthurs said, referencing a study published in Obesity, the journal of the Obesity Society in the US. 

“Those with obesity were even more likely to have internalised weight bias.” 

Ms Arthurs was speaking to the Medical Independent (MI) in advance of World Obesity Day, which took place on 4 March. 

In Ireland, 60 per cent of the adult population live with overweight and obesity, as well as one-in-five primary school-aged children. 

Attitudes 

According to the Rudd Centre for Food Policy and Health at the University of Connecticut, US, up to 70 per cent of adults with obesity have reported experiencing stigmatisation in the healthcare setting.

“It’s really important for health professionals to be aware of their own attitudes and behaviours towards people with obesity,” said Ms Arthurs. “We [healthcare professionals] don’t study for ‘x’ number of years to do harm. One of the first things you learn in medical school or on healthcare professional courses is ‘do no harm’.” However, she said there was a lack of awareness and understanding that attitudes about obesity are causing patient harm. 

Research published in Obesity Reviews in 2015 (‘Impact of weight bias and stigma on quality of care and outcomes for patients with obesity’) noted there were several ways in which the attitudes of healthcare professionals may affect patient-centred care for people with obesity. 

For example, healthcare professionals “may allocate time differently, spending less time educating patients with obesity about their health”. The research also found healthcare professionals “may overattribute symptoms and problems to obesity and fail to refer the patient for diagnostic testing or to consider treatment options beyond advising the patient to lose weight”. In addition, they may not engage in patient-centred communication with patients living with obesity, due to the belief these patients are “lazy, undisciplined and weak-willed” and will not adhere to treatment. 

A joint international consensus statement for ending the stigma of obesity, published in Nature Medicine in 2020, stated that weight stigma “can mislead clinical decisions, and public health messages, and could promote unproductive allocation of limited research resources”. Weight bias and stigma can result in “discrimination and undermine human rights, social rights, and the health” of the individual. 

The longer a period in which a person does not receive appropriate care and treatment, the greater the risk of complications developing, said Ms Arthurs. This negatively affects the person’s quality-of-life, as well as placing more demands on the health service. 

Stigma or bias in primary and secondary care appointments has led to patients missing or cancelling subsequent appointments, which “on occasion” also resulted in “exacerbation of minor ailments to more serious medical issues”, noted a November 2021 study in PLOS One (‘A qualitative exploration of obesity bias and stigma in Irish healthcare; the patients’ voice’). 

After experiencing stigma “more often than not, [patients] resorted to unhealthy behaviours, such as binge eating and increased sedentary time”. 

Dr Gráinne O’Donoghue, Assistant Professor at the School of Public Health, Physiotherapy and Sports Science in University College Dublin, was the lead on this study. 

“We need to move away from solely focusing on diet and [physical activity] levels,” Dr O’Donoghue told MI. “While an individual’s choices about exercise or food are important, weight has more to do with genetics, what we are exposed to in the womb and environmental factors, than what we eat and how much we move.” 

The study also found patients had a positive experience when engaging with specialty services for weight management in tertiary care, compared to primary and secondary care. 

“And that again, I suppose, highlights the importance of education across all healthcare professions in this area,” said Dr O’Donoghue. 

Training 

“The inclusion of obesity education needs to happen within the curricula of… healthcare professional courses and in medical school,” said Ms Arthurs. “We know from the research it’s not being covered, it’s not in the curricula of students.” 

A 2014 study in Academic Medicine (‘Are medical students aware of their anti-obesity bias?’), which surveyed medical students in the US, found nearly two-thirds were unaware of their obesity bias. 

“We know that for the most part, stigma is not intended,” Ms Susie Birney, an advocate with the Irish Coalition for People living with Obesity (ICPO), told this newspaper. “But the problem is that it still causes harm.” 

Dr O’Donoghue underlined the role of educators and ensuring students are exposed to the competencies and learning outcomes required to care for people with obesity, so they have a better experience in healthcare. 

“You need [education] driven from every level, it doesn’t just come from undergraduate education,” she commented, in relation to healthcare professionals working in the system. “We change our practice all the time; look at how we were able to change our practice around the pandemic,” she added. 

Model of care 

Dr O’Donoghue said the HSE model of care for the management of overweight and obesity, which was officially launched on World Obesity Day, is helping obesity management to become a priority. 

The mode of care was approved in December 2020 and is aligned with Sláintecare principles, providing “person-centred care”. 

The main objectives of the model are “to define specific services for the effective management of obesity and overweight in children, young people and adults across the life course incorporating prevention, early identification and treatment to prevent progression of disease and complications”. It also aims “to ensure effective integration and support across levels of services, across the lifespan and with services for high-risk groups”. 

The model states all management of overweight and obesity will be underpinned by “non-judgemental and non-stigmatising conversations with all healthcare professionals” and in collaboration with patients, “individualised treatment options and supports will be available”, along with follow-up support. 

Covid-19 

The National Child Measurement Programme, England 2020/21 School Year, published in November 2021, showed that while childhood obesity had plateaued in recent years, there was an increase in the prevalence of childhood obesity during the pandemic. 

“We don’t have the stats [for Ireland] yet,” said Ms Arthurs, “but we would track quite closely to the UK.” 

“The effects of the lockdown and the Covid-19 pandemic over the past two years are yet to be seen. Undoubtedly, we know that they have placed a greater demand on our health service,” she noted. 

Ms Arthurs also works on a Sláintecare project led by Dr Grace O’Malley, Clinical Lead for the Child and Adolescent Obesity Management Team in Children’s Health Ireland, which provides “free, online and CPD-accredited training in childhood obesity for all health staff in Ireland” (visit childhoodobesity.ie for further information). 

During the pandemic, a high number of people with obesity have been admitted to ICU with Covid-19, according to the HSE. It is known that people with obesity have an increased risk of experiencing a more severe form of Covid-19. The US Centres for Disease Control and Prevention has said obesity may triple the risk of hospitalisation due to Covid-19 infection. 

People who have obesity with a body mass index greater than 40 are included in the HSE’s ‘extremely vulnerable’ category in respect of the potential impact of Covid-19.