Fat shaming is stopping doctors from helping overweight patients—here’s what medical students can do about itBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2830 (Published 17 November 2021) Cite this as: BMJ 2021;375:n2830
- Triya Chakravorty, sixth year medical student
People who are obese are highly stigmatised in society and face many forms of discrimination due to their weight.1 This weight bias translates into inequalities faced in healthcare, employment, and education.1 In a healthcare setting, negative attitudes held by healthcare professionals will make patients feel stigmatised and reluctant to access healthcare services, further damaging their long term health. The social stigma faced by overweight healthcare professionals will also have an impact on their own confidence and ability to deliver healthcare advice.2
The healthcare harms
Although obesity is a risk factor for several diseases and many public health interventions rightly aim to reduce it,3 the stigma around obesity does not make obese people healthier. Instead, it increases individuals’ risk of depression and suicide, and further entrenches disordered eating behaviours.14 Such negative perceptions also make people less likely to engage with preventative healthcare services.5 In other words, fat shaming does not work as a weight loss tool6 and can even harm health.
This stigma has perhaps the most damaging effect when it comes from healthcare providers themselves. Research has found that healthcare professionals often believe that overweight patients are less compliant with advice about weight loss.1 In a study of 2500 overweight individuals in the US, Puhl and Brownwell found that 53% reported receiving inappropriate comments from doctors about their weight.6 These negative interactions with healthcare professionals can deter patients from accessing medical care due to fears of being judged. Several studies have shown that obese individuals are less likely to take part in screening programmes for breast, cervical, and colorectal cancer.17
Obesity stigma may also increase the risk of eating disorders. A growing body of evidence suggests that obesity and eating disorders can co-exist in individuals and have shared risk factors, such as body dissatisfaction and dieting.8 Stigmatising comments from healthcare professionals can perpetuate the negative thoughts that a person has about their weight or body shape, which are known drivers of eating disorders. Furthermore, while eating disorders have high rates of morbidity and mortality, they may be more likely to be missed in patients who are overweight or who don’t fit with societal preconceptions of what a person with an eating disorder should “look” like.9 As future healthcare professionals, we need to acknowledge the bias that exists in our medical curriculum.
What can medical schools do?
Highlight the multifactorial causes of obesity
Educating students on the multifactorial causes of obesity may help reduce stigma and “victim blaming.” Obesity is not solely caused by patients being “lazy,” “lacking in self-discipline,” or being “noncompliant,” as many stereotypes suggest.1 Environmental, genetic, lifestyle, and other unknown factors all interact to cause obesity.3 A key part of reducing obesity stigma in healthcare workers and medical students is educating them about these many factors and taking the “blame” for obesity off the patient’s shoulders. A preliminary study in the US showed that an educational intervention focusing on the multifactorial causes of obesity, empathy induction, and roleplay improved the attitudes of medical students towards obese people.10
Question the use of BMI
Medical students should be taught to critically analyse the use of body mass index (BMI) as an indicator of health. Earlier this year, there was a call from members of Parliament to abandon the use of BMI, due to reports that it can worsen obesity stigma and damage people’s physical and mental health and wellbeing.11 BMI has been called a “very poor proxy of health,” which is not surprising given that it was created using studies of European males, making it less relevant for a diverse population.11 Medical students should instead be encouraged to look at other measures of health, such as waist circumference, blood pressure, and blood sugar.
Health at Every Size (HAES)
The Health at Every Size (HAES) approach has gained momentum in removing the focus from body weight, and instead encouraging a “fulfilling and meaningful lifestyle” through eating according to hunger and engaging in reasonable levels of physical activity.12 Its purpose is to reduce the social stigma and discrimination faced by overweight individuals and tackle chronic dieting behaviour, using a weight neutral approach that focuses on an individual’s overall health and wellbeing, as opposed to the number on the scale.12 Weight loss diets have been found to have minimal success in the long run, which underlines the importance of exploring other methods of promoting health.13
Address stigmatising behaviour
Learning from and modelling the behaviour of senior doctors is an important part of medical education, which is sometimes called the hidden curriculum of medical school. Observing role models who demonstrate prejudice or discrimination towards obese individuals may perpetuate the cycle of stigma. In a study of healthcare students, 40% reported witnessing seniors make negative comments and jokes directed at obese patients.14 Addressing stigmatising behaviour in a respectful way is important to break this cycle. A zero tolerance policy in healthcare settings towards discriminatory or derogatory behaviour may help achieve this goal. Furthermore, tackling weight stigma could help to focus consultations on the patient’s needs, in instances where weight bias shifts the consultation away from this.
The stigma around obesity and its long term impact is seldom covered in medical school and is rarely included in the core curriculum.15 Discussing this stigma and strategies such as HAES as part of the curriculum via a lecture or a module could be a way to tackle doctors’ stigma towards obese and overweight patients at the ground level.
Competing interests: none declared.