More than 30% of the American population is obese.¹ Studies have repeatedly demonstrated a bias against obese patients, present even in health care professionals.^2-4 As emergency providers, we risk providing suboptimal care to a large percentage of our patients unless we proactively address this bias. Such prejudice or discrimination against individuals who are overweight is commonly referred to as weightism.⁵ This article outlines some of the literature demonstrating a bias against the obese and suggests concrete measures emergency physicians can take to safeguard against it.

Obesity Bias

Studies in psychology, psychiatry, sociology, and medical literature consistently demonstrate bias against obese persons by other individuals in a variety of contexts. Preschoolers deem overweight peers to be less desirable playmates.6 Obese students may face lower college acceptance rates, and higher rates of wrongful dismissal from college. Once they join the workforce, obese individuals are less likely to be hired for a variety of jobs,^2,7 and they may earn wages that are substantially less, on average, than other workers.⁸

While we may believe we treat all of our patients equally, physicians, too, are guilty of this bias. In a controlled survey of physicians, Klein et al. observed a tendency for physicians to associate obese patients with poor hygiene, hostility, noncompliance, and dishonesty.⁹ Even health care professionals who specialize in obesity have been found to harbor a bias against the very patients they treat.⁴

The practice of medicine may in fact exacerbate weightism. In a study of nursing students and registered nurses, Poon and Tarrant found that although both groups demonstrated bias against obese patients, RNs demonstrated more negative attitudes against obese patients than the students did.³ This study raises the question of how the bias against obese patients propagates.

Medical professionals can face real physical challenges when examining and caring for obese patients, including difficulty with venous access and limb manipulation. Do these challenges further worsen an already negative association with obesity?

The bias against obese patients likely affects their care. A study by Adams et al. revealed a majority of obese patients were reluctant to undergo a pelvic exam and that 87% of physicians were reluctant to perform a pelvic exam on an obese patient.¹⁰ Amy et al. showed a discrepancy in rates of pap smears when examining different BMI groups among a study population consisting entirely of obese patients; the rate of pap smear among those with BMI between 25 and 55 kg/m2 was 86%, compared with only 68% in those patients with BMI greater than 55.¹¹

What other aspects of obese patients’ health care is negatively impacted by a weightism bias? This bias that exists among health care professionals and may significantly affect the health of a large percentage of patients deserves attention and correction to ensure that all patients have access to quality care.

Solutions

To address weightism, physicians need to explore the mindset behind the bias and bring it into consciousness, and address some of the physical barriers inhibiting proper care of the obese.

Studies demonstrating health care provider associations of obesity with negative personality attributes suggest a component of blame may be involved. Obesity is viewed as a character flaw rather than a disease.

Many of the diseases treated by emergency physicians are consequences of a combination of genetics, socioeconomic factors, and patient choices. Blame seems to fall more heavily on the obese, however, than on other diseases with components of patient contribution, such as COPD or even overuse musculoskeletal strain. Separating the blame and the character associations from the disease process is a critical step in addressing weightism.

Identifying and labeling the bias is another essential element of reducing discrimination against the obese. This label helps validate the existence of the discrimination, a concrete step on the path to addressing and counteracting biases. Physicians should become comfortable using the label “weightism” so that this real problem receives due attention.

The significant physical challenges of caring for obese patients also must be addressed in order to prevent propagating the bias. Emergency departments can be equipped with bariatric equipment, such as specialized lifts and CT scanners with higher weight limits. Staff can also be educated regarding specialized techniques to facilitate caring for the obese, such as ultrasound-guided peripheral IV placement and lumbar puncture. Such concrete steps might help improve obese patients’ comfort level in seeking medical care and physicians’ confidence in treating these patients.

Conclusion

The bias against obese patients is real and has the potential to negatively impact a significant proportion of emergency department patients. Perpetuation of the bias against obesity is the result of our willingness to accept it. No longer should we be willing to tolerate such discrimination in our practice. Promoting sensitization and consciousness of weightism starts by acknowledging the problem and talking about it. Eliminating weightism bias in our practice will require a multifacted approach, including education of all members of the health care team and medical equipment modifications to minimize barriers and promote confidence in providing equitable care to all patients.

Dr. Baine is Chief Resident at Stanford Kaiser’s emergency medicine residency program and the EMRA representative for ACEP’s Ethics Committee and Well-Being Committee. Dr. Farley is Assistant Chair of the Department of Emergency Medicine at Christiana Care Health System, Newark, Del.; Assistant Professor at Jefferson Medical College; and president of the Delaware ACEP chapter.

References

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