Obesity Bias: Easy to Measure But Hard to Change

By Mara Z. Vitolins, DrPH, MPH, RD, professor and vice chair, Department of Epidemiology and Prevention, Wake Forest School of Medicine

Sonia Crandall, PhD, MS, professor, director of scholarship and research, Department of Physician Assistant Studies, and director, Medical Education Research and Scholarship, Wake Forest School of Medicine

David P. Miller, MD, MS, associate professor, Internal Medicine, Wake Forest School of Medicine

In our study, “Are Medical Students Aware of their Anti-obesity Bias,” we found that approximately 40% of medical students have an unconscious bias against obese individuals.  Bias can harm patient care by damaging trust, hindering empathy, and affecting health care providers’ treatment decisions.  Accordingly, we have been holding small group seminars with medical students rotating on the family medicine clerkship to discuss obesity bias and strategies for reducing its impact.  We have had mixed results.

During one seminar a student commented, “It is easy to lose weight, and a patient just needs to eat less and do more physical activity; being overweight is simply a lack of self-control and will power.”  This student was not alone in his belief.  Others followed with comments like “Fat people give excuses for why they are overweight and do not want to change their habits to improve their health.” and “I don’t think fat people care about themselves otherwise they wouldn’t be fat.”  Not all of the students agreed with these statements, but the discussion that followed was quite interesting, sobering, and insightful.   It is difficult to fault the students who expressed their bias, as our society supports their beliefs and glorifies the thin ideal.  Although we cannot change societal beliefs overnight, we as educators must strive to counteract this bias in our students if we are to successfully equip them to care for a condition which now affects over one-third of Americans.

We know that countless patients have heard from their health care provider, “You need to lose some weight.”  Those words are so easy to say, not so easy to put into practice, and do not reflect the amount of effort it takes to actually implement lifestyle changes.  What if a patient has already lost and gained and lost and gained weight after following different diets and is highly frustrated by his/her inability to maintain the weight loss? Everyone can lose weight, but how many can maintain the weight they have lost?  The skill that is needed is the ability to join with patients to reach a common goal.

We received funding from the National Cancer Institute to develop a comprehensive web-based medical school curriculum on obesity prevention and management.  Our completed curriculum (www.NEWLifestyle.org) includes techniques and examples of how to empathetically counsel patients about reaching a healthy weight.  We encourage students to advise patients to make one change at a time, to avoid fad diets that are difficult to sustain, and to focus on longer term health benefits of reaching a healthy weight.

We also developed a video of overweight and obese patients describing their everyday barriers and the good and bad experiences they have faced in receiving medical care.  We are currently evaluating whether this approach impacts students’ attitudes.  Our sense is that we still have work to do.  Our hope is that other medical schools and educators will also share their experiences so we may learn which approaches are most effective.

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One Comment

  1. Kemi Tomobi
    June 20, 2013 at 10:46 AM

    Thank you for sharing details about your study.  I always look forward to these discussion rounds, especially as they pertain to health professions education.  I agree that in order to help patients implement the changes we expect them to make physicians and physicians-in training need to be more empathetic.  The comments from some of the medical students in study are quite sobering and reflect the biases against obese people in society.  I liken these biases to the subconscious biases that are at the foundation of health disparities.

    Counseling and advising patients needs to be more than a “reporter-style,” or “declarative style” where the doctor just states the obvious.  I highly doubt that patients come and see the doctor solely to discover what the BMI is, how high the blood pressure is, what the Hemoglobin A1c is, or what the health status is for whatever variables the doctor is monitoring.  The patient also wants to know how to specifically go about becoming healthier, and it takes being empathetic; it also takes giving specific directions and specific steps to get a patient to make permanent changes to his or her health, and to regain the trust that was once lost in the doctor-patient relationship. 

    I hope that whatever changes being suggested in health professions education will be reflected in patient care. I also look forward to more imput from medical students as these changes are being initiated.

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