Prejudice Against Overweight Patients: An Issue To Ponder

[TheCommuter]

Weight discrimination is the treatment of someone in an unfair manner due to the person's size. Even though extremely thin individuals are occasionally treated poorly due to their size, overweight and obese people are the most frequent targets. Weight discrimination occurs in families, hiring practices, schools, places of business, the media, and healthcare settings.

Yes, I said it. I have opened the can of worms. Many healthcare professionals harbor prejudices against overweight patients. Some of these biased people are remarkable in their abilities to keep their negative feelings in the closet, while others are more vocal about their animus toward people who have excess body fat.

Some physicians are notorious for their unfavorable attitudes toward overweight patients. In 2003, researchers at the University of Pennsylvania surveyed more than 600 primary care doctors and found that more than half viewed obese patients as awkward, unattractive and noncompliant (Ulene, 2010). Furthermore, a Yale study of 2,449 overweight and obese women, published in 2006 in the journal Obesity, found that they identified doctors as one of the top sources of negative comments about their weight (Rabin, 2008).

A number of nurses are appalled by overweight patients, too. A 2006 review of research focusing on nurses' attitudes toward adult overweight and obese patients reported that nurses consistently express biased attitudes toward obese patients, reflecting common weight-based stereotypes that obese patients are lazy, lacking in self-control, and noncompliant (Puhl & Heuer, 2009).

How does weight discrimination affect patients in the healthcare setting? Well, the effects can be rather detrimental because overweight patients may avoid seeking care due to the fear of being shamed or ridiculed. Several obese patients said in interviews that they went to see a doctor only when it was unavoidable and often left feeling that they hadn't gotten the help they needed (Rabin, 2008).

Are there any solutions to the issue of prejudiced attitudes against overweight patients? First, the healthcare provider must acknowledge that they have a bias. After all, a person cannot expect to solve a problem if he/she has not yet identified one. Secondly, the healthcare professional needs to practice the interpersonal skill of being nonjudgmental. Finally, the Golden Rule is applicable when interacting with patients: treat people in the same manner that you would want to be treated.

Weight discrimination is a significant issue in healthcare settings and in society as a whole. Together we can strive for equal treatment of our overweight patient populations. Although attitudes do not change overnight, the small changes that we make can snowball into profoundly positive results.

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[tothepointeLVN, LVN]

Eating Disorder diagnoses for the obese aren't that common unless the person is seeking it out for some reason. I can't recall if I seen ED NOS on a patients chart other than a patient that has/had some variant of anorexia/bulimia that didn't fit the traditional diagnosis.

What is your professional background? Psychologist? Nurse? I'm trying to figure which discipline you belong to so I can better interpret what you are saying without getting the message crossed.

[Pets to People]

What's changed? I can offer several ideas:

1) Portion sizes are larger than they were 30+ years ago. If you're over 45, you can remember when Coca-Cola came in those six- and 8-oz bottles. That was a serving size, and no one got fat drinking a single Coke. They got fat when the Big Gulp came along.

2) We've automated activity practically out of existence. Now we have to do make-work exercises in order to get what used to come naturally with hanging laundry out to dry, chasing kids around, cleaning house, even getting up and changing the TV channel.

3) We are bombarded with ads for fatty, sweet, salty, and otherwise unhealthy foods almost every hour of the day on TV, radio, even online. When was the last time you heard the slogan "Broccoli---it's what's for dinner"?

4) At no time in human history have more foods of so many varieties been available in so many places. You may not be able to find fresh strawberries in the ghetto Safeway, but chances are they carry Mexican entrees and hot pizzas.

5) Today's fast-paced world has created a culture of stress, which in turn has led to higher rates of eating disorders, as well as other psychiatric issues that sometimes require the use of drugs that tend to increase appetite. (Sometime I'll tell you about my Zyprexa experience and the 12 lbs. I've gained in 2 1/2 weeks. Hint: the sofa is starting to look pretty tasty, and I just ate lunch a couple of hours ago.)

6) A very large segment of our population is aging....and with the years come unwelcome pounds, AKA the notorious "middle-age spread".

7) Cheap, plentiful, easily available packaged foods. Need I say more?

And lets not forget the main ingrediant in all of these new, supersized, delicious, unhealthy foods that are in our face everywhere we turn...and thats CARBS! I have been paying much more attention to this because I am looking for things without carbs for snacks and meals and....there are none! Or atleast only in the fruit and veggie and meat aisles. How sad is that? Every where I look carbs, carbs, carbs. Even the foods advertised as healthy have high sodium, high fat or still have a decent amount of carbs.

Very confusing for people who don't know what to look for and are constantly getting confused information on what is actually healthy.

[hiddencatRN, BSN, RN]

It's possible to be respectful to patients without having to be supportive of unhealthful aspects of their life. Being overweight is unhealthy. It's not the only way to be unhealthy, but I thing saying nothing and providing no education or resources on weight reduction does the patient a disservice.

I just took care of a very young (low 20's) patient who had a boil on her thigh that developed in to a pressure ulcer due to her weight. This person now needs follow-up with plastics and wound care. I've taken care of morbidly obese children, who in addition to having major health problems directly related to their weight, likely face social problems among their peers with all the psychological sequela that causes.

It is completely appropriate to tell patients that they need to lose weight. (Or quit smoking, or eat a healthier diet, or exercise, or follow up with a dermatologist about that suspicious spot on the skin). Sometimes truth is unwelcome and uncomfortable. But ignoring sensitive subjects because it might "hurt feelings" does our patients a major disservice.

[Stephalump]

Eating Disorder diagnoses for the obese aren't that common unless the person is seeking it out for some reason. I can't recall if I seen ED NOS on a patients chart other than a patient that has/had some variant of anorexia/bulimia that didn't fit the traditional diagnosis.

What is your professional background? Psychologist? Nurse? I'm trying to figure which discipline you belong to so I can better interpret what you are saying without getting the message crossed.

My background is in clinical psychology and I have a long standing affiliation with the National Eating Disorders Association - I started volunteering as a recovering bulimic when I was 19 or so.

Not talking in terms of nursing here...saw a reference to DSM and I switched over lol. I wouldn't think you'd see it frequently on a non-psych chart unless the pt is/was being treated elsewhere.

[tothepointeLVN, LVN]

No worries I slip back into shoe talk any chance I get mid nursing discussion (used to own my own dance shoe company)

What I was MOST concerned about was someone made the correlation that most obese people were "addicted" to food. To me thats insulting to people with obesity and makes light of people who DO have addiction or disordered eating issues. So I wanted to nip that in the bud.

I think that the NANDA definition is probably the best. Food Intake Imbalance : Greater than bodies requirements.

Imagine if psych illnesses were treated with tough love. "Yes well your problem is your crazy you need to try being less crazy." So simple yet so ridiculous.

As mentioned above I became obese literally overnight. It's mind boggling sometimes.

[anotherone, BSN, RN]

The only personal stories welcome on these type of threads are : thin person who admits that s/he eats a lot, by anyone's definition, 2000cal+ and never exercises. or a overweight person who has some thyroid /medication issue who RUNS `10 miles a day and is still fat etc......... never can anyone say I am fat because I EAT more calories than I should and do not exercise enough to burn them off or I am thin because I eat 1200 cals a day and exercise hours a week. Like I said before, I have been fat and thin and in between. The thin part was not easy or some genetic blessing. I exercise/d HOURS everyday, was often hungry, and ate 1200 cals OR LESS. and 1200cals comes quick- 13 chips are 120 cals, some cream and sugar for my coffee can be 90cals or more and I would have a few cups a day. The addiction view point comes from somewhere( did not pull it off the sky) and some personal experience. it exists whether it is part of DSM V or not , does not change MY VIEWS. Has anyone else not found themselves eating and eating and thinking, "hmm this is bad, i should stop " and not been able to? any feelings of comfort or euphoria after eating sweets? what if this happened not just once a year or 4-5 times a year but everyday. there is some loss of control there. Isn't that binge eating? what happens to binge eaters that don't throw up, abuse laxatives or over exercise? I think that the amount of people doing that is larger than we think becuase of under reporting and the shame associated with it.

[tothepointeLVN, LVN]

I can't even begin to read that until you edit it and put some formatting and capitalizations. Otherwise it just comes across as a string of rants.

[anotherone, BSN, RN]

I can't even begin to read that until you edit it and put some formatting and capitalizations. Otherwise it just comes across as a string of rants.

Which is what it is.

[Double-Helix, BSN, RN]

Here's an example from work today that fits this issue perfectly:

The patient was a seven year old female with a diagnosis unrelated to weight. She weighed 70 kgs (155 pounds). As a reference, the 98th percentile for a 7 year old girl is 70 pounds. The patient refused to do simple things for herself- such as help reposition herself in bed, feed herself, and wipe herself after she had a bowel movement. If I told her she had to help or had to do something for herself, she would whine and complain that she "can't do it" or she "didn't know how."

Instead, her mother would do these things for her. Her mother also brought her extra snacks and juices (mom reported the child drinks up to 64 ounces of juice per day). When the child refused to eat the meals that dietary had prescribed for her, the mother would bring her bacon and sausage, grits covered in butter, McDonald's cheeseburgers and french fries, cookies, etc. I don't think she ate a vegetable all day.

It was extremely frustrating for me to take care of the patient when the child was acting so helpless and the mother was enabling her laziness and poor eating habits. I'll freely admit that I had more than a few judgmental thoughts about the family. But what really irritated me was not that the child was morbidly obese, but the attitude that accompanied it. The weight wasn't the issue- it was the fact that the patient (in this case, the patient's mother) refused to acknowledge there was a problem or invoke change, despite education from our nutritionists.

I realize that this situation is not the child's fault. Seven year olds cannot go out and buy McDonalds themselves. They can't drink a gallon of juice per day unless someone is bringing it home for them. They don't get away with doing nothing for themselves unless someone is willing to do everything for them. So my bigger issue was with the mother, not with the child. While the child wasn't admitted for a condition directly related to her weight (but she did have a history of hypertension and obstructive sleep apnea) a good diet is very important in the management of her condition. And even though she wasn't in the hospital for a weight issue, there was no doubt that her weight was directly affecting her medical care and her recovery.

I suppose my point in all of this was that, for many people in the healthcare field, it's not the patient's weight that causes them to have prejudice or be judemental- it's the attitude of the person who is overweight. Or, it's the health care worker's repeated exposure to the attitudes that I described above that cause them to have negative associations.

Finally, even if you don't have a medical problem that's caused by being overweight, the weight can still be a factor in the management of that condition and the overall health and recovery time. A hysterectomy may not be related to weight, but a morbidly obese patient who can't get up and walk after surgery is at much greater risk for complications and much more likely to end up staying in the hospital longer or going to a SNF. So if it wrong of the gynecologist to bring up weight, even though it isn't directly related to the issue at hand?

[jadelpn, LPN, EMT-B]

I sometimes think, many obese people are addicted to food. addicted like an alcoholic or crack addicts. etc. I think because of that and the feelings of loss of self control that come with an addiction some people get defensive/angry when it is mentioned. just like in that CAGE acronym. how else can we explain the eating a whole bag of chips that don't taste that great, eating a whole pizza, etc. Not every obese/overweight person is addicted to food, i am not saying that, but I think some are. just like one can be addicted to anything.

Ah, but here's the catch....People who are addicted to drugs and alcohol when deciding to quit, can conceivably then wipe it out of their lives. (for some not easily, but they can). People can't wipe food out of their lives. People have to eat. That is the balancing act that is difficult.

[jadelpn, LPN, EMT-B]

I do find it frustrating overall that as a nurse you might hear a patient say "I had the worst day ever, I am gonna go have a few drinks" and that is an acceptable statement to a number of people. "I smoke pot to relax and 'zone out' sometimes" (or for chronic pain, or for sleep....)," I smoke cigarettes to relax" or "I need some ativan".....there's all sorts of things that patients do,(and a number of family,friends, co-workers) that we need to educate on. (educate the patients--the family, friends and co-workers get a bit testy when one tries to "educate" them...) These, unless a chronic condition, (or a keen sense of smell) are not always a visual. Patients need to share that with you in order for the nurse to be aware and educate accordingly. For people who have issues with their weight, it is an immediate visual, and often patients would not have to share a thing with a nurse, and there are sweeping generalizations. There are a number of reasons that a person can be overweight. It doesn't always mean that they are eating incorrectly, have disordered eating or don't exercise enough. Of course, it could be, but not always. With a visual, it seemingly goes right to a character assault. As nurses, I think that we need to seperate the patient's character from the issues at hand that need educating. Otherwise, we are doing a dis-service to patients.