Overcoming Weight Bias in the Management of Patients With Diabetes and Obesity

摘要

Rising obesity rates in the past several decades have been paralleled with increasing evidence of bias, stigma, and discrimination toward individuals with obesity ( 1 ). Weight discrimination is commonly reported by Americans ( 2 ) at rates comparable to those of racial discrimination (especially in women) ( 2 , 3 ) and has increased in recent decades ( 4 ). Individuals with obesity are vulnerable to stigma and unfair treatment from multiple sources, including inequities in employment settings, educational institutions, and health care facilities, as well as in the broader society and the mass media ( 1 ), all of which can lead to negative consequences for their psychological and physical health. Several decades of evidence demonstrate consistent weight bias expressed by health care providers (HCPs), which can impair quality of care to patients with obesity and diabetes. In this brief review, we summarize evidence in these areas, discuss the importance of addressing weight bias in clinical care for patients with obesity and diabetes, and highlight the need for increased awareness of this form of bias in diabetes management. Health Consequences of Weight Bias Being the target of weight bias and discrimination can lead to numerous adverse health consequences affecting psychological, social, and physical health ( Figure 1 ). Individuals who experience weight stigma have an increased risk for depression, anxiety, low self-esteem, poor body image, substance abuse, and suicidality ( 5 – 8 ). These outcomes remain even after controlling for variables such as BMI, obesity onset, sex, and age, suggesting that psychological consequences are not associated with obesity per se, but rather with experiences of weight stigmatization ( 9 , 10 ). FIGURE 1. Health consequences resulting from experiences of weight stigma. Weight stigma also increases vulnerability to unhealthy behaviors that can contribute to weight gain and obesity ( 11 ), including increased likelihood of engaging in binge-eating behaviors, maladaptive weight control, disordered eating patterns, increased calorie intake ( 11 – 16 ), avoidance of exercise, and lower motivation for physical activity ( 17 – 19 ). Experimental studies have demonstrated increased calorie consumption after exposure to weight stigmatization among women with overweight or obesity compared to women at a lower body weight ( 15 , 20 ). These findings parallel self-report research showing that as many as 79% of women with obesity report eating food as a coping strategy to temper the distress of being stigmatized ( 21 ). Emerging evidence has additionally demonstrated heighted physiological reactivity in response to experiences of weight stigmatization, including heightened cortisol reactivity, C-reactive protein, and blood pressure ( 22 , 23 ). This evidence has relevant implications for people with diabetes, especially given research showing that weight discrimination exacerbates the harmful effects of waist-to-hip ratio on glycemic control (indexed by A1C) ( 24 ). Finally, recent longitudinal evidence has documented more direct links between perceived weight discrimination and obesity and weight gain. In a nationally representative study of >6,000 adults from the Health and Retirement Study, those who reported experiences of weight discrimination (but not other forms of discrimination) were 2.5–3 times more likely to develop obesity or maintain obesity through time compared to individuals with no experiences of weight discrimination, regardless of baseline BMI ( 25 ). In a similar study of 2,944 adults from the English Longitudinal Study of Aging, participants who reported experiencing weight discrimination had greater odds of developing obesity and increases in weight and waist circumference regardless of baseline BMI ( 26 ). Taken together, this evidence indicates that weight stigma can impair quality of life through a range of health consequences, some of which may reinforce behaviors that contribute to obesity, interfere with weight and diabetes management, and ultimately increase risk of further weight gain over time. These findings highlight the need for increased awareness among medical providers treating people with obesity and diabetes about weight bias and its adverse health consequences. Weight Bias in Clinical Care Unfortunately, negative societal weight biases against people with obesity often are shared and expressed by HCPs. Weight bias has been demonstrated among primary care providers (PCPs), endocrinologists, cardiologists, nurses, dietitians, and medical trainees, including attitudes that patients with obesity are lazy, lack self-control and willpower, personally to blame for their weight, noncompliant with treatment, and deserving targets of derogatory humor ( 27 – 33 ). A recent study of 2,284 physicians found that weight bias is as pervasive among medical doctors as it is in the general public ( 31 ). Other research shows that women with obesity view physicians