Obesity Stigma: A Newly Recognized Barrier to Comprehensive and Effective Type 2 Diabetes Management
Teixeira EM, Budd GE.
J Am Acad Nurse Pract. 2010;22:527-533
Obesity and type 2 diabetes mellitus (T2DM) are interrelated healthcare epidemics. Obesity (body mass index ≥ 30 kg/m2) affects 34% of the adult population and is associated with multiple chronic diseases. Diabetes affects 23.6 million people in the United States, and more than twice that many people have prediabetes. Obesity coexisting with T2DM is of great concern, because it accelerates the cardiovascular and diabetic processes that may result in higher morbidity and mortality. Previous research has demonstrated the benefits of lifestyle modification in reducing T2DM-associated morbidity and mortality. However, lifestyle modification can be difficult to implement when obese patients with T2DM face the antifat social attitudes common in Western culture, even from their healthcare providers.
Substantial evidence suggests that implicit and explicit negative attitudes toward obesity contribute to the stigma experienced by these patients. Stigma is defined as an attribute that is "deeply discrediting" and that reduces a person "in our minds from a whole and usual person to a tainted, discounted one" who may be excluded from many social groups or even shunned by others within the same stigmatized group. Thus, healthcare providers, society, and obese individuals themselves often share these attitudes. Negative stereotypes typically associated with obesity include a lack of willpower, laziness, ugliness, a weak will, emotional and moral instability, and being responsible or to blame for one's weight. The obesity stigma's psychological effects are destructive and pose significant barriers to diabetes care. This stigma curtails the willingness of some patients to even go to regular office visits, preventing them from getting the support they need to make difficult lifestyle changes.
Teixeira and Budd reviewed and analyzed the literature, spanning the years 1994 to 2008, that focused on the social problem of obesity stigma in the context of healthcare for patients with T2DM. Although the research in this area was limited, some conclusions and implications for practice could be formulated:
Obesity stigma can be a barrier to management of both obesity and T2DM;
Obese patients often internalize the obesity stigma, and feel responsible not only for their excessive weight but also for their diabetes;
Negative attitudes toward obesity by healthcare professionals must be confronted using self reflection and an understanding of how these attitudes affect patients; and
Nurse practitioners should examine their biases and use counseling strategies with these patients to decrease weight-related stigmatization and improve continuity of care.
Teixeira and Budd offer recommendations that may help reduce the bias perceived by patients. By implementing effective strategies to reduce weight-related bias, provider-patient relationships will be improved, leading to more effective management of both weight and diabetes in these patients.
This article should provoke some introspection by thoughtful providers. I remember an obstetrician telling me once that he didn't chastise pregnant women about their weight gain, because he learned early in his career that all it did was drive them away. This was a valuable lesson for me to learn early as a clinician. It resonated as something rooted in valid psychological reasoning as well as observed behavior.
One thing that would have made this article more comprehensive would be to consider the problem of obesity stigma in different cultures. Although Teixeria and Budd write as if obesity stigma is universal, I'm not certain that obesity stigma translates across all cultures, or means the same thing everywhere in the world or even in the United States. In some very poor cultures, being overweight may be viewed positively, because the person is seen as someone who has the money to buy food. In some cultures and younger age groups, bigger hips, legs, and breasts are valued and desired. The clinician must be sensitive to how the obesity stigma is perceived by each patient and individualize intervention strategies with respect to how obesity is discussed and managed.
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Cite this: Marilyn W. Edmunds. Is "Fat Bias" Making You Ineffective? - Medscape - Nov 24, 2010.