SEATTLE — The American Association of Clinical Endocrinology (AACE) has released a new consensus statement aimed at helping clinicians reduce stigma and bias around obesity.
Highlights from the statement, entitled, "Addressing stigma and bias in the diagnosis and management of patients with obesity/adiposity-based chronic disease and assessing bias and stigmatization as determinants of disease severity," were presented May 4 at the AACE Annual Meeting 2023. It will be published later this year in Endocrine Practice.
The document reiterates AACE's previous proposal to use the term "adiposity-based chronic disease (ABCD)" to refer to the spectrum of complications of obesity beyond weight. AACE has incorporated weight bias, stigmatization, psychological health, and social determinants of health into disease staging based on the degree to which these factors impair quality of life and could negatively affect treatment. Another change is the use of a scale from 1 to 3 for ABCD staging, in contrast to the previous scale from 0 to 3, as follows.
Stage 1 (previously 0): No known physical ABCD complications (for example, cardiovascular, biomechanical) but with increased risk that might be reduced by weight loss, and/or internalized weight bias and stigmatization, psychological conditions, and social determinants of health that don't have immediate adverse health effects but may require individualized care.
Stage 2 (previously 1): One or more mild–moderate ABCD complications plus increased risk of other complications and/or bias/stigma/social determinants that adversely affect quality of life or could impair ABCD treatment.
Stage 3 (previously 2): At least one severe ABCD complication plus increased risk for others, and/or bias/stigma/social determinants with pronounced adverse effects on quality of life or that interfere with weight loss treatment plans or render them harmful.
To accomplish this staging, clinicians are advised to use validated questionnaires to screen patients for the presence and degree of self-stigmatization and internalized weight bias, and to refer patients to mental health professionals for related psychological issues. The document also advises clinicians to implement practice policies such as implicit bias training and obesity education for their staff.
"I really hope that this document will increase awareness of the vicious cycle of weight bias, stigma, and internalized weight bias for patients with obesity, both on an individual basis and a bigger chronic care model basis...By utilizing these concepts in the document, we hope to at least take steps towards reducing the stigma and internalized weight bias and slowing down or reversing that vicious cycle to better care for people with a focus on their health...It's not just about a person's weight," Karl Nadolsky, DO, the statement's co-lead author, told Medscape Medical News.
The new statement builds on previous AACE efforts, including the 2014 publication entitled, "Advanced framework for a new diagnosis of obesity as a chronic disease," the 2016 management guidelines, and the 2016 position statement, which introduced the ABCD term. All are meant to advance the concept of obesity or ABCD as a medical condition, rather than a cosmetic problem or lifestyle choice.
Now, AACE is explicitly calling attention to the integral role of internal and external weight bias and stigma as both drivers and complications of the condition. The AACE writing panel adopted some of the concepts from a 2020 international consensus statement focusing on obesity stigma, Nadolsky said.
"We need to focus on health, the biopsychosocial mode. We have to think about the person as a whole. The disease of obesity is really a quintessential disease state that needs a very good holistic approach," he said.
Asked to comment, Yoni Freedhoff, MD, associate professor, Department of Family Medicine, University of Ottawa, and Medical Director of the Bariatric Medical Institute, Ottawa, Ontario, Canada, told Medscape Medical News: "I do think staging/categorization are important in the context of bias and stigma, and also to combat the notion that the goal is simple medicalization…It's good to see the consideration of internalized weight bias as part of an effort to understand the impact of obesity on an individual."
However, Freedhoff said he would have preferred that the implicit and internalized bias concepts had been incorporated into the 2009 Edmonton Obesity Staging System, which he believes is easier to use than the AACE staging system.
Freedhoff also disagrees that it was necessary to remove "0" from the staging (still present in the Edmonton system), done by AACE out of concern that people might mistakenly think it implies zero risk. "It just means no current objective or subjective impact of weight on health or quality of life," he said.
But, Nadolsky noted that data on people with "metabolically healthy obesity" suggest that "they might have zero complications but they're still at high risk, from cancer to stigma and bias, which are a cause of and consequence of obesity and should be part of the ABCD staging system."
Indeed, Freedhoff noted, "Obesity confers risk. Just like hypertension. And just like with hypertension, risk is not a guarantee of problems. But we still discuss treatment and people can be symptom- or problem-free when we start it. It can also be 'borderline' or mild. But no one gets upset about (the) idea of treating a known risk factor, or diagnosing a known risk factor, when minor, and when it's not had any impact on a person's health. That we don't do same with obesity is consequent to bias."
In addition to influencing healthcare providers and healthcare systems, the statement also concludes: "Society, including payers and policymakers, should support policies, education, research, and access to care to limit bias and stigma faced by individuals with obesity/ABCD."
Nadolsky has reported no relevant financial relationships. Freedhoff has reported working with the Bariatric Medical Institute and Constant Health, which has received a research grant from Novo Nordisk.
AACE 2023. Presented May 4, 2023.
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.
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Cite this: New AACE Statement Tries to Fight Weight Bias and Stigma - Medscape - May 04, 2023.