Revised Presentation of Obesity May Reduce Internalized Bias

Fran Lowry

August 10, 2023

Presenting obesity as a chronic medical condition, rather than as a failure to eat less and move more, may improve self-esteem among patients with obesity and enhance their relationships with their doctors, a new study suggests.

In an online study, patients with obesity reported significantly less internalized weight bias and significantly enhanced perceptions of positive communication with their medical providers after watching a video of a doctor who framed obesity as a treatable medical condition, compared with a video of a doctor who emphasized willpower.

"Recent research has identified the dominant role that biology (both genetics as well as homeostatic, hedonic, and executive brain systems) and environment, rather than willpower, play in the development of obesity and the resistance to weight loss," wrote study authors Sara English, a medical student, and Michael Vallis, MD, associate professor of family medicine, both at Dalhousie University, Halifax, Nova Scotia, Canada. "Yet the false narrative that ideal or goal weight can be achieved by eating less and moving more using willpower continues to dominate the public narrative."

The findings were published July 30 in Clinical Obesity.

Medical Complexity

The public discussion generally places all responsibility for the health outcomes of obesity on the patient. As a result, patients with obesity face bias and stigma from the public and the healthcare system, wrote the authors.

This stigmatization contributes to increased mortality and morbidity by promoting maladaptive eating behaviors and stress. It also causes mistrust of healthcare professionals, which, in turn, leads to worse health outcomes and increased healthcare costs.

The 2020 Canadian clinical practice guidelines for obesity management in adults emphasize that obesity is complex and that nonbehavioral factors strongly influence it. They recommend that treatment focus on improving patient-centered health outcomes and address the root causes of obesity, instead of focusing on weight loss alone.

In the present study, English and Vallis evaluated how presenting obesity as a treatable medical condition affected participants’ internalized weight bias and their perceived relationship with their healthcare provider. They asked 61 patients with obesity (average age, 49 years; average BMI, 41) to watch two videos, the first showing a doctor endorsing the traditional "eat less, move more approach," and the second showing a doctor describing obesity as a chronic, treatable medical condition.

Nearly half (49.5%) of participants reported that their healthcare provider rarely or never discusses weight loss, and almost two thirds of participants (64%) reported feeling stigmatized by their healthcare provider because of their weight at least some of the time.

After having watched each video, participants were asked to imagine that they were being treated by the corresponding doctor and to complete two measures: the Weight Bias Internalization Scale (WBIS), which measures the degree to which a respondent believes the negative stereotypes about obese people, and the Patient-Health Care Provider Communication Scale (PHCPCS), which assesses the quality of patient-healthcare provider communication.

Virtually all participants preferred the care provider in the video with the revised presentation of obesity. Only one preferred the traditional video. The video with the revised presentation was associated with significant reductions in internalized weight bias. Participants' WBIS total score decreased from 4.49 to 3.36 (P < .001). The revised narrative video also had a positive effect on patients' perception of their healthcare providers. The PHCPCS total score increased from 2.65 to 4.20 (P < .001).

A Chronic Disease

Commenting on the study for Medscape Medical News, Yoni Freedhoff, MD, associate professor of family medicine at the University of Ottawa, Ottawa, Ontario, Canada, said, "If you’re asking me if it is a good idea to treat obesity like a chronic disease, the answer would be yes, we absolutely should. It is a chronic disease, and it shouldn’t have a treatment paradigm different from the other chronic diseases." Freedhoff did not participate in the study.

Dr Yoni Freedhoff

"We certainly don’t blame patients for having other chronic conditions," Freedhoff added. "We don’t have a narrative that, in order for them to qualify for medication or other treatment options, they have to audition for them by failing lifestyle approaches first. And yet, I’d say at least 85% of chronic noncommunicable diseases have lifestyle factors, but obesity is the only one where we consider that there is a necessity for these lifestyle changes, as if there have been studies demonstrating durable and reproducible outcomes for lifestyle in obesity. There have not." 

Telling patients and doctors that obesity is a chronic disease driven by biology, not a failure of willpower, is going to reduce stigma, "which is what this study was able to demonstrate to some degree," Freedhoff said.

"What is more stigmatizing? Being told that if you just try hard enough, you’ll succeed, and if you don’t succeed, the corollary, of course, is that you did not try hard enough? Versus, you’ve got a medical condition where you’ve got biological drivers beyond your locus of control, affecting behaviors that, in turn, contribute to your adiposity? I’m pretty sure the second statement will have far less impact on a person’s internalized weight bias than what we’ve unfortunately been doing up until now with the focus on willpower," Freedhoff said.

No funding for the study was reported. English and Vallis reported no relevant financial relationships. Freedhoff reported that he receives clinical grants from NovoNordisk.

Clin Obes. Published July 30, 2023. Full text.

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