June/July 2020 Issue

The Untold Story of Obesity
By Lauren Harris-Pincus, MS, RDN
Today’s Dietitian
Vol. 22, No. 6, P. 28

How Weight Bias Influences Treatment, Management, and Patient Outcomes

Imagine a disease that has no specialty to manage it. Health care professionals aren’t taught how to treat it and don’t know how to get reimbursed for treating it. Patients are discriminated against for having it, and they have few treatment options. This describes the disease of obesity.

Obesity is a health issue, not a matter of willpower. Dietitians know scientifically that obesity is similar to diseases such as hypertension and dyslipidemia; yet it’s the one illness that remains socially acceptable to blame patients for having it.

The World Health Organization defines weight bias as negative attitudes toward and beliefs about others because of their weight. These negative attitudes are manifested by stereotypes and/or prejudice toward people with overweight and obesity.

Typically, people view obesity as the result of poor choices; however, it’s a highly heritable disease in which genes dominate and environmental triggers activate, and then people choose how to respond. Two types of biases corrupt the health care community’s response to obesity: intellectual bias, which favors personal convictions, and weight bias, which is directed at people with obesity. These attitudes influence not only how the general public views individuals with obesity but also how medical professionals treat them.

Causes of Obesity
Overeating doesn’t cause obesity; the disease of obesity causes overeating. Clinically, obesity is diagnosed when a practitioner determines there’s excessive fat accumulation that impairs health. Obesity, which is measured quantitatively with the use of CT, dual-energy X-ray absorptiometry, or MRI, can be estimated by biomarkers, including BMI, waist circumference or waist-to-hip ratio, and risk scores.1 In terms of etiology, there’s more than one cause; in fact, there may be several, and these are tough to pinpoint.

“If blood pressure measured with a cuff is high, you have hypertension. But there are multiple causes of high blood pressure. [Hypertension is a signal] there is something going on, but we don’t know what the underlying cause is,” says B. Gabriel Smolarz, MD, FACE, Dipl. ABOM, medical director at Novo Nordisk in Plainsboro, New Jersey. “Similarly, with obesity, a higher BMI indicates something is going on, but we need to look at the underlying causes to figure out what they are and how to address them.”

Broadly speaking, there are four main factors that play a role in the expression of obesity: genetics, environment, human behavior, and appetite signals (hormones).

Genetics
Genetics predispose certain people to obesity and determine where they are on the BMI curve. The degree to which genetics play a role in obesity is variable, ranging anywhere from 40% to 70%. Genes also determine how much environmental factors impact weight. For example, hundreds of genetic markers contribute to obesity risk. If an individual has any of these markers in their genetic makeup, certain environmental and behavioral factors may exacerbate weight gain, such as inadequate sleep, increased stress, certain medications, decreased physical activity, and endocrine disruptors.

Environment
In addition to genetics, the following environmental factors may influence weight to a lesser or greater degree:

• unavailability of fresh, healthful foods in a community;
• modern heating units and air conditioners, which can prevent the body from working hard enough to stay cool or warm;
• social environment, such as the influence of other people’s habits on one’s lifestyle; and
• use of medications such as glucocorticoids, insulin, antipsychotics, antidepressants, and sulfonylureas.

Modern environmental factors have shifted the BMI curve to the right. And while there always have been people on the high end of the BMI curve throughout history, many people have higher BMIs now than ever before.

According to the Centers for Disease Control and Prevention, in the 1960s, the mean BMI was just above 25 for men and almost 25 for women. Fast forward to 2015–2016, and the mean BMI increased to just over 29 for men and 29.6 for women.

Human Behavior
It’s common knowledge that diet quality and the quantity of food people eat and how much physical activity they get impacts the way they express weight. Sedentary lifestyles due to technology, public and personal transportation, lack of scheduled physical activity, and the loss of jobs requiring physical exertion (ie, people are sitting more often at desk jobs and for longer periods of time) add fuel to the obesity fire.

In addition, family dynamics, lack of cooking skills or access to affordable food, socioemotional factors, and mental health all significantly affect food choices. Dining out frequently with access to cheap, high-calorie foods subjects people to ingredients not present in their own kitchens. And factors such as stress and inadequate or interrupted sleep also play a role in obesity development.

Appetite Hormones
Finally, our bodies make hormones that control appetite. Leptin is a hormone made by fat cells that decreases appetite, while ghrelin is a hormone that increases appetite, signaling hunger to the brain. Our bodies are designed to preserve fat stores to help us survive in lean times—something we haven’t yet adapted to in today’s era of abundance.

In normal pathophysiology, decreases in body fat prompt the body to produce more ghrelin, sending a signal to the brain to increase eating and restore those body fat levels. However, in the pathophysiology of obesity, the body continues to produce ghrelin even with ample body fat stores, which cues hunger signals. To complicate matters, when people lose weight, ghrelin is produced, signaling hunger. This causes a vicious cycle: increased hunger and decreased satiety, leading to overeating and increased adiposity.

The nail in the coffin is the body’s metabolic reaction to weight loss. As people lose weight, the body, in its attempt to retain fat stores, becomes more energy efficient. The body is able to conserve energy during weight loss, thus requiring fewer and fewer calories to achieve weight loss and even maintain weight. This decrease in metabolic rate, combined with an increase in ghrelin and decrease in leptin, creates an internal tug of war, which is why obesity is considered a chronic disease that requires ongoing multidisciplinary care.

Weight Bias and Its Effect on People With Obesity
While these complex factors may influence obesity, many health care professionals are unaware of the intricacies, which leads many to harbor either explicit or implicit weight bias that negatively affects patient care interactions and patient health outcomes.

Explicit weight bias refers to conscious attitudes and beliefs someone has about a person or group. On the other hand, implicit weight bias is marked by unconscious attitudes and stereotypes that affect one’s understanding, actions, and decisions. While research shows that explicit bias is decreasing, implicit bias is increasing.2

According to Ted Kyle, RPh, MBA, founder of ConscienHealth, a company that works with leading health and obesity experts and organizations to develop policy and innovative approaches to addressing the obesity epidemic in North America, people don’t think about implicit bias, so individuals with obesity face the sting of weight bias every day. They experience it at work and school and even at home. They notice it from colleagues, friends, and family—it even comes from strangers, Kyle says. This bias occurs because the truth about obesity that health care providers know in their heads—that it’s a complex chronic disease—hasn’t fully penetrated their hearts, Kyle adds. As a result, clients and patients with obesity often experience decreased mental and emotional health.

The journal Nature Medicine recently published the “Joint International Consensus Statement for Ending Stigma of Obesity.” It says that “weight stigma, rather than obesity itself, may be particularly harmful to mental health and is associated with depressive symptoms, higher anxiety levels, lower self-esteem, social isolation, perceived stress, substance use, unhealthy eating, and weight-control behaviors, such as binge eating and emotional overeating. Experimental studies also show, paradoxically, that exposing individuals to weight stigma can lead to increased food intake, regardless of BMI. Correlative and randomized controlled studies also show that experience of weight stigma is linked with lower levels of physical activity, higher exercise avoidance, consumption of unhealthy diets, and increased sedentary behaviors, as well as increased obesity and weight gain over time, and increased risk of transitioning from overweight to obesity in both adults and adolescents.”3

This consensus statement supports other findings that bias and stigma harm millions of individuals with obesity and make them sicker. Only 10% of those living with obesity in the United States seek medical treatment, likely because, based on what is known from an international study, 82% of people believe weight loss is solely their responsibility.4

Because of weight bias’ negative effects on mental and emotional health, unsupervised self-care often is the only remaining option for patients with obesity, which leaves them at the mercy of misinformation, fad diets, and weight loss scams.

To make matters worse, they often deal with fat shaming. At its root, fat shaming is the implication—either explicit or implicit —that body size is the patient’s fault due to his or her own choices and suggests that people with obesity should be ashamed of their body size.

Obesity’s Link to Chronic Disease
Obesity’s impact on mental and emotional health is compounded with its link to many weight-related comorbidities and complications that impact several organ systems that can cause great patient burden and lead to increased morbidity and mortality. These comorbidities and complications include the following5:

• migraines, depression, pseudotumor cerebri, and obstructive sleep apnea;
• COPD and asthma;
• nonalcoholic fatty liver disease;
• type 2 diabetes and metabolic syndrome;
• polycystic ovarian syndrome;
• venous stasis disease;
• CVD and hypertension;
• gastroesophageal reflux disease;
• various forms of cancer;
• stress urinary incontinence;
• knee and hip osteoarthritis; and
• gout.

Steps Being Taken to Address Obesity Care
Given the mental and emotional issues and consequent morbidities associated with obesity, the health care community has taken steps in an effort to reduce weight bias and discrimination and prevalence of obesity-related complications.

Use of Person-First Language
One important step being taken in the health care community is the purposeful use of respectful language when discussing or referring to patients. Instead of calling people “obese” or using the term “obese patient,” it’s recommended to say “persons with obesity” or “patients with obesity” and to refer to obesity as a chronic disease that requires treatment.

People-first language has been widely adopted for most chronic diseases and disabilities, but not for obesity. Referring to individuals as “obese,” as opposed to “having obesity,” has been shown to negatively influence how they feel about their condition, how motivated they are to lose weight, and how likely they are to seek medical care. The Obesity Action Coalition (OAC) and other supporting organizations are calling on authors and editors of scholarly research, scientific writing, and publications about obesity to use person-first language.6

Increased Education on Obesity
Another step health care practitioners are taking to improve patient care is to deem obesity a disease process that needs ongoing treatment and management and increase access to education.

It’s common knowledge that there’s a lack of obesity care education in the current medical system, Smolarz says. In fact, less than one-fourth of physicians report feeling adequately trained to counsel patients on healthful eating and physical activity.7 But efforts have been increasing, and there are several ways doctors can bolster their education and training in obesity care. For example, Smolarz says the STOP (Strategies to Overcome and Prevent) Obesity Alliance and 20 leading health organizations have developed the first education competencies in obesity prevention and management. These competencies provide a common set of core knowledge and skills essential for optimal obesity care that can be integrated into existing education curricula, training, and practices.

One of the best ways health care providers can address their own weight biases is to first recognize they have them. Often, health care practitioners have implicit biases that are at odds with their conscious values. To determine whether they have implicit biases, the nonprofit organization Project Implicit has developed the Implicit Association Test to enable individuals to measure their weight biases.

Moreover, in a global effort to combat weight bias, OAC has joined other advocacy organizations as part of the Global Obesity Patient Alliance, a coalition of patient organizations from around the world. The goal is to ignite and inspire global change for people living with obesity. This involves reducing bias, stigma, and discrimination; elevating patients’ voices in policymaking and advocacy; and, most importantly, raising the standard of care for people with obesity.

The Debate in Dietetics
While progress is being made to improve obesity care, there are conflicting voices within the medical and dietetics community regarding obesity and weight management. Health at Every Size advocates, self-labeled antidiet dietitians, and intuitive eating proponents often are at odds with RDs who specialize in weight management and bariatrics. Many have gone so far as to accuse those helping patients lose weight of being irresponsible and claim there’s no evidence that obesity increases disease risk. Some dietitians believe body positivity and obesity treatment are mutually exclusive, which, according to Kyle, is a false dichotomy.

“Losing weight is not always the best option. Nor is it the only option for someone who is living with obesity,” he says. “There’s nothing wrong with losing weight. However, losing weight is only a part of dealing with the chronic disease of obesity. It’s not the end of the story. It’s not a cure, nor is it the only thing that good obesity care has to offer. Even after bariatric surgery, people with clinically significant obesity often don’t conform to a fictitious ‘thin ideal,’ even though their health most often is greatly improved.”

While weight loss may not always be the best answer for improving one’s health, body positivity is essential to good health, because the concept involves taking good care of the only body one has. Focusing on the principles of body positivity can be combined with respectful and complete obesity care involving shared decision making on healthful eating and physical activity recommendations, behavioral therapy, psychotherapy, pharmacotherapy, and surgery.

Current understanding of the science of obesity shows that including prescription medications as part of an individualized care plan can greatly increase the likelihood of weight loss and keeping those pounds off long term. It’s important for dietitians to understand that in someone with obesity, the body’s natural response to weight loss is to put the weight back on. That’s why weight management appears to be a constant tug of war and requires continued care.

Looking Ahead
Overall, the medical community must continue to do better to provide respectful, personalized treatment approaches for people with obesity. According to Kyle, the most important thing to bear in mind is that obesity is like any other chronic disease—it’s the result of human physiology not working the way it should.

In the case of obesity, the metabolic and homeostatic processes that govern energy balance and fat storage have gone awry. Good intentions aren’t enough to correct problems with physiology, just as they aren’t enough to manage diabetes. Evidence-based care is needed for good clinical outcomes. Supporting body positivity with compassionate weight management care can mutually coexist. It’s the dietitian’s professional responsibility to adopt the acceptable person-first terminology and increase awareness of programs and coalitions designed to advance the care and treatment of those living with obesity.

— Lauren Harris-Pincus, MS, RDN, is the author of The Protein-Packed Breakfast Club and owner of Nutrition Starring YOU, LLC, which specializes in weight management and prediabetes nutrition. Follow her on social media @LaurenPincusRD and online at www.NutritionStarringYOU.com.

References
1. Obesity and overweight. World Health Organization website. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Published March 3, 2020.

2. Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: I. long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174-192.

3. Rubino F, Puhl RM, Cummings DE, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020;26(4):485-497.

4. Kaplan LM, Golden A, Jinnett K, et al. Perceptions of barriers to effective obesity care: results from the national ACTION Study. Obesity (Silver Spring). 2018;26(1):61-69.

5. Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocr Pract. 2016;22(Suppl 3):1-203.

6. People-first language. Obesity Action Coalition website. https://www.obesityaction.org/action-through-advocacy/weight-bias/people-first-language/

7. Butsch WS, Kushner RF, Alford S, Smolarz BG. Low priority of obesity education leads to lack of medical students’ preparedness to effectively treat patients with obesity: results from the U.S. medical school obesity education curriculum benchmark study. BMC Med Educ. 2020;20(1):23.