Today I will be attending a Summit on Weight Bias at the University of Calgary, that will explore the the issue of weight-based discrimination and ways to address this – especially in health care settings.
It should come as no surprise that weight bias and discrimination are a major barrier to providing proper preventive and therapeutic health care due to the widespread attitudes and beliefs about obesity that exist amongst health professionals and decision makers.
The scientific summit, co-sponsored by the Canadian Obesity Network, Campus Alberta, and the Canadian Institutes of Health Research (CIHR), is complemented by a public Cafe Scientifique that will be held on Thursday, March 12, 7.00 at the Parkdale Community Association, 3512 – 5 Ave NW, in Calgary.
For more information and pre-registration for this free public event, which features
Leora Pinhas, MD
Child & Adolescent Psychiatrist, Physician Lead, Eating Disorders Unit, Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto
Tavis Campbell, PhD
Professor, Department of Psychology and Oncology & Director, Behavioural Medicine Laboratory, University of Calgary
Yoni Freedhoff, MD, CCFP
Medical Director, Bariatric Medical Institute, Assistant Professor, University of Ottawa
Even, if one were to limit more intense obesity management (such as behavioral, pharmacological and/or surgical treatments) to those with more severe obesity (Edmonton Obesity Staging System 2+), this would still overwhelm the capacity of existing tertiary care systems.
Thus, as William Dietz and colleagues point out in their recent article in the 2015 Lancet Obesity Series, even the majority of severe (or complicated) obesity will still need to be managed in primary care.
“Care for adults with severe obesity has generally been delivered in tertiary-care centres. Although such programmes are efficacious, they are poorly suited to address the number of patients with severe obesity. Alternative approaches for the management of adults with severe obesity include primary-care settings or community settings to deliver care.”
“Transition from efficacy to effectiveness will require substantial and challenging changes in how primary care is delivered. Practices often lack the organisational structure, such as patient registries and methods for systematic tracking to assess clinical interventions, care teams to manage patients with chronic illnesses, or health information systems that support the use of evidence-based practices at the point-of-care to provide longitudinal care for chronic illnesses.”
Where they exist, these structures are already at capacity dealing with other chronic diseases including diabetes, hypertension, COPD and other lifelong disorders.
Even if many of these problems are directly related to excess weight (or would at least substantially improve with weight loss), most primary care practitioners have yet to take on the challenge of managing obesity (not just the obese patient).
Surely enthusiasm for obesity management will increase in primary care settings as more effective obesity treatments become available – making these available to those who stand to benefit, needs to be a key priority of health care system planners and payers.
The fact that many payers chose not to cover obesity treatments by delegating this to the category of “lifestyle”, shows that they have yet to take obesity seriously as a chronic disease in its own right.
It may also demonstrates their biases and discrimination of people living obesity – after all the same payers have no problem shelling out billions of dollars to treat other “lifestyle” disorders like strokes, heart attacks, type 2 diabetes or COPD.
This is where health policies can and should make a difference to people living with obesity – the sooner, the better.
For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd.
To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here.
To register – click here.
This lack of professional training in obesity is not helped by the well known and widespread weight-bias and discrimination that is rampant amongst most health providers, administrators and policy makers (not to mention the general public).
“Weight bias by preclinical and medical students includes attitudes that patients with obesity are lazy, non-compliant with treatment, less responsive to counselling, responsible for their condition, have no willpower, and deserve to be targets of derogatory humour, even in the clinical-care environment. These biases can also lead to views that obesity treatment is futile and feelings of discomfort, which students report as a barrier to discussing weight with patients, both of which are likely to impair care.”
These attitudes have real consequences for people living with obesity,
“Providers spend less time in appointments, provide less education about health, and are more reluctant to do some screening tests in patients with obesity. Furthermore, physicians report less respect for their patients with obesity, perceive them as less adherent to medications, express less desire to help their patients, and report that treating obesity is more annoying and a greater waste of their time than is the treatment of their thinner patients”
It should come as no surprise that patients who experience these attitudes are less likely to seek medical care, even when needed,
“Among the heaviest women, 68% reported delaying use of health-care services because of their weight, due to previous experiences of disrespectful treatment from health-care providers, embarrassment about being weighed, and medical equipment that was too small for their body size.”
This not only directly harms patients but also substantially adds to the cost of the disease as the delay in diagnosis and treatment for obesity-related comorbidities can impair the quality of care for individuals with obesity.
However, these challenges are not insurmountable,
“Information about obesity that indicates contributing factors beyond personal control (eg, biological and genetic contributors) as well as the difficulties in obtaining clinically significant and sustainable weight loss, has been shown to reduce negative bias and stereotypes among preclinical and medical students and improve self efficacy for counselling patients with obesity.”
This is why the Canadian Obesity Network has made addressing weight bias and discrimination its #1 priority in all educational activities geared to health professionals and decision makers.
As long as we basing our discussion of obesity prevention and treatment on unhelpful and harmful stereotypes, we will not be helping the people who actually have the problem.
“…health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity.“
This quote, taken from the paper by William Dietz and colleagues included in the 2015 Lancet series on obesity, pretty sums up the dire state of affairs when it comes to health professionals’ ability to help people living with obesity.
While governments around the world continue to dither on prevention measures, and even if these were implemented, would take decades to substantially reduce global obesity rates (a halting in progression would already be widely considered a major success), health care systems the world around are challenged with an enormous clinical burden that will require innovative treatment and care-delivery strategies are needed.
Well, not all that innovative – after all, the very same health care systems are well versed with providing ample care for scores of other chronic diseases – obesity is just not one of them.
As Dietz points out,
“Existing shortcomings of current health-service delivery include poor teamwork, a mismatch of competencies to the needs of patients and populations, episodic rather than continuous care, and hyperspecialisation.”
In fact we don’t even know if health professionals are actually being trained for this at all,
“A scarcity of information exists for undergraduate medical education in obesity, and even less information is available for nursing and allied health professional students.”
Despite various high-sounding recommendations,
“Overall, the level of implementation of health professional education in obesity at all levels appears inadequate in several countries….The Royal Australian College of General Practitioners is the only specialist training college to include obesity in the prescribed curriculum.”
In Canada we are still licensing family physicians without any requirement to have spend even a single day in a bariatric centre. The recently released Canadian Obesity Practice Guidelines, endorsed by the Canadian College of Family Physicians, provide virtually no guidance to family doctors apart from the rather strong recommendation (based on virtually non-existent evidence) to record BMIs on all patients.
According to Dietz,
“Commonly identified areas for additional training in the care of adults with obesity include motivational interviewing, the comanagement of bariatric surgery patients, and nutrition and exercise counselling.”
Clearly, the emerging role of pharmacotherapy will add a further dimension to the need for health professional education.
None of this will happen without also addressing the stigma and bias against people presenting with excess weight continue to face in their dealing with health professionals. More on this in tomorrow’s post.