Patient Barriers to Obesity CareWednesday, January 13, 2021
In yesterday’s post I discussed some of the policy barriers one must consider when setting up an obesity program. As important, are barriers that arise from the beliefs and misconceptions as well as the shame and internalised stigma commonly present in people living with obesity.
For one, research (e.g. the ACTION Study) shows that although most people living with obesity are well aware of the potential health implications of excess weight and are largely open to the notion that obesity is a chronic disease, they generally do not seek professional help from their doctors or other health care providers, as they would for other health conditions (e.g. hypertension or diabetes). Rather, they tend to try to tackle the problem on their own, often turning to fad diets or weight-loss programs and products offered by the commercial weight-loss industry. Although most people living with obesity state that they know what to do (namely, eat-less-move-more) and believe weight to be under their control, they rarely experience long-term success in maintaining weight loss.
There are several factors that explain this behaviour. For one, the message that the root cause of obesity is simply eating too much and not moving enough is so pervasive, that trying to manage weight simply by eat less and exercising more appears to be the obvious solution. This message is of course amplified both by public health messages and by the commercial weight-loss industry that directly benefits from this simplistic notion of what causes obesity and how to manage it. The commercial weight-loss industry spends millions of marketing dollars to reinforce this message with their anecdotal “before-and-after” success stories and promises of simple and ever-lasting weight-loss whilst promoting unrealistic weight-loss expectations by anchoring the magnitude of weight loss to outliers (results not typical!) rather than the average client (never mind the lack of prospective long-term RCTs or ITT analyses).
Perhaps an even more important factor is the shame and self-blame together with internalised weight bias that prevents people with obesity from reaching out to health professionals. After all, if I am convinced that I only have myself to blame, know what to do (just eat-less-move-more), and simply seem to lack the motivation or will-power to do what is necessary, why would I expect my doctor to be of much help. Indeed, what is my health professional going to tell me that I don’t already know? So I’d much rather avoid the embarrassment of even bringing up this topic in my doctor’s office.
Unfortunately, in the instances, where people living with obesity have indeed reached out to their doctors or other health professionals, their experience has often not been a positive one. If anything, they are likely to come away with little more than the recommendation to try even harder and not give up. This of course lies in the fact that the vast majority of health professionals have little more than a layman’s understanding of obesity and the complex biology of body-weight regulation and have never been trained in obesity assessment or management. These past negative experiences can thus be a major barrier in patients seeking help from an obesity clinic.
However, even when patients manage to locate a health professional who understands and has experience in evidence-based obesity management, they may not be happy with what they hear. Thus, they may well go to an obesity clinic expecting sophisticated endocrinological or other medical assessments to get to the root of the problem and may be disappointed to learn that such tests rarely reveal treatable medical conditions that account for their weight gain. Or they may simply be looking for diet and exercise plans and are surprised that their doctor would rather talk about their mental health, relationship issues, or even past-trauma. There are many who may not fully appreciate any suggestion that they could perhaps benefit from obesity treatments such as anti-obesity medications or surgery, which carries apprehension and stigma of their own (in addition to not having access to such treatments due to lack of coverage). Many patients are also deeply disappointed and often disillusioned when they are told that their weight-loss expectations may be highly unrealistic in the long-term and that we don’t really have a “cure” for their condition.
Lastly, we cannot ignore that there may well be a perceived stigma of going to an obesity clinic – this is not something you would wish to share even with your closest friends or colleagues. Somehow, going to a gym or following the next fad diet appears far more socially acceptable than seeking obesity treatment from a medical professional.
All of these “patient” barriers need to be considered when setting up a program in order to anticipate why patients may or may not flock to a program, or give it a poor rating, even when it is offered and provided with the best of intentions and based on the best evidence.