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Confronting Weight Stigma in Obesity Care, with Scott Kahan, MD, MPH

Scott Kahan, MD, MPH, discusses the concept of weight stigma, its historical impact, and avenues for confronting weight stigma that currently exists in clinical care settings.

When the words bias and stigma are brought up in medicine, they often refer to disparities related to the racial- or gender-based differences in care for patients. At the Association of Diabetes Care and Education Specialists (ADCES) 2022 annual meeting, a presentation by Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness, took aim at addressing weight stigma and the impact it can have on patients as well as their ability to meet treatment goals.

According to the National Eating Disorders Association, weight stigma, also known as weight bias or weight-based discrimination, is defined as discrimination or stereotyping based on a person’s weight. With an interest in learning more about the history of weight stigma versus the current landscape and how a new emphasis on patient-first language in diabetes management may influence the fight to eliminate weight stigma in clinical care settings, Endocrinology Network reached out to Kahan, and that conversation is the subject of the following Q&A.

Understanding Weight Stigma, with Scott Kahan, MD, MPH

Endocrinology Network: Can you describe the origins of weight stigma and how it impacts patients today?

Kahan: So, at the most basic level, weight stigma is driven by assumptions, and often judgments, about people based on their appearance. That goes back forever, because in Western societies and, in particular, in the US, there is just so much judgment about people based on appearance and weight is one of those areas that tends to be judged. Studies on weight stigma started in the mid-20th century, but really increased over the last 20-30 years.

We have been making real progress. Unfortunately, not nearly enough. The progress has largely been made in terms of minimizing explicit weight stigma, like just yelling out at somebody: "You're such a fat slob!". Or something like that. We don't see that nearly as much as we used to, but implicit weight stigma, which is much more subtle. Things where we make assumptions and have various beliefs about people that are, again, driven by their weight. Whether it is about their intelligence or whether about their likelihood to be compliant with medical recommendations. Those are quite common and even ubiquitous. That's something that we haven't made all that much progress on.

Endocrinology Network: How difficult is addressing weight stigma in clinical practice?

Kahan: It doesn't have to be as difficult as it seems. Ultimately, what we want to communicate to patients is that we care about them and we want to help them to live healthy lives as well as to be able to participate in their lives and not be limited. Whether by their weight and weight problems, like diabetes, and, certainly, not to be limited by experiencing weight stigma, the important thing to get across to patients is to communicate that gaining a lot of weight is not a healthy thing, to communicate those healthful behaviors will improve their lives, their enjoyment of their lives, and their quality of life. Typically, this is done without words—it's done in the tone of our voice and it's done in the way we interact with them. But let them know that carrying excess weight doesn't make them a bad person, nor does losing weight make them a good person. We want to separate the condition and the behaviors from the value of the person itself.

Endocrinology Network: How does use of patient-first language in diabetes and obesity management help reduce weight stigma?

Kahan: So, I certainly think there's a lot of overlap. In some ways, the use of patient-first language in obesity is following on the heels of the use of patient-first language in diabetes. The focus on that started earlier in the field of diabetes. It didn't start with diabetes, there's plenty of other areas that we were it's now second nature to us people first language.

For example, we don't call people with depression, depressives. It's just it's not natural and, largely, I think in diabetes we've made a lot of progress. It's not common anymore to call people with diabetes, diabetics. We're quite at the early stages of imparting the importance of using people-first language in obesity. So, we'll see where that goes.

I think it's a very important thing, in part, because it's a really easy thing. There are a lot of things that take time and money and effort. This is not one of them. It takes just a little bit of attention and a little bit of practice. It's nothing off our shoulders to utilize people first language and it makes a difference. No one likes to be called obese, let alone morbidly. So, there are plenty of studies showing that the terminologies we use can be more or less motivating for patients. It's a subtle thing, but it's an important thing and a valuable thing for all clinicians to consider when they interact with their patients.

Editor's note: This transcript has been edited for length and clarity.