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Obesity discrimination in healthcare
EJINME-03663; No of Pages 2 European Journal of Internal Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Obesity discrimination in healthcare
Keywords: Healthcare Obesity Weight management
Existence of prejudice and discrimination in the society is not new. All societies have histories of discrimination in one form or the other, with the weak, the less powerful, or the minorities being made the scapegoats. Recognition of these prejudices has led to a decrease in the unfair treatment of vulnerable individuals on the basis of gender, sexual orientation, race, religion, colour, nationality, socioeconomic status, age, physical or mental disabilities, or disease. Discriminations in the form of jokes, fewer chances of employment, less pay with more work hours, or derogatory remarks are looked down upon in many societies. Healthcare centres should be free from discrimination and provide equal care for all patients. Many countries have laws to protect the patients and ensure equal benefits. Prejudices exist in the minds of patients also, as many patients prefer physicians of specific gender, race, religion, or nationality. An agenda for the elimination of all forms of discrimination in healthcare was setup by UNAIDS (a United Nations program on human immunodeficiency virus and acquired immune deficiency syndrome) and the World Health Organization's Global Health Workforce Alliance. On 1st December 2013, UNAIDS launched its Zero Discrimination Campaign. The first Zero Discrimination Day was celebrated by the UN on 1st March 2014 [1]. Most people are not aware about the discrimination against the obese. Obese children are exposed to teasing and bullying by peers [2] and stigmatization continues into adult years with negative stereotypes like lazy, unattractive, weak-willed, unsuccessful, and unintelligent being associated with the obese [3]. Many people, including physicians, believe teasing or criticism will motivate such patients to lose weight, unaware that negative experiences compel people to eat more and further increase their weight, establishing a vicious cycle [4]. Although most adults do not inflict pain deliberately, the obese are considered a legitimate target for overt expression of ridicule. Anti-obese attitude has pervaded healthcare, is compromising the care of overweight and obese patients, and is still not recognized as discrimination by most healthcare workers. The anti-obese environment in healthcare centres is apparent form the infrastructure (narrow doors, small chairs with arm rests), medical equipment (small hospital gowns, blood pressure cuffs and stretchers, weighing scales unable to record weight more than 300 lb, small size of CT/MRI scanners) [5], as well as behaviour of the healthcare providers (insistence on weight measurement on every visit, assumptions that the patient is unaware of his/her weight problem, is having every health problem due to the extra weight, is less intelligent and non-compliant, and has not tried to reduce weight). This results in shorter counselling
time and reluctance to physically examine the patient or perform surgical procedures [6]. Fat people also suffer during treatment as data regarding dosage of medicines is often confined to normal weight persons [7]. Many obese patients dread hospital visits due to implicit or explicit discrimination, especially if they have not been able to reduce their weight as per the physician's advice [6]. The number of obese people is increasing throughout the world. If the present rate of increase in the incidence of obesity continues, 18% men and 21% women will be obese by 2025, while 6% men and 9% women will be severely obese [8]. Medical consequences of obesity are [9]: • Psychological: stigma of obesity leading to depression, bullying tendency, decreased social interaction; • Physical: osteoarthritis, sleep apnoea, stretch marks, acanthosis nigricans; • Metabolic: diabetes mellitus, diseases of the liver and kidney, hypertension, cardiovascular diseases, and some forms of cancer.
These facts suggest there are high chances of healthcare centre visits by the overweight or obese, and it would be unfair to provide suboptimal care to these patients. Obesity is a multifactorial condition. About 250 quantitative trait loci for different obesity-related phenotypes have been reported responsible for the monogenic, syndromic, and polygenic obesity. Epigenetic modifications are also involved. Hormonal, psychological, life-style related causes, and obesogenic environment are also responsible for obesity. Some people are more sensitive to their environment - they are more influenced by food advertisements or adopt unhealthy eating habits in response to mental stress. Such personality types may be classified as obesogenic personalities. The first step to reduce weight bias is to recognize its existence. Biased attitudes can occur with or without conscious awareness. Education tools provided by The Rudd Center for Food Policy and Obesity help recognize negative attitudes [10]. The governments of all developed and developing countries should realize that the obesity epidemic is here to stay. Infrastructure and equipment of the healthcare facilities should be able to accommodate severe obesity. Continuous medical education programs should be compulsory for health providers to reduce the anti-fat prejudice. Anti-obesity attitudes encountered in the medical and nursing students [11] can be addressed during the classes by the teachers and physicians to produce a more empathetic generation of healthcare providers. Conflicting and competing interests None. Funding None.
http://dx.doi.org/10.1016/j.ejim.2017.09.006 0953-6205/© 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Saxena I, Kumar M, Obesity discrimination in healthcare, Eur J Intern Med (2017), http://dx.doi.org/10.1016/ j.ejim.2017.09.006
2
Letter to the Editor
References [1] https://www.timeanddate.com/holidays/un/zero-discrimination-day. [2] van Geel M, Vedder P, Tanilon J. Are overweight and obese youths more often bullied by their peers? A meta-analysis on the relation between weight status and bullying. Int J Obes 2014;38:1263–7. [3] Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health 2010;100(6):1019–28. [4] Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity 2014;22:2485–8. [5] Gardner LA. Class III obese patients: is your hospital equipped to address their needs? Pa Patient Saf Advis 2013;10(1):11–8. [6] Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015;16: 319–26. [7] Pai MP. Drug dosing based on weight and body surface area: mathematical assumptions and limitations in obese adults. Pharmacotherapy 2012;32(9): 856–68. [8] NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet 2016;387:1377–96.
[9] Pi-Sunyer X. The medical risks of obesity. Postgrad Med 2009;121:21–33. [10] http://www.uconnruddcenter.org/weight-bias-stigma. [11] Phelan SM, Burgess DJ, Burke SE, et al. Beliefs about the causes of obesity in a national sample of 4th year medical students. Patient Educ Couns 2015;8:1446–9.
Indu Saxena* Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India Corresponding author. E-mail addresses: [email protected], [email protected]. Manoj Kumar Department of Physiology, TS Misra Medical College, Lucknow 226008, Uttar Pradesh, India 26 August 2017 Available online xxxx
Please cite this article as: Saxena I, Kumar M, Obesity discrimination in healthcare, Eur J Intern Med (2017), http://dx.doi.org/10.1016/ j.ejim.2017.09.006
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Obesity discrimination in healthcare
Keywords: Healthcare Obesity Weight management
Existence of prejudice and discrimination in the society is not new. All societies have histories of discrimination in one form or the other, with the weak, the less powerful, or the minorities being made the scapegoats. Recognition of these prejudices has led to a decrease in the unfair treatment of vulnerable individuals on the basis of gender, sexual orientation, race, religion, colour, nationality, socioeconomic status, age, physical or mental disabilities, or disease. Discriminations in the form of jokes, fewer chances of employment, less pay with more work hours, or derogatory remarks are looked down upon in many societies. Healthcare centres should be free from discrimination and provide equal care for all patients. Many countries have laws to protect the patients and ensure equal benefits. Prejudices exist in the minds of patients also, as many patients prefer physicians of specific gender, race, religion, or nationality. An agenda for the elimination of all forms of discrimination in healthcare was setup by UNAIDS (a United Nations program on human immunodeficiency virus and acquired immune deficiency syndrome) and the World Health Organization's Global Health Workforce Alliance. On 1st December 2013, UNAIDS launched its Zero Discrimination Campaign. The first Zero Discrimination Day was celebrated by the UN on 1st March 2014 [1]. Most people are not aware about the discrimination against the obese. Obese children are exposed to teasing and bullying by peers [2] and stigmatization continues into adult years with negative stereotypes like lazy, unattractive, weak-willed, unsuccessful, and unintelligent being associated with the obese [3]. Many people, including physicians, believe teasing or criticism will motivate such patients to lose weight, unaware that negative experiences compel people to eat more and further increase their weight, establishing a vicious cycle [4]. Although most adults do not inflict pain deliberately, the obese are considered a legitimate target for overt expression of ridicule. Anti-obese attitude has pervaded healthcare, is compromising the care of overweight and obese patients, and is still not recognized as discrimination by most healthcare workers. The anti-obese environment in healthcare centres is apparent form the infrastructure (narrow doors, small chairs with arm rests), medical equipment (small hospital gowns, blood pressure cuffs and stretchers, weighing scales unable to record weight more than 300 lb, small size of CT/MRI scanners) [5], as well as behaviour of the healthcare providers (insistence on weight measurement on every visit, assumptions that the patient is unaware of his/her weight problem, is having every health problem due to the extra weight, is less intelligent and non-compliant, and has not tried to reduce weight). This results in shorter counselling
time and reluctance to physically examine the patient or perform surgical procedures [6]. Fat people also suffer during treatment as data regarding dosage of medicines is often confined to normal weight persons [7]. Many obese patients dread hospital visits due to implicit or explicit discrimination, especially if they have not been able to reduce their weight as per the physician's advice [6]. The number of obese people is increasing throughout the world. If the present rate of increase in the incidence of obesity continues, 18% men and 21% women will be obese by 2025, while 6% men and 9% women will be severely obese [8]. Medical consequences of obesity are [9]: • Psychological: stigma of obesity leading to depression, bullying tendency, decreased social interaction; • Physical: osteoarthritis, sleep apnoea, stretch marks, acanthosis nigricans; • Metabolic: diabetes mellitus, diseases of the liver and kidney, hypertension, cardiovascular diseases, and some forms of cancer.
These facts suggest there are high chances of healthcare centre visits by the overweight or obese, and it would be unfair to provide suboptimal care to these patients. Obesity is a multifactorial condition. About 250 quantitative trait loci for different obesity-related phenotypes have been reported responsible for the monogenic, syndromic, and polygenic obesity. Epigenetic modifications are also involved. Hormonal, psychological, life-style related causes, and obesogenic environment are also responsible for obesity. Some people are more sensitive to their environment - they are more influenced by food advertisements or adopt unhealthy eating habits in response to mental stress. Such personality types may be classified as obesogenic personalities. The first step to reduce weight bias is to recognize its existence. Biased attitudes can occur with or without conscious awareness. Education tools provided by The Rudd Center for Food Policy and Obesity help recognize negative attitudes [10]. The governments of all developed and developing countries should realize that the obesity epidemic is here to stay. Infrastructure and equipment of the healthcare facilities should be able to accommodate severe obesity. Continuous medical education programs should be compulsory for health providers to reduce the anti-fat prejudice. Anti-obesity attitudes encountered in the medical and nursing students [11] can be addressed during the classes by the teachers and physicians to produce a more empathetic generation of healthcare providers. Conflicting and competing interests None. Funding None.
http://dx.doi.org/10.1016/j.ejim.2017.09.006 0953-6205/© 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Saxena I, Kumar M, Obesity discrimination in healthcare, Eur J Intern Med (2017), http://dx.doi.org/10.1016/ j.ejim.2017.09.006
2
Letter to the Editor
References [1] https://www.timeanddate.com/holidays/un/zero-discrimination-day. [2] van Geel M, Vedder P, Tanilon J. Are overweight and obese youths more often bullied by their peers? A meta-analysis on the relation between weight status and bullying. Int J Obes 2014;38:1263–7. [3] Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health 2010;100(6):1019–28. [4] Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity 2014;22:2485–8. [5] Gardner LA. Class III obese patients: is your hospital equipped to address their needs? Pa Patient Saf Advis 2013;10(1):11–8. [6] Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015;16: 319–26. [7] Pai MP. Drug dosing based on weight and body surface area: mathematical assumptions and limitations in obese adults. Pharmacotherapy 2012;32(9): 856–68. [8] NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet 2016;387:1377–96.
[9] Pi-Sunyer X. The medical risks of obesity. Postgrad Med 2009;121:21–33. [10] http://www.uconnruddcenter.org/weight-bias-stigma. [11] Phelan SM, Burgess DJ, Burke SE, et al. Beliefs about the causes of obesity in a national sample of 4th year medical students. Patient Educ Couns 2015;8:1446–9.
Indu Saxena* Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India Corresponding author. E-mail addresses: [email protected], [email protected]. Manoj Kumar Department of Physiology, TS Misra Medical College, Lucknow 226008, Uttar Pradesh, India 26 August 2017 Available online xxxx
Please cite this article as: Saxena I, Kumar M, Obesity discrimination in healthcare, Eur J Intern Med (2017), http://dx.doi.org/10.1016/ j.ejim.2017.09.006