Perceptions of Obesity: An Opportunity to Improve Patient Safety

A 44-year-old morbidly obese woman (body mass index [BMI] 65.8) had a sleep apnea test that was monitored by a technician on a recording system.

The technician observed that the patient had fallen out of the bed and was unable to get up. Instead of responding, the technician assisted another patient. The patient struggled for almost 10 minutes before she was able to get up by herself.

The patient went back to sleep but awoke later with a prolonged episode of coughing. Again, the technician failed to assist in a timely manner and did not help the patient remove the CPAP mask. When the patient coughed some phlegm onto the floor, the technician chastised her. The patient left after that incident, saying that the staff at the healthcare facility had not treated her with respect.

These episodes were captured on DVD as part of the sleep apnea workup. The technician was fired for his inattention and his unacceptable response to the patient.

This case illustrates an employee’s inappropriate behavior toward a patient and may also indicate a negative attitude toward obese patients. This necessitates a closer examination of attitudes.

There is a social stigma associated with being obese. Evidence supports that obese people are portrayed negatively by the media and have problems within education and employment areas. Obese people are viewed as being responsible for their condition, that weight gain and loss are within the individual’s control.1 These perceptions lead to judgments that obese individuals are lazy, passive, and lack self-discipline.2

Being overweight is classified as having a BMI of 25 to 29.9. A BMI of 30 to 39.9 is categorized as obese, and a BMI of 40 or greater is considered morbidly obese. A trend exists in the U.S. toward increasing obesity rates. According to the Centers for Disease Control and Prevention (CDC), the obesity rate in 2009–2010 was 35.7 percent for adults and 17 percent for children. The CDC also reported that every state had an increase in the prevalence of obese adults. Unfortunately, some studies indicate that obese individuals may delay seeking healthcare treatment, including preventive treatment.3

It’s likely that the negativity associated with obesity extends to the hospital setting. Studies have examined healthcare providers’ perceptions of obese patients. Nurses have described obese patients as emotionally and physically demanding. Obese patients reported more negative attitudes from the nurses caring for them compared to non-obese patients. Some studies suggest that older nurses with more experience have less negative attitudes toward obesity. More research is needed to identify nurses’ attitudes toward obese patients and how these attitudes may be related to quality patient care and outcomes. More research is needed in regard to the obese patient’s perspective on the attitudes of healthcare providers toward them.4

Another study investigated physicians’ perceptions and attitudes toward patients in an outpatient weight loss clinic. The study also collected information from the patients on their experiences at the clinic. The findings showed that physicians reported more negative attitudes toward patients with higher BMIs, and the patient responses clearly indicated that same perception. As the patient’s BMI increased, the physician’s respect for the patient decreased.5 The main concern arising from this study was the possible impact on the quality of care.

The Obesity Society offers advice to healthcare providers to help address this issue. The first step is to become aware of any personal bias against obese people. The Obesity Society recommends that healthcare providers ask themselves these questions:

  • Do I make assumptions based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?
  • Am I comfortable working with people of all shapes and sizes?
  • Do I give appropriate feedback to encourage healthful behavior change?
  • Am I sensitive to the needs and concerns of obese individuals?
  • Do I treat the individual or only the condition? 6

Answering these questions can assist healthcare providers in developing empathy and meeting the needs of obese patients. It can also help them create a positive health experience for obese patients. Here are some specific strategies that healthcare providers can use:

  1. Consider that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity.
  2. Recognize the complex etiology of obesity, and communicate this to colleagues and patients to avoid stereotypes that obesity is attributable to personal willpower.
  3. Explore all causes of presenting problems, not just weight.
  4. Recognize that many patients have tried to lose weight repeatedly.
  5. Emphasize behavior changes rather than just the number on the scale.
  6. Offer concrete advice; e.g., start an exercise program, eat at home, etc.
  7. Acknowledge the difficulty of lifestyle changes.
  8. Recognize that small weight losses can result in significant health gains.
  9. Create a supportive healthcare environment with large, armless chairs in waiting rooms, appropriately sized medical equipment and patient gowns, and friendly patient reading material. 7

Medical and nursing schools need to educate students about possible bias before they enter healthcare arenas. Current providers need to be alerted to their own possible biases. Acknowledging and understanding personal biases and attitudes can enable providers to improve the quality of care for all patients.


1.  Brown I. Nurses’ attitudes towards adult patients who are obese: literature review. J Adv Nurs. 2006;53(2):222-223.
2.  Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001 Dec;9(12):788-805.
3.  Overweight and obesity. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention website. Accessed January 9, 2013.
4.  Brown I. Nurses’ attitudes towards adult patients who are obese: literature review. J Adv Nurs. 2006;53(2):229-231.
5.  Huizinga M, Cooper L, Bleich S, Clark J, Beach M. Physician respect for patients with obesity. J Gen Intern Med. 2009;24(11):1236-1239.
6.  Obesity, bias, and stigmatization. The Obesity Society website. Accessed January 2013.
7.  Ibid.


By Jacqueline Ross, PhD, RN, Senior Clinical Analyst, Department of Patient Safety, The Doctors Company.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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