Implicit Bias Against Obesity: An Opportunity to Improve Patient Safety

Jacqueline Ross, PhD, Coding Director, Department of Patient Safety and Risk Management, The Doctors Company

A social stigma is often associated with being obese, leading to negative portrayals in the media, discrimination in the workplace, and difficulties in relationships. These societal perceptions may lead to judgments that individuals with obesity are lazy, passive, and lack self-discipline. In reality, obesity is a complex, chronic condition.¹ Because healthcare providers are not immune to outside influences, these stigmas can seep into the healthcare setting as implicit biases held by providers.

Implicit biases are unconscious, but their impact can have long-term effects. Implicit biases are involuntary and may not align with our declared beliefs. They extend past judgments and are reflected in our non-verbal cues and actions.² In healthcare, these implicit biases can impact the interactions between healthcare providers and patients and impede effective communication. Consider the following scenario.

Case Example

A 44-year-old female with severe obesity (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 from the floor.

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 recorded on video as part of the sleep apnea workup. Because of this negative experience, the patient left the facility without receiving adequate care or a complete diagnostic workup. The technician was fired for his inattention and his unacceptable response to the patient.

Obesity-Implicit Bias

The employee’s behavior toward the patient may indicate an implicit bias against patients with obesity that necessitates a closer examination.

Acknowledging the potential for obesity-implicit bias is an important step since U.S. obesity rates are increasing for all age groups. According to the Centers for Disease Control and Prevention (CDC), the 2019 prevalence of adults with obesity (a BMI of 30 to 39.9) is 42.4 percent, and the prevalence for children and adolescents between 2 and 19 years with obesity is 18.5 percent. Racial disparities in obesity also exist with Hispanics and non-Hispanic blacks having a higher obesity prevalence than non-Hispanic whites. The CDC also reported that every state had adults with obesity at greater than 20 percent of the population.³

In addition to unconscious implicit bias, explicit bias is evident among healthcare workers for patients with obesity. Explicit bias refers to the attitudes and beliefs that a person has on a conscious level. In self-reported studies physicians have characterized patients with obesity as being noncompliant, lazy, lacking in self-control, unsuccessful, and dishonest. Nurses also had self-reported descriptions that portrayed individuals with obesity as overindulgent, lazy, non-compliant and unsuccessful.⁴ Healthcare providers need to consider obesity for what it is, a chronic disease and not a character flaw.

The effects of implicit and explicit obesity bias in healthcare can be observed in various ways. Many individuals with obesity postpone seeking care or are reluctant returning to medical care based on their previous negative experiences. Patients with obesity cancel appointments more frequently or they delay making needed appointments. Patients with obesity have less time spent with the physician, as well as less intervention and discussion. Patients with obesity receive fewer preventative health services and exams. They also have less access to screening exams, like mammograms. Additionally, many people with obesity develop low self-esteem, depression, and anxiety.⁵

In regard to possible implicit weight bias, be careful in labeling individuals as “obese.” It is better to use the terms “weight problem” or “unhealthy weight” or to use people-first language such as “patient with obesity” (not “obese patient”). Many individuals with obesity have had negative experiences in the healthcare environment because of their weight. Obesity is a chronic illness. The goal is healthy, positive discussions about weight within a supportive environment.

Implicit Bias Beyond Obesity

It is important to be aware that implicit bias in healthcare extends beyond obesity. Studies have shown that implicit bias can delay diagnosis, and there is a negative correlation to quality of care.²

Healthcare providers strive to give impartial care, but this goal can be sidetracked with the unconscious perceptions or implicit stereotypes we may have of already vulnerable populations. These vulnerable populations include racial groups, drug users, socioeconomic groups, those with mental illness, sexual minorities, the elderly, individuals with obesity, children, and those with disabilities. While many healthcare providers believe they are providing fair treatment, in practice it may not be the case.

Individual practitioners should take the time to evaluate their potential biases. Utilize the free implicit bias tests (Implicit Association Tests) provided by Project Implicit. Test topics include weight, race, and gender.

For further information, see our articles, “Overview of Obesity-Related Malpractice Claims” and “Safely Caring for the Hospitalized Patient with Obesity” or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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