Amy Murlowski, BSN, RN

Challenging Weight Bias in Patient Care

Let’s start off strong. Fat Studies is a field of its own, usually found under the sociology, psychology, and gender studies umbrellas. Fat is the preferred term amongst people in this field and amongst groups who do advocacy like the National Association to Advance Fat Acceptance - who push for legal protections for fat people in employment, housing, and other situations (naafa.org, n.d.). It is preferred because obese and overweight are medical terms that pathologize weight variations, and the Fat Studies and advocacy cover both medical and social concerns. Even amongst contemporary medical literature, we have competing concepts like “the obesity paradox,” “healthy fat,” “metabolically obese normal weight.” We also see variations in ideal BMI range, like in geriatric patients, where ideal BMI is between 25 and 35 (Kıskaç, et al., 2022). In day-to-day patient interactions, I defer to patient preferred terms, or terms considered more neutral by current medical professional standards.

Why Me, Why This?

As I was discovering what fascinated me about medicine, I was also hearing story after story of people having concerns dismissed, coercive healthcare experiences, and generally poor treatment by the people they sought care from. While I do not have citable examples, First, Do No Harm is a defunct website with dozens of examples (or more) (First, Do No Harm, 2014). I also learned about how pervasive weight bias is within healthcare providers - providers spend less time with larger patients and provide less education on average, view larger patients as free game for ridicule amongst co-workers, and describe larger patients as less compliant, less intelligent, lazy, unmotivated, and worthless (Puhl & Heuer, 2009). The evidence continues to confirm substantial bias against larger patients (Laurence, et al., 2021).

This evidence and the lived experience of friends, loved ones, acquaintances, and hearing biased statements from peers fuel my ongoing passion about improving care for this population.

Where Is There Room for Innovation?

My focus for many years has been to provide an environment conducive to care of patients of all sizes- including tangible decisions like appropriate chairs, exam tables, gowns, cuffs, scales, etc., but also how weight bias affects patients emotionally, affects patient outcomes and decreases the likelihood and frequency of provider visits (Puhl & Heuer, 2009).

While conversations about weight can be appropriate, I personally focus on a general health behavior promotion model with my patients. This includes adequate sleep, stress reduction, decreasing or eliminating alcohol and nicotine usage, increasing enjoyable physical activity, and promoting beneficial dietary choices including increasing fiber, fruits and vegetables, and proteins. Ideally, improving health behaviors and diet quality results in weight loss, but we know that sleep, stress, and diet affect blood pressure, diabetes risk, and other chronic health conditions in patients of any weight.

In tracking some of the early research that influenced me, I found a 2012 powerpoint I gave on exactly these topics. I peer-to-peer educate on these and related topics, like how restrictive eating disorders are underdiagnosed and delayed in larger patients, leading to worse outcomes (Harrop, et al., 2021). I also reinforce with coworkers and educate patients on the importance of using the correct equipment- longer needles for vaccinations (Chhabria & Stanford, 2022), possible need for more chloraprep sticks in a c-section prep based on skin surface area, and accurate sizing of blood pressure cuff, including that ‘long’ blood pressure cuffs serve no clinical purpose - one manufacturer, SunTech Medical, explained “we have kept customer demand in mind by making the long sized cuff available” (Monk, 2011). I hope to focus research on this type of infrastructure in the future.

Between current advocacy around practice design, patient care, and education, and future research and leadership, I hope to influence systems level changes within my professional lifetime.

References

Adapted from a paper submitted in 2023 for the UNMC course ‘NRSG 703: Transformational Leadership’