CAMERON IS A clinical nurse working in an outpatient cardiology clinic. The interprofessional care team frequently discusses the best approach to patient education on a heart-healthy lifestyle. Several staff members have expressed concern about not being able to help patients meet weight-loss goals, and they believe that patients are often working against their own best interests when it comes to diet and exercise. “I know there is a lot of research to show that obesity causes health problems and makes many conditions worse,” Cameron says, “but many patients just don't want to hear it. How do I respect the patient's right to autonomy and still meet my ethical obligation as a nurse to provide the best care? I know we have so many patients who would feel and do better if they lost weight.”
Nurses and other healthcare professionals may feel frustrated when a patient's choices seem contradictory to achieving the best outcomes, despite believing that patients should be considered experts of their own bodies and supported in their decisions. Often this stems from what we have learned from research about modifiable factors related to health and wellness. We want to share this knowledge with our patients and assist them in meeting their goals. Provision 7 of the American Nurses Association Code of Ethics specifically requires that nurses incorporate evidence and research as a component of practice.1
Although we have a great deal of research about obesity and its adverse effects on health, that is only half of the story. An expanding public discussion questions what we know—and what we think we know—about obesity and health. Short-term weight loss is achievable, but many diets do not work in the long run. A growing body of literature documents that our “best intentions” may cause additional harm.
Nurses must be aware of all aspects of available research in order to be truly informed by the best and most comprehensive evidence and meet their ethical obligations to patients. This article examines the evidence and discusses how nurses may unintentionally use evidence incorrectly when it comes to obesity, health promotion, and disease prevention.
The myth of individual choice
Although excess body weight results from consuming more calories than expended through physical activity, advances in science suggest the reality is much more complicated. Some people have a genetic predisposition to obesity.2 Others may live in neighborhoods where it is difficult to buy nutritious food (known as a food desert) or where there is a high concentration of junk food (known as a food swamp).3 Chemicals in the environment and bacteria in the gut also may play a role.4 Family environment and childhood experiences may be related to body weight in adulthood. Certain illnesses and medications cause weight gain, and metabolism slows with aging. Clearly, body weight is regulated by a complex interplay of behavioral, environmental, biological, and genetic factors.5 Yet evidence suggests that nurses and other healthcare providers may be holding on to the outdated notion that individual behavior causes obesity. Nurses may embrace public health messages based on a model of “calories in, calories out.”6 This can inadvertently reinforce the notion that individuals are responsible for their weight gain and can reverse it simply by choosing to eat less and exercise more.
Not paying attention to long-term outcomes
When a patient presents with a condition that could benefit from a reduction in weight, the first thought is usually to “go on a diet.” Cameron says that patients “don't want to hear it,” which is likely not the case; rather, they have probably heard the oversimplified message to “lose weight” many times. The right to self-determination demands that nurses provide patients with accurate, complete, and understandable information to facilitate individual decision-making.
Hundreds of studies have tested diets, and many have shown a clear and demonstrable effect on short-term weight loss. However, there is just as much compelling evidence showing that the people on those same diets frequently regain the weight.7 Even when specific interventions are employed to maintain loss, the long-term effect is minimal.8 Advice and guidance from healthcare providers that is focused on weight loss must include the caveat that maintaining weight loss is often more difficult than the diet itself. Nurses have an ethical obligation to tell patients that the “treatment” is not as simple as it sounds and there is no “cure” for obesity. Also, what works for one person might not work for another, so well-intentioned advice can potentially create a scenario where some patients are destined to fail.
Many dieting messages in our culture are not about helping people, but commerce. In 2018, the dieting industry in the US was estimated to be worth over $68 million.9 Companies selling weight loss want to create a strong customer base, and they can do that by encouraging dissatisfaction and promoting products that provide short-term success and long-term failure. The ubiquity of consumer-oriented dieting messages (often disguised as “wellness” or “clean eating”) can easily reinforce commonly held beliefs about weight loss and social expectations. Healthcare providers have an obligation to help patients navigate the marketing hype while debunking pseudoscience and the latest fad diets.
Ignoring evidence has unintended consequences
Nurses must provide care that respects the inherent dignity and worth of every patient, which means care that is free from bias or prejudice.1 Obesity is not only associated with serious comorbidities such as diabetes and heart disease, but also equally serious outcomes such as stigma and discrimination.10
One common stereotype is that people who live in larger bodies are to blame for their weight problems, and they are lazy, undisciplined, noncompliant, unintelligent, sloppy, and gluttonous.11 These misconceptions—whether explicit or subtle—can lead to bias in healthcare and interfere with effective multidisciplinary care.11 Patients often report feeling disrespected, blamed, embarrassed, and upset, leaving some who are struggling with their weight to avoid seeking care. Well-intentioned public health messages that simplify and contribute to the stigma are not only ineffective but counter-productive; research shows that they interfere with interventions meant to encourage weight reduction.12
When individuals internalize these destructive messages, their efforts at weight management may be thwarted, and other aspects of their health are put in jeopardy. The effects of internalized bias can range from chronic dieting to overeating.13 Internalized bias can also contribute to decreased quality of life, poor body image, and depression.14-16 Nurses must take deliberate actions to address weight bias if they are to work collaboratively with patients to help them with their health goals.
Approaching conversations about weight
Nurses must work with patients in a way that creates trust, allows for well-informed decision-making, and respects the dignity and worth of every patient. To begin, consider these steps:
- Reflect on your own stereotypes. What do you think and feel when you care for individuals of different sizes and shapes? What are your automatic thoughts and assumptions? How might these play out at work? How do you feel about your own weight and what it says about you? Acknowledging your own bias will help you recognize potentially stigmatizing approaches to care.
- Do not presume that you have the right to initiate a discussion about weight loss. Educate yourself and be ready to provide accurate information in a nonjudgmental way. Realize that body weight may be a sensitive topic; avoid placing blame on the patient. Obesity is a complex disease and evidence-based treatments are available, including diet, pharmacotherapy, and bariatric surgery, but there is no cure. After evaluating individual risk and benefits, some patients may wish to try more intensive treatments, others may not.
- Pay attention to your language and choose your words carefully. Use terms such as weight or body mass index (BMI) rather than ideal weight.17 Height-weight charts can be based on outdated actuarial data, and the term ideal weight can convey a subjective judgment of perfection rather than a neutral concept of health risk. Even the term overweight may imply that there is a desirable or “normal” weight and anything else is abnormal. Although the term obese is frequently used in healthcare and research, often it carries strong negative connotations. BMI categories are based on increasing risks for disorders such as coronary artery disease and type 2 diabetes, so they are not perfect and do not take into consideration other health risks such as waist circumference or smoking status. Understanding and using patients' preferred terms may help start a conversation and improve clinical interactions.
- When talking with patients about their health and managing conditions that may have a connection to weight, ask yourself, “What would I say to a patient who was living in a smaller body?” Make sure you provide the same information to every patient. Your patients have the right to make informed choices based on the best available evidence.
- Meet your patients where they are in terms of readiness to change behavior. Some may be thinking about making lifestyle changes and others may not. Even when well intentioned, your conversation can stigmatize rather than motivate.18 For example, one patient may have decided that lifestyle changes have been ineffective and is ready to try a more intensive intervention such as bariatric surgery. If the patient has difficulty accessing accurate information about it or feels criticized for pursing a “quick fix,” this could be stigmatizing. On the other hand, a patient who is not ready for surgery might feel stigmatized if pressured to learn more about it.
- Learn more about what works—and what does not. For information on weight bias and stigma, visit the UConn Rudd Center for Food Policy and Obesity at www.uconnruddcenter.org/weight-bias-stigma and the American Association of Nurse Practitioners at www.aanp.org/practice/clinical-resources-for-nps/clinical-resources-by-therapeutic-area/obesity-and-weight-management.
Representing the complete picture
Patients have the right to make their own decisions about their health, and nurses must respect those decisions. Cameron is right to think that ethical practice includes a commitment to using research to guide decision-making. Healthcare providers have an ethical obligation to use an approach that represents the complete picture, including newer information that challenges conventional wisdom.
1. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements
. Silver Spring, MD: American Nurses Association; 2015.
2. Goodarzi MO. Genetics of obesity: what genetic association studies have taught us about the biology of obesity and its complications. Lancet Diabetes Endocrinol
3. Cooksey-Stowers K, Schwartz MB, Brownell KD. Food swamps predict obesity rates better than food deserts in the United States. Int J Environ Res Public Health
4. Menni C, Jackson MA, Pallister T, Steves CJ, Spector TD, Valdes AM. Gut microbiome diversity and high-fibre intake are related to lower long-term weight gain. Int J Obes (Lond)
5. McCaffery JM. Precision behavioral medicine: implications of genetic and genomic discoveries for behavioral weight loss treatment. Am Psychol
6. Hafekost K, Lawrence D, Mitrou F, O'Sullivan TA, Zubrick SR. Tackling overweight and obesity: does the public health message match the science. BMC Med
7. Dulloo AG, Montani JP. Pathways from dieting to weight regain, to obesity and to the metabolic syndrome: an overview. Obes Rev
. 2015;16(suppl 1):1–6.
8. Dombrowski SU, Knittle K, Avenell A, Araújo-Soares V, Sniehotta FF. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. BMJ
10. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring)
11. Puhl RM, Latner JD, O'Brien K, Luedicke J, Danielsdottir S, Forhan M. A multinational examination of weight bias: predictors of anti-fat attitudes across four countries. Int J Obes (Lond)
12. Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health
13. Ashmore JA, Friedman KE, Reichmann SK, Musante GJ. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eat Behav
14. Palmeira L, Pinto-Gouveia J, Cunha M. The role of weight self-stigma on the quality of life of women with overweight and obesity: a multi-group comparison between binge eaters and non-binge eaters. Appetite
15. Jung F, Spahlholz J, Hilbert A, Riedel-Heller SG, Luck-Sikorski C. Impact of weight-related discrimination, body dissatisfaction and self-stigma on the desire to weigh less. Obes Facts
16. Robinson E, Sutin A, Daly M. Perceived weight discrimination mediates the prospective relation between obesity and depressive symptoms in U.S. and U.K. adults. Health Psychol
17. Lydecker JA, Galbraith K, Ivezaj V, et al Words will never hurt me? Preferred terms for describing obesity and binge eating. Int J Clin Pract
18. Puhl R, Peterson JL, Luedicke J. Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. Int J Obes (Lond)