Good afternoon, it's a real pleasure for me to introduce to Dr. Scott Caham a little bit of some of his introduction. Dr. Caham is a physician trained in clinical medicine and public health, and his clinical practice mainly focus on obesity and his public health on policy and advocacy to counter weight stigma. As you all are aware, this is a very hot topic right now, and we will have some obesity consensus on weight stigma on Sunday. He's the director of the National Center of Weight and Wellness in Washington, D.C., and he has an academic appointment in multiple universities in the area. He served in multiple boards, including the Obesity Society, the Endocrine Society, and the American Diabetes Association, and he received his undergraduate degree in bioengineering from Columbia University, and his medical degree from the Medical College of Pennsylvania. He did his residency and master in public health at Johns Hopkins University. He's very well international, a lot of publication, being involved in multiple guidelines, so a lot of achievements. So for me, it's a great pleasure to introduce you to Dr. Caham. Thank you so much. Thank you. And even with all that amazing stuff that I seem to do, I can't get more than, you know, just a few people here. No, so thanks. Thanks everyone for coming. This is, as he said, a very important topic, and I'm glad that we can talk about it here. So let's see. All right, so let's start with some basic background. So this is just the dictionary definitions of bias, stigma, and prejudice. So bias, a personal and unreasoned judgment. Stigma, a mark of shame or discredit. And prejudice, an adverse opinion formed without just grounds or before sufficient knowledge, or an irrational attitude of hostility directed against an individual, a group, a race, or their supposed characteristics. And when we look at the psychology definitions, it's a little more in-depth, but largely the same. Stigma, an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole and usual person to a tainted and discounted one. And prejudice, an aversive or hostile attitude toward a person who belongs to a group simply because he belongs to that group and is therefore presumed to have the objectionable qualities ascribed to the group. So they're all saying some version of the same thing, where one, there is a predetermined belief or attitude or judgment about a given person, and that's based on some attribute that that person has, be it the way they look, be it where they're from, their gender, their race, their ethnicity, their size, and such. And so for weight bias, this is the definition that I use. This is my definition. You won't find it anywhere necessarily, but it's to the point and very helpful, I think. It's making assumptions or judgments based on the appearance of excess weight. That's what it is. Now those assumptions are almost always negative, and it can be conscious or unconscious, but it's about making assumptions or judgments based on appearance, and in this case, the appearance of being bigger, one's weight or size or shape or the like. Now it's been said that in liberal democracies and free societies, bias, stigma, prejudice, and discrimination are inherently evil. They're seen as a threat to the health, happiness, and social status of those targeted, but also to the nation's fundamental values of inclusion and equality, except when it comes to obesity. It's long been considered okay to stigmatize people about their weight, to treat them differently, to believe that they are less than simply because of their appearance. So let's look at sort of a subtle way that that can play out. So take a look at this woman and just think of some words that come to mind, what you think her life is like, what you think she does for fun, the sort of words that come to mind, and do the same for this woman here. Now with such an intimate crowd here, I could get feedback from you all and ask you what the words that come to mind are. I won't do that because when I do that, everybody lies. They look at the one on the left and they say, oh, she looks strong, and she looks, you know, beautiful, and she is, but that's not what we think. And I know that, and I'll show you data on that later. What we tend to think when we see people like this is something like this. So the heavyset woman, we assume she doesn't exercise very much. We assume she sits on the couch eating, you know, bonbons, watching TV or the like. Maybe we sort of picture that she's an emotional eater and crying about being lonely on the couch or something like that. And then the other one, the one who looks very fit, we assume that she's really healthy, leads a very healthy life, that she's probably on her way home from her yoga class and on her way to go get a salad for lunch or something like that. And certainly there are plenty of heavier people that sit on the couch and don't exercise. There are plenty of thin people that do nothing but exercise and eat healthy. But we don't know anything about these two women, just simply looking at the shape of their face or whether they're heavy or not or the like. And there's a whole lot of nuance and subtlety here that likely describes much more about what their lives are like. For example, who's to say that the woman on the left, while she may be very heavy, she very well may have already lost 150 pounds. She may have been born into a family of four or 500 pound people. Everybody in the family dies early of heart attacks and gets diabetes and so forth. And she's been bucking those odds and she's already lost 100 or 150 pounds. She's the one that's coming from the gym. She's the one that's eating the salad. And while she's not perfect, she's fighting an uphill battle against her genetics, against her upbringing, et cetera. And the one on the left, I'm sorry, the woman on the right who's thin, who knows? Maybe she smokes three packs of cigarettes a day just to avoid overeating. Maybe she's born to a thin family and has never had to exercise or worry about her weight. Again, we don't know anything about either of these people, but we all tend to make assumptions. And they may be implicit and they may be unconscious, but we all make assumptions that are fairly similar about heavier and thinner people. Weight bias hides in plain sight everywhere you look once you start to look for it. So this was an interview I did. It's funny, this is Russian television, RT, they don't even allow that anymore, thankfully. This was an interview I did. It was a very thoughtful interview about the increase in obesity rates and what we can do to help people. Very thoughtfully done, very sincere, it was a great interview. And when you're in the studio doing this, there's just a green screen behind you. So you don't see what's actually the visuals that they're going to put up there. So when I saw the video of it later, this is an example of the types of pictures that were up there. So not the face or the whole figure of someone who's heavy, but a picture of their big butt or their big belly. That's the type of thing that is shown over and over and over again in the B-roll that went along with the spot. Another picture that was up there, people eating potato chips and drinking soda pop and so forth. Again, this is all driven by the either implicit or explicit assumptions that we tend to have about people who are heavy. Here's another example. So this is an op-ed by Eugene Robinson. He was the main opinion writer for the Washington Post when he wrote this. He's now the executive editor of the opinion section. He's a good friend of mine. He is as liberal and thoughtful and warm and kind a person as I know in the world. And yet what he wrote in this article, this was about Chris Christie when he was running for president, is essentially he shouldn't run for president because you can't be president if you're really, really fat. And what you really need to do, Chris Christie, is push away from the table, eat a salad, take a walk, and lose some weight. He wasn't meaning to be mean. He wasn't meaning to be stigmatizing. He was expressing an opinion that is held by many, many, many people. On the one hand, the opinion that heavy people can't be or shouldn't be in the public eye or in figurehead-type jobs, and two, the opinion that all heavy people behave badly, they eat too much, they exercise too little, and if they just sucked it up and picked themselves up from their bootstraps and had a little motivation, then they would eat healthier, they would exercise, and they wouldn't have the weight problem anymore. It is subtle, but it is pervasive, and it affects so much about how we interact with people based on those assumptions and beliefs. And then there's also quite a lot about people who are heavy that is based in judgment, not just the assumptions we make, but harsh judgments we make and harsh ways of treating people. So the one on the left, these are two tweets out of nowhere that these people made. The one on the left, this guy just put out there, listen, we're all Americans, which means we have 10 or 20 pounds to lose, but if you're a completely fat, disgusting pig, then put the fork down and stop stuffing your fat ass with cake at Ruby Tuesday, and don't sit next to me on the plane because I judge you, so go away, and stop, and he keeps going on and on. The scary thing here, perhaps, even more than his words, is who he is. So this was, he got fired, this was the superintendent of a school district in upper New York at the time when he put that out there. The one on the right, he put out a tweet, dear obese PhD applicants, if you didn't have the willpower to stop eating carbs, you won't have the willpower to do a dissertation. Not only is he a dissertation director in a university, he's actually a psychologist. He's a PhD psychologist, an evolutionary psychologist, but nonetheless. So these are people, you know, you would think that anyone should know better, but especially an educator, two educators, let alone a psychologist, you would think they know better, and yet we see things like this, unfortunately, all too frequently. Weight bias is extremely common throughout society, but particularly in healthcare. So when asked about experiences of weight bias, doctors are the second most common reported source of weight bias. Only behind, believe it or not, only behind members of people's family. So roughly two-thirds to three-quarters of patients who are heavy report experiencing weight bias in the healthcare system from doctors, about half from nurses, about a third to a half from dieticians, and even mental health professionals, about a quarter say they've experienced weight bias from their psychologists or social workers. Here's some examples. So these are some structural examples. It was written in the newspaper, the British public health minister has urged doctors to call overweight patients fat rather than just obese. Doctors and health workers are too worried about using the term fat, but doing so will motivate people to take personal responsibility for their lifestyles. Calling them obese doesn't provide sufficient motivation, just call them fat, because plain speaking doctors will jolt people into losing weight. And then on the right here, there was a GYN, a large GYN practice in South Florida, in Miami, that made an explicit policy that they wouldn't allow women who were greater than 200 pounds into the practice. So these are examples of structural weight stigma in the healthcare system. And both of these are a few years older, but they continue to happen. They're just particularly good examples, frankly, I keep using them. Here's some individual examples. I asked the gynecologist for help with low libido, his response was, lose weight so your husband will be interested in you, that'll solve your problem. Now the only good news here is most people that are treated poorly by their doctors, they just take it, they assume that they deserve it. At least this person pushed back and said, I changed doctors after that, and I told everyone I know to stay away from that doctor. I became very frustrated when a provider disregarded what I was telling him, because he'd already made up his mind that obesity was at the root of all my problems. And that's a very, very common thing that patients say. They go in with a headache, they go in with a sore throat, they go in with a bellyache or whatever, and often they feel that the doctor isn't even listening to them, and just simply ascribes everything to the weight and tells them to lose weight. You could walk in with an ax sticking out of your head and they would tell you your head hurts because you're fat. And there are a lot of more subtle implicit examples. So assuming a patient hasn't attempted lifestyle changes to eat healthy, exercise, or lose weight due to their appearance. So think about it. How often do we assume if you see a very heavy person come into your office and you're seeing them for the first time, most of us I think would assume that they've not really tried to lose weight before, or they haven't tried to do it with a doctor, or they haven't tried in a formal weight loss program or whatever, and that's what we're basing our interaction with them on. Or refusing to refer to bariatric surgery or consider an obesity medication due to the perception that the patient doesn't deserve it because they haven't already made sufficient lifestyle changes on their own. I hear this all the time, particularly from primary care physicians. Think about this by analogy. Imagine if you had a patient with diabetes and their A1C is out of control and you don't want to treat them medically because you feel like they haven't really given it the old college try yet. You want them to take care of it, to pick themselves up by their bootstraps before you're willing to treat for their glycemic control. It makes no sense when you think about it in the context of diabetes or hypertension or hyperlipidemia or the like, and yet it's a very common scenario in the context of weight management. This happens incredibly frequently and it's largely driven by deep down feelings about people or about people who are heavier or about obesity itself. There's been studies showing that the heavier patients are, doctors have less respect for them. They literally admit to having less respect. This was one of those studies. The investigators taped about 300 doctor-patient interactions and then gave a set of questionnaires to both the doctors and the patients and then looked at the data and cut it up a number of ways. One of the things they asked is, what's your feeling of respect for the doctor you just met with or for the patient you just met with? When they looked at the data, bless you, when they looked at the data across these characteristics, no difference, so whether someone was male or female, no statistical difference in whether the physician felt that they had respect for them or didn't have respect for them or lower or higher respect. If they were black, white, or whatever, no difference in the reported respect toward the patient, whether they had a high school diploma or not, whether they had a low or high income, whether they had health insurance or not, no difference in their reported level of respect for the patient. When we look across people's weight, their BMI, there's a big and statistically significant difference in the reported respect that the doctors have for those patients. This likely underlies a lot of the bias in healthcare from doctors, from nurses, from support staff, and the like. Weight bias can and does harm across a number of ways. On the one hand, when people are treated this way, particularly by healthcare providers, they feel like crap, they feel berated, disrespected, blamed, dismissed, they perceive they won't be taken seriously by that doctor or the next doctor, so they are often reluctant to talk about weight, whether to bring it up, whether to ask for help in the future. One of my patients, she described it this way, after having a really terrible interaction with her primary care doctor, she just felt rotten to the core. Imagine what that feels like. There's also physical effects of experiencing weight stigma. People who experience weight stigma, on average, have elevated cardiovascular reactivity and blood pressure, increased stress hormones, vulnerability for psychological distress, low self-esteem, poor body image, and even suicidality, and lowered quality of life. Then there's lesser quality of care. Across a number of studies, there's large disparities in the type of care that patients get as a function of their weight. Doctors tend to spend less time in appointments with heavier people. They tend to do less intervention and preventive health services and screenings. There's all sorts of examples of misdiagnoses, and I'll give you just a couple of notable ones that stand out in my mind. This is the first one. A patient of mine who, we'd been working together for a while, she'd lost almost 100 pounds at the time. She had terrible back and hip pain, and we tried all sorts of stuff. Her primary care doctor tried stuff. Finally, we referred to an orthopedist. She went there and then sent me this email right afterwards. I began describing my symptoms when the doc interrupted, lose weight. I told him I just lost 70 pounds in the past year, and he said, lose more. I'm not sure why you're in pain, but I'm sure it's from your weight. He didn't ask about my symptoms or examine my hip. The only thing he touched was my hand when he shook it before walking out. And then she wrote, it's ironic because I asked for his help because the pain interferes with my ability to exercise. I don't doubt that my weight is involved, but to so quickly attribute everything to that one factor, especially when the pain began after I dropped all this weight, seemed too pat and answer. By the way, she then wrote, he noticed I was about to cry and commented, see, you're even crying from the pain, and again referenced my weight. I told him it wasn't the pain, it was the disappointment that I can't exercise as much as I would like, but that too was a lie. I was really crying because of the way he treated me. All he saw was my weight. So this doctor called me afterward, and he said, I know what she has. You won't find it in a textbook, but it's called obesity pain. I see it all the time. She just needs to lose weight. So this was from her orthopedist. We went to another orthopedist, of course, after that. They finally did an actual exam and an X-ray, and some other testing, and that's what they found. She has severe progressive scoliosis. I mean, her spine is almost at a right angle there, and that doctor missed that diagnosis. You could argue that that is malpractice, but you know what? I missed that diagnosis too. I'd been seeing the patient for a number of years, and I never diagnosed it. I never referred her until that time. It can be subtle, but it's just an example how this is not just about treating people badly. It goes way beyond that, and there are tangible potential consequences. I'll give you another example. So I practice in D.C. Another patient of mine, she lives north of Baltimore, so it's a solid two hours plus from my office. She called me up one day. She said she's having shortness of breath and chest pain. We talked a little bit. It didn't sound good. I told her to go to the emergency room. She headed to the emergency room, got there. It was packed, so she left and went to an urgent care center. They saw her pretty quickly in the urgent care center, but they didn't do anything. They brought her in. She told her story. They asked a couple questions, and they didn't do a physical exam, didn't listen to her heart or lungs, didn't do an EKG, didn't do a chest X-ray, told her that she can't breathe because she has too much fat pressing up against her lungs and sent her off. And so she went to her car and cried for a good long while and finally got herself together, called me up. We talked a little bit more. It didn't sound good at all. She was starting to be febrile. She had shortness of breath. She had chest pain, tachycardia, so I implored her to go to the emergency room. She went. They were able to triage her pretty quickly. Turns out she had a massive PE, and they caught it just barely in time. She's now okay after several years of anticoagulants. Maybe she's still on anticoagulant. But again, it's another example where weight bias impacts how we care for patients and can ultimately impact health. And it's not a stretch to say that this woman easily could have died. And if so, on that death certificate, should have been weight bias or weight stigma as the cause of death. So we have poor quality of care. And then here's the one that people often don't appreciate even more so. Weight, experiencing weight bias tends to lead to more weight gain. So it's not uncommon for people to think that if someone's really heavy, if you're just really sort of cold to them and strict to them, it'll kind of jolt them into having motivation to exercise or to lose weight if you're kind of really harsh as opposed to being sort of warm and supportive. And the truth couldn't be farther from that. Study after study after study shows that when people experience weight stigma, particularly in the healthcare setting, but outside of it as well, it tends to impair weight loss efforts. In experimental studies, leads to higher calorie intake, higher weight loss program attrition, and less weight lost when people try weight loss programs. Increases the risk for maladaptive eating behaviors such as binge eating, crash dieting, emotional eating, and lower motivation for exercise and avoidance of physical activity. So it does the exact opposite. People tend to gain weight. Here's one example of those studies. This was an experimental study where they brought a bunch of patients in and showed them some engineered like commercials. The experimental condition were commercials that had some subtle and some not so subtle weight stigmatizing messages. And then the other one, they were more neutral, benign commercials. Then they got a, in order to, after they brought them in, then they got a gift certificate to go to the cafeteria in the hospital. They could eat anything they wanted and it was an engineered cafeteria. So everything that they were ordering and eating was being measured. And so the people who were exposed to the weight stigmatizing commercials ate significantly more, about double the caloric intake at that next meal compared with people who were shown the benign commercials. And then when we look across over time, here people were followed over four years and as a function of whether they experienced weight prejudice during the course of that time across a number of attributes, whether race, ancestry, gender, age, et cetera, no difference in whether they developed or gained weight enough to develop obesity or if they had obesity at baseline, maintain their obesity. Whereas with respect to weight, people who experienced weight stigma over the course of that four years had a three times higher likelihood of gaining more weight and developing obesity and a two and a half times more likelihood of maintaining that obesity or I just reversed that. So lots and lots of data suggests that weight stigma makes more weight come on. It doesn't help, it harms significantly and not just psychologically but also in terms of weight management. So unfortunately, we don't have great data on what to do about this. There's been a couple systematic reviews looking at interventions for dealing with weight bias in healthcare and we just don't have clear data. So we need lots more study as we do in many areas. But I put together a few things that I think will be helpful. Even if it's not completely sort of evidence-based, it's hard to argue against the things that I'm gonna tell you here. And I put them together like a whole lot of our guidances. I put them together as seven A's. It's not as cool and easy off the tongue like Tim's ABCD but it's better than nothing, right? So the seven A's to address weight bias in healthcare. And we'll start with appreciate the complexity of obesity. And that's essentially what we're doing in this conference and other conferences that are dedicated to obesity. I think it's really hard. Once you learn about the science of obesity, the pathophysiology, what patients have to go through, the genetics, et cetera, it's hard to be as stigmatizing toward patients just simply based on that. That in and of itself helps to move forward in terms of more sort of fair impressions of patients. The second is to become aware of our own implicit assumptions and beliefs. Because let's face it, anybody that's working in this area, you know, we don't explicitly hate people who have obesity. We don't explicitly treat them badly. We don't intentionally do that. But once we learn about our implicit beliefs, it's fascinating what that shows. So there's a systematic way of doing that. The implicit attitudes test, which is hosted by a group at Harvard, it measures the automatic associations that we have in memory by assessing and categorizing how we categorize and how quickly we categorize pictures of people, some that are heavy, some that are thin, along with value-laden terms as they appear on the screen. So they keep coming at us, some of the people are fat, some are thin, some of the words are positive value-laden terms, like good and motivated and so forth, and other of the terms are negative value-laden terms, like bad, like unmotivated, like undesirable, et cetera. And when these are done almost across the board, I mean, 98, 99% of the time, we see things like this. People tend to categorize heavier people consistently with negative value-laden terms, bad, lazy, unmotivated, et cetera, and we tend to categorize thin people much more consistently with positive value-laden terms. This is exactly what I did when I first did this test, and it was after I was actively practicing as an obesity specialist for several years. It says a lot. It says a lot about what is deep down in our heads, and you almost can't get away from that. I mean, from living in our thin-obsessed society, we build these implicit assumptions, but just becoming aware of it helps us to make it more conscious in our minds and counter those implicit beliefs. Here's another example that I think is fantastic. So this was done by a college professor that put together a course on diet and obesity, and he asked all of his students to actually go on a diet of their choosing for a week as part of the course, and then keep a journal and keep notes about what their experience was, and they could do any diet they want as long as they were changing what they ate in an intentional way. So he asked, were you able to follow the diet? Most of them weren't. He asked why they weren't able to follow it, and there's a number of reasons, largely because they were hungry all the time, they felt irritable, things like that. And then he looked at what they reported in their journal. So here's some examples. This was much harder than I thought it would be. I became obsessed with sweets. All I could think of was brownies and ice cream. All I could think about was food. I couldn't wait for the week to be over. I found myself daydreaming of pizza and milkshakes and burgers and fries. I was so irritable by midweek, my roommates were avoiding me. It's very hard to create delicious meals on 1,200 calories. I felt like following the diet was a part-time job. I hope I never have to do this again. Boy, was I ever ignorant about how hard this would be. Being of normal weight, I was never aware of my prejudices. I will no longer associate lack of motivation and laziness with overweight. My judgmental attitude certainly got a readjustment. So trying to walk in people's shoes is incredibly helpful. And again, it helps us to become more aware of what our implicit beliefs are that often underlie our interactions with patients in the clinic. So next, pay attention to what's in our control. There's a lot in medicine we can't control. There's a lot in our interactions with patients that we can't control. But there are some things that are really basic. So one is nobody likes to be called obese, let alone morbidly so. People find it upsetting and they find it unmotivating. More neutral terms are much more preferred. Perhaps the most neutral and preferred is just weight. So rather than talking to a patient about being obese, talk to a patient about weight. It goes, even when it's not grammatically correct, it's a really easy thing to do. You just pay attention a little bit to it and it helps. When people hear you calling them obese, even if you don't mean anything negative by it, it turns them off. And it often closes them off to wanting to talk to you about it. And another term, and I think you've heard this here from some of the presenters, is to use people first language. And this is standard in other areas of medicine. We don't call people with diabetes, diabetics anymore. We don't call people with cancer, cancerous. We don't call people with depression, depressives. And we shouldn't call people with obesity, obese. It's just a basic and now codified part of medicine. So the AMA formally codified this. And most of the journals in this area also codify this in their instructions to authors. So it's a simple thing. It's a little awkward when you start with it. And it wasn't that long ago when you submit a paper, if you were to write patient with obesity, that they would actually change it and make it the more, the easier sort of obese. But now most of the journals in this area are now expecting patient first language or people first language. Again, this is something that's in our control. It's easy to do. We have good data suggesting that people prefer this. So why not do it? And this is a little bit more of a structural example. Patients start to make assumptions about us as clinicians, about the care they're gonna get even before they start talking to us. So they walk into the waiting room and if they can't even fit into the chairs, they make a number of assumptions about the care they're gonna get. So those chairs on the left there, they're very narrow. A lot of the more heavier patients we see can't even fit into those chairs. So having chairs instead that either don't have arms so they can fit a wider range of people, chairs that have higher capacities, chairs that people feel they can sit on and they're not gonna break it. It's a relatively small thing, but it's something that's in our control largely. Even in healthcare systems where you can't necessarily on your own buy a bariatric chair, more and more I'm finding that it's not difficult to make that happen as long as you know that that needs to be there. Another thing in waiting rooms are the reading material. I don't know anyone who's heavy who finds the magazine on the left to be motivating. That is unattainable for virtually everyone, certainly for me. I go through my waiting room literature and I try to put in there things like the one on the right. So things that are just more neutral. Plus nobody's gonna learn anything from the fitness magazines anyway. It's just gonna make our jobs harder anyway. So again, it's a small thing, but it sets a little bit more of the expectation of neutrality and supportiveness that we hopefully want all our patients to expect when they come into our offices. And then here's some other things that are really important. So provide wide-based, higher capacity chairs as well as exam room tables, bariatric furniture when possible. You should have extra large blood pressure cuffs, which could be just thigh-sized cuffs if that's all you can get. Neutral waiting room literature. Make sure to have extra large size gowns and then make sure to have high capacity scales, ideally at least 500 pounds capacity. And make sure to keep them in a private area rather than expecting patients to step on them where other people are gonna see them. And make sure to train your staff to keep that number private rather than blurting it out after it's done. It's a part of their private protected health information and it should be kept private. When possible, pedestal toilets rather than wall-mounted ones are important because the much heavier patients, every once in a while you hear that they'll bust it, they'll knock it down from being too heavy. And then educate the staff about obesity and about weight bias. A lot of the times what we hear is stigmatizing attitudes and statements and interactions coming from staff, receptionists and nurse assistants and so forth. I'm just gonna skip that. So the next day is appreciate that shaming doesn't motivate. I was saying that before. It's all too often to think that if you just are kinda harsh with the patient, do a little of this, it'll get them to be motivated to lose weight. And the data show the exact opposite. Here's another example. So this was a one-year randomized trial of a physician. I'm sorry, it wasn't a randomized trial. But it was a one-year trial of PCP counseling for weight loss. And when they asked patients what their experience were with the healthcare provider, and then looked at their weight loss over the course of that year as a function of whether they felt judged because of their weight by the clinician or not, there's a significant difference here. About a 50% higher chance of achieving clinically meaningful weight loss, at least 5% for patients who weren't judged compared to those who felt judged by their primary care doctor. So support, warmth and a nonjudgmental attitude is always gonna be more valuable for patients. And that's the case whether you're talking about a patient who isn't consistent with their diabetes medication and their A1C is through the roof, it's the same thing. Next, support patient's autonomy. So one of the ways of doing that is by asking permission. So rather than when you see a patient for the first time or for a physical exam or the like, and they come in, they're really heavy and you really wanna get them to focus on the weight, it's really helpful if we support their autonomy by putting the decision in their lap rather than in ours. So rather than just diving in and saying, hey, you really need to lose some weight, even if you say it in a nice way and mean it very, very thoughtfully, it's often helpful if you give them the opportunity of whether they want to talk about it or not. Think about when you think about what the most sensitive area of people's lives are. For so many of us, it's our body weight, our body size and shape. And so just going in there and saying, look, you're really heavy and you need to do something about it can really take people by surprise and really be very upsetting and doesn't make them want to open up to you and trust you and look to you for guidance on this. So even something as simple as, over the past few years, I've noticed that your weight has been increasing and I'm concerned that that's going to lead to a worsening of the diabetes or development of the diabetes or whatever. I have a lot of training in this and this is something that I'd like to work with you on if you're open to it. Would it be okay if we talked about weight today and tried to figure out where we can go from here? Something like that almost always is going to be well accepted by patients. And it's going to be the start of a more productive set of interactions. And if they don't want to talk about it, that's okay. Because you've still set the expectation that when they're ready, they have someone they can go to that's going to be respectful toward them, that's not going to judge them about the weight, and that is not going to push them into something, but rather is going to be there and respect their situation. So it's a small thing, but a really valuable thing that we can do clinically. Another small aspect of this is using pull versus push language. This comes from the motivational interviewing literature. So push language is sort of where we're pushing people to do something. You must do this, you should do this, you really need to do this, let me tell you what to do, here's what to do. It's more sort of old school, paternalistic, big doctor talking to the low down patient. As opposed to pull language, it's a subtle difference, but it's important. You might consider this. How might you consider this or why might you consider this? In what ways is this important to you? Maybe we could work together to help you find your way. How might you possibly go about making this change? So again, these are all very common statements in motivational interviewing that are particularly helpful for people that are not yet ready to aggressively move forward, for people that are sort of on the cusp of being ready to engage in a diet attempt or engage in a new exercise attempt or even engage in talking to you about weight. These subtleties in different language have a big difference. Again, it underlies motivational interviewing. Six is address the consequences of stigma. So frankly, this might be a little beyond what you all may be able to do if you're not working in a dedicated obesity clinic, but when we think longitudinally about the patient, we not only have to consider the potential for stigmatizing interactions in real time when we're in the office with them, but likely, especially if they're heavy enough, they have experienced a lifetime of weight stigma, both inside and outside the healthcare system. And because that has all sorts of negative outcome risks, as I showed you before, treating the experiences of weight stigma is likely going to be helpful. So one is treating them with respect and not furthering those experiences, but treating the experiences of weight stigma is going to be important. So there's been a number of largely cognitive behavioral therapy driven trials on improving patients' self-regard, internalization of weight bias in clinical practice, and it generally goes well. People go through a six or eight week group program on this, and they end up feeling better about themselves, they end up having less psychological consequences of the weight bias, and they end up having more motivation for positive behavioral changes. So this is what we do in our clinic in part. Of course we counsel patients about diet, about exercise, about medications, about surgery, but we also do a lot in terms of treating existing consequences of weight stigma. And then lastly, advocate and educate. So this is one of my favorite quotes in medicine by Rudolf Virchow from Virchow's triad. Should medicine ever fulfill its great ends, it must enter into the large political and social life of our time. It must indicate which barriers that obstruct the normal completion of the life cycle and remove them. In other words, we have a lot of clout, and we could be the best doctors in the world in the clinic, but we're leaving a lot on the table if we don't use our sort of bully pulpit and our reputations as doctors to make the world a little bit of a better place. And that could be in the clinic, that could be in national or state or local advocacy, that can be in healthcare systems, but we should do something to make sure that people understand how prevalent weight stigma is, how negatively it affects patients' lives, and why it's so important that we change that. So there was recently a big consensus statement, an international consensus statement that essentially said this. You can find it, it's freely available online, Nature Medicine 2020, and this is something that is now underlying many of the health societies and large health systems. I believe there's going to be a program here after the conference is over, putting together an ACE, another ACE statement, I believe, on weight stigma. So educate people around you about the complexity of obesity and about weight stigma. Be an advocate, not only in your practice, but ideally in your hospital, in your community, with your peers, in your healthcare system, to policymakers, and challenge weight bias in the public. So it's not uncommon, for example, that there's a sitcom or a movie that is very negative toward heavy people, very prejudicial, et cetera. It's not enough to just not watch it, or when you see it, to not laugh at it. We should step up and say something about it. Now that could be an op-ed, it could be a tweet, and it could be something like this. So at the Obesity Action Coalition, which is the primary patient advocacy organization for obesity, we put together a weight bias reporting form. So you can go online, and you could write in there that, I just saw this movie, and it just made me feel horrible. This just doesn't seem right. And you can let us look into it and try to do something about it. And it's not like calling the weight bias police. We're not going to go and harm people, obviously. But this gives us an opportunity to put the weight of the organization and the field behind trying to change this. And we've done it with a number of examples, a number of sitcoms, a number of movies. We reach out to them. We help them understand what the problem is in making fun of fat people or the like. And frequently, we get really, really good feedback from that. Typically, they'll say they didn't realize, they didn't know, and that they'll take it into account as they go forward. So I'm going to stop there. We have time for questions. I really appreciate you all being interested in this and listening to me. And I hope you enjoy the rest of the conference. Thank you. Thank you so much, Dr. Cahan, for an amazing presentation. So let's open for some questions right now. There's two microphones, so anyone can approach the microphones. Meanwhile, I want to start a little bit of a question. You talk about specifically weight bias in general. But have you figured out if this weight bias, when you include race, ethnicity, changed a little bit? And this toxic stress that exists in racism and discrimination applies when we put weight bias and then race, ethnicity? Yeah, there's certainly some differences across a number of racial and ethnic groups. But the data that I show is, first of all, adjusted for those, but consistent across. Yeah. Please. Hi. I was just wondering, I've been in the other side. There was this one patient a couple of years ago. The moment I opened the door in my practice, she said two bad words about me, being thin. You know, she was like... Being thin, yeah, yeah, yeah. Yeah. But it was like really... She was really rude. Yeah. And she mentioned them twice. But I just opened the door and then she was kind of insulting me for being thin, like a thin doctor trying to treat obesity. That was one. And the other one, she's kind of famous in social media. And she engaged. I didn't, but she engaged. And she said I was a thin woman talking through my privileges. I don't know how to say it. And I was disarmed. I don't know... I mean, what do I... What do we go from there? I know it's not personal. You know, things are not... I don't take it personal, but being on the other side, I don't... I was just wondering, what would you do? What do you do? What do you say? Like, I understand, but... Yeah. So first of all, I'm sorry that you had that experience, those experiences. And it's not right. I mean, at the core of everything I said here is that it's inappropriate and unfair to judge people based on appearance. Whether that is the appearance of a given ethnicity, a given race, a size, whether heavy or thin, or the like. So that's not appropriate. Now, you can appreciate, I'm sure, where it's coming from. Because their whole life, they've likely been teased from being the fat kid on the playground to in the healthcare system. And so, at least now you can go into those situations with a little bit of a coat of armor. And quickly, in most cases, again, when they see respect from you toward them, and that respect is not only coming directly from you, remember I mentioned before, it's even when they walk into the waiting room, for example, and see chairs that are appropriate or a blood pressure cuff, or think about what might have happened even right before you saw them. They got put into a gown that barely even covers their backside. You know what I mean? So it already, even though it's not your fault, it already sets the expectation for what they think is gonna be the interaction with you. So part of it is to have a little bit of a thin skin and appreciate that. Part of it is to do what you can proactively so that all different people that come in have a feeling like they fit in the office, figuratively or literally. And then, if you're then going into it and not sort of taking it personally and not put it back so far, then you can ask, you can push back on that. You could say something like, I don't know, I'm kind of stuck, I was like that, you're right. Yeah, yeah. Let me think about it. Let's go to Tim so we'll come back to it. I think that something is, when you have to address, sorry Dr. Garvey, so when you have to address this kind of disparities is first acknowledge that you understand where they are coming and then you can say whatever Dr. Cahan would say, but always in this discussion that we have in any kind of discrimination is acknowledge the other person, even though it's difficult to do it from our standpoint, that's important. Thank you. You know, it sounds like that this patient is probably come to you after being shamed for it through her contacts with the healthcare system and this is her way of just being aggressive right off the bat to deflect what she expects is more shaming, you know, because you're another healthcare professional. But anyway, Scott, thank you so much for such an excellent lecture. Every time I listen to you give a talk, I just, I feel like it makes me a better doctor, so I really appreciate it. My question is, you know, and we talked about shaming by contacts with the healthcare system and you made the point, it's not just the doctors, it's the staff, it's nurses, it's other healthcare professionals that are involved in care of the patient, the clerks and everybody, and it seems to me we've really got to deal with this at the level of healthcare professional training, medical schools, nursing schools, you know, whatever school. And I think we're doing a better job in terms of discrimination on the basis of race and other types of potential areas of discrimination, but not so much what you're talking about. Has the Obesity Action Coalition been active in this way, talking to the ACGME or AAMC or somebody, kind of how we can kind of introduce this, because if we don't tackle this early on in a broad way involving all kinds of healthcare professionals, this is just going to continue, it seems to me. I couldn't agree more, Tim. And the good news is we actually are making some progress there. So first of all, this is a bit of a microcosm of the broader issue, which is traditionally obesity is not included in medical school or other health professional curricula. And so that, we've been working very hard on that for a number of years, and that's been slowly changing. We literally even, we published a study, this was probably five or six years ago, where we went into the office of the, yeah, the people that do the USMLE tests. We went through 800, 1,000 questions in their database randomly, looking for obesity information. And there was almost no questions on obesity, first of all. The only questions that were there were largely about obesity comorbidities. So questions on diabetes, for example, questions on sleep apnea, et cetera. So we published that data and we worked with USMLE to include more questions on obesity because sometimes demand drives supply and vice versa. We've been working with universities to try to get general obesity education into their curricula and we've been working to try to get weight bias information into their curricula. Frankly, even just getting obesity information is likely valuable because, again, when you appreciate more about the complexity of obesity, it's hard to be as explicitly negative toward people when you understand that. But of course, the Holy Grail is getting training on weight bias explicitly. I spoke this year in three different medical school courses. The courses were specifically on weight stigma, which is above and beyond what I even expect. If you can just get a quarter of one lecture in a broader class that covers obesity, that would be wonderful. But there's actually three, just that I spoke in, I'm sure there's some others, three courses explicitly on weight stigma in three medical schools. So we're making progress. We have a long way to go there. It'll take a lot more advocacy, but that is something that we see as important and that is moving forward. Now, granted, you get it into schools now and it's only going to help the next generation of doctors, but that's something. So we're still moving forward longitudinally here. We have a lot more to do. I think something our society should think about is endocrine training programs. You know, we have a lot of program directors here and there's a group called Afton that's kind of where they kind of communicate with each other. And I'm not so sure that this area gets a lot of attention there either. I'm not probably, perhaps in some programs more than others, I'm not uniform, but I'm not aware that this is an area that consistently receives attention across endocrine training programs. I think it's something we should think about perhaps with your help. How many people here are endocrinologists or endocrinology fellows? So almost everybody, of course. How many people had explicit training on weight bias in their fellowship? So no one. How many people? You tell me if you disagree. I think until relatively recently, I don't think there was much explicitly on obesity in endocrine training programs either. We're making some progress on that, of course, but you're right, Tim. I think this would be a really important thing to advocate to program directors. Yeah. Endocrine University might be a good avenue. Yeah. The other thing that I want to add, Dr. Garvey, so next week, we presented this yesterday, May 19th. We're releasing from ADDEM a health equity curriculum, specifically one of the cases address weight stigma. So this is going to change the entire program, the entire nation programs in endocrinology. Two other things. One, there is a specific resolution from the ACP to address the same thing at the level of internal medicine programs. And working with the AAM, that's what the ACP is trying to achieve. And there is the statement from the AAMC that is addressing weight stigma at the level of the medical school. So coalition is very important. We have one in Hispanic community called LULACS that is part of the coalition that is working on this, mainly on addressing this stigma in Hispanic populations. So I think that a lot of things to do, but it's in process. And sorry that it's over time. I think that we have no more time, but you can address Dr. Kahana outside. Thank you so much for your time, and thank you for being here. Thank you. Thank you.

weight stigma

healthcare

weight bias

physical health

mental health

obesity

implicit assumptions

people-first language

non-judgmental language

advocacy efforts