treating obesity seriously -...
TRANSCRIPT
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Treating Obesity Seriously
Overcoming Bias
Tapping Opportunity
Ted Kyle, RPh, MBA April 25, 2014
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Disclosure
• Outspoken
advocate for
– People with obesity
– Obesity research
– Evidence-based
treatment & prevention
• Advisor to– Anyone who listens
– The Obesity Society,
Obesity Action Coalition,
Obesity Care Continuum,
Eisai, Vivus, EnteroMedics,
Vivus, BMIQ, BodyMedia, GI
Dynamics, GSK, Center for
Medical Technology Policy,
IOM Roundtable on Obesity
Solutions
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More Information
• www.conscienhealth.org/news
• Facebook.com/ConscienHealth
• @ConscienHealth
• For these slides:http://conscienhealth.org/wp-content/uploads/2014/04/CT-AND.pdf
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Three Objectives
• Describe why & how
to deal seriously with obesity
• Identify the problems bias creates and
strategies for overcoming it
• Define opportunities for Dietitians
to play a critical role in addressing obesity
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Why and How?Dealing Seriously with Obesity
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Obesity Is the Biggest Threat to American Health for This Century
• Prevention is
necessary
• And insufficient by
itself
• Two thirds of the
population is already
affected
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Untreated Obesity Harms Nearly Every Organ System
• Pulmonary
• Nonalcoholic
fatty liver
• Gall bladder disease
• Gynecologic
• Osteoarthritis
• Dermatologic
• Gout
• Intracranial
hypertension
• Stroke
• Cataracts
• Cardiovascular
• Diabetes
• Pancreatitis
• Cancer
• Phlebitis
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“But I Thought We’reGetting Obesity Under Control”
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We’re Running Out of People Susceptible to Obesity
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Severe Obesity Is Growing in Adults
0%
200%
400%
600%
800%
1000%
1200%
BMI > 50
BMI > 40
Cumulative Increase Since 1987
BMI > 30
Source: Sturm and Hattori. 2012.09. IJO
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…And in Children
100%
120%
140%
160%
180%
200%
220%
240%
1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012
Childhood Obesity Rate Indices, Base = 1999/2000
Class 3
All Obesity
Class 2
Overweight
Source: Skinner & Skelton, 2014.04, JAMA Pediatrics
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Obesity Is Costly
• $2700/person/year
• $200 billion
• Costs especially high
in severe obesity
• Disabilities add
• Medicare bears many
of these costs
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Our Sick Care System Treats the Results of Obesity
• Heart disease
– Dyslipidemia
– Hypertension
– Coronary Artery
Disease
– $444 billion
• Diabetes
– Heart attacks
– Strokes
– Kidney failure
– Amputations
– $245 billion
• Cancer, liver disease,
and more
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Treating Obesity? Not So Much
Primary Care Physician Practices
Routinely Assessing BMI
and Following Up
26%
Not
74%
Source: Klabunde et al, 2014.01, Am J Health Promotion
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We Need a Better Understanding of Obesity
• A complex, chronic
disease Characteristic signs and
symptoms
Impairs normal metabolic
function
Causes harm to multiple
body system and
premature death
• > 100 potential causes
• Many subtypes
• Not fully understood
• Badly misunderstood
by the public
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We Need to Use the Treatment Options We Have
• Self-care
• Intensive behavioral treatment
• Expert Clinicians
(RDNs, Obesity Medicine Physicians)
• Pharmacotherapy
• Surgery
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We NeedMore & Better Treatment Options
• Efficacy of behavioral treatment is modest
• Drugs are few, with modest efficacy
• Surgery unacceptable to many
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Weight Bias and DiscriminationProblems and Solutions
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Overview
• What is weight bias?
• Why does it matter?
• How can I change things?
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What Is Weight Bias?
• Negative attitudes toward individuals with obesity
• Stereotypes leading to:
– Stigma
– Rejection
– Prejudice
– Discrimination
• Verbal, physical, relational, cyber
• Subtle and overt
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Weight Bias Invades Every Corner of Life
Substantial Evidence of Bias in:
– Media
– Employment
– Education
– Healthcare
– Interpersonal Relationships
– Youth
Puhl & Brownell (2001); Puhl & Heuer (2009).
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Weight Bias in The Media
• Stereotypical portrayals
• Abundant but often ignored
• Reinforces social acceptability of bias
• Affects public perceptions about
obesity
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News Media Images Are Powerful
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Biased Images Promote Prejudice
• Findings
• 72 percent of images stigmatized individuals with obesity
• 65 percent of videos stigmatized adults with obesity
• Experimental studies
• Stigmatizing images worsen public attitudes
• Non-stigmatizing images improve attitudes
• Public prefers non-stigmatizing images
Heuer, McClure & Puhl (2011) J Health Commun. Puhl, Peterson, DePierre & Luedicke, in press, J Health Commun.
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Weight Bias in the Workplace
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Inequitable hiring practices
Prejudice from employers
Lower wages
Disciplinary action
Wrongful job termination
What Does the Science Say?
Population Studies Experimental Research
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Discriminatory Hiring Practices
Job candidates with obesity are:
– Less likely to be hired
– Ascribed more negative attributes
– Perceived as poor fit for position
– Assigned lower starting salary
– Evaluated less favorably,
even when compared to thin applicants
who were unqualified
Finkelstein, Frautschy Demuth, Sweeney (2007); Kutcher & DeNicolis Bragger (2004); Sartore & Cunningham. (2007).
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Reports of Workplace Discrimination
• 2,449 Women with overweight/obesity:
– Weight Prejudice
from Employers: 43%
– Weight Prejudice
from Co-workers: 54%
Puhl & Brownell (2006). Obesity.
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Weight Bias in Healthcare
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Weight Bias Documented in Healthcare Professionals
• Physicians
• Nurses
• Medical Students
• Psychologists
• Dietitians
• Fitness Professionals
Puhl & Brownell, 2001; Puhl & Heuer, 2009.
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• Non-compliant
• Lazy
• Lack self-control
• Awkward
• Weak-willed
• Sloppy
• Unsuccessful
• Unintelligent
• Dishonest
Ferrante et al., 2009; Campbell et al., 2000; Fogelman et al., 2002; Foster, 2003; Hebl & Xu, 2001;
Price et al., 1987; Puhl & Heuer, 2009; Huizinga et al., 2010.
Providers Harbor False Assumptions about Patients with Obesity
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Physicians
• View Patients with Obesity as…
• Less self-disciplined
• Less compliant
• More annoying
• As patient BMI increases, physicians report:
• Having less patience
• Less desire to help the patient
• Seeing patients with obesity was a waste of their time
• Having less respect for patients
Hebl & Xu, 2001; Huizinga et al., 2009.
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Nurses
• View patients with obesity as:
• Lazy
• Lacking in self-control/willpower
• Non-compliant
• In one study…
• 31% “would prefer not to care for obese patients”• 24% agreed that obese patients “repulsed them”• 12% “would prefer not to touch obese patients”
Poon & Tarrant, 2009; Brown, 2006; Bagley, 1989; Hoppe & Ogden, 1997; Maroney & Golub, 1992.
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Weight Bias in Education
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Students with Obesity Face
• Harassment and bullying
– From other students
– From teachers
• False and low expectations from
teachers
• Barriers to opportunities
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Weight Bias Persists in Universities
• Candidates for undergraduate
admission
• Identical but for weight status
• Candidates with obesity judged less
qualified
• Study of graduate psychology
programs
• Interviews favored thinner candidates
• Regardless of qualifications
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Why Does Weight Bias Matter?
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Weight Bias Matters Because
• It’s no different from any other bigotry
• Violation of human dignity
• Dehumanizing people
• Waste of human potential
• Barrier to overcoming obesity
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Weight Bias Has Far-reaching Effects
• Keeping people with obesity from seeking help
• Keeping professionals from offering help
• The last socially acceptable form of discrimination
• Making obesity initiatives ineffective
• Erecting barriers to treatment access
Recognizing and combating bias,
both your own and from others,
is critical to defeating obesity
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Obesity Wage Penalties
• 12,686 people followed throughout 15
years to examine wage effects of
obesity:
– Women’s Wages:
6.1% lower with obesity
– Men’s Wages:
3.4% lower with obesity*Controlled for socioeconomic and familial variables. Baum & Ford (2004) Health Economics.
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Weight Bias Makes Health Worse
Provider interacting with those affected:
• Spend less time in appointments
• Discuss less with patients
• Offer less empathy
• Assign more negative symptoms
• Perform certain screenings less
• Offer less treatment
Bacquier et al., 2005; Bertakis & Azari, 2005; Campbell et al., 2000; Galuska et al., 1999; Hebl & Xu, 2001;
Kristeller & Hoerr, 1997; Price et al., 1987
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Adams et al., 1993; Drury & Louis, 2002; Fontaine et al., 1998; Olson et al., 1994, Ostbye et al., 2005;
Wee et al., 2000; Aldrich & Hackley, 2010.
Impact on Care
Patients with obesity less often get:
• Preventive health services & exams
• Cancer screens, pelvic exams, mammograms
And more often:
• Cancel appointments
• Delay appointments and preventive care
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“You could walk in with an ax sticking out of your head and they would tell you your head hurt because you’re fat.”
From a New York Times Reader:
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Weight Bias Makes the Obesity Worse
Source: Yale Rudd Center
Obesity
Weight
Bias
Health
Impact
Health
Care
Healthcare
Avoidance
Unhealthy
Behaviors
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Using Shame and Blame Against Obesity Is a Lie
• Some rationalize weight bias and stigmaas a source of motivation for healthy weight
• Research shows weight discrimination doubles the risk of developing obesity
• And triples the risk of persistent obesity
• Encouragement, not blame, is needed
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Change Begins with MeDefeating Obesity and Weight Bias
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Obesity Is a Disease, Not a Choice
Research shows• People reject bias
when they understand the external causes of obesity
• People express bias when they perceive it as a choice
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Reject Labels
• Labels put people in a box
• “I know what kind of person you are”
• “Obese” is a label to reject
• Obesity is a disease, not an identity
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People-First Language Is a Measure of Respect
• People who label others “obese”
harbor more weight bias
• Shift the conversation from “being obese”
• Toward “obesity” as the foe
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Rise to the Challenge of Weight Bias
• Reject labels
• Put people first
• Respect people of all sizes
• Reject negative agendas
• Promote a positive agenda of health
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Opportunities for DietitiansAddressing Obesity
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The ACA Holds Opportunities
• Prevention services
– Intensive weight
counseling
• Better access to care– No caps
– No pre-existing conditions
– No cancelled policies for
weight
– Appeals process
• More needs for RDNs
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Gaps Remain in the ACA
• Obesity treatment
often not included in
essential health
benefits
• Access to skilled
providers
• Access to the full
range of EBT
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Medicare Has Helped
• 1977 Obesity is not a disease
• 2004 Obesity is not not a disease
• 2005 Surgery coverage
• 2011 NCD for intensive counseling
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Medicare Has Two Big Gaps
• Skilled Providers for
Counseling - RDNs
• Proven obesity meds
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Who Can Bill for Obesity Treatment?
• Only primary care
docs
• In primary care
practices
• NOT
– RDNs
– Clinical psychologists
– Obesity medicine
physicians
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Statutory Exclusion of “Weight Loss Drugs”
THERAPY GAP
Coverage for sustainable weight
management with lower risk
than bariatric surgery
Diet,
Exercise
& Lifestyle
Strategies
Adjustable
Gastric Band
Gastric Bypass
Sleeve
Gastrectomy
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Treat and Reduce Obesity Act
• Legislative fix
• Addresses both gaps
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Bipartisan Legislation
• House sponsors
– Kind D-WI
– Cassidy R-LA
• Senate Sponsors
– Murkowski R-AK
– Carper D-DE
• 70 Co-sponsors
• Soon to be 100
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Empowering Skilled Providers
• Align with
USPSTF guidelines
• Registered Dietitians
• Clinical Psychologists
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Covering Evidence-Based Treatment
• Gives CMS an option
• Covering safe and
effective obesity
medicines
• Currently excluded by
Medicare Part D
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Prevention Saves
• Modest weight loss
5-10%
• Holds potential to cut
Medicare spending
• Estimated $10,000 per
personSource: Thorpe et al 2013
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Stop Digging!
• Failed obesity policies
• Neglecting treatment
• Limiting access
• Shutting out skilled
providers
• TROA is a step in the
right direction
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Summary
• Obesity is a complex, chronic disease
• Causing a growing health burden
• Bias and discrimination make it worse
• Growing commitment to address obesity
is creating opportunities for RDNs