The effectiveness of GLP-1 agonist drugs (such as semaglutide, dulaglutide, and tirzepatide) for weight loss has resulted in renewed attention to obesity and a focus on reducing clinician bias against those who are overweight. Stigmatization by Nurse Practitioners (NPs) and other clinicians can result in failure to discuss all treatment options (including weight-loss drugs) and to develop a comprehensive weight-loss plan. Patients may then engage in litigation; for example, stating that lack of proper treatment caused their inability to lose weight and the development of comorbidities.
Stigma can also cause patients to feel the NP isn’t properly addressing their health concerns and to perceive the provider as rude or inconsiderate. These feelings could prompt the patient to file a complaint against the provider with the state licensing board.
By understanding the effects of stigma and collaborating with patients to develop a treatment plan, NPs can better serve their patients and reduce their risk of legal and/or licensure actions.
Effects of stigma
A 2022 consensus statement from six leading U.S. organizations (with the main focus on obesity) notes obesity is a “highly prevalent chronic disease” that is prevalent in the United States. Unfortunately, many healthcare providers fail to understand the multifactorial, complex web that contributes to obesity. Individuals have no or limited control of many of this web’s components, such as genetics, socioeconomic factors, environment (e.g., neighborhoods with poor walkability), cultural emphasis on food, and a system highly reliant on ultra-processed foods. This lack of understanding leads to weight bias, which refers to negative beliefs and attitudes towards people who are overweight or obese. In turn, bias leads to weight stigma. An international consensus statement on ending the stigma of obesity notes that weight stigma refers to “social devaluation and denigration of individuals because of their excess body weight.”
A systematic review and synthesis by Ryan and colleagues found that patients who are overweight or obese frequently experience verbal and non-verbal communication of stigma from providers, which negatively affects their health. For example, healthcare providers who feel weight loss is under the patient’s control fail to provide individualized care and may instead engage in generalities, such as “exercise more,” that do little to set the patient up for success. The mental health of those who experience weight stigma can suffer (e.g., low self-esteem, depression, anxiety), and they can have a reduced quality of life.
In addition, patients who experience stigma may avoid visiting providers, leading to less optimal care, including lack of access to weight-loss drugs.
The effects of stigma can be widespread. For example, the international consensus statement on the stigma of obesity noted that people with the condition “are often subject to unfair treatment and discrimination in the workplace, education, and healthcare settings” and that many healthcare facilities lack the equipment needed to treat these patients.
Even when healthcare providers understand factors that contribute to obesity, they may still engage in weight stigma due to inherent bias related to societal views. Current society attributes many negative stereotypes (e.g., laziness, lacking in will power) to people who are overweight. Clinicians must be aware of inherent biases and work to overcome them.
Delivering less-than-optimal care because of weight stigma increases the risk of legal or licensure action, but NPs and nurses should know that engaging in this behavior also violates ethical standards.
For example, Provision 1 of the American Nurses Association Nursing Code of Ethics says that nurses should practice with compassion and respect “for the inherent dignity, worth, and unique attributes of every person.”
A plan of care that is free from bias and stigma will help NPs and other providers avoid negative patient, legal, and ethical effects.
A comprehensive approach
NPs should take the following actions to ensure they are meeting the needs of patients who are overweight and that they put in place a comprehensive plan of care.
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Be welcoming. Don’t be judgmental: Patients need to feel comfortable talking about their weight. Use non-stigmatizing language (see ‘Talking about weight’). In addition, create a welcoming environment for patients of all sizes, for example, have chairs with a variety of seating widths and gowns that provide sufficient body coverage.
Conduct a thorough assessment. Use appropriately sized equipment such as blood pressure cuffs. Remember to ask about non-prescription medications and supplements. The consensus statement on obesity notes that although body mass index (BMI) can be used for screening, it doesn’t replace clinical judgment because social determinants, race, ethnicity, and age may modify the risk associated with the BMI.
Assess whether a patient is a candidate for a weight-loss drug. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says that medications may be an option for some adults; FDA has typically approved these drugs for a BMI of 30 or greater or 27 or greater if at least one weight-related comorbid condition is present.
Partner with patients. Collaborate with the patient in developing a plan of action related to weight. Discuss all options, including the pros and cons of weight-loss drugs. Many patients do not understand that taking these drugs is a long-term commitment; stopping them usually results in regain of weight. In addition, research related to adverse effects is ongoing.
Build a comprehensive plan. The plan, which should be tailored to each patient, should include multiple strategies, such as food diaries, exercise, diet modifications, and weight-loss drugs. The idea that one needs only to cut calories or exercise more is incorrect and not supported by research.
Refer as needed. Some patients may benefit from referral to a specialist in weight loss or a mental health provider to address psychological issues contributing to the weight. Document referrals, including that needed patient information was shared with the consulting provider (after obtaining patient consent to do so).
Provide education. Educate the patient so they understand all aspects of the plan. If weight-loss medications are prescribed, cover topics such as side effects (see ‘Weight-loss medications consideration’), and if these drugs are not prescribed, explain why.
Document. Document completely in the electronic health record. Include items such as assessment results, patient discussions, details of the plan, and education provided. Note that the education was delivered in the patient’s preferred language.
NPs should also educate themselves about obesity and the challenges of weight loss. Seek out resources such as the “Talking with your patients about weight” section of the NIDDK website. Topics include how weight stigma affects patients, how to start a conversation about weight, and how to help patients make healthy lifestyle changes. There are also links to additional resources.
As with any treatment plan, ongoing follow-up is essential to assess progress and make refinements as indicated.
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Strategies for success
The wider availability of weight-loss drugs has helped many patients lose weight, so patients need to know about this option. However, it’s also important that patients (and providers) understand that the long-term effects of these drugs are unknown and that they are only one part of the treatment approach.
Providers also need to understand that obesity and excess weight do not comprise a “choice” by the patient but rather are conditions that deserve serious attention. By avoiding stigma, creating a comprehensive weight-loss plan, and keeping informed of developments, NPs and other providers can ensure patients receive optimal care and protect themselves from litigation.
Lynn Pierce, FNP-C
Senior Risk Management Consultant with NSO
REFERENCES
- American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. 2015. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
- American Society for Metabolic and Bariatric Surgery. Consensus statement on obesity. 2022. https://asmbs.org/resources/consensus-statement-on-obesity-as-a-disease/
- CNA/NSO. Nurse practitioner professional liability exposure claim report: 5th edition. 2022.
- Daub E. Are the new weight loss drugs too good to be true? UCSF Magazine. 2024. https://magazine.ucsf.edu/weight-loss-drugs-too-good-to-be-true
- FDA. FDA approves first treatment to reduce risk of serious health problems specifically in adults with obesity or overweight. 2024. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-reduce-risk-serious-heart-problems-specifically-adults-obesity-or
- Langmaid S. Prescription weight loos drugs: GLP-1.s, tirzepatide, and more. WebMD. 2024. https://www.webmd.com/obesity/weight-loss-prescription-weight-loss-medicine
- National Institute of Diabetes and Digestive and Kidney Diseases. Talking with your patients about weight. 2023. https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/weight-management/talking-with-your-patients-about-weight#benefit
- National Institutes of Health. Eating highly processed foods linked to weight gain. 2019. https://www.nih.gov/news-events/nih-research-matters/eating-highly-processed-foods-linked-weight-gain
- Rubino F, Puhl RM, Cummings DE, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 26(4):485-497. doi: 10.1038/s41591-020-0803-x
- Ryan L, Coyne R, Heary C, et al. Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis. Obes Rev. 2023;24(10):e13606. doi: 10.1111/obr.13606
- Westbury S, Oyebode O, van Rens T, barber TM. Obesity stigma: Causes consequences, and potential solutions. Curr Obes Rep. 2023;12(1):10-23. doi: 10.1007/s13679-023-00495-3
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