Approaches to achieve health equity in obesity management 

Employer health plan sponsors have good reasons to be concerned about obesity, which is linked to a number of serious conditions including diabetes, osteoarthritis, heart disease, and cancer. But because the prevalence of obesity – 41.9% overall in 2017 – varies greatly by race, education, age, location, and physical ability, it raises questions of health equity as well. According to the Robert Wood Johnson Foundation, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible.” Yet it is clear that not everyone has access to affordable, nutritious food and safe places to be physically active.

Addressing health inequities calls for an equity lens—a viewpoint that allows one to see both obvious and subtle injustices at work and to reject biases and stereotypes that blame people for circumstances that are beyond their control. Fully 80% of a person’s health outcomes are attributed to social factors and only 20% are influenced by the healthcare received. Clearly, focusing on social determinants of health (SDOH) – the conditions in which we are born, live, learn, work, play, worship, and age – should be a key component in efforts to address obesity. Here are a few suggestions for how employers, health plans, and providers can work together to have a positive impact.

Food, education, and environment

Food deserts – areas that lack suppliers of fresh foods – tend to be neighborhoods inhabited by low-income residents with inadequate access to transportation, which makes them less attractive markets for large supermarket chains. People on limited incomes tend to purchase fatty meats and processed carbohydrates that ‘fill’ yet may not nourish. Most people understand the importance of eating nutritious foods like fruits and vegetables and avoiding processed foods like chips and fast food. When you live in a food desert, however, this can be difficult to do.

• With weight management issues, it is important for providers to screen for food deserts and food insecurity – and, of course, providers and staff need to be aware of what these concepts mean, and how to talk about these issues in a respectful manner.
• Once a social need has been identified, the organization should have a process to make referrals to community-based organizations (CBOs) to meet those needs.

Obesity and diversity

Patterns of obesity prevalence include marked disparities by race/ethnicity. For example, compared to white adults (41.4%), Non-Hispanic Black adults (49.9%) have the highest age-adjusted prevalence of obesity, followed by Hispanic adults (45.6%). Social disadvantage means a greater likelihood of living in poor-quality housing and in neighborhoods with fewer services and limited options.

• Ensure that those disproportionately affected by obesity can benefit from preventive services
• Be mindful of the steps taken. Simply assessing and documenting disparities does not necessarily trigger deliberate or effective action to address them
• Ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis, and treatment
• Ensure food literacy, including skill development within education materials and practitioner/vendor sessions

Cultural competency and weight bias

Currently across most cultures, there is a value placed on thin or fit bodies. This type of body is associated with overall health. Individuals affected by obesity or excess weight frequently confront stigma and discrimination. These stigmatizing experiences can impair emotional well-being, leading to depression, anxiety, low self-esteem, and even, in extreme cases, suicidal behaviors. Unfortunately, weight stigma in the workplace, educational institutions, healthcare facilities, and other settings can lead to unhealthy behaviors and risk factors that worsen obesity.

Individuals living with obesity may receive inferior health care, and these patients are more likely to avoid routine preventive care as well. When patients feel stigmatized, they are vulnerable to low self-esteem and are less likely to feel motivated to adopt lifestyle changes. Weight bias is a form of discrimination and perpetuates inequity. Given the pervasiveness of weight bias among health professionals and its direct influence on the patient’s attitude toward clinical care, employers may want to ask their health plan partners whether they are addressing any of the following with providers:

• The detrimental effects of weight bias and actions providers are taking to ensure all patients receive equal and unbiased care they deserve
• Efforts to raise provider and staff awareness of other cultures as well as self-awareness of one’s own bias regarding weight
• Use of specific language guidelines; ask for permission to discuss weight, limit the use of the word obese or obesity during the patient-provider conversation and avoid labeling or identifying the person by their medical condition. And, use of people-first language such as, “there are many people affected by excess weight.”

Inclusive healthcare sessions

It is estimated that weight bias and weight-based discrimination may affect as many as 40-50% of individuals living with overweight or obesity. Studies utilizing self-reports found physicians view individuals living with overweight or obesity as lazy, non-compliant, or unsuccessful. Physicians are also noted to be the second most-common source of weight bias.

Conversations about weight tend to be very personal and sensitive to many patients. It is important for providers to reflect upon their own attitudes toward weight and obesity, to ensure they are equipped to provide compassionate care for patients who are seeking weight loss.

• Although BMI is a helpful tool, there needs to be some flexibility in identifying the risk associated with this measurement and the desired BMI for an individual member. This means that the desired weight may not fit into the traditional BMI category of “normal.”
• Educate providers to keep messaging positive and avoid scare or shaming techniques. Rephrase typical health advice to be more sensitive to avoid stigma. For example, instead of using the word “excuses,” try talking about strategies to minimize triggers. Instead of “discipline” or “self-control,” suggest ways to practice healthy habits as part of daily routines. Other words to avoid include “cheat” and “overindulge.”
• Use open-ended questions to elicit change talk during a visit, i.e., “How would you go about making this change if you decided to change?” “If you were successful with making a change, what would be different?”
• Meeting the complex challenges of health inequity and obesity will require healthcare purchasers, payers, and practitioners to adopt an “equity” lens that uses principles of social justice to acknowledge the realities of inequity – and design and evaluate interventions accordingly.