Chapters Transcript Weight Bias and Intersections with Racial/Ethnic Discrimination in Obstetric Care Course: Health Disparities in Obstetrics and Gynecology: Approaches to Understanding and Improving Care Um, I'm Kim Glazer, and I'm gonna speak today about weight bias and its intersections with racial and ethnic discrimination and obstetric care. So we'll start with a little bit about me. So I'm a perinatal epidemiologist and implementation scientist at Mount Sinai, and I conduct mixed methods research on perinatal quality of care, um, and maternal health disparities, and I have a specific focus on weight-related health and pregnancy, which is what I'll be speaking about today. Um, I include my positionality on this slide because I think it certainly impacts the way that I approach and interpret the research that I'll be talking about today. And I want to start with a motivating question. How can we move beyond merely documenting health inequities toward understanding and challenging the power hierarchies that undergird them? So this is a quote from a 2010 paper in social science and medicine by Ford and Arian Bua, and it's a call to action for anti-racist Public Health Research. And this quote also captures the objective underlying the research on weight stigma that I'll present today. So I'll give you a little bit of background of how I got here. Um, when I started researching obesity and pregnancy as an epidemiologist, I was overwhelmed by the robustness of the literature, you know, with paper after paper documenting a dose response association between higher BMI and pregnancy risks. And these associations are not fully explained by comorbidities and obstetric complications related to excess adiposity. So why? We must be missing part of the story. And thinking about this call to action, so understanding the problem and challenging it, what can we do to change these data? So too often, the recommendation that follows from perinatal obesity studies is intervention should target achieving a healthy weight prior to pregnancy, full stop. But we know how challenging it is to lose weight, and we know that most weight loss interventions are ineffective, and as we heard from Doctor Groman this morning, we know that cardio metabolic health is rooted in context, instructural and social conditions. And We don't really have much by way of preconception care in this country, and we know there's huge gaps in continuity of care between pregnancies. So this recommendation, putting everything on the individual. Pregnant person. It doesn't sit great. So how can we think differently about weight? And what changes do we need to make to practice to better support women and improve obstetrics experiences and outcomes. So I'd like you to keep those questions in mind throughout this talk. Uh, that go? OK, so this is just an outline of what we'll talk today. I'll give an overview of weight bias and stigma speaking then specifically about weight stigma and maternal health care. Uh, I'll discuss its intersections with racial and ethnic health iniquity, and do a highlight of um one of my ongoing research projects called Embody, and then I'll conclude with some unanswered questions and future directions that I promise I will try not to be too long, cause I know everybody is ready to go to lunch. Obesity is a complex health condition. It's defined by the abnormal or excessive accumulation of body fat that impairs health. So this graph shows data from the National Health and Nutrition Examination Survey or and Haynes, summarizing obesity trends over the past two decades. So overall obesity prevalence among adults, defined as having a body mass index or BMI of 30 or higher. Um, that's shown in the dark blue line at the top here. Overall, obesity prevalence has increased from 30.5 kg per meter squared to 40.242.4, um, from 1999 to 2000 to 2017 to 2018. In addition to overall obesity rates, rates of severe obesity or having a BMI of 40 or higher have also increased, and that's shown on the green line at the bottom, and both of these classifications show a significantly increasing linear trend over time. And there are significant disparities or differences in obesity rates according to sex and biracial and ethnic background. So you can see here, moving to this right hand cluster of columns on the chart that non-Hispanic black women, uh shown in light blue, have the highest obesity rates, 56.9%, and that rate is significantly higher than all other racial and ethnic groups, and it's significantly higher than non-Hispanic black men. There are also elevated rates among Hispanic individuals, not statistically significant in the Haines data, but it does vary depending on geographic location and higher rates in indigenous populations who are not shown on this graph. So these disparities are important to keep in mind throughout this talk. So I'm sure these data are not brand new information to anyone in this room. These rising obesity rates, and the disparities in the groups affected are a significant public health clinic and clinical concern. But the focus is typically on the pathophysiologic effects of adiposity itself, which is an important contributor to the burden of chronic disease and rising health care costs in the US. But what we're going to focus on today is the often overlooked issue of bias and stigma directed at people based on their weight and body size, and the implications of that bias and stigma for health outcomes and health equity. So I'll start by defining some related terms. Weight bias is negative attitudes uh held toward a person based on their weight or size. Weight stigma is the act of discrimination or stereotyping based on a person's side. And the word cloud that I show here, uh, it depicts, um, some of the common stereotypes of people with higher body weight. They're lazy, they're unintelligent, they're unmotivated, even that they're dishonest. So these stereotypes are prevalent, and they have real consequences for how individuals experience their environments and are treated in their daily lives. Today, weight stigma is one of the most common forms of discrimination, and Rebecca Poole, who's a prolific uh weight stigma researcher at UConn, um, she often describes weight as the last acceptable target of discrimination. And when people with obesity internalize this stigma, they apply the harmful rate related stereotypes to themselves. And as you can see here, over 80% of people with obesity in a national survey believed that they alone were responsible for weight loss. And the most cited reason that they gave for not seeking medical help was personal responsibility for their weight. So, signaling to people. That they're devalued because of their size. And that it's an individual level failure to be fat. It's counterproductive. To promoting healthy lifestyle behaviors and weight management. So this slide was adapted from a great presentation by Lee Kaplan at last year's meeting of the Obesity Society, and it illustrates the ubiquitous adverse effects of weight stigma. So moving clockwise through this figure, um, there are psychosocial implications of stigma, social exclusion, feelings of alienation, stigma is associated with higher risk for depression, and it's associated with chronic stress, which we know has important uh negative health impacts. There are physical consequences of experiencing stigma. It triggers obesogenic pathways and contributes to further weight gain. Um, experiencing stigma is associated with developing chronic illness, and it's associated with mortality independent of BMI. So a 2015 study in psychological science found that people who reported experiencing weight discrimination had a 60% increased risk of dying regardless of their body size. There are clinical consequences of weight stigma. There are weight-based disparities in screening practices and diagnosis and treatment and follow up. And there are economic implications. There are data that individuals with higher weight have fewer employment opportunities, lower pay, and face barriers to promotion. So this slide shows what's called the cobwebs model or the cyclic obesity weight-based stigma model, and this characterizes weight stigma as a vicious cycle of weight gain, whereby stigma causes stress, which can cause increased eating and cortisol release and further weight gain. So this cycle is critical to understanding the chronic. The effects of chronic social stress on weight related health, and in 2018, the creator of this model, Janet Tomiyama and her colleagues, they published an opinion piece in BMC Medicine, where they argued that bias against fat people is actually a larger driver of the obesity epidemic than adiposity itself. Weight stigma in health care settings. It's common. Um, in fact, in a survey of US adults, um, respondents named healthcare providers as one of the most common sources of stigma that they experienced. Um, and medical students also when surveyed, you can see on the each of the data points here about 40 to 65% of medical students in this, uh, fairly large survey, they reported that they heard instructors, peers, or other healthcare providers speaking derogatively about individuals because of their weight, making negative, you know, comments or jokes about people with obesity. And this has detrimental effects on healthcare engagement. Patients who feel stigmatized are less likely to complete healthcare appointments and adhere to care guidelines. So the table on this slide is from the action study, and that surveyed patients, healthcare providers, and employers on their weight-related attitudes and perceptions, and respondents were asked to what extent they agreed that the following factors listed um in the rows of the table are barriers to initiating weight loss efforts. So, you can see here there's a disconnect in the perceptions by stakeholders, particularly in what I bracketed in blue here. Healthcare providers and employers were more likely to agree that things like lack of exercise, lack of motivation, and a preference for unhealthy foods were barriers to initiating weight loss efforts, and that Aligns to some of the norms and the weight loss in the pharmaceutical industries, um, with some medical professionals, not all, some medical professionals, health and wellness companies, the media, often perpetrating messaging that individual level solutions like dietary control are the solution to this health problem. But you can also see if you look at the column for PWO where people with obesity. There are clearly factors missing in individuals with this lived experience. The only real contextual factor listed here is cost of healthy food. And perhaps things that describe an individual's environment and opportunity for health, factors like food insecurity, lack of safe and walkable neighborhoods, um, inflexible work schedules, psychosocial stressors, things that describe the context of their lives may be salient barriers that are missing from this slide. Now focusing specifically on weight stigma and maternal health care, there are multiple reasons that pregnancy and postpartum may be times of heightened exposure and susceptibility to weight stigma. There are frequent medical visits during prenatal care. It's a time of heightened engagement with the health care system. It's a time of a lot of body changes and weight monitoring. Typically you go in for your prenatal visits, one of the first things you do is step on the scale. There's also a lot of scrutiny on the pregnant person's health behaviors, their dietary intake, their medication use, and a lot of prenatal messaging and guidance focuses on fetal risks. So this does have the potential to perpetuate blame on the mother for any negative outcomes that arise. And then postpartum, we know there are a lot of weight concerns and pressures to lose the baby weight. So, this is a time when I think it's really important to think about how weight related health and particularly how our social ideas around weight may impact experiences and outcomes in pregnancy. Um And there are some studies that have examined how stigma may manifest in the obstetric setting. So in one, researchers analyzed audio recordings of prenatal encounters, um, and they found associations between provider communication and patient body weight. They found that providers asked fewer lifestyle questions and gave significantly less lifestyle information to pregnant patients with obesity versus normal weight. And they also surveyed the prenatal care providers, and they found that the providers were less likely to strongly agree that patients with obesity provided accurate health histories, and they were even less likely to strongly agree that they liked patients with obesity. And so There is an emerging literature on weight stigma and body image in pregnancy that shows associations with psychosocial well-being that are similar to what we see in the general population, depression, maladaptive eating, and weight gain. And there's some evidence um that there may be lower rates of initiation of breastfeeding among individuals with high levels of body concerns. Um, one study found that higher weight bias internalization was associated with increased risk of gestational diabetes, and in fact, the association between weight bias internalization and gestational diabetes was stronger than the association association for BMI. And I, I want to be clear, the maternal and fetal risks associated with excess weight are real, and they present real clinical and public health challenges. I would not want you to come away from this talk, thinking I'm arguing otherwise or downplaying the complexity of obstetric decision making in the setting of real medical risks. But the potential for weight bias and stigma to influence care practices is also real, and there are important gaps in our understanding of how to facilitate individualized, risk appropriate patient centered care in the context of obesity. So now that we've reviewed weight stigma in healthcare in general and specific to pregnancy, I'm gonna set the stage for talking about um the embodied research study by briefly discussing how perinatal weight bias and stigma intersect with racial and ethnic inequity in maternal health. I'm not gonna go into this in detail because we've uh talked about it in many of our talks, but I will note the literature on racial and ethnic health disparities has come a long way in acknowledging racism as a root cause of the maternal health crisis in the US, and this is a paper by one of my wonderful colleagues and. Our team, um, on, uh, it's a conceptual framework in their systematic review of the influence of racial and ethnic discrimination and healthcare outcomes and how it manifests in provider bias, patient perceived discrimination and differences, um, in interpersonal differences that result in different care. And the result of racism in maternal health care is reflected in this graph, which is just 11 depiction of the inequities that we now appreciate, um, and know exist. And so this depicts pregnancy related mortality ratios by race, ethnicity, and educational attainment. And black and indigenous people have the highest rates of pregnancy related mortality, that's shown in green and in pink. But what's particularly alarming is what Doctor Groman alluded to in his conversation, that not only are black and indigenous women more likely to die a pregnancy related death, um, than individuals of their same educational attainment, um, they're more likely to die a pregnancy related death, regardless of their level of education. So, Black college graduates are more than 5 times likely to die than white college graduates, and they're more likely to die than white individuals with less than a high school education. So, figures like this have been critical in driving home the message that racism and bias cause preventable maternal deaths. And so bringing together these two threads, we've talked about, weight and body size and race ethnicity, we see these being two sources of discrimination in health care, and in both cases, these biases perpetuate adverse health outcomes. So intersectionality, which is depicted on this slide, is a theoretical and analytical framework that acknowledges that no person has one single essential identity, um, but rather multiple identities that are experienced simultaneously and reflect interlocking systems of privilege and oppression. And so the power wheel on this slide depicts marginalized identities of birthing people, and this was done by um Veronica Barcelona in her recent um Green Journal paper, that's really fantastic to read on the power of language and obstetric care. There's very little intersectional research on weight stigma experiences and internalization. Most studies on body image have been conducted among majority white populations, and there is a common misperception that body concerns are not prevalent among black and brown individuals. So the embodied study was motivated by this gap in understanding perinatal weight stigma among racially and ethnically minoritized groups who face both higher obesity rates and multiple marginalized identities. And EOI stands for engaging mothers in a study of body size and stigma, and there's my little logo that I created, so. So our objective was to examine weight stigma and obstetric care among racially and ethnically diverse individuals with obesity. This was a qualitative study, um, we more specifically aimed to understand how participants felt about their bodies, influences on their body image. How stigma manifested in prenatal delivery and postpartum care experiences, and then to tease out potential differences across racial and ethnic groups in the source, nature, and internalization of stigma. So we conducted 5 racially concordant focus groups, one each with individuals who identified as non-Latina black, Latina, Latina and Black, South Asian and non Latino white. We included individuals who gave birth in one of our two New York City study hospitals, um, within 1 year, less uh 1 year prior to recruitment, and they had a self-reported pre-pregnancy BMI of 30 or higher. Um, we created a semi-structured, uh, topic guide, and, uh, recorded our groups and transcribed them, and then engaged in both deductive and inductive qualitative content analysis, where we created a start list of key categories and concepts that were deductively identified from theory and previous studies and then engaged in an iterative feedback loop. Um, throughout data collection and analysis, where we adjusted and modified our codebook, finalized it, tested it on a sample of transcripts, coded all the transcripts, and then synthesized and compared across groups. So our results Uh, it merged along two overarching categories, the first of which was stigmatizing cues. So I'm gonna show you three subcategories of stigmatizing cues, and then talking about patterns in these results across the groups. So, the first is stereotyping in healthcare encounters, which reinforce, don't read the quote yet, which reinforce, I'll give you a minute to it. Uh, which the stereotyping reinforced social stereotypes that individuals experienced in other areas of their lives. And so this theme specifically centered on providers making assumptions about a patient's lifestyle or health risks, a patient feeling labeled, and then feeling like that label drove the information, the referrals, and the care that they received. So now, I'll give you a minute, and you can read the quote. The next main subcategory was negative weight focused communication and its impact on the patient-provider relationship. Read this quote. And then one of the final, the final key category that I'll show you today is pressure to snap back postpartum. Um, so snap back is an inductive quote, it reflects the participant's own words, and this pressure came from multiple sources, particularly family and then peers in the media. And participants describe contending with these expectations without having adequate support to prioritize their own well-being, especially in the initial um weeks and months postpartum. I'll summarize just a few of the patterns that we noted and how these categories emerged across racial and ethnic groups. Um, for example, there was a lot of discussion in the focus group with black individuals about generalizing based on BMI. They wanted to hear more recognition that people have all different body shapes and sizes and carry weight differently, um, and that having a larger body is not always a problem. Um, as one black participant told us, um, you can be slim and still have complications, so don't just make assumptions about me. Um, patterns in across our groups also suggested how the nature of body ideals and expectations in pregnancy and postpartum may reflect underlying cultural norms about the female body. So in both the Hispanic or Latina and the South Asian focus groups, participants emphasized social pressure to snap back to their pre-pregnancy weight. They spoke of wearing pressure garments, um, they spoke of wanting plastic surgery or the mommy makeover and really internalizing pressure from family members um to lose the baby weight. In this slide lists common findings from studies of racial bias and discrimination in maternal health care. So you can read this list, and what I'd like to point out is that all the themes listed here were raised in our embodied focus groups. We heard them to some extent across all our groups. And so, this overlap and biases related to weight, and related to race and ethnicity supports the importance of an intersectional lens in working to address the potential double burden of bias among minoritized pregnant individuals with obesity. The second category was protective factors against internalizing, oops, internalizing stigma. So the first was ways in which participants fostered gratitude for what their bodies were able to achieve in pregnancy and birth, and this was especially helpful for participants in counteracting unrealistic expectations about their bodies, and to foster confidence and be kinder to themselves. And the second is being treated as a whole person versus being defined by their BMI. So participants spoke positively when care experiences addressed multiple aspects of their lives, their medical history, their work and family structure. They spoke about how there are so many challenges during and after pregnancy, and so it goes a long way to recognize that everyone's doing their best in their individual circumstances. So, particularly in the postpartum period, we heard, weight is one aspect of my life as a new mother, and I know it's important. But it may not be my top priority right now. So these kinds of opinions, it's important to take into account when we're thinking about how we craft our weight management and lifestyle interventions and think about meeting people where they are with support may go a long way in setting them up for longer term success in weight management. Briefly, the strengths of the study, um, the qualitative methods that allow for participants to describe their experiences, and the meaning that they make of those experiences in their own words, our intersectional design and racially and ethnically concordant focus groups, and we had a study team with really diverse. positionalities. Um, limitations, uh, we had a fairly small sample limiting comparisons across our racial and ethnic groups, and of course, there was potential underreporting of negative experiences as they were speaking to researchers at Mount Sinai, which is where they got their care. So in conclusion, people with obesity experience stigmatizing obstetric encounters that sit at the intersection of weight-based and racial and ethnic stereotypes. And perinatal interventions that promote body appreciation and address multiple sources of stigma may improve quality and equity in maternal care. And in our next phase of research, we're um doing a larger qualitative study to probe the racial and ethnic differences suggested by our focus group data. And the last I'll talk about are just a couple of unanswered questions and future directions. First, what to do with BMI? There is a lot of discussion around what to do with BMI. On the one hand, it's a simple and easy to calculate measure. Um, it can be a really useful epidemiologic tool. But it has questionable generaliability across diverse populations and limitations as an individual level clinical tool. So it's utility varies across purposes. It may be useful for screening, but less so for diagnosis. And so the question is, what is the goal of using BMI and is BMI a complete measure for that goal? There are also new obesity chronic care models and diagnostic frameworks coming out um that provides staging approaches based on anthropometric measures like BMI and then the presence of cardio metabolic, biomechanical, and psychosocial complications. So, similar schemas have not been tailored for obstetric populations and may be useful in developing clinical goals and obstetric management plans for diverse patients with obesity. Next critical question, I think, is how do we change the blame game? And when I talk about the blame game, I don't just mean blame on patients. I mean blame on patients and providers. So we speak about provider level biases and practice differences, but provider competencies, attitudes, training needs around weight related health are vastly under research. So why are there barriers in communicating about weight? Where are the training gaps? What tools are missing to facilitate more productive conversations? And also, I think there's a lot to be gained from thinking about how we can integrate both body appreciation and body positivity and weight management, which are two movements or fields that are often pitted against each other. They're not mutually exclusive, and I think integrating them could actually have some real benefit for our patients and maybe move the needle a bit on the effectiveness that we see of our interventions. And then finally, oh, and GLP ones I just put a bunch of question marks because we do not know right now. And then finally, I would just echo and urge what we're hearing about today. Research that addresses the root causes, and in this case, research that addresses racism, sexism, and weightism. Because only by understanding and intervening on these root causes, will we move from merely documenting disparities to deploying solutions. Um, I want to acknowledge my amazing study team and my mentors, um, the Doris Duke Foundation and ISOMS for a, um, for funding that supported this work and my research institute. Thank you all. Published May 3, 2024 Created by Related Presenters Kimberly Glazer, MPH, PhD
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