Oby: From the campus of Harvard Medical School, this is Think Research, a podcast devoted to the stories behind clinical research. I'm Oby.

Brendan: And I'm Brendan. And we're your hosts. Think Research is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center--

Oby: --and by NCATS, the National Center for Advancing Translational Sciences.

Brendan: As one of the first fellowship-trained obesity medicine physicians, Fatima Stanford understands how the biases in the US around weight impact her patients. Dr. Stanford prioritizes people-first language, patient advocacy, and public policy to bring a broader understanding of discrimination to Massachusetts legislators and the community at large. On today's episode, Dr. Stanford discusses how language reflects negative perceptions of people with obesity and her unique research aimed at understanding how lawmakers view anti-discrimination legislation.

Fatima Cody Stanford is an assistant professor of medicine and an obesity medicine physician at Massachusetts General Hospital and Harvard Medical School. Dr. Stanford, thank you very much for joining us. Welcome to Think Research.

Fatima Cody Stanford: It's a delight to be here.

Brendan: You received a pilot grant in 2018 from Harvard Catalyst to look at weight discrimination laws. What are some ways that weight discrimination manifests and what are the impacts?

Fatima Cody Stanford: Absolutely. So first of all, thanks for having me, [inaudible] you. And I really want to talk about this issue with regards to weight discrimination and its myriad of impacts.

So we'll look at it from several different lenses. Number one, we'll look at how it affects hiring and hiring practices. Number two, we'll look at how it impacts health care delivery and the level of care that one is able to receive. And number three, we'll look at just overall health impacts of weight discrimination.

So first, let's look at health-- or weight discrimination in hiring. What we see is that persons that have excess weight do face significant scrutiny when they go out for jobs and positions in all areas, whether it be health care or tech or education. People make value judgments about who they are, what their value and worth is to their work, based solely upon their size.

This is unfortunate because they're not being evaluated based upon their value, their worth, their education, their credibility with regards to their work, previous work they may have done. They are being evaluated solely based upon their size. This is something that I've seen dealing with patients that have this disease of obesity.

I'd like to highlight one of my patients who came in to see me when she carried about 200 pounds in excess weight. What was interesting about this interaction is that she went into a local retailer to try to get hired for a position. She was told very quickly that she was not qualified for the role.

She began to work with me as an obesity medicine physician scientist here at Mass General. She was able to lose quite a bit of her excess weight, went into the exact same retailer with the exact same hiring manager three years later, and was hired on the spot. This particular patient felt empowered after she was hired to go and speak to the hiring manager to express that she had indeed not done any additional training, not gotten any additional skills, and that she was indeed this exact same person that came in for the exact same role, and how she really hopes that her story of how this impacted her would hopefully benefit those that came behind her.

Second, let's look at what happens when a patient has obesity and they seek care in the health care setting. What we find is that they may face issues with discrimination from the time they walk into the doctor's office. Maybe they receive snickers or laughing from behind the counter at the people that are checking them in. Then they go to be weighed, and they feel as though people are judging them in that setting. So before they even get back to see me as a physician, they face several layers of scrutiny about who they are, their size, their value, and their worth. By the time they get to me, you can imagine that they're probably dismayed about the treatment they've received.

But unfortunately, physicians and other health care providers are the source of significant bias. We presume it's the patient's fault, something they did wrong to be the way they are. And we place value judgments on what their level of adherence would be secondary to their size. This is problematic.

And what we do know is that this weight discrimination, this weight stigma and bias, actually leads to poor physiologic health. When we evaluate those that internalize that bias that they receive in the health care setting, they have higher hemoglobin A1Cs, which means their average blood sugar is higher. They often have higher blood pressure. They have higher levels of inflammatory markers like cortisol or CRP, which is C-Reactive Protein. This actually affects their health.

And it also affects their psychological health. So we see a higher level of depression, anxiety, and unfortunately, suicidality, associated with weight discrimination that may be experienced in the health care setting. That's indeed unfortunate because the place that patients go to seek solace, to seek care, is the health care setting. And if they're not getting that care within the health care setting, then we're failing them as providers, as physicians. And that's unfortunate.

I think those are some of the key things that I want to really capture when we're thinking about weight discrimination and its impact on individuals. And this is part of why I sought this particular work, to get a sense of what's being done at a legislative level to impact what's happening with individuals that are my patients throughout their entire scope of their life.

Brendan: You're talking about pretty blatant discrimination, and based on somebody's physical characteristic and based on what's considered in the medical field a disease.

Fatima Cody Stanford: Absolutely.

Brendan: And there are laws about discriminating based on disability and race and gender, but not so for weight. So I was wondering-- there are some laws. But I was wondering if you could just talk about what laws exist now in the US to combat weight discrimination.

Fatima Cody Stanford: Absolutely. So first of all, the only state to ever pass a law to really look at weight discrimination is the State of Michigan. Back in the late '70s, they passed what's called the Elliott-Larsen Act. And this particularly gave some protection against discrimination based upon weight and height.

Now, my presumption with why that passed back in the late '70s was because in this bill, they also included other protections. So it was protection against issues with regards to race and ethnicity, and also with regards to gender. So all of this was in one large bill. It wasn't just a bill itself or an act just itself to look at weight and height. It was bundled within that particular bill, and so did pass the Michigan legislature in the late '70s. We have not seen any other state come forward and actually have an actual bill that is passed that speaks to the same issue.

Different cities, however, have looked at this issue. So for example, if you're looking at San Francisco and Santa Cruz, Binghamton, New York, they do explicitly include weight as a protected category of individuals. You have Washington, DC, you have Madison, Wisconsin and Urbana, Illinois, that provide protection against discrimination based on physical appearance, physical or personal appearance. So there are some states that have tried to do this.

The reason why this was particularly germane to the work here in the Commonwealth of Massachusetts is that Massachusetts has been considering anti-weight discrimination legislation for the last 13 years. So every year, it somehow never quite makes it across the finish line. In this current legislator, there are two bills that are before the House for consideration. There's a Senate bill 2495 and a House bill 3413, which have received support from Senator Rausch on the Senate side and Representative Nguyen then on the House side. The problem is that COVID-19 happened. And so while this had made it out of committee for the first time ever, it's unclear where this bill lies in both the House and Senate side here in the Commonwealth.

But it was favorably voted out of the judiciary committee to the ways and means committee for the first time. So there is promise, in the fact that there is a continued dedication amongst the legislators here in the Commonwealth, to make this a reality. But as you can tell with the number of years that it has been an issue and not yet made it across the finish line, that there are obviously some potential barriers, maybe even some biases that may lend itself to why it has not yet passed.

Brendan: Mm-hmm. Yeah. You mentioned that COVID-19 threw a wrench into this bill-- or these bills getting voted on.

But they had been circulating for, you said 13, years before that. And you mentioned the maybe possible biases of legislators. And I think the research study-- or this pilot study that you received a grant for is trying to get at what those biases may be. And it's a little bit different from a typical research grant. I wonder if you could just quickly describe how this pilot project works and what your aim is with this research, how you're conducting the research.

Fatima Cody Stanford: Yeah. So actually, what we did was we paired with several organizations to basically go and educate the legislators and their staff about weight bias and stigma. So right literally before everything closed in the Commonwealth, we did hold a program at the state house, where we actually went in.

I gave a talk. Others gave talks. Persons that have obesity that may have experienced weight discrimination spoke. And we taught them about weight discrimination, bias, its impact from a patient perspective, obviously from my realm, and then obviously from a person-level perspective, those that aren't necessarily thinking in the health realm, that are persons that have experienced these types of inequities.

At that time, we also administered a survey. So we got a sense of some of the things that the legislators might be thinking, but also their staffs, recognizing that the legislative staff plays a large role in the lawmaking process. We asked questions such as, in the USA, those targeted because of their weight suffer discrimination. Many of the legislators and their staff believe that to be the case.

Many disagreed with the following statement, "Those categorized because of their weight can wish away the social label given to them." So there are some things where they appear to align. Now, keep in mind that some of these people may have taken this after their education, which may have influenced some of their responses. But there were still biases that were noted amongst the legislators and their staff with regards to weight discrimination that were pervasive in the study.

The reason why we thought it was important to talk to legislators is I can talk until the cows come home, I guess, about obesity and weight discrimination. But until it becomes law, we don't really see it having major impact unless individual employers, for example, or individual health care providers decide to really take it upon themselves to do the work. When it becomes part of the law, they are in some ways forced to do the work whether or not they want to or not, and then we begin to see downstream change and impacts on those that struggle with this disease of obesity. So hopefully that gives some idea or understanding to what our goal was. Our goal was to go in-- just educate legislators and their staff, survey them about what they believe to be true, and then ascertain how we could maybe make some changes with regards to that.

Brendan: I think the language is really important. And you talk about people with obesity, not obese people.

Fatima Cody Stanford: Mm-hmm.

Brendan: So I wonder if you could just talk about how language is important here and maybe just describe how you approach that and how people with obesity approach language.

Fatima Cody Stanford: Absolutely. So I'm a strong advocate, and have been a international advocate, of the use of people-first language. And what that means is that patients have the disease of obesity. We acknowledge it for the disease and the pathophysiology and the complexity that it is. We also recognized that it is a chronic, relapsing, remitting, progressive disease process.

When I call someone "obese," that is a label. That often comes with a lot of stigma, a lot of bias. It precludes the level of quality care that I deem that I provide to my patients.

And so we want to get away from the terminology that can cause significant disdain, distress, amongst patients. So a better terminology would be "a patient with obesity." "A patient with mild, moderate, or severe obesity" is a more accurate description than "an obese person with X."

Or often, I look at clinical notes, and I'll see "someone with an obese abdomen." That really sounds not very lovely. A better term on the clinical side would be "someone who has central adiposity," adiposity meaning fat tissue, and located in the central region, for example, in the stomach region. You can see that it gives much more descriptors without being inflammatory to an individual.

Along these same lines, I'm very careful about the use of the word "morbid." So a lot of times, you'll see "morbid obesity," which is another label. And I think it's highly stigmatizing and doesn't really capture what we're trying to discern. We're trying to say that this person has very severe obesity, which is lending itself to poor health outcomes, more sickness, and a higher likelihood for death.

But we don't use that "morbid" term to describe any other disease process despite the fact that other disease processes cause morbidity. So we don't call it "morbid cancer" or "morbid heart disease" or "morbid diabetes." So you can see that even in the language that we've been taught to use about persons that have obesity, that it's an inflammatory-- it promotes weight bias and stigma. So we encourage that use of that people-first language, again, "people with obesity," "people with mild, moderate and severe obesity," "a patient with obesity," instead of labeling them with a negative label.

Brendan: Yeah. You mentioned that you thought it was important to actually talk to legislators because they're the ones making laws and you felt like that was more effective than talking about it maybe in the form of a public service campaign or something like that. And I wonder if you could just talk about your views on how your role as a clinician and a scientist intersect with your role as a policy advocate or someone who is trying to influence policy.

Fatima Cody Stanford: Well, I think, first of all, it's interesting that I have done degrees in all of the policy, public health fields. So my first advanced degree actually was my master's in public health, which I received almost 20 years ago, and really was how I got my entree into work in the public health sector. But while I was in fellowship, completing my obesity medicine fellowship here at Mass General and at Harvard Medical School, I did my mid-career degree at the Harvard Kennedy School of Government directly in policy. And the reason why I sought to do that work at that given time was my recognition of, the work that I do as the clinician does not-- I'm not able to do the work unless I have the laws to help protect the work that I'm doing.

So for example, one of the big bills that we've been trying to get through US Congress is called TROA, which stands for the Treat and Reduce Obesity Act. This particular bill, that has strong bipartisan support, but does not have, I think, the necessary omnibus to make it over the hump to actually passing, is really set to look at two different things, number one, behavioral coverage for the treatment of obesity, meaning work with people like dietitians, and number two, the coverage of pharmacotherapy, meaning medications used to treat obesity. One of the major frustrations that I have in caring for patients that have obesity is not the care itself that I'm able to deliver, but the fact that I have to govern my treatment decisions based upon what I'm able to get for the patient.

So I may feel, for example, that work with a dietitian is something that's really desirable and needed. Unfortunately, that won't be covered by many insurance plans. They only decide to cover work with dietitians once a patient has actually developed diabetes. So their obesity is not enough. You have to wait until they get a pretty significant chronic disease for them to get coverage, which I think is unfortunate for patients.

Number two, for medications-- many of the medications that we could utilize to treat the chronic disease of obesity, we can't get access to because of coverage issues. I might know that X medication or Y medication might be good choices for me to utilize with a patient that has obesity, yet I can't get them covered. So it is prudent for me, knowing that on the clinical side, to utilize that knowledge to then educate and inform legislators about the inadequate care that patients are getting at all levels here in the United States with obesity, recognizing that only 1% of patients that meet criteria for, let's say, bariatric surgery get access to such care, and only 2% of patients that meet criteria for the use of medication for the treatment of their obesity get access.

Those numbers are quite low. We're talking about a total of 3%, keeping in mind that 42.4% of US adults have the disease of obesity, so a pretty sizable, over 100 million individuals. It's unfortunate that we're not doing a better job for our patients. But the job I'm able to do for my patients really hinges upon what policies exist to support them [inaudible] label.

Brendan: Thank you. Yeah, that's great. And I wonder-- you talked about 42% of Americans could be categorized as having obesity. And I wonder if you could just talk about the way-- there's some discussion or controversy about the body mass index chart.

There are people who maybe in terms of body mass index would be considered to have obesity, but they're tall and they're heavy because they're athletic or whatever the case may be. And they're heavier than the average, but by all measurements are healthy. So could you talk a little bit about is there anything going on in this realm to make this less stigmatizing?

Fatima Cody Stanford: Yeah. So I think that looking at BMI-- so BMI takes into account height and weight, but doesn't tell you much about what height-- or I would say the height is the height. It doesn't tell you what kind of weight one has. So maybe someone has a medical issue where they have fluid overload as opposed to adipose, which is fat tissue. And there's no distinguishing that when you look at the BMI, which just takes into account height and weight.

So the World Health Organization, the Centers for Disease Control and Prevention, use this BMI chart to classify people. I do think it's a pretty good population-wide measure. So when we talk about that 42.4% of US adults that have the disease of obesity, I think it is a pretty decent representation. But when you're working with individual patients, it's important to recognize there are significant nuances.

I pay attention to where weight is distributed. That tells me a lot more about someone's metabolic health than actually the number on the scale. So if they carry a lot of that central adiposity, that weight that's carried in the midsection, then that's when I'm concerned.

Because when you carry that central adiposity, it's around all of the major vital organs. It's around the heart, it's around the lungs, it's around the liver. And these things can lead to significant other disease processes.

Now let's say someone carries more of their weight in the hip, buttock, and thigh region, mostly underneath the skin, what we call subcutaneous adipose tissue. That doesn't lend itself to a poor health outcome. So I have to pay attention to the whole person. And I can tell you that my patients do get waist circumference measurements at all of their visits so I can really pay attention and hone in on that weight that tends to be problematic, that weight that's carried in the midsection. So it's important for, when you're working not just at the population level but with individual persons, to think about what's going on with them and their overall metabolic health.

Unfortunately, there are not many people that fall into these highly-athletic builds that really push them slightly over into a category of having obesity. There are so few that actually have that degree of athleticism for that to be a major issue. But for example, I published a paper that came out in the Mayo Clinic Proceedings last year where I actually redrew the BMI lines based upon gender and the major racial ethnic groups here in the United States, non-Hispanic white, non-Hispanic Black adults, and those that are Hispanic in origin. And I defined it based upon major obesity-related diseases such as diabetes, hypertension, for example.

What I did find in looking at all of the NHANES, which is the National Health and Nutrition Examination Survey, data was that the lines did draw differently when you looked at the most current data, keeping in mind that the BMI chart has been around for quite some time, and not necessarily reanalysed with current data based upon the NHANES. And so what I found was for all men across the three main racial ethnic groups in the United States, actually, the BMI curve has shifted down. So 30, which is typically the cutoff for someone having obesity, no longer becomes the cutoff. The cutoffs are sometimes 27 or 28 when you actually look at the current data in terms of the risk one might have associated with obesity-related diseases like hypertension or diabetes.

For Black women, interestingly enough, the group that has the highest rates of obesity here in the United States based upon the BMI guidelines, it shifts up slightly from 30 to somewhere between 31 and 33. But notice that 30 to 34.9 is mild obesity, so even with the shift, not a dramatic shift. So while it may reclassify a few people or some portion of the population, probably not a sizable number. And so like I said, the BMI is not the end-all, be-all for evaluating one's status in terms of their weight and metabolic health.

My patients can tell you that I never give them a target weight, although they ask me every single visit for many years. I will look at their response by how much excess based upon BMI their loss, the percentage, and then how much total body weight their loss. And I use them as their own reference point. I don't compare them to their sibling or to their spouse or to whomever else.

I let them know that their body is the answer key to the problem, meaning I have to try different modalities to figure out what works for them. But I'm thinking of them as an individual and not thinking of them compared to the patient that came before them or the patient that comes after them. And I think that that sets up a healthier relationship than a hyper-focus on getting to X number for weight, recognizing that there's such significant heterogeneity in us and individuals and how we respond and our weight distribution, that one solid number based upon a height and weight often will set itself up for deleterious views of oneself and maybe deleterious behaviors, such as maladaptive eating practices and things of that sort.

Brendan: Mm-hmm. So to finish up, maybe we could get back to the study, and you could just talk a little bit about based on the research that you've conducted-- and I know there is some interruption because of the COVID pandemic. Based on what you've done with the legislator interviews and the survey, what do you see as the hopes for getting this legislation passed? And if it is passed, what do you hope the impact would be here in Massachusetts?

Fatima Cody Stanford: Mm-hmm. Well, I think that with the-- we were able to get through all of our work, for the most part, despite the COVID-19 pandemic-- that people hopefully have some awareness, although I don't know if this is at the forefront of their mind in the midst of the pandemic. I would hope that the pandemic has highlighted the need to really focus on issues surrounding obesity. Obesity was found to be a major risk factor for COVID-19 morbidity and mortality. So I'm hoping that there's a heightened awareness surrounding how this may affect individuals here in the Commonwealth.

I think that maybe a reintroduction or re-invigoration of the work that we did literally two days before the entire state shut down is always going to be welcome. And as an individual who's committed to this work and happens to live less than maybe eight minutes' walking distance from the Massachusetts State House, that I will welcome the opportunity to continue the work that we did prior to the pandemic, and getting those to see why this is important and see how much of a percentage of the population is really impacted by this work.

I would hope that I don't have additional stories to tell about my patients that have faced discrimination for hiring practices or in the care that they receive, which is, I think, quite egregious, I think, for them, especially within the health care setting, to have to face these issues. That's what my hopes are with this work and why I continue to commit myself to what's being done here at the state level here in the Commonwealth of Mass, and also continue my work to advocate strongly for the TROA Act that we talked about, the Treat and Reduce Obesity Act, in the US House and Senate.

Brendan: Dr. Stanford, thank you very much for joining us. It was a pleasure to have this conversation with you.

Fatima Cody Stanford: Thanks so much for having me.

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Oby: To learn more about the guests on this episode, visit our website, catalyst.harvard.edu/thinkreserach.