Health Care Bias May Affect People With Obesity and Type 2 Diabetes

Young doctor visiting her senior patient at home. Medical worker checking blood sugar test to hers diabetic patient
Almost 40% of adults with obesity are discriminated against because of their weight. A study from Brazil investigated whether a bias toward people with obesity who also have type 2 diabetes receive different care decisions from health care professionals as well.

People with type 2 diabetes (T2D) and obesity frequently do not receive pharmacologic treatment intensification when necessary, researchers reported in Diabetes Care, adding that this discrepancy may be due, in part, to a “cognitive bias” of health professionals toward people with both obesity and type 2 diabetes.

“Weight-based stereotypes may interfere with health care decision-making in these patients,” the researchers said.

A cross-sectional study evaluated the prevalence of pharmacologic diabetes treatment intensification based on weight status in patients with type 2 diabetes. The participants received outpatient care in southern Brazil from October 2011 to December 2019.

Eligible participants had a regular follow-up for ≥1 year, were aged ≥18 years, and had ≥2 measurements of glycated hemoglobin (HbA1c) in the study period.

The patients were randomly selected and then stratified into 2 groups according to their body mass index (BMI)—obesity (BMI ≥30.0 kg/m2 ) and without obesity (<30.0 kg/m2). The primary outcome was the adequacy of pharmacologic treatment intensification between the groups based on individualized glycemic targets.

A total of 402 participants (mean age, 66.9 ± 9.1 years; 56% female; 86.8% White) were included. Participants without obesity (n = 198) and those with obesity (n = 204) had mostly similar baseline characteristics. Patients without obesity were older than those with obesity (68.7 ± 9.0 vs 65.2 ± 8.9 years, respectively, P < .001), and fewer used insulin (49.5% vs 66.7%,respectively, P < .001).

The investigators found that 43.4% of participants without obesity and 46.6% with obesity presented with an HbA1c level greater than the target (P = .53).

Regarding patients who received pharmacologic treatment intensification when their HbA1c level was higher than the target, those without obesity more frequently received treatment intensification vs those with obesity (67.4% vs 53.7%, respectively, P = .05).

In a sensitivity analysis that considered HbA1c ≤7.0% (≤53 mmol/mol) in participants aged <65 years and without major comorbidities, 15.2% of those without obesity and 25.0% of those with obesity did not receive treatment intensification when indicated (P = .01).

Adjusted analyses for complexity of care level, age, HbA1c, hypoglycemia, insulin use, and hypertension also demonstrated that patients in the obesity group more frequently failed to receive pharmacologic treatment intensification when required (odds ratio 1.87; 95% CI, 1.02-3.45).

“Our findings suggest that patients with obesity may have some of their disease aspects neglected and that the limits of glycemic control in patients with type 2 diabetes and obesity are more permissive, which reflect the need to carefully revisit therapeutic decisions in these patients,” the investigators stated.


Alessi J, de Oliveira GB, Nunes Erthal I, et al. Diabetes and obesity bias: are we intensifying the pharmacological treatment in patients with and without obesity with equity?  Diabetes Care. Published online October 8, 2021. doi:10.2337/dc21-1294