3 Ways Weight Stigma in Medicine Harms Patients’ Health

*Trigger warning- This blog post uses the words “overweight” and “obesity” in the context of discussing medical care and research.

patient in a larger body experiencing weight stigma from their doctor

Current US Preventative Services Task Force guidelines recommend that clinicians weigh their patients to screen for obesity1. Their goal is to intervene early and offer behavioral interventions to those with a BMI greater than 30 kg/m²1. However, these recommendations have placed a heavy emphasis on our patients’ weight as something that “must be fixed”. As a result, weight stigma has become a serious problem in the medical field that needs to be addressed. The following describes three ways research has determined how weight stigma in medicine does far more harm than good.

1. Weight stigma decreases the quality and quantity of patient-centered care.

The stigma that people with obesity are lazy, personally to blame for their weight, lack willpower and self-control, and are non-compliant with medical treatment and recommendations transcends into the medical field2. These same beliefs have worsened over time, even for clinicians who specialize in obesity treatment2. There are many clinicians who support the energy balance model, in which “energy in equals energy out”. They believe that if patients with obesity simply reduce the number of calories they consume and increase their level of physical activity, they will lose weight. If they do not lose weight using this approach, they “clearly” were not compliant with it. This places personal responsibility on the individual in their pursuit of weight loss2. However, there are many genetic and socioeconomic factors that play into an individual’s “ability” to lose weight.

Weight stigma causes many clinicians to deliver less patient-centered care to their patients with obesity. This is due to the belief that these patients will not be compliant with medical treatment and recommendations. As a result, they spend less time with their patients educating them regarding their health concerns. One study indicated clinicians were more likely to rate an encounter with these patients as a “waste of time”. On average, they reported spending 28% less time with them compared to patients with a normal weight1. However, less patient-centered care predicts lower adherence to treatment, reduced trust in the patient-clinician relationship, and worse outcomes for the patient1.

2. Weight stigma leads to reduced trust in clinicians and avoidance of needed care.

Patients with obesity have reported feeling blamed for their weight and unsettled by statements made by their clinicians2. Paired with a perceived lack of empathy, patients with obesity state they are reluctant to discuss their health concerns during appointments2. They may even avoid seeking care to prevent feeling embarrassed about their weight. If they do seek out care, they may be withdrawn or may not fully participate in the appointment. This could prevent patients from being able to recall education or instructions, reducing their ability to adhere to recommended treatment prescribed by their clinicians1. As a result, these patients may come back to their attending clinicians with more severe and difficult to treat conditions in the long-term1.

3. Weight stigma increases stress levels, which can lead to short-term and long-term health complications.

Patients who believe they are experiencing weight stigma may also undergo an immediate stress response2. This triggers a release of stress hormones in the body. In the short-term, this stress response can reduce the patient’s ability to communicate effectively and both learn and retain new information2. In the long-term, the accumulative nature of the stress response may potentially increase their risk for depression, anxiety, heart disease, and stroke1. In other words, just perceiving weight stigma from their clinician can negatively impact the health of a patient with obesity.

How can we reduce weight stigma in the medical system?

If you are a clinician:

1. Know what your implicit biases are. It is important to first determine what your implicit biases are, so you can directly improve how you interact and counsel your patients. You can take the Harvard Implicit Bias test here.

2. Ask permission to speak to your patient about their weight. In many cases, you are not the first clinician your patient has seen in their lifetime. Which means it is almost guaranteed a clinician has brought up their weight at least once- so their weight is not new news. The reason why they made the appointment to see you may be completely unrelated to their weight. Discussing their weight without their permission damages the patient-clinician relationship, often by making incorrect assumptions about their health behaviors. In addition, unless you are screening every patient you see for an eating disorder, centering the appointment around their weight can be incredibly triggering and invalidating of their lived experience.

3. Be mindful of the language you use when talking to and about people in larger bodies. Avoid referring to patients in larger bodies as an “obese/overweight patient”. Ask the patient how they prefer to describe themselves and their body. (For example, do they feel comfortable describing their body as fat? Do they prefer person-first language?) When referring to patients in documentation or conversations with colleagues, use phrases like “a patient with obesity/overweight”. This shows that you respect the patient and their needs as a unique individual rather than labeling them by their “disease”2. (On a side note, you could just eliminate the use of obesity/overweight altogether. They may be seeing you for reasons other than their weight.)

4. Switch to the use of motivational interviewing when counseling patients. Frankly, telling a patient to eat less and exercise more is incredibly inappropriate. It does not acknowledge or take into consideration where the individual is on their health journey. Motivational interviewing is designed to determine what specific health concerns or goals the patient wants to work on. It empowers patients by reducing ambiguity and giving them a voice in how they want to address their health.

5. Create an environment that is welcoming to patients in larger bodies. Look around your office. Do you have chairs that are too small and have armrests that may dig into your patients’ sides? Do your scales have small platforms that only go up to 300-500 pounds? Do you keep examination gowns, blood pressure cuffs, and other equipment for people in larger bodies in a separate location of the clinic? If you answered yes to any of these questions, your clinic’s environment may promote an identity threat to your patients in larger bodies. When equipment is too small or kept on the opposite side of the clinic, it suggests to the patient their size is unusual or does not belong in your clinic. These interactions can be incredibly humiliating for them1.

6. Reduce the frequency to which you weigh patients. There are obvious medical reasons in which weighing a patient is necessary. But ask yourself, “Do I have the blanket policy of weighing every patient, because that’s just what we do?” Weighing a patient for every single appointment creates a focus on the patient’s weight rather than the reason they are there to see you in the first place. In addition, you cannot determine by looking at the size of a patient’s body if they have disordered eating or an eating disorder. Being weighed at a clinic can be a very triggering experience for these individuals.

If you are a patient:

1. Request to not be weighed. There are various medical conditions and reasons why your clinician may need to weigh you. However, you have the right to request not being weighed or to ask for the reason why you are being weighed. Asking this question can start a conversation with your clinician on how your care can be more patient-centered.

2. Shop around for weight-inclusive practitioners. If a clinician is not giving you the level of or type of care you prefer, you have the right to switch to a different clinician. Read Google reviews of clinicians online. Do other patients describe them as the type of clinician you would want to work with? You can also search for clinicians who identify as Health at Every Size (HAES) aligned. They tend to use a weight-inclusive, patient-centered approach when working with their patients.

3. Voice your opinion during your appointment. If you feel like you are not getting the level of care you deserve or need, voice it during your appointment. Ask your clinician, “Are these the same recommendations you would make or tests you would order for someone at a ‘normal’ weight?” If they refuse to order a specific test or treatment for you due to your weight, request that they document that refusal in the note for your appointment.

4. Report any inappropriate interactions with clinicians. Most hospitals and clinics have a patient advocacy program established for questions and complaints. If you do not feel comfortable speaking to someone on your care team, you can always ask to talk to a social worker or someone from their patient advocacy team. It is never OK for any clinician to degrade you for your weight or body shape.

Weight stigma is something that needs to be addressed in the medical field. Over both the short-term and long-term, it can have a significant negative impact on our patients’ health. As a HAES-aligned registered dietitian nutritionist, I have made it a priority to treat people of all weights, sizes, and shapes with the same amount of respect and dignity as any of my patients. I firmly believe there are other ways to help our patients live happy, healthy lives without focusing on their weight.

1. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, Ryn MV. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews. 2015;16(4):319–26.

2. Puhl RM, Phelan SM, Nadglowski J, Kyle TK. Overcoming Weight Bias in the Management of Patients With Diabetes and Obesity. Clinical Diabetes. 2016;34(1):44–50.

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