Weight stigma in healthcare may sometimes be a misguided attempt to help, but that doesn’t excuse shaming, scare tactics, or poor medical care. What happened to “First, do no harm”?
Thankfully, there is a lot more discussion these days about weight stigma, body acceptance, and Health at Every Size®. I appreciate all the online activity around these important issues. It’s especially difficult to hear about the stigma people face from their own healthcare providers. Stigma of any kind makes me feel ashamed to be part of the healthcare profession.
(A word about words: The medical literature uses the words “overweight” and “obese.” They appear in this article when specific studies are referenced. However, these terms are problematic. “Overweight” implies that there is a weight all people should be. The word “obese” is from the Latin obesus—having eaten until fat—which mistakenly represents the cause.)
Weight stigma in healthcare – do no harm?
Weight stigma involves actions against people in larger bodies that can cause exclusion and marginalization and lead to inequities such as inadequate healthcare.(1)
While I believe most healthcare professionals (at least the ones I know) are compassionate and caring, their weight bias, including their implicit bias (unconscious attitudes and stereotypes) affects the care they provide to their patients. (Learn about your own implicit bias by taking one of the Harvard Implicit Association Tests. You can only change things you are aware of!)
I also want to believe that a health care provider wouldn’t dismiss their patients’ symptoms, concerns, and illnesses as a consequence of some perceived “failure,” and recommend weight loss, however elusive, as some miracle cure for just about anything wrong with a patient in a large body.
Weight stigma in a healthcare setting may sometimes be a misguided attempt to help, but “good intentions” does not excuse rudeness, shaming, guilt, scare tactics, cruelty, or poor medical care. More important, weight stigma can be deadly, as shared in this obituary for Ellen Maude Bennet.
Research and personal anecdotes show that weight stigma happens all the time in healthcare settings. Weight bias leads providers to behave in stigmatizing and harmful ways: over-attributing symptoms and problems to obesity, failing to refer for diagnostic testing, and failing to consider treatment options beyond weight loss.(2)
And weight stigma in healthcare has significant repercussions for patients. Patients who experience stigma in healthcare settings may delay or forgo essential preventive care. Several studies show that obese persons are less likely to undergo age‐appropriate screenings for breast, cervical, and colorectal cancer.(3)
One researcher concluded, ““Removing the stigma‐related barriers to receiving cancer screenings may help to diminish the relationship between excess body weight and cancer mortality.”(4)
Prior to giving a presentation on “Making the Shift from Weight to Well-Being,” I asked a question on the Am I Hungry? Facebook page: What do you want doctors to know about your concerns and experience with weight stigma in healthcare settings? Here’s what they said:
- Forcing you to be weighed or arguing when you refuse.
- Not having a BP cuff or gown large enough.
- Assuming I don’t exercise or eat well.
- Unsolicited weight loss advice.
- Prescribing weight loss for every problem.
Healthcare professionals must know better and do better!
An old problem with a new target
We’ve been down this road before, and we should know better. Early in my career as a Family Physician, I was very active in the politics of the American Academy of Family Physicians (AAFP). At the time, over two decades ago, the AAFP leadership decided to actively address the needs of underrepresented physicians and patients by establishing the National Conference on Special Constituencies (NCSC), now known as the National Conference of Constituency Leaders (NCCL).
As volunteers representing Women, Minority, Gay, Lesbian, Bisexual, Transgendered (LGBT), New Physicians, and International Medical Graduates (IMG), we came together annually to debate issues relevant to our constituencies and send elected representatives and resolutions to the AAFP Congress of Delegates. You could argue that such a conference should not need to exist, but it did and it does, and I feel that the AAFP was courageous in admitting it and doing something about it.
The AAFP had given us a seat at the table and we embraced the uncomfortable but necessary opportunity to challenge this large medical organization to examine and address the challenges and issues brought forth by our constituencies. While I am well aware that inequality, bias, prejudice, and discrimination sadly still exist, I know that the activities and voices of the NCSC helped moved the needle on the awareness, attitudes, and policies of AAFP for the benefit of ALL physicians and their patients.
As Maya Angelou said, “When you know better you do better.” There is still much work to be done, but we are slowly headed in the right direction.
What does all that have to do with weight stigma? The lessons apply here too.
Weightism: Another Stigma
During those early days of NCSC, I didn’t realize that another group (now in the majority), defined by their body size, are increasingly stigmatized—and by the medical profession no less! (And to be clear, it is not just physicians.)
As we become more aware of the extent and severity of the damage done by bias, stigma, and discrimination based on sex, race, nationality, and sexuality, we must also address the harms of weight stigma. And when these identities overlap—intersectionality—various forms of inequality often operate together and exacerbate each other.
My healthcare colleagues are bombarded from all sides about the “war on obesity.” (Don’t get me started on the problems with creating a war on people’s body size!) Physicians are sometimes blamed for not doing enough and criticized and even penalized for not raising the issue with every patient, no matter what they came in for.
Medical journals are packed with research about the effectiveness (more accurately, ineffectiveness) of various “treatments” and conflicting data on the causes and risks of obesity.
Still, physicians are pressured to talk to their patients about losing weight, even though most don’t have any better advice than “eat less, exercise more,” or “have you thought of joining Weight Watchers?” (Uh, yeah, thanks.)
Clearly, we’ve got to do better.
And I am not blameless in all of this, but I know better now. My own approach has evolved significantly as I’ve learned about the harms of weight bias and stigma.
Facts about weight and weight loss health professionals should know
There’s an abundance of information available about weight and weight loss for health professionals who choose to look for it and listen to it. Let me share what I know from reading the literature and after many years of working with people with weight concerns:
- Weight is not a simple matter of “calories in vs. calories out.”(5)
- “Eat less, exercise more” ignores the complex set of genetic, metabolic, physiological, cultural, social, and behavioral determinants – not all of which are within an individual’s control.(6)
- Popular narratives about weight and weight loss often focus on individual behaviors and perceived failures, while neglecting to take
into consideration important biological, social, and environmental factors (including structural inquality and social determinants of health).
- Weight is not a behavior, and therefore is not subject to behavior change. Recommending weight loss instead of focusing on specific beneficial health behaviors is a missed opportunity to help your patient or client incrementally improve their well-being.
- Focusing on weight leads to dieting. Diets don’t work.(7)
- No weight loss initiatives to date have generated long term results for the majority of participants.(6)
- Body weight is defended by a powerful biological system that reacts to a negative energy balance by lowering metabolism and increasing hunger, food preoccupation, and hedonic responses to food.(8,9)
- Weight focus contributes to food and body preoccupations, weight cycling, disordered eating, eating disorders, and weight stigma.(10)
- Weight is a poor indicator of health. Studies linking weight and health are based on correlation, not causation.(6)
- Using BMI as a surrogate measure of health is misleading.(11)
- Based on a review of 21 long-term randomized controlled studies, weight loss diets lead to minimal improvements in cholesterol, triglycerides, systolic and diastolic blood pressure, and fasting blood glucose.(12)
- Health and beatuy comes in all shapes and sizes.
- Health is a personal and evolving concept for each individual, one that cannot be measured in numbers.
- Weight stigma is harmful. Shaming and threatening people not only doesn’t improve their health, it hurts them.(1)
- Weight stigma leads to delayed and misdiagnoses, and inappropriate “treatment” to lose weight.(1)
- All people deserve respect and a life free of judgment about the size of their bodies.
A weight-inclusive approach improves health
Instead of imagining that well-being is only possible at a specific weight, a weight-inclusive approach considers empirically supported practices that enhance people’s health in patient care and public health settings regardless of where they fall on the weight spectrum.(6)
Am I Hungry? is a weight-neutral, non-diet, mindfulness-based approach. Mindful eating can heal a broken relationship with food. It is about living in the present moment, not postponing one’s life until you attain (or in order to attain) some idealized version of beauty or health. Mindful eating is a doorway to vibrant living!
What can patients do about stigma?
- Set clear boundaries with your healthcare providers, preferably at your first meeting, but anytime will do! For example, you could say something like, “I am looking for a doctor who will be a partner in caring for my whole self. I am interested in living a healthy lifestyle, but I am not interested in lectures, guilt, or scare tactics. I want my symptoms, issues, and concerns to be taken seriously, and I will not accept ‘lose weight’ as the treatment for whatever ails me. Can you be that kind of partner in my healthcare?” (This can be difficult to do. Ragen Chastain developed helpful cards for “What to Say at the Doctor’s Office.”
- It helps to learn about medical issues from a non-stigmatizing perspective. Check out these Health at Every Size® based guides for blame-free, shame-free explanations of common medical conditions: HAES Health Sheets
- If you feel that you are being stigmatized by a healthcare professional, set firm boundaries, and if you feel able, educate them about weight stigma. If the problem is severe or persists, find a new healthcare professional. You deserve better! (In some cases, you might consider reporting the issue to the appropriate local medical board or oversight agency.)
- Be compassionate with yourself. Internalized weight stigma is common and difficult to overcome when you life in a culture that idealizes thinness. It is understandable that you may want to to reduce oppression and stigma with weight control activities.
To my health and wellness professional colleagues, if you are still reading this, you are already headed in the right direction. Please, know better so you can do better!
And if you know of an organization that would benefit from my presentation From Weight to Well-Being: Making the Shift from Weight-Centered to Weight-Inclusive Care, I’d love to set up a conversation!
Weight Stigma in Healthcare References:
- Puhl RM. Weight stigmatization toward youth: a significant problem in need of societal solutions. Child Obes. 2011;7(5):359
- Phelan, S., et al. (2015), Obesity stigma and patient care. Obes Rev, 16: 319-326.
- Amy, N. et. al. (2005). Barriers to routine gynecological cancer screening for White and African-American obese women. International Journal of Obesity, 30(1), 147-155.
- Puhl, R. M., & Heuer, C. A. (2009). The Stigma of Obesity: A Review and Update. Obesity, 17(5), 941-964.
- Hall, K., et al. (2012). Energy balance and its components: Implications for bodyweight regulation. The American Journal of Clinical Nutrition, 95(4), 989-994.
- Tylka, T., et al. (2014.) The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity.
- Mann, T. et al. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62, 220-233.
- S. MacLean, A. Bergouignan, M. Cornier, and M. R. Jackman, “Biology’s response to dieting: the impetus for weight regain,” American Journal of Physiology: Regulatory Integrative and Comparative Physiology, vol. 301, no. 3, pp. R581–R600, 2011.
- Sumithran and J. Proietto, “The defence of body weight: a physiological basis: for weight regain after weight loss,” Clinical Science, vol. 124, no. 4, pp. 231–241, 2013.
- Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(1).
- Tomiyama, A. J., et al. (2016). Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. International Journal of Obesity, 40(5), 883-886.
- Tomiyama, A. J., Ahlstrom, B., & Mann, T. (2013). Long-term Effects of Dieting: Is Weight Loss Related to Health? Social and Personality Psychology Compass, 7(12), 861-877.
(Here’s a list of additional references.)
This article is updated from a previous version.
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