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On Saying No To the Scale
Who has the privilege to decline the doctor's office weigh-in?
Last week, I had my first physical since 2019. I am not proud of this lapse in preventative healthcare. But the pandemic, of course. And even once it felt safer to go to doctor’s offices, every time I’d do my family’s exposure/risk math, my own relatively mundane healthcare needs felt like the obvious thing to postpone, unlike say, my daughter’s cardiology check-ups.
But the other reason I kept putting off this appointment was because I wanted to find a new doctor. One who wouldn’t care about the scale.
The last time I was weighed in a doctor’s office was 2018. My second baby was barely six months old and had just (like, the night before) started sleeping through the night. I wanted to talk about the lingering knee pain and heartburn I was still carrying as uncomfortable souvenirs from that pregnancy. But my BMI was in the “ob*se” range for the first time and so my doctor only wanted to talk about my weight. “How much are you exercising?” she asked. I explained how sleep-deprived I was, how I had just gotten back to work and how, yes, I like exercise, but all of our daily routines were in a state of flux while we tried to figure out this new phase of life with two small beings. I also wondered if maybe I should get some physical therapy for my knee before I jumped back into working out.
“When my kids were that age, I just put them both in the stroller every night after dinner and went for an hour jog around our neighborhood to get the weight off,” she said. “It’s not hard, you have to prioritize it.”
I never got physical therapy for my knee, which continues to pop like bubble wrap when I go upstairs. But I stopped getting on the scale, at her office and at every other doctor I saw. And (pandemic lapse notwithstanding), the quality of my healthcare has dramatically improved.
The first question that comes up, anytime I talk about declining to be weighed in a healthcare setting is: “You can do that?” Yes. You can. I’ve done it at primary care, gynecology, dermatology, and urgent care visits. Most medical practices weigh patients during the medical intake process in a way that feels mandatory, but they can’t require you to do it, just like they can’t require you to undergo any other medical procedure without obtaining your informed consent. “There is no obligation for a patient to be weighed and they have the complete right to refuse,” said Louise Metz, MD, a weight-inclusive internal medicine doctor in Chapel Hill, North Carolina when I interviewed her for Scientific American in 2019. Doctors aren’t cops and they can’t legally require you to get on a scale, though they can refuse to treat a “noncompliant” patient (more on that in a minute). “Biomedical ethics says that both informed consent and informed refusal are rights that patients have, and physicians are obligated to respect then as part of protecting patient autonomy,” Michelle Allison, RD, also known as @fatnutritionist, wrote when I sussed this out on Twitter yesterday.
The next question is, “But should you do that?” Your answer may be more complicated but for me, right now, this is also a clear yes. Doctors want to weigh you in order to calculate your Body Mass Index. Their primary motivation for getting this number is often financial; insurance companies include it on a list of “quality measures” and may offer incentives or pay bonuses when doctors meet all of their quality measures, explained Metz. “We do receive higher reimbursement rates for participating in quality measures. So providers working in big healthcare systems may be told it’s mandatory. But we told insurers that we would not be participating in this measure and it hasn’t impacted us in any way.”
As Dr. Metz explains here, we also know that BMI is a trash measurement of general health.In fact, there are only a handful of situations where body weight itself is medically relevant, notes Gregory Dodell, MD, an endocrinologist in New York City: “If you’re in heart failure and need fluid levels monitored, if you’re recovering (and weight restoring) from an eating disorder, if you’re on a feeding tube for any other reason, if you’re about to undergo anesthesia or if you’re taking a medication that is dosed by weight.”
It’s also true that while weight should not be our primary measure of health and usually is not the root cause of health issues, a significant weight gain or loss can be a correlating symptom of another condition. That list includes hormonal issues like diabetes and PCOS, as well as mental health conditions and trauma. If you have a family history or other circumstances that increases your risk for these issues, weight may be a useful touchpoint, especially if it’s a condition (depression, say) where you might struggle to disclose other symptoms to your doctor because they are difficult or stigmatizing to discuss. But this will only work if your doctor can look beyond the scale. If they unequivocally treat all weight loss as good and all weight gain as bad, they may obscure the reality of what’s happening with your health.
When doctors practice weight-centric healthcare, they are perpetuating and reinforcing anti-fat bias. And they do this at great cost to our health. A 2019 survey of 400 Canadian doctors revealed that 24 percent were uncomfortable even having friends in bigger bodies, and 18 percent “felt disgusted” when treating a larger patient. This attitude pervades every medical specialty; I’ve previously documented it in the fields of infertility, and eating disorder recovery, and in the treatment of Covid-19 patients. A 2011 study found that medical students were more likely to blame people for conditions like respiratory distress if they were in a bigger body, and tended to prescribe weight-loss strategies rather than symptom management. Providers spend less time with patients with high BMIs and are sometimes even less willing to perform standard care such as pelvic exams at the gynecologist’s office. Fat people are also likely to have eating disorders go undiagnosed, or even be reinforced by doctors eager to encourage weight loss. In May 2018, a Canadian woman named Ellen Maud Bennett died only a few days after receiving a terminal cancer diagnosis; in her obituary, her family wrote that Bennett had sought medical care for her symptoms for years, but only ever received weight loss advice. Similar stories go viral on social media every few months.
My experience with my old doctor’s fatphobia was mild by comparison, though still infuriating: She assumed my fatness was caused by a lack of exercise and was uninterested in exploring whether it represented a real health issue in need of treatment (looking back, post-partum anxiety might have been an obvious choice?). She made my weight into a problem to solve, while failing to address my actual health concerns. And she told me to fix it by doing what had worked for her, instead of trying to understand more about what might be helpful for my lifestyle and my body.
So taking weight out of the exam room can go a long way towards improving medical care. Doctors have to ask patients more thoughtful questions, and try to actually understand their life. To her credit, my former provider began doing that once I stopped getting on her scale, but I still wanted to start fresh with someone who wouldn’t have my BMI right at the top of their file. Last week, my new doctor asked “do you exercise?” while running down his list of routine questions. And then, remembering that I had just told him about spraining my ankle and recently getting over Covid, he corrected himself: “I mean, do you aspire to exercise? What’s feeling doable for you right now?” It was a subtle shift, but I felt like we were having a conversation about me as a person, not a number.
But here’s the thing: Not getting on the scale only takes the anti-fat bias out of my healthcare experience because I have thin privilege. Yes, even with a BMI in the ob*se range; as Aubrey Gordon explains it, “the closer you are to looking thin, the more thin privilege you get. And that includes many fat people.” Thin privilege is also amplified by every other kind of privilege we might hold, especially in healthcare settings. As I reported for Health.com last year:
Between March and September 2020, Black women died from COVID-19 at 3.8 times the rate of white men in Michigan and 1.6 times the rate of white men in Georgia, according to a new study from Harvard researchers. Other research has documented that Black people are less likely to be tested and sicker when they do receive treatment than white patients. Studies have linked similar biases with worse health outcomes for other communities of color as well.
Queer patients also face systemic bias and stigma in health care settings. One 2015 study found implicit bias in favor of straight patients was pervasive among heterosexual health care providers, who tended to prefer straight male patients over everyone else. As a result, many lesbian, gay and transgender patients feel unsafe even sharing their identities with health care providers, which limits their ability to access necessary treatment. In a 2017 survey, 8% of LGBQ participants and 29% of transgender patients said a health care provider had refused to even see them; the survey subjects also reported verbal abuse and unwanted physical contact from providers.
Our levels of able-bodied privilege, financial security and education also intersect and impact the quality of the medical care we receive. Someone who is visibly fatter than me, or carries other marginalizations will both have a harder time declining to be weighed and may find it doesn’t improve their healthcare enough to be worth the effort. “A medical professional does not have to weigh me to know that I’m fat,” writes Linda Gerhardt, over on Fluffy Kitten Party. “This is because they have eyeballs and can see me.” For Linda, and many other fat folks, declining to be weighed feels risky:
“I’m already judged as noncompliant the moment a medical professional lays eyes on me. [...] Before I open my mouth at an appointment, I am perceived as difficult. Anything I do to advocate for myself is further evidence of my noncompliance. I just want access to competent medical care. That’s all. I have to save my energy to fight for things that are important to my care.”
Linda’s essay (which you should go read in full, it’s so good), also highlights a fundamental disconnect in the doctor weigh-in debate: When we refuse to see the number on the scale, we reinforce the notion that high numbers on scales are bad and to be avoided. “It’s necessary to talk about the fact that the fear and dread we feel stepping on the scale is fatphobia,” she writes. “And you cannot fight fatphobia with fatphobia.” I stumbled once, in declining to be weighed, when a nurse sympathetically responded, “Oh I know, that number makes me feel terrible too.” She wasn’t wrong, exactly. But she was failing to challenge the underlying reasons that scale numbers make us feel terrible. And my refusal didn’t name the real problem either.
This is a sticky one to wade through. Most of us likely recoil from the number on the scale because of our own fatphobia. But if we’re fat, we’re also recoiling because we know that number helps the system’s anti-fat bias kick in. And regardless of body size, if we have past trauma around the scale or an eating disorder history, the scale is not a safe place for us to be. The answer here is not for everyone to risk a stigmatizing experience by getting weighed. We cannot safely name and reckon with this underlying fatphobia while in a healthcare setting designed to reinforce that bias. But: If you know, on some level, you’re refusing to see the number because it will make you feel bad, it’s worth noting that you have some work to do disentangling body size and value.
The bigger picture here is that anti-fat bias is thoroughly woven into most mainstream medical experiences. And so we risk dangerously oversimplifying things by focusing too much on the power of the scale. “For people like myself who are undeniably fat, it’s not that simple,” Linda writes. “We need seismic, systemic change in the healthcare system in order to access better care.” Yes. And: I think that if you have the privilege to benefit from refusing to be weighed, you should do it as an act of allyship and a crucial first step towards making that kind of seismic change. Which means, if you have thin privilege, your and my work is not done when we say a polite “no thank you” and then silently appreciate how that takes the focus off our weight during the rest of the visit. We also need to engage our providers on why we are refusing.
I’m still figuring out what this piece of advocacy looks like for me. I know I’ll feel most comfortable having this conversation after I’ve established a decent rapport with my new doctor. So during this first visit, I just dropped a few breadcrumbs. When he asked about my profession, I didn’t just say “journalist,” but told him what I write about, and we chatted a little bit about how the pandemic has spiked everyone’s weight anxieties. When I got my clinic’s follow-up survey in my email later that day, I gave the doctor a high rating and specifically thanked them for respecting my decision not to be weighed and for providing weight-inclusive care. I’ll be looking for ways to take the conversation further in the future.
This part is harder. Those of us who have been conditioned to follow rules, please others, and avoid confrontation have to reckon with what we lose by not being our doctor’s A+ student at every visit. Even if that’s not your concern, it will feel awkward and maybe scary, because you are disrupting the unspoken power balance in the room. But it also has the potential to do some real good.
Okay But How Do I Do It?
If you are a person with any degree of thin privilege and/or various other privileges, skipping the weigh-in may be easier than you think. I’ve never had to do more than say a polite no thank you. Of course, some doctors offices are more weight-centric than others and even thin people can encounter healthcare providers who will insist. If you suspect your provider falls into that category, it could be time to doctor shop. But you can also bring in some back-up; I love the “Don’t Weigh Me” cards created by Ginny Jones, founder of More-Love.org. And if you need something more comprehensive, this letter by (weight-inclusive providers and sisters!) Anna Lutz, RD and Louise Metz, MD is excellent.
The fatter you are, of course, the harder this conversation will be. My conversations with Ragen Chastain and Gregory Dodell, MD will give you some helpful starting points, but I’ll also direct you to Ragen’s Doctor’s Office Survival Kit and video workshop, which has evidence-based, nuanced advice to help you advocate for yourself in a fatphobic healthcare system. I also love this resource from Dr. Asher Larmie’s #NoWeigh Campaign, which walks through the reasons to get weighed or not, and how to ask questions to suss out whether getting weighed will be safe and medically useful for you. (Note for my British readers that Dr. Larmie is @fatdoctoruk so their resources are NHS-compatible.)
What About A Blind Weight?
A “blind weight” is when you agree to be weighed, but stand backwards on the scale so you can’t see the number. Lots of folks love this as a compromise position, but I’m not crazy about it. For starters, you have to have a lot of faith that the medical technician collecting the number will respect your request. (The one time I tried this, during a medical exam for a life insurance policy, they didn’t.) But the visual of turning your back to the scale seems to reinforce the “high scale numbers are dangerous” myth maybe even more than opting out altogether. That said: Mental health first. If opting out doesn’t feel possible, this may be an important tool for self-care.
What About Pregnancy?
No matter what your body size, if you’re pregnant, you’ll likely encounter resistance to opting out of the weigh-in at every prenatal appointment in the United States. But I regularly hear from readers in other countries (as well as my own family in the UK) that their weight wasn’t tracked, or was tracked far less frequently, during their pregnancies. So the science is far from cut and dried on this. If you want to dive into what the science says about getting weighed while pregnant, Christy Harrison did a wonderful deep dive here, and concluded that she would be opting out during her own pregnancy. She also discusses how to approach the conversation with your provider. Jen McClellan, creator of Plus Mommy, also has this post on finding size-friendly providers and this episode on navigating weight stigma during maternity care.
What About Kids?
A sudden weight loss in kids who should be growing and gaining is often cause for concern. (The first red flag we had for our daughter’s congenital heart condition was when she weighed less at her one month well visit than she had at birth. Weight loss can also be a symptom of diabetes or, in older children, an eating disorder.) Knowing your child’s weight is also useful when you’re trying to figure out how much Tylenol you can give them for a fever or whether they’re big enough to finally graduate from the damn five-point harness car seat. So for the moment, I still have my kids weighed at their annual well visits.
But it’s also true that pediatricians can cause real damage when they focus on a child’s weight in a negative way. (I wrote more about that here.) And the frequency with which we weigh kids in the United States is probably unnecessary; many other countries do it less often or not at all after age 2. In 2017, the American Academy of Pediatrics issued a policy statement recommending that healthcare providers avoid discussing weight and weight loss in front of kids because of the high potential for harm. So while you may choose to have your child weighed, I see a strong case here for the blind weight. My conversation with Anna Lutz, RD gets into more detail about how to interpret kids’ growth charts and her letter to your child’s doctor is an awesome tool for navigating this conversation with your pediatrician. Ginny Jones also has you covered with more cards.
Editor’s Note: In the initial publication of this piece, I neglected to include one other fabulous resource; Mia O’Malley’s Fat Friendly Healthcare Spreadsheet! If you’re doctor-shopping, it’s a great first stop. And if you have a fat friendly doctor, you can add them to the spreadsheet here. -VSS
ALSO I joined The Colin McEnroe Show on Connecticut Public Radio last week, for an in-depth discussion of diet culture, weight and health. Am now very excited to read Louise Foxcroft’s Calories and Corsets: A History of Dieting Over 2000 Years. Y’all may also enjoy the part when I chatted with Evan Forman, a Drexel University weight loss researcher. Listen here.
This last one is more relevant for kids, where even over-the-counter meds are often dosed by weight. But the majority of adult medications, both OTC and prescription, are dosed the same way for everyone.