I know others will have better, more helpful things, but for me, I wish my PCP (who is trying very hard) could understand that while it might be the first time I’ve talked to her, I’m bringing every conversation I’ve had with a doctor with me. So yes, my blood pressure is likely to be higher and my tone defensive, but that doesn’t come from nowhere. It comes from having what seemed like a perfectly good, productive appointment and then getting a phone call at home for for the doctor to push weight loss drugs and tell me I’m obese. It comes from having the assumption that my numbers would be improved by a diet when I’m actually concerned that I don’t eat enough. I don’t have the long history a lot of fat folks have with medical mistreatment, and I’m sure other prowl will have better advice, but those are things I wish my current PCP knew.
YES. Understanding that defenses are up and NOT interpreting that as “noncompliant” or hostile is key. I’d love to see doctors taking a minute to consider why a fat patient (or any marginalized patient) might be extra stressed in their care.
Two things for me - 1) that all health conditions are not tied to my weight. I have a family history of high cholesterol. My paternal grandfather repaired air conditioners and fridges and did farm labor his whole life - "healthy" weight, healthy diet, etc. He has high cholesterol. So does my dad. I could live off of saltines for the rest of my life and still have high cholesterol.
And 2) If you DO bring up my weight, actually listen when I say I have a history of disordered eating. Don't suggest I cut all carbs, sugar, red meat, and shellfish from my diet. That's not helpful. If I wanted that advice I could go to the internet. I'm coming to you because I want you to LISTEN and use your best judgment to come up with a treatment plan that works for ME.
Oh, and a 3) If you do gynecological exams, do not, under any circumstances, talk about my weight while I'm in a paper gown, naked. I'm already vulnerable because, hello, naked!
- Ask me if I want to be weighed, don't put it on me to have to ask to opt out. But if I do opt out just say okay and move on.
- Don't assume weight loss is a goal of mine.
- Every time you assess a medical concern in a fat patient ask yourself "if a thin patient presented with these same symptoms what would I do?" And maybe do that instead of ascribing it to your fat patient's weight.
- Don't make assumptions about my general "compliance" as a patient based on my "compliance" with weight loss recommendations. If you recommend a medication and we've aligned that I'll try it, my next stop will be the pharmacy to pick it up and I'll take it as directed and contact you if I have any issues. I'll buy that blood pressure monitor and track it so we know if the medication is working.
- Speaking of home blood pressure monitors, don't just recommend the same one to everyone, know which ones have large enough cuffs available for your larger patients. And of course, you'll have a variety of cuff sizes for your office machine, right? And your team will describe them neutrally like "let me grab a different cuff."
- Do you have gowns? Have some larger ones available please!
- Above all else please just treat me as a whole person who really does want to have a trusted relationship with you. If you're my PCP for a while, I'm likely to see you for all manner of things and I don't want to have to put my defenses up to avoid a conversation about my weight if I'm worried about that new mole on my back or why I can't turn my neck to the right, or why I'm having trouble sleeping.
You may genuinely think you are just doing your part in noting weight, making suggestions, etc, but please recognize that not only have your larger-bodied patients almost surely heard it many times, but many have tried for decades, with limited results. For many of us, often overachievers in other areas of life, your making us feel like we just haven't tried can be truly stigmatizing and injurious. I still remember the childhood doctor 'Calories in, Calories out.' I have had undiagnosed eating disorders and multiple exercise overuse injuries (one permanent due to a muscle tear that has never healed.) You may truly feel your suggestions are a benign part of a medical checklist, but please understand they may be tossing grains of salt into still-open, sensitive wounds. If you are a life-long thin person who also has 'healthy habits', you may understandably assume that your thinness is due to those habits, but- trust us- many of us have those same habits with quite different bodies, and it is maddening that we cannot break through to you. It is as though you would tell someone to will themselves to better eyesight, or just snap out of depression, or just try harder and the headache will go away. If you would read the research on this, and recognize how much of body size is genetic, instead of assuming your life-long slim body shape is due to your 'good' behavior, that would be game-changing. And thank you for reading this; every doctor who is sensitive and aware can make such a difference!
As you read our answers, think about who is not here to be in conversation with you, and how often those people face the most oppression and barriers to support. If the better practices centered those people, we would avoid the problem of designing for the dominant group here as if we represent the platonic ideal of "fat people" when we are actually mostly white, mostly cisgender women, mostly small fat, mostly people with some healthcare access and financial resources. What we are pissed off about is the way we are not getting our usual privilege, and that is fine, but you also have to listen to all the other people who are not getting healing support for all the additional barriers as well if we are going to address the barriers fat people face.
Yes, this is beautifully stated. As I wrote my answer I thought "I'm writing this as a privileged cisgender white woman." I have some barriers and stigmas that come with being female and fat, but I do not face other stigmas that would compound those. As you've said, I hope that medical providers not only hear what this group is saying but also seek out other voices!
Having recently read the breathtakingly cruel thread on r/Residency about fat patients, I'd suggest burning the entire medical training establishment to the ground and starting over.
If that seems a bit difficult for one person to undertake, I'd suggest not assuming that your patient is unaware that she's fat. I don't need to hear a breathless announcement that I'm fat. Do you really think I reached adulthood unaware of that? Since most providers feel professionally bound to comment on weight, please do so in a normal, conversational manner. My nurse-practitioner is a gem. I tell her that she can go ahead and write down on the billing code that she advised the patient about best practices for weight loss and now let's move on. She just laughs.
I once had a doctor ask me if my weight was something that I wanted to discuss with her and I said no and that was that. It was brilliant and revelatory and has sadly never happened again. But if you're looking for a way to figure out where the patient is at, that might be a good starting point. Please note the question was asked to me in a very neutral way, with no value judgment attached to it. Wording is everything.
This reminds me of something I heard probably on maintenance phase that fat patients often bring up weight just because they assume a health care provider is gonna do it anyway. So I love the idea of a provider bringing it up in a way to get it out of the way.
It seems like so many doctors and dieticians assume I'm fat because I just don't know how to be thin. But I'm a 41 year old person with two masters degrees who has been fat my whole life. Trust me, I've done my research, I've tried the things you're about to suggest. What I need are ways to feel better in the body I have, not the useless advice that I'll feel better if I lose the weight.
I had an OBGYN tell me I should aim to not gain any weight while pregnant (meaning lose weight while pregnant to.compensate for the baby's growth). She made me feel like I didn't deserve to have a baby because I was fat.
And lastly, growing up every doctor I met focused hard on 'prevention' so that I didn't grow into a fat adult from a chubby kid. It sent the message from day one that my weight was a result of my own failings and made me believe I deserved any pain I have.
As for what I'd like a doctor to do? Don't start by weighing me. Ask why I'm there and ask about experiences I've had before. Lastly, don't prescribe weight loss. Work with the body I have.
I can echo what many commenters have already said, but a few of my specific thoughts:
-Actually LISTEN to your patients and respect their wishes. My now-former PCP repeatedly brought up weight loss surgery, even after several different conversations where I expressed my anti-diet stance and set a hard boundary around WLS.
-Understand that people who have been fat their whole lives likely already know a lot more about nutrition than you do because we've heard it forever and most of us have tried it. I don't need your fucking nutrition printouts ever really, but even less when I'm seeing you for illness or earache, etc.
-Have a larger blood pressure cuff handy and maybe take my blood pressure at the end of the appointment when I'm likely to be less anxious.
-Talk to your colleagues! You have more power to push for change from where you are.
-And finally, if you are actually using a weight-neutral approach, publicize this fact and make that approach clear for people looking for a doctor. I recently searched for a new PCP and realized that unless I had specific recommendations from other fat patients, I was going to have to go blind and try a few out. This is exhausting and stressful and ensures that my defenses are up before I even step foot in the office. Make it easier for fat patients to find you.
And, like all systemic issues, if you’re advertising that, please make sure you’re truly doing the work. I saw a new PCP once who advertised a HAES approach, had a whole conversation with me about how my weight was not a concern and weight loss suggested were not wanted and then sent me a message when my cholesterol came back a bit high to consider losing 5-10% of my body weight. When I pointed out the contrast of that with our conversation she said it was one of her standard replies in the system...
My new doctor has a whole practice with experience working with eating disorders and a commitment to a weight neutral approach and a few things they do are: when weighing is essential (like for my growing kid) it’s blind to me and never discussed or visible in any portal, we discuss what activities I enjoy, and my doctor was quick to find a HAES dietitian for me when I was diagnosed with a condition partially managed by dietary changes. She always considers quality of life in her recommendations and is able to be really firm with me when I waver and wonder if I could be better off trying to lose weight again that there’s lots of evidence against that and I haven’t caused my own health issues. She puts a lot of effort into referrals to ensure I don’t encounter a fatphobic specialist too.
yes many times over to this last point! I'm looking for a new pcp myself and the ones recommended by my other fat friends aren't taking new patients. I have no way to know how it will be with the ones my thin friends are recommending
Read the Weight and Healthcare substack. I know, it's not the things published in your medical textbooks, but, the author is a very thorough researcher. Probably at least as thorough as anyone who ever wrote a textbook.
Don't talk negatively about your own body. And show yourself compassion as well as me. My doc is currently dealing with hot flashes and she referred to her sweat as "really gross" as she wiped her face with a tissue. Does that mean if I'm sweaty she'll think I'm gross?
Your second point really resonates with me, Anastasia. I once had a fat PCP who felt compelled to give me diet advice. The conversation devolved into a lengthy description of her own eating habits. I know she meant to -- and thought she was -- presenting herself as a model, but there were strong "good fatty" vibes, and she also unwittingly revealed some evidence of disordered eating patterns. The whole experience was tedious and not at all affirming.
My PCP happened to be fat, so in this case, the feelings may have been a bit rawer on both sides. But fat folks are obviously not the only ones with body issues. If you're a practitioner -- fat or thin -- who has body issues, maybe put some thought into how you're using shared trauma to relate to your patients. If you can't help patients heal their existing battle wounds, at least refrain from demonstrating how to acquire additional, self-inflicted ones.
Please don't treat me like I am stupid. I had one NP say, "If you fill up on the good stuff, like fruits and veggies, it keeps you from eating the bad stuff." First, good vs. bad food is not a good way to think about eating, don't assume because I am fat that, I don't eat fruits and veggies, and I am almost 60 years old and have lost (and gained) hundreds of pounds over my lifetime--I am familiar with this kind of simplistic weight loss advice. (and of course, I don't have health problems that may be affected by weight, so why even discuss this with me?
Wow. Just wow. I have a friend I call Wonder Woman. She's 6'3", large, and in charge. I'd love to see anyone say something that idiotic to her, just to watch them shrink and pee their pants as she tilted her head, raised an eyebrow, and asked them to repeat that.
As others have said, listen to your patients, believe them, and change your recommendations accordingly. If you don’t need my weight for some concrete medical purpose (anesthesia, dosing, etc.), don’t even ask to weigh me. Assume I know I am fat and you don’t need to tell me. Rely on health markers rather than just assuming that fat=unhealthy. So many times I’ve heard, all your numbers are perfect but if you want to be healthy, you should lose weight. And try to keep in mind what have likely been my previous negative experiences with the medical field. Why haven’t I been to the doctor for years? Why was I hesitant to bring up an issue? Why did I delay care for something you think is obvious? Maybe I tried to seek care previously, was dismissed, and just received a weight loss recommendation no matter what it was. Does that really matter? Don’t shame me, meet me where I am and treat me.
Fight the pressures to have all the answers. You don't know how to make fat people into thin people because no one does.
Shift your focus to the eugenics root of your training to "prevent," pathologize, and get rid of us. Learn how you have been trained harm us, by prescribing weight suppression that leads to either weight cycling (in the best case scenario) or eating disorders, and by withholding life-saving care hostage.
Open your frame of consideration to the wider world of harms (social determinants of health, capitalism, anti-Blackness, anti-fatness, ableism, healthism, colonialism, cisheteropatriarchy, bigotry of all kinds) as potential sites for intervention by doctors too.
Open your mind to what your medical education didn't know, didn't get right, and didn't teach you; get good at doing what you can as a partner to your people when you don't have all the solutions.
Reclaim the original spirit of why you went into the field, to support people's well-being; and divest from any practices and demands to impose judgments and barriers, or to have the best performance stats, because it makes you turn away from the people who need the most.
Organize yourselves because you are suffering needlessly as well, and the system is doing exactly what it is designed to do, and it needs to go.
Embrace the wisdom of your peoples' lived experience.
Design research around what we prioritize rather than the agendas of thin people who want to get rid of us.
Perfect timing, as I had an issue just this week. If you are not compelled by your health system to bring up a patient's weight, even if you feel it might be a (correlated) cause of the current health issue, don't work it into a subsequent appointment. You will lose any trust the patient has in you. I'm recovering from major surgery and really liked my surgeon. Every pre-op appointment was focused on the issue that required the surgery, he answered all my questions, took a lot of time with me, even made himself available over the phone. I completely trusted him going into the surgery and through the first post-op appointment. At this week's second appointment he did a thorough exam, answered all my questions, then sat himself down on the stool and said, "I can't remember, did we ever have the weight conversation? It's a big risk factor for your condition." Just when I thought that was going to be a non-issue and we were just going to treat the condition. And though I am kicking myself a bit for not having a ready response (because I worship Reagan Chastain), I also know that there are a multitude of risk factors for my condition, including genetics and age, which I can't change. PLEASE listen to what your patient is telling you in the moment and don't have your head full of the thing you think is obvious just by looking at them. Believe us, we know we're fat, and we know that even if we wanted to change that, everything your industry has been prescribing hasn't worked for almost all of us. We don't want to waste the precious five minutes we get with you talking about it again.
Ugh, I am so sorry that your surgeon broke your trust like that. My last surgery was an emergency appendectomy so there wasn't a lot of pre-surgical consult other than "hey, you need this, here are the risk factors, do you consent?" and I was relieved that the anesthesia team and the surgeon did not express any weight bias throughout the whole process. In the few hours between diagnosis and surgery I was bored and in pain and trying to distract myself so I read up on appendicitis, and found myself strangely relieved to learn that despite it being a very common condition, there aren't any known risk factors, other than it being somewhat more common in boys/men than in girls/women, and more common in the 10-30 age range than in other age cohorts. So no one could say "ah, if you weren't fat your appendix would be fine."
The only time my weight came up was with antibiotics for a follow-on infection and the surgeon mentioned consulting with a pharmacist to see if the pharmacist recommended a higher dose for a higher weight. Very neutral, just a factual discussion.
I so appreciate these comments. I am a primary care nurse practitioner and am learning so much from this community. I am committed to doing better. I do agree the system is failing us. For example, I am supposed to assign a diagnosis every time a patient has a BMI above normal range. Then I am supposed to document on the interventions I recommended. If I don’t, someone from my organization contacts me to edit/fix my encounter with the patient so that I can get maximum reimbursement from insurance. Before I started learning about health at every size, I used to just have my medical assistant get a weight on every patient no matter what they were there for so I could make sure I did this. This is so wrong!! I read here the suggestion of asking “is there anything about your nutrition or movement habits that you want to discuss with me?” And leave it at that. I know this is the very tip of the iceberg. It’s not an understatement to say this community will change the way I practice for the better. Thanks for having this discussion.
". . . so I can get maximum reimbursement from insurance . . ." this is a great example of structural sources of harm, where you as the clinician are under great pressure to be the perpetrator of harm so more money goes into [someone's?] pocket. Do you think clinicians could band together to say, "this is no longer going to be a source of revenue to this organization because of the harms of stigma, weight cycling, disordered eating, etc., as it is unethical." As a clinician watching the last thirty years unfold, I am sickened by the erosion of clinical decision-making power in order to maximize profits. It's a much bigger issue and it means clinicians need ways of organizing to protect ourselves so we can practice ethically. BTW, this could be a useful reference for this discussion that was just published: https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2023-06/joe-2307_0.pdf
Thank you for the reference. It sadly seems incredible to me that the ethics journal would devote an entire issue to this. I too am an PCP in a large teaching university who wishes to shift this paradigm. But it's a solid wall to knock your head against. Is anyone aware of formal teaching within medical/nursing programs regarding weight stigma/HAES/eating disorder prevention?
YES, it is a growing network! Lisa Erlanger MD contributed content to the AMA ethics journal and has been working on this in Seattle, and Lisa DuBreuil LCSW has been building a network in Boston; please join
ASDAH.org to find more people working on these issues, and connect with
this side of it is frustrating, especially because insurance providers aren't medically trained! I'm sure you have many frustrations with their hoops
I see that insurance only wants to fully pay for the visit if you do this, but would your job be at risk if you just stopped? Or record a made up BMI? Or what if you diagnose something fully unrelated and minor like "water in the ear" and recommend "naps, laying on that side of the face" as an intervention? I understand you may not have that freedom, and I don't know what impact these actions might have for your patients; just brainstorming in case it is helpful
Thank you for sharing this! From the patient perspective, can I ask what happens when a patient declines to be weighed? Does that successfully sidestep the BMI-related insurance pressure on your end?
I know others will have better, more helpful things, but for me, I wish my PCP (who is trying very hard) could understand that while it might be the first time I’ve talked to her, I’m bringing every conversation I’ve had with a doctor with me. So yes, my blood pressure is likely to be higher and my tone defensive, but that doesn’t come from nowhere. It comes from having what seemed like a perfectly good, productive appointment and then getting a phone call at home for for the doctor to push weight loss drugs and tell me I’m obese. It comes from having the assumption that my numbers would be improved by a diet when I’m actually concerned that I don’t eat enough. I don’t have the long history a lot of fat folks have with medical mistreatment, and I’m sure other prowl will have better advice, but those are things I wish my current PCP knew.
YES. Understanding that defenses are up and NOT interpreting that as “noncompliant” or hostile is key. I’d love to see doctors taking a minute to consider why a fat patient (or any marginalized patient) might be extra stressed in their care.
Two things for me - 1) that all health conditions are not tied to my weight. I have a family history of high cholesterol. My paternal grandfather repaired air conditioners and fridges and did farm labor his whole life - "healthy" weight, healthy diet, etc. He has high cholesterol. So does my dad. I could live off of saltines for the rest of my life and still have high cholesterol.
And 2) If you DO bring up my weight, actually listen when I say I have a history of disordered eating. Don't suggest I cut all carbs, sugar, red meat, and shellfish from my diet. That's not helpful. If I wanted that advice I could go to the internet. I'm coming to you because I want you to LISTEN and use your best judgment to come up with a treatment plan that works for ME.
Oh, and a 3) If you do gynecological exams, do not, under any circumstances, talk about my weight while I'm in a paper gown, naked. I'm already vulnerable because, hello, naked!
- Ask me if I want to be weighed, don't put it on me to have to ask to opt out. But if I do opt out just say okay and move on.
- Don't assume weight loss is a goal of mine.
- Every time you assess a medical concern in a fat patient ask yourself "if a thin patient presented with these same symptoms what would I do?" And maybe do that instead of ascribing it to your fat patient's weight.
- Don't make assumptions about my general "compliance" as a patient based on my "compliance" with weight loss recommendations. If you recommend a medication and we've aligned that I'll try it, my next stop will be the pharmacy to pick it up and I'll take it as directed and contact you if I have any issues. I'll buy that blood pressure monitor and track it so we know if the medication is working.
- Speaking of home blood pressure monitors, don't just recommend the same one to everyone, know which ones have large enough cuffs available for your larger patients. And of course, you'll have a variety of cuff sizes for your office machine, right? And your team will describe them neutrally like "let me grab a different cuff."
- Do you have gowns? Have some larger ones available please!
- Above all else please just treat me as a whole person who really does want to have a trusted relationship with you. If you're my PCP for a while, I'm likely to see you for all manner of things and I don't want to have to put my defenses up to avoid a conversation about my weight if I'm worried about that new mole on my back or why I can't turn my neck to the right, or why I'm having trouble sleeping.
YES to not assuming weight loss is a goal. This is a really big one.
You may genuinely think you are just doing your part in noting weight, making suggestions, etc, but please recognize that not only have your larger-bodied patients almost surely heard it many times, but many have tried for decades, with limited results. For many of us, often overachievers in other areas of life, your making us feel like we just haven't tried can be truly stigmatizing and injurious. I still remember the childhood doctor 'Calories in, Calories out.' I have had undiagnosed eating disorders and multiple exercise overuse injuries (one permanent due to a muscle tear that has never healed.) You may truly feel your suggestions are a benign part of a medical checklist, but please understand they may be tossing grains of salt into still-open, sensitive wounds. If you are a life-long thin person who also has 'healthy habits', you may understandably assume that your thinness is due to those habits, but- trust us- many of us have those same habits with quite different bodies, and it is maddening that we cannot break through to you. It is as though you would tell someone to will themselves to better eyesight, or just snap out of depression, or just try harder and the headache will go away. If you would read the research on this, and recognize how much of body size is genetic, instead of assuming your life-long slim body shape is due to your 'good' behavior, that would be game-changing. And thank you for reading this; every doctor who is sensitive and aware can make such a difference!
As you read our answers, think about who is not here to be in conversation with you, and how often those people face the most oppression and barriers to support. If the better practices centered those people, we would avoid the problem of designing for the dominant group here as if we represent the platonic ideal of "fat people" when we are actually mostly white, mostly cisgender women, mostly small fat, mostly people with some healthcare access and financial resources. What we are pissed off about is the way we are not getting our usual privilege, and that is fine, but you also have to listen to all the other people who are not getting healing support for all the additional barriers as well if we are going to address the barriers fat people face.
Yes, this is beautifully stated. As I wrote my answer I thought "I'm writing this as a privileged cisgender white woman." I have some barriers and stigmas that come with being female and fat, but I do not face other stigmas that would compound those. As you've said, I hope that medical providers not only hear what this group is saying but also seek out other voices!
Having recently read the breathtakingly cruel thread on r/Residency about fat patients, I'd suggest burning the entire medical training establishment to the ground and starting over.
If that seems a bit difficult for one person to undertake, I'd suggest not assuming that your patient is unaware that she's fat. I don't need to hear a breathless announcement that I'm fat. Do you really think I reached adulthood unaware of that? Since most providers feel professionally bound to comment on weight, please do so in a normal, conversational manner. My nurse-practitioner is a gem. I tell her that she can go ahead and write down on the billing code that she advised the patient about best practices for weight loss and now let's move on. She just laughs.
I once had a doctor ask me if my weight was something that I wanted to discuss with her and I said no and that was that. It was brilliant and revelatory and has sadly never happened again. But if you're looking for a way to figure out where the patient is at, that might be a good starting point. Please note the question was asked to me in a very neutral way, with no value judgment attached to it. Wording is everything.
This reminds me of something I heard probably on maintenance phase that fat patients often bring up weight just because they assume a health care provider is gonna do it anyway. So I love the idea of a provider bringing it up in a way to get it out of the way.
It seems like so many doctors and dieticians assume I'm fat because I just don't know how to be thin. But I'm a 41 year old person with two masters degrees who has been fat my whole life. Trust me, I've done my research, I've tried the things you're about to suggest. What I need are ways to feel better in the body I have, not the useless advice that I'll feel better if I lose the weight.
I had an OBGYN tell me I should aim to not gain any weight while pregnant (meaning lose weight while pregnant to.compensate for the baby's growth). She made me feel like I didn't deserve to have a baby because I was fat.
And lastly, growing up every doctor I met focused hard on 'prevention' so that I didn't grow into a fat adult from a chubby kid. It sent the message from day one that my weight was a result of my own failings and made me believe I deserved any pain I have.
As for what I'd like a doctor to do? Don't start by weighing me. Ask why I'm there and ask about experiences I've had before. Lastly, don't prescribe weight loss. Work with the body I have.
I can echo what many commenters have already said, but a few of my specific thoughts:
-Actually LISTEN to your patients and respect their wishes. My now-former PCP repeatedly brought up weight loss surgery, even after several different conversations where I expressed my anti-diet stance and set a hard boundary around WLS.
-Understand that people who have been fat their whole lives likely already know a lot more about nutrition than you do because we've heard it forever and most of us have tried it. I don't need your fucking nutrition printouts ever really, but even less when I'm seeing you for illness or earache, etc.
-Have a larger blood pressure cuff handy and maybe take my blood pressure at the end of the appointment when I'm likely to be less anxious.
-Talk to your colleagues! You have more power to push for change from where you are.
-And finally, if you are actually using a weight-neutral approach, publicize this fact and make that approach clear for people looking for a doctor. I recently searched for a new PCP and realized that unless I had specific recommendations from other fat patients, I was going to have to go blind and try a few out. This is exhausting and stressful and ensures that my defenses are up before I even step foot in the office. Make it easier for fat patients to find you.
And, like all systemic issues, if you’re advertising that, please make sure you’re truly doing the work. I saw a new PCP once who advertised a HAES approach, had a whole conversation with me about how my weight was not a concern and weight loss suggested were not wanted and then sent me a message when my cholesterol came back a bit high to consider losing 5-10% of my body weight. When I pointed out the contrast of that with our conversation she said it was one of her standard replies in the system...
My new doctor has a whole practice with experience working with eating disorders and a commitment to a weight neutral approach and a few things they do are: when weighing is essential (like for my growing kid) it’s blind to me and never discussed or visible in any portal, we discuss what activities I enjoy, and my doctor was quick to find a HAES dietitian for me when I was diagnosed with a condition partially managed by dietary changes. She always considers quality of life in her recommendations and is able to be really firm with me when I waver and wonder if I could be better off trying to lose weight again that there’s lots of evidence against that and I haven’t caused my own health issues. She puts a lot of effort into referrals to ensure I don’t encounter a fatphobic specialist too.
yes many times over to this last point! I'm looking for a new pcp myself and the ones recommended by my other fat friends aren't taking new patients. I have no way to know how it will be with the ones my thin friends are recommending
Read the Weight and Healthcare substack. I know, it's not the things published in your medical textbooks, but, the author is a very thorough researcher. Probably at least as thorough as anyone who ever wrote a textbook.
Don't talk negatively about your own body. And show yourself compassion as well as me. My doc is currently dealing with hot flashes and she referred to her sweat as "really gross" as she wiped her face with a tissue. Does that mean if I'm sweaty she'll think I'm gross?
Your second point really resonates with me, Anastasia. I once had a fat PCP who felt compelled to give me diet advice. The conversation devolved into a lengthy description of her own eating habits. I know she meant to -- and thought she was -- presenting herself as a model, but there were strong "good fatty" vibes, and she also unwittingly revealed some evidence of disordered eating patterns. The whole experience was tedious and not at all affirming.
My PCP happened to be fat, so in this case, the feelings may have been a bit rawer on both sides. But fat folks are obviously not the only ones with body issues. If you're a practitioner -- fat or thin -- who has body issues, maybe put some thought into how you're using shared trauma to relate to your patients. If you can't help patients heal their existing battle wounds, at least refrain from demonstrating how to acquire additional, self-inflicted ones.
Please don't treat me like I am stupid. I had one NP say, "If you fill up on the good stuff, like fruits and veggies, it keeps you from eating the bad stuff." First, good vs. bad food is not a good way to think about eating, don't assume because I am fat that, I don't eat fruits and veggies, and I am almost 60 years old and have lost (and gained) hundreds of pounds over my lifetime--I am familiar with this kind of simplistic weight loss advice. (and of course, I don't have health problems that may be affected by weight, so why even discuss this with me?
Wow. Just wow. I have a friend I call Wonder Woman. She's 6'3", large, and in charge. I'd love to see anyone say something that idiotic to her, just to watch them shrink and pee their pants as she tilted her head, raised an eyebrow, and asked them to repeat that.
As others have said, listen to your patients, believe them, and change your recommendations accordingly. If you don’t need my weight for some concrete medical purpose (anesthesia, dosing, etc.), don’t even ask to weigh me. Assume I know I am fat and you don’t need to tell me. Rely on health markers rather than just assuming that fat=unhealthy. So many times I’ve heard, all your numbers are perfect but if you want to be healthy, you should lose weight. And try to keep in mind what have likely been my previous negative experiences with the medical field. Why haven’t I been to the doctor for years? Why was I hesitant to bring up an issue? Why did I delay care for something you think is obvious? Maybe I tried to seek care previously, was dismissed, and just received a weight loss recommendation no matter what it was. Does that really matter? Don’t shame me, meet me where I am and treat me.
Fight the pressures to have all the answers. You don't know how to make fat people into thin people because no one does.
Shift your focus to the eugenics root of your training to "prevent," pathologize, and get rid of us. Learn how you have been trained harm us, by prescribing weight suppression that leads to either weight cycling (in the best case scenario) or eating disorders, and by withholding life-saving care hostage.
Open your frame of consideration to the wider world of harms (social determinants of health, capitalism, anti-Blackness, anti-fatness, ableism, healthism, colonialism, cisheteropatriarchy, bigotry of all kinds) as potential sites for intervention by doctors too.
Open your mind to what your medical education didn't know, didn't get right, and didn't teach you; get good at doing what you can as a partner to your people when you don't have all the solutions.
Reclaim the original spirit of why you went into the field, to support people's well-being; and divest from any practices and demands to impose judgments and barriers, or to have the best performance stats, because it makes you turn away from the people who need the most.
Organize yourselves because you are suffering needlessly as well, and the system is doing exactly what it is designed to do, and it needs to go.
Embrace the wisdom of your peoples' lived experience.
Design research around what we prioritize rather than the agendas of thin people who want to get rid of us.
Call us your people, not your patients.
"You don't know how to make fat people into thin people because no one does." YES YES YES!
Eagerly awaiting these comments!
Perfect timing, as I had an issue just this week. If you are not compelled by your health system to bring up a patient's weight, even if you feel it might be a (correlated) cause of the current health issue, don't work it into a subsequent appointment. You will lose any trust the patient has in you. I'm recovering from major surgery and really liked my surgeon. Every pre-op appointment was focused on the issue that required the surgery, he answered all my questions, took a lot of time with me, even made himself available over the phone. I completely trusted him going into the surgery and through the first post-op appointment. At this week's second appointment he did a thorough exam, answered all my questions, then sat himself down on the stool and said, "I can't remember, did we ever have the weight conversation? It's a big risk factor for your condition." Just when I thought that was going to be a non-issue and we were just going to treat the condition. And though I am kicking myself a bit for not having a ready response (because I worship Reagan Chastain), I also know that there are a multitude of risk factors for my condition, including genetics and age, which I can't change. PLEASE listen to what your patient is telling you in the moment and don't have your head full of the thing you think is obvious just by looking at them. Believe us, we know we're fat, and we know that even if we wanted to change that, everything your industry has been prescribing hasn't worked for almost all of us. We don't want to waste the precious five minutes we get with you talking about it again.
Ugh, I am so sorry that your surgeon broke your trust like that. My last surgery was an emergency appendectomy so there wasn't a lot of pre-surgical consult other than "hey, you need this, here are the risk factors, do you consent?" and I was relieved that the anesthesia team and the surgeon did not express any weight bias throughout the whole process. In the few hours between diagnosis and surgery I was bored and in pain and trying to distract myself so I read up on appendicitis, and found myself strangely relieved to learn that despite it being a very common condition, there aren't any known risk factors, other than it being somewhat more common in boys/men than in girls/women, and more common in the 10-30 age range than in other age cohorts. So no one could say "ah, if you weren't fat your appendix would be fine."
The only time my weight came up was with antibiotics for a follow-on infection and the surgeon mentioned consulting with a pharmacist to see if the pharmacist recommended a higher dose for a higher weight. Very neutral, just a factual discussion.
I so appreciate these comments. I am a primary care nurse practitioner and am learning so much from this community. I am committed to doing better. I do agree the system is failing us. For example, I am supposed to assign a diagnosis every time a patient has a BMI above normal range. Then I am supposed to document on the interventions I recommended. If I don’t, someone from my organization contacts me to edit/fix my encounter with the patient so that I can get maximum reimbursement from insurance. Before I started learning about health at every size, I used to just have my medical assistant get a weight on every patient no matter what they were there for so I could make sure I did this. This is so wrong!! I read here the suggestion of asking “is there anything about your nutrition or movement habits that you want to discuss with me?” And leave it at that. I know this is the very tip of the iceberg. It’s not an understatement to say this community will change the way I practice for the better. Thanks for having this discussion.
". . . so I can get maximum reimbursement from insurance . . ." this is a great example of structural sources of harm, where you as the clinician are under great pressure to be the perpetrator of harm so more money goes into [someone's?] pocket. Do you think clinicians could band together to say, "this is no longer going to be a source of revenue to this organization because of the harms of stigma, weight cycling, disordered eating, etc., as it is unethical." As a clinician watching the last thirty years unfold, I am sickened by the erosion of clinical decision-making power in order to maximize profits. It's a much bigger issue and it means clinicians need ways of organizing to protect ourselves so we can practice ethically. BTW, this could be a useful reference for this discussion that was just published: https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2023-06/joe-2307_0.pdf
Thank you for the reference. It sadly seems incredible to me that the ethics journal would devote an entire issue to this. I too am an PCP in a large teaching university who wishes to shift this paradigm. But it's a solid wall to knock your head against. Is anyone aware of formal teaching within medical/nursing programs regarding weight stigma/HAES/eating disorder prevention?
YES, it is a growing network! Lisa Erlanger MD contributed content to the AMA ethics journal and has been working on this in Seattle, and Lisa DuBreuil LCSW has been building a network in Boston; please join
ASDAH.org to find more people working on these issues, and connect with
Medical Students for Size Inclusivity https://sizeinclusivemedicine.org/
Also see the many of the outstanding workshops from the recent Weight Stigma conference https://weightstigmaconference.com/programme-2023/
Follow Monica Krete, Marquisele Mercedes, Rachel Fox
Ragen Chastain's Health and Weight Newsletter WeightandHealthcare.substack.com
Gloria Lucas with Nalgona Positivity Pride has an ED training NalgonaPositivityPride.com
Alishia McCollough has an ED training https://alishia-mccullough-s-school.teachable.com/
Shilo George does consulting with medical clinicians, organizations, and learners ShiloGeorge.com
this side of it is frustrating, especially because insurance providers aren't medically trained! I'm sure you have many frustrations with their hoops
I see that insurance only wants to fully pay for the visit if you do this, but would your job be at risk if you just stopped? Or record a made up BMI? Or what if you diagnose something fully unrelated and minor like "water in the ear" and recommend "naps, laying on that side of the face" as an intervention? I understand you may not have that freedom, and I don't know what impact these actions might have for your patients; just brainstorming in case it is helpful
Thank you for sharing this! From the patient perspective, can I ask what happens when a patient declines to be weighed? Does that successfully sidestep the BMI-related insurance pressure on your end?