Weight Bias Is a Problem in Health Care. Here’s What Doctors Can Do
Aubrey Gordon still recalls going to the doctor and having her blood pressure checked three times—because the provider couldn’t believe it was normal, given the fact that she’s overweight. Considering the treatment she’s received at doctors’ offices all her life, she wasn’t exactly surprised.
“It’s kind of wild to see that my size comes with so many assumptions,” she says. “From the moment I walk in, my fatness is considered a problem to be solved. Even before I speak, there’s bias and misconceptions based on how I look. I’m considered lazy, non-compliant, and less worthy of care than a thin person.”
Gordon, who’s the cohost of the anti-diet podcast Maintenance Phase and author of What We Don’t Talk About When We Talk About Fat, often hears similar stories about fat people who are refused care, sent home without treatment, and later discovered to have serious illness. Or, they’re simply told—over and over again—to lose weight even if they’ve been trying for decades. Often, they’re given this guidance despite meeting other measures of health, like normal blood pressure and blood sugar levels, and good cholesterol numbers.
“When you start from a place of thinking someone who’s fat is unhealthy, and not deserving of support or empathy, that will inform their care at every level,” Gordon says. “The good news is that we know even a small amount of awareness can make a difference. You can’t change the culture of thinness we live in, but as a doctor, you can shift your mindset about fat patients and see them in a different way.”
Roots of bias
American society has long valued smaller bodies, and a robust pool of research indicates that medical professionals continue to value thinness as a marker of health.
For instance, a 2013 study in the journal Academic Medicine surveyed 350 medical students on their views around fat and thin patients. More than half of respondents showed significant implicit weight bias, including anti-fat views. Two-thirds of these students were unaware of that bias, according to the findings. Another study, published in 2003 in the journal Obesity Research, found that even doctors who specialize in clinical management of obesity showed very strong weight bias and used words like “lazy, stupid, and worthless” to describe fat patients.
Other studies have shown that higher-weight individuals often experience shorter appointment times, less comprehensive exams, fewer referrals for specialists and imaging, and longer wait times for surgeries and other procedures. A 2019 research review in Primary Health Care Research & Development about weight bias and utilization found evidence of patronizing and disrespectful treatment, poor communication, and assumptions about weight gain.
Another aspect to consider is the common use of body mass index (BMI) as a measuring tool, says Sabrina Strings, an associate professor of sociology at the University of California, Irvine and author of Fearing the Black Body: The Racial Origins of Fat Phobia. BMI—a person’s weight in kilograms divided by height in meters squared—was developed as a way to assess a population, not individuals. It’s especially problematic because it’s based on white men, while Black and white people tend to have different body compositions, says Strings.
“Use of BMI is rooted in anti-Blackness and sexism,” she says. “Shifting away from BMI would require a tremendous overhaul in medicine and society since it’s so ubiquitous, but the reward would be taking away this harmful approach that contributes to racism, fatphobia, and misogyny.”
When patients anticipate judgment, bias, and stigmatizing language from doctors, they tend to avoid seeking health care—not just in terms of checkups, but also for potentially significant concerns that are already causing symptoms. For example, they may not get a lump checked for cancer, talk about blood in their stool, or report issues such as fatigue, migraines, or pain.
“We’re seeing that patients aren’t seeking medical care or are delaying care when they’re ill because of anti-fat bias in health care,” says Dr. Rekha Kumar, an endocrinologist who’s the former medical director of the American Board of Obesity Medicine. It’s part of the reason why patients with obesity may have suffered worse outcomes as a result of COVID-19, she adds. “Another negative outcome is the lack of continuity of care, because patients may not return to the same physician if they feel judged based on their weight.” When that happens, strong patient-doctor relationships aren’t formed, “and there’s a lack of trust and of routine screenings.”
Weight bias can also have significant psychological consequences, Kumar says, potentially increasing the risk of depression and anxiety.
If weight bias is contributing to shorter and less comprehensive exams, or a reduced willingness to order imaging and lab tests, that means even if a fat patient comes in with an issue, it’s possible a doctor won’t detect a serious problem.
Small changes, big difference
Weight bias exists at multiple levels: within medical education, clinic policies, research, and patient interactions. As a result, it can feel overwhelming to find a starting point for change. But as with any major shift, it’s helpful to start where you are, and do what you can.
For example, consider the chairs in your waiting room, suggests Dr. Florencia Halperin, an endocrinologist and chief medical officer at Form Health, an app-based medically-supervised weight-loss program. Not having appropriate seating forces a fat patient to stand, and that draws attention to them in a way that’s further stigmatizing, she says. Similarly, these patients might need larger exam tables, bigger blood pressure cuffs, and imaging equipment that can accommodate their bodies. Even stock photos around the office—the kind prompting people to get health screenings, for example—can show a lack of inclusivity if only one body type is depicted.
“This is simple stuff, but you can’t believe how much of an impact it makes,” Halperin says. “Not only does it communicate to patients that you’re ready to care for them, but it sends a message to other patients and staff. It improves the environment for everyone.”
Adopting people-first language is another respectful tactic, she adds. For instance, instead of calling someone obese, the preferred terminology is a person who has obesity. “You wouldn’t say someone is cancerous, you’d say they have cancer,” Halperin says. “Yet it’s become very common to say ‘the obese patient,’ which is dehumanizing.”
Posture, eye contact, and body language also play a role, adds David Tzall, a Brooklyn, New York-based clinical and health psychologist who’s worked in public hospital settings. Sitting with your arms crossed, looking away while a patient is speaking, having an expression of skepticism or disgust, or glancing at the clock more often are all behaviors that can send strong signals about your attitude—and you may not even realize you’re acting this way, Tzall says.
Another strategy that may seem minor but could have major benefits is not weighing every patient for every appointment, adds Halperin. Although this has become standard practice at many offices, it’s often done automatically without questioning whether it adds to knowledge about a patient’s health. Unless weight gain or loss is a factor for a specific diagnosis, scale numbers may be irrelevant—and worse, may be one more source of discomfort for a larger patient.
That doesn’t mean never talking about weight. But it does involve a shift toward more respect and collaboration, and a thoughtful approach around how weight is discussed, says Dr. Kecia Gaither, a physician and associate professor of clinical obstetrics and gynecology with Cornell Weill Medicine.
“The manner in which you discuss obesity with a patient makes a difference in how it’s received,” she says. “The conversation should be around how to optimize health, rather than just about losing weight. It should center on patient engagement so they feel part of the process, instead of feeling judged negatively.”
Also, take a step back when trying to apply knowledge about obesity and chronic conditions to the patient who’s right in front of you, suggests Stephanie Fitzpatrick, a clinical health psychologist who’s an associate professor in the Institute of Health System Science and Feinstein Institutes for Medical Research at Northwell Health. Even a large-scale study doesn’t represent the lived experience of an individual patient who has goals, unique health concerns, and factors like socioeconomic status at play, she says.
Moving in the right direction
In addition to adjusting behavior, and perhaps the clinic or hospital environment, it’s helpful for physicians to consider anti-fat bias with a wider lens. To some degree, weight bias is moving in the right direction with more awareness, Tzall says. But it will require much more effort on the part of not only physicians but also the entire medical system—including educators, administrators, other health professionals, and insurers—to keep navigating away from weight stigma.
A big step would be finally decoupling weight from personal responsibility alone. While patient choices around nutrition and exercise are certainly a factor in their health and weight, they’re far from the only variable, Halperin says.
For instance, obesity is a more heritable trait than heart disease, and a 2010 study in Current Diabetes Reports shows heritability estimates between 40% to 70%. Commentary published in the journal Nature in 2014 calls obesity “one of the strongest genetically influenced traits we have,” with both genome influence and hormone involvement.
Another aspect to consider is whether excess weight truly confers only health disadvantages. While being at higher weight has been shown to increase risk for some conditions, such as Type 2 diabetes, that doesn’t mean everyone who has obesity will be unhealthy or develop chronic issues. Similarly, not everyone who’s thin is healthy.
Most of all, doctors should cultivate more awareness around their own beliefs, language, and approach, Strings advises. “Being fat is not an illness,” she says. “Just using that perspective would take us a long way toward change.”
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Contributor: Elizabeth Millard