Dear Doctor, Here’s What Fat Patients Need From You

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I spent nearly a decade away from doctors’ offices.

I was insured. I could afford my copay. But I weighed around 400 pounds, and nearly every doctor I saw made it clear that bodies like mine weren’t worth their time. So I simply stopped going.

And I’m not alone. 62% of fat women report that they’ve experienced inappropriate or stigmatizing behavior at the doctor’s office. A 2018 study in the journal Body Image found that women with higher BMIs both experienced and internalized weight stigma at higher rates, leading many to postpone health care or avoid it altogether. For many of us, some of our most lasting experiences of stigma took place at the hands of health care providers.

It isn’t in our heads either. A 2003 Obesity Research study found that 50% of doctors described fat patients as “awkward, unattractive, ugly, and noncompliant.” A 2009 study in the Journal of Clinical Nursing found that a majority of nurses thought that fat patients “liked food, overate, and were shapeless, slow and unattractive.” And a 2004 study in Obesity found that 74% of medical students exhibited some level of anti-fat bias. The American Journal of Public Health concluded that anti-fat bias leads to “serious risks for [fat patients’] psychological and physical health, generates health disparities, and interferes with the implementation of effective obesity prevention efforts.”

Like all of us, health care providers have been raised in an era of fat panic and in a culture that reviles fatness wherever it’s found.

So, fat people aren’t getting thinner. And when so many health care providers regard us with judgment or even outright disdain, it means we’re also not getting the health care we need.

Of course, the harm that so many of us face at the hands of health care providers isn’t intentional. Most providers joined their field out of a drive to help others, not to harm them. But like all of us, health care providers have been raised in an era of fat panic and in a culture that reviles fatness wherever it’s found. And for all its technical training, most medical training programs — for doctors, nurses, physician assistants, and techs alike — don’t currently do much to counteract that lifelong socialized bias.

While the prevalence and effects of anti-fat bias and weight stigma are well-documented, many health care providers revert to the only tactics they’ve been taught when it comes to treating fat patients: telling us to lose weight. (As if we didn’t know. As if we haven’t spent a lifetime trying.) But there’s so much more to fat health care than that. So, for health care providers wanting to do better for their fat patients, from a patient perspective, here are a few key steps you can take to provide more meaningful, effective care for your fat patients.

Make your office physically accessible

Ensure that waiting areas have chairs without armrests and wide aisles so that fat patients and patients with mobility aids can easily navigate the space. Make sure you’ve got equipment that will function for fatter people: larger blood pressure cuffs, roomier gowns, exam tables with high weight capacities, and more.

Ask for consent before discussing a patient’s weight

It wasn’t until I turned 36, after a lifetime as a fat person and a fat patient, that a health care provider asked me about my history with eating disorders. That oversight stands in stark contrast to the experiences of fat people. The pressure for fat people to lose weight is immense — every fat person I know has dieted, and many have also formed eating disorders or body dysmorphia.

Many fat patients have a lifetime of personal experience with weight loss and with weight stigma. Some will have decades-long histories of doggedly trying to lose weight. Discussions of weight can trigger both disordered eating and the trauma of weight stigma. If specific health conditions require a conversation about a patient’s weight, ask for their consent first. And, for patients with eating disorders or body dysmorphia, ask for their consent before weighing them at all.

Adjust your language

A growing number of fat folks experience terms like “obese” and “overweight” as slurs, having regularly heard them as justification for street harassment, employment discrimination, and even violence. Experiment with changing your language around size to better reach those patients. “Your BMI is higher than we recommend — is it okay if we talk about that?” is a world away from “I’m concerned about your morbid obesity. You’ll need to lose at least 100 pounds.”

Don’t assume — ask

Studies show that doctors spend less time with fat patients and develop less rapport. As a patient, this has most frequently shown up for me in the form of a bewildering lack of curiosity from my health care providers about my life, my behaviors, and my concerns.

Most assume I am sedentary, that I eat fast food regularly, and perhaps most perplexingly, that I don’t know I’m fat. Even seeking treatment for ear infections has led to lengthy weight loss lectures from my providers. Rather than jumping to conclusions, ask your fat patients what they’re doing to tend to their health and believe them when they tell you.

Test blood pressure at the end of the visit

Seeking health care is one of the most stressful and frightening things I do as a fat person — and often, that shows up in my vitals. Nearly every time my blood pressure is taken at the doctor’s office, it’s taken at the beginning of an office visit, when I don’t yet know if I’m in a safe medical setting or one that will judge, reject, misdiagnose, or mistreat me. As such, my blood pressure is often elevated due to all that stress. Try taking (or retaking) fat patients’ blood pressure at the end of the office visit, after you’ve established trust and set us at ease.

Reassess your approach to conversations about size and weight loss

Perhaps the largest factor that kept me out of doctors’ offices for eight long years was the relentless drumbeat of conversations about weight loss. Those conversations overwhelmingly ignored any history of eating disorders, food insecurity, and trauma. Often, health care providers skipped straight to a lecture without even asking about my current diet or activity levels. It felt like someone had pressed play on a recording, and I just had to wait it out. And those lectures felt both condescending — as if I hadn’t considered or attempted to lose weight — and imprecise.

Here are a few questions you can ask yourself to rethink your approach to weight loss conversations:

  • What is your success rate with your current approach to weight loss interventions? How many of your fat patients have become thin as a result of it? If your patients’ rates of long-term weight loss aren’t high, you aren’t alone. Research shows that, two years after weight loss, 83% of fat people who lose weight have gained back more than they initially lost. By the three-year mark, that number rises to 97%.
  • Is there a more precise recommendation you can offer that yields more reliable results? For example, if a patient has high blood pressure, could you encourage them to increase their physical activity regardless of whether it causes weight loss? What more tangible, controllable practices can you offer in place of a simple, isolating, and likely ineffective mandate to lose weight?
  • Dietary changes for weight loss have also been linked to developing eating disorders. 35% of dieters become “pathological dieters” — and of those, 20–25% develop eating disorders. Teenagers who engaged in even moderate dieting are five times more likely to develop an eating disorder, according to the National Eating Disorders Association.
  • If you recommend weight loss surgery, does your approach acknowledge the very real barriers to patients? Most insurers don’t cover weight loss surgeries, and the out-of-pocket cost can run up to $25,000, to say nothing of follow-up procedures. Some patients may have histories with eating disorders. Others simply may not want surgery. If a patient tells you they don’t want to discuss weight loss surgery, believe them.

Look into effective and emerging frameworks for fat patients

As the body of research on weight stigma has grown, alternate modes of care provision have also blossomed. If you haven’t already, research frameworks like Health at Every Size and Intuitive Eating.

Disproportionately, our world is geared toward talking about fat people without talking to fat people.

And, above all, ask fat patients for feedback. Talk to fat folks about how they would respond to particular recommendations. Seek feedback from your existing fat patients. Disproportionately, our world is geared toward talking about fat people without talking to fat people, browbeating us into a change many of us have never managed to bring into being. As a health care provider, you’re in a powerful position to shift that dynamic with your patients.

Research fat people’s social determinants of health

Our individual health isn’t just determined by personal habits and behaviors — it’s also shaped by social determinants of health: things like where we live, our socioeconomic status, and what kinds of bias or discrimination we may face in the world. And according to the Centers for Disease Control and Prevention, those social factors may determine as much as 75% of our health outcomes.

Take some time to learn about the specific barriers to health for fat people. Seek out medical research that’s specific to fat patients. Get familiar with fat folks’ lived experiences. Read memoirs by fat authors — personal stories from fat people. Ask the fat people you know about their experiences. Research shows that fat people face significant workplace discrimination, disparities in education, and lack of access to health care — all significant social determinants of health. Learn those barriers so that you can account for, and counterbalance, them in your care provision.

Critically, be sure to acknowledge the trauma that fat folks face when seeking health care — especially fat people of color, disabled fat people, and fat trans people. For those of us experiencing multiple forms of oppression, it can take weeks (even years) to work up the courage to seek health care, knowing that we may be traumatized all over again. Recognize that you’re in a position of immense power for your fat patients and for any patients who have been marginalized in health care settings. Learn to reread noncompliance as reasonable mistrust and trauma reactions.

Inventory the ways anti-fat bias may show up in your practice

Do you or your colleagues react with shock when fat patients have low blood pressure or don’t have diabetes? Do your office visits with fat patients run shorter than visits with thin patients? Do you offer different courses of treatment to thin patients than to fat patients? Do you shudder or recoil from touching fat bodies or complain about needing to adjust your approach with fat patients? Do you keep your judgments about fat patients to yourself, assuming we can’t read your disgust? All these send signals to fat patients that we aren’t welcome, that our bodies aren’t worth caring for, and that our health care providers may not even believe it’s possible for us to be healthy.

Take some time to observe and inventory the ways in which anti-fat bias may show up in your mind, your patient interactions, your body language, your word choices, and your systems. Find ways to measure and assess that bias, like Harvard’s Implicit Associations Test on weight or the fatphobia scale. And seek out the work of providers who are actively challenging weight stigma in their work: folks like Peter Attia, Joshua Wolrich and Christy Harrison.

Don’t withhold care until fat patients lose weight

Many of us have spent a lifetime chasing weight loss that never comes. Treat our bodies as they are now. Too many fat patients have stories of misdiagnoses, incuriosity, and withheld care. Fat trans people, in particular, are regularly told they won’t be able to access lifesaving gender-affirming care unless and until they’re thin.

Don’t treat health care as an incentive. If you don’t have a choice about adhering to weight loss guidelines around particular treatments, explain why and what those barriers are in concrete terms. If you do have a choice, take a moment to reassess your practices.

I realize not every provider will be able to take all these steps. Some are systemic, determined by the health system you’re working within. Others won’t fall within your purview. Some also won’t be feasible for every single patient — and of course there are things you already do, measures you already take.

But these recommendations are designed to help you create more space for fat patients to find the responsive, compassionate care they need. And all of them will reduce the inadvertent harm so many providers can cause—even when trying to help.

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