A Weighty Matter

My patient sat across from me and tearfully shared her account. After finally gathering the courage to discuss her disordered eating, her doctor skeptically responded, “You don’t look like you have an eating disorder.” Despite the patient’s report of alternating cycles of intense restriction and binge eating episodes over the last 10 years, her physician was recommending weight loss because the patient’s body mass index (BMI) was 28 and fell in the “overweight” range.  

Weight stigma in clinical practice 

Unfortunately, this patient’s experience is not an anomaly. Patients are told, “your knee hurts because you need to lose weight,” or “you’re obese, you need to be more disciplined,” and even “a BMI of 18 is perfectly healthy,” (reader, it’s likely not). Restricting behaviors including fasting and skipping meals may increase the risk of binge eating and loss of control eating episodes. However, patients are implored to “try harder” without adequately assessing current eating and exercise behaviors or the patient’s reported efforts are doubted. Additionally, alternative causes for patient’s symptom presentations are not explored due to the focus on weight as the likely cause of illness.  

Obesity is a multifactorial disease influenced by genetics, hormones, medical comorbidity, and environmental factors, as well as diet and exercise. Of concern, obesity is strongly correlated with increased rates of morbidity and mortality. However, the intense public health emphasis on combatting obesity, combined with inadequate knowledge regarding its etiology and limited face-to-face patient time, has led physicians to overly rely on BMI to determine a patient’s health status. A recent study in the Journal of the American Medical Association reported that explicit and implicit weight-related biases are common among medical providers and may influence diagnostic and treatment decisions.  

These factors combine to negatively impact care for patients with obesity including the potential for misdiagnosis. Patients may feel judged and unheard, which may result in avoidance of routine preventative care and scheduling appointments only when absolutely necessary. This is problematic given the elevated rates of cancer and heart disease among patients with obesity, as early intervention has been shown to improve outcomes for these illnesses.  

How to advocate for your patient:  

1. Offer support.

Listen empathically without judgment and express understanding of the patient’s concerns. When the patient tells you about their experience of weight bias from another healthcare professional, believe them and offer comfort. 

2. Educate the clinician.

Follow up with the clinician either by phone or email. This is undoubtedly a delicate matter: tread lightly! Clinicians may be unaware of their own biases, lack knowledge of causes of obesity, or not realize the effect of their words on the patient. If appropriate, provide information and resources including up-to-date literature on obesity management best practices. Importantly, explore your own potential biases with respect to weight.  

3. Focus on behavior.

Often, a patient’s eating and exercise habits are better indicators of health than BMI alone. Assessing health behaviors is key to creating an effective treatment plan. Primary care providers don’t have the time to implement needed interventions. Further, multifactorial diseases need multidisciplinary care. Standard practice could include specialist referrals to rule out underlying medical conditions contributing to weight gain, as well as creating a team including dieticians, physical therapists, and behavioral health to address the patient’s needs.