Changing conversations around weight could benefit both patients and physicians.
On July 14, 2018, the Victoria Times Colonist of British Columbia published an obituary for Ellen Maud Bennett, who died of “inoperable cancer,” at the age of 64, shortly after her diagnosis. The loving tribute remembered a vibrant, funny, creative soul who made her last days count. Her “death bed edicts” included fresh lobster shipped from Nova Scotia and bouquets of fresh peonies.
Bennett also asked her family to share a message in her obit, “about the fat shaming she endured from the medical profession.”
“Over the past few years of feeling unwell she sought out medical intervention and no one offered any support or suggestions beyond weight loss,” her family wrote. “Ellen’s dying wish was that women of size make her death matter by advocating strongly for their health and not accepting that fat is the only relevant health issue.”
Bennett’s death was not a tragic-yet-rare incident of malpractice. The prejudice she endured plays out every day in doctors’ offices across North America and the world, often at the hands of well-meaning practitioners who believe that weight is, indeed, the most relevant health issue affecting the people sitting in front of them.
Even before they reach medical school, future physicians hear the same messages that the public receives, ad nauseum: being fat is bad. It’s unhealthy. It’s killing you. Then as med students they learn, incontrovertibly, that too much weight causes type 2 diabetes, hypertension, cardiovascular disease, stroke, arthritis, cancer—the list goes on.
But many doctors’ concerns about their patients’ weight exceeds the academic, the clinical, the objective. It’s hardly surprising, in a culture that reveres skinniness and demonizes fatness, that physicians steeped in that same milieu share those biases. In studies and surveys, doctors have said people in larger bodies are lazy, lack willpower, and worse. Unsurprisingly, these negative attitudes translate to shorter office visits and less proffered care.
Weight stigma “prevents you from seeing the person in front of you as a human being,” says Uchechukwu Onwunaka ’19 MPA’20 MD’24. “You just dismiss their concerns without even giving it a second thought. It’s why you can sit in a doctor’s office and hear people talk about weighing fat people at the zoo as opposed to at the clinic.”
Meanwhile patients who perceive that stigma are more likely to delay or avoid care, for fear of being judged. When doctors are dismissive, and patients are afraid to show up, the consequences can be dire. Horror stories abound, in the medical literature and the popular press: undiagnosed cancers and kidney conditions and pulmonary disorders, ignored until, like Ellen Bennett, the worst happens, or nearly so.
Assistant Professor of Psychiatry and Human Behavior Carly Goldstein F’17, PhD, works with cardiac rehabilitation patients after a heart attack or other major event. “I have met numerous patients … who hadn’t been to the doctor in 30 years, because they went to the doctor and the doctor said something disparaging about their weight, and they decided to not go back. And think of all of the literal decades of preventative cardiovascular care that person did not receive that maybe would have changed the outcome,” she says. “And that’s barely a horror story. That’s literally what I encounter all the time.”
Goldstein believes that higher weight can be a risk factor in cardiovascular disease, and her research aims to help people lose some of it “when appropriate.” But she and a growing number of experts say that focusing too much on the number on the scale can be harmful in itself. The stress and even trauma patients feel when pressured to lose weight can have the paradoxical effect of weight gain. Some studies have even suggested that shame and stigma are more harmful to health than excess pounds.
“I tell providers all the time that being at a higher body weight is not going to kill most people overnight,” Goldstein says. Investing in a respectful, long-term relationship with each patient goes a long way toward improving their health, no matter what they weigh.
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In the exam room, the demand to lose weight is hardly one-sided; many patients initiate these conversations, and want help from their doctors. But appearance, more than health, is the chief motivator. Where does our obsession with being thin come from?
Onwunaka first heard the term “fatphobia” in a workshop she took as a junior at Brown. “Maybe you don’t have a word for it, but you know the stigma that’s attached to weight in our society,” she says. “So to finally have someone put a name to it, and to explain the way that it’s not just an interpersonal issue, but … a product of the system and society that we live in, was really groundbreaking for me.”
Last spring Onwunaka, who is completing the Scholarly Concentration in Medical Education, presented a module to first-year Doctoring students called “Race, Fatphobia and Nutrition Counseling.” Citing the work of the sociologist Sabrina Strings, PhD, Onwunaka explained that the Rubenesque body type celebrated by 17th-century white Europeans went out of fashion with the advent of the transatlantic slave trade, when fatness became defined as a characteristic of Black people.
“One of the ways that [Europeans] distinguish themselves from Black people is developing this thin ideal,” adds Clara Pritchett ’22, who led an undergraduate independent study on fatphobia and diet culture that included readings from Strings’ book, Fearing the Black Body. “We started to see fat as savage, or associated with Blackness.”
In the US, dieting took off in the 19th century among middle-class white men to prove their “rationality and willpower,” and thus their gender, class, and racial superiority, writes the historian Katharina Vester, PhD. To be fat was to be lazy, greedy, and weak; political cartoonists depicted corruption with obese men, and caricatures of immigrant and Black women were typically overweight—stereotypes that “served to further exclude African Americans and immigrants from access to equal political and cultural representation,” she writes.
The body mass index lent a scientific veneer to sorting people by weight. The 19th-century Belgian astronomer Adolphe Quetelet devised the metric, a ratio of weight to height, as something of a curiosity: what were the proportions of the “ideal man”? He gathered data on French and Scottish soldiers—hardly a representative sample of the world’s population—and calculated the average, defining anyone outside of that as over- or underweight.
It was the American physiologist Ancel Keys who enshrined Quetelet’s measurement as the BMI in the 1970s, after leading a decades-long study of predominantly white nations that failed to find a connection between height, weight, and coronary artery disease. Nonetheless, he endorsed the BMI as an indicator of obesity—a condition he considered, according to a 1961 profile in Time, “disgusting” and “immoral.”
Keys’ attitudes live on in medicine. Numerous studies have found high rates of weight discimination among physicians, trainees, and medical students; that doctors have less respect for larger patients; use such terms as “unattractive,” “non-compliant,” and “lazy” to describe them; and consider them a “waste of time.” Even obesity medicine specialists exhibit high levels of anti-fat bias.
“Whenever I hear the word ‘fat,’ I replace it with ‘Black,’” Onwunaka says. “Today in medicine, the language you hear used about fat people is not something you’d say about any particular group of people.”
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Patients who feel stigmatized in their doctor’s office are more likely to avoid the place. “I’m a fat person myself, and … doctors would tell me, if you lose weight, everything will get better,” Christina Roullard RES’21, DO, says. “As a patient, I always felt like I wasn’t allowed to seek medical care because I was fat.”
Now a family medicine physician in Dallas, she regularly sees patients whose prior doctors ignored their concerns “for years,” and instead prescribed weight loss. That’s not news to Roullard, who has asthma, and has gone to the doctor wheezing and been told to lose weight.
Research bears out her exact experience: in a study of medical students in the International Journal of Obesity, a virtual patient reporting shortness of breath was more likely to be blamed for her condition, advised to diet and exercise, and judged noncompliant if she was obese than if she was not, and she was less likely to receive a prescription for an inhaler.
Shira Hirshberg, MS, RDN, LDN, a dietitian in Providence, says many clinicians tell her that patients’ “risk for heart disease and diabetes is lower if they’re smaller, so it’s ethically problematic for me not to recommend weight loss.” But such advice is not free of risk, and often causes harm. Physicians “don’t see the impact, because the patient leaves their office and cries in their car,” Hirshberg says.
Krista Handfield, LICSW, is the director of Size-Inclusive Health Care at Thundermist Health Center in Rhode Island. She launched the initiative in 2019, she says, so that “people experiencing weight stigma could have a better experience in health care.” One of the first things she tells providers, in trainings at her own and other medical offices, is that “weight stigma is a health issue, and it leads to negative health outcomes independent of a person’s weight.”
That’s less radical than it may sound. Regardless of BMI, the “mere perception of oneself as being overweight” correlates with increased blood pressure, cholesterol, C-reactive protein, triglycerides, glucose, and A1c, according to a 2018 paper in BMC Medicine. Diseases associated with obesity, like hypertension and diabetes, can result from such stress-related factors. People who experience weight stigma are more likely to develop mood and anxiety disorders as well as eating disorders. In sum, a 2015 analysis concluded, they have a nearly 60 percent greater chance of dying—independent of any risk factors.
Emily Panza, PhD, an assistant professor of psychiatry and human behavior (research) who studies how discrimination relates to obesity, says that people who experience stigma from doctors or other providers—due to sexual orientation or race, for example, as well as weight—are at risk, and not only because it discourages them from seeking care.
“The real stress of experiencing weight stigma, the physical effect that that has on the body and then all of the ways in which people try to cope with that stress—chronically, over time, all of those factors can add up,” Panza says. On top of the stress itself, if someone’s coping strategies tend toward overeating and not exercising, that compounds the harm.
Celeste Corcoran, MD, sees this in children. “Their weight is a source of their bullying,” the assistant professor of pediatrics says, “which lowers their self-esteem, which lowers their motivation to change, which creates more weight gain from stress, and we’re in a vicious cycle.”
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Thundermist family physician Chelsea Graham RES’18 F’19, DO, remembers being told in medical school that “you’re doing a good job as a doctor by pushing weight loss.” But she also recalls the words of a patient who had been pressured by other physicians to lose weight: “Don’t you think I would have done that by now if it was that easy?”
That’s the thing: it’s not. For the majority of people, diets simply don’t work—after two to five years, nearly everyone gains back the pounds they lost, and sometimes more. (As Pritchett points out, “If you went on Amazon and saw something had a 95 percent failure rate, you would not buy it.”) Yet even as research consistently identifies factors affecting weight that have nothing to do with willpower, like genes, stress hormones, metabolism, and environmental toxins, the “calories in = calories out” myth stubbornly persists.
“Hunger is a very complex, mediated phenomenon,” Corcoran says. “If it was all calories in and calories out, lifestyle treatment would be 100 percent effective.”
Corcoran runs the HEALTH Clinic at Hasbro Children’s Hospital, which helps children with high BMIs eat better and move more. While these behavior changes can make kids healthier, she says, they don’t significantly move the needle on the scale. Most of her patients are from underserved populations who struggle with food insecurity, which is associated with childhood obesity, and have less access to care. Yet for lifestyle treatment to be effective, national guidelines recommend that patients come in every two weeks. “That’s pretty much impossible for patients,” Corcoran says—not to mention providers.
In other words, helping someone lose weight is time-consuming and complicated, may conflict with social factors beyond anyone’s control, and certainly can’t be accomplished in a short primary care visit.
“The PCP is given an impossible task,” says Jason Lillis, PhD, a research scientist at The Miriam Hospital’s Weight Control and Diabetes Research Center. “In a 10-minute primary care visit, you’re going to what, tell someone, eat different and be active? OK, both of those things are really hard to do. I can say that because I do these intensive interventions and only have modest success rates with people.”
Lillis, an associate professor of psychiatry and human behavior (research), studies how acceptance and mindfulness can help promote healthy behavior change, and how weight stigma can impede that. While simply telling a patient to eat less and exercise more “has an infinitesimal chance” of actually producing long-term weight loss, he says, it could very much make them feel terrible. “There needs to be more support there and more intervention if you actually want the outcome,” Lillis says.
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In the past few decades, BMI has become a proxy for individual health status—inviting stigma for people at higher BMIs, with the potential to harm patients of all sizes. It doesn’t differentiate between fat, muscle, and bone mass, nor does it account for how people’s body compositions vary across gender and racial groups. Disregarding these factors, along with other measurements and medical history and lifestyle, may lead a clinician to over- or underestimate a patient’s disease risk based on weight and height alone.
“We don’t know based on someone’s BMI whether they have high blood pressure or high cholesterol. You have to do the actual test to do that,” says KayLoni Olson, PhD, an assistant professor of psychiatry and human behavior (research) and a clinical health psychologist at the Weight Control and Diabetes Research Center. “And making assumptions about health status while neglecting to do those follow-up tests on someone who has a ‘healthy,’ quote-unquote, or a higher BMI is dropping the ball, and jumping to conclusions.”
Weight loss for the sake of weight loss doesn’t guarantee better health. A 2013 meta-analysis of the long-term impacts of numerous diets did not find significant correlations between weight loss and improvements in indicators of metabolic health like blood pressure, glucose, cholesterol, or triglycerides; nor were there clear differences in outcomes like diabetes and hypertension. Other studies suggest that up to a third of people falling in the “normal” BMI range are metabolically unhealthy, while a third of those classified as “obese” and almost half in the “overweight” category are metabolically healthy.
Jonah Cohen ’04 MD’10, an interventional gastroenterologist and the director of Bariatric Endoscopy at Mass General, says that while the BMI is useful, it certainly isn’t the be-all end-all representation of metabolic health. But metabolic health is “often poorly understood,” he cautions. For example, while A1c reflects average glucose levels over three months, “what it does not tell you is how hard your pancreas is working to keep that blood sugar at a normal rate.”
“We can do a disservice to patients when we focus too much on BMI,” Cohen says; he sees it as just one tool in his health assessment toolbox. He points to the “Western lifestyle”—the abundance of processed foods and stress, the lack of activity and sleep—for so many people’s health problems, regardless of their weight.
For more than 20 years, two randomized controlled trials, the Diabetes Prevention Program and Look AHEAD, have followed thousands of participants as they made intensive changes to their diet and exercise habits. Both led by Professor of Psychiatry and Human Behavior Rena Wing, PhD, the director of the Weight Control and Diabetes Research Center, researchers across the US have found numerous associations between lifestyle interventions, weight loss, type 2 diabetes risk, and other health effects.
Panza, a research scientist at the center, says adults in the Diabetes Prevention Program who increased their physical activity and made dietary changes lowered their risk of developing type 2 diabetes significantly more than those who took metformin, which helps control blood glucose levels. Many participants also lost a modest amount of weight.
However, Olson notes, “There was a legacy effect of that weight loss that, over a decade later, even if weight was regained, that group still had a lower risk of converting to diabetes.” That may be because the participants maintained lifestyle changes, she says: “Most of the health benefits we tout you will get from weight loss you can get from physical activity alone.”
“One of the real challenges with weight loss studies is disentangling improvements in quality of dietary intake and increased physical activity from the weight loss,” Olson adds. “The scope of the literature documenting that weight loss can, in randomized trials, lead to health benefits is very compelling. The question comes back to that individual variability. You have the science in large groups. And then you have a patient sitting in front of you. And the degree to which you can promise that health benefit is, of course, not the same as talking about large groups.”
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Once a year Goldstein, a psychologist in the Weight Control and Diabetes Research Center, talks to internal medicine residents about weight stigma and how to address weight loss with patients. Her first rule: ask permission to even talk about weight. “If someone says ‘no,’ then that needs to be the end of that conversation,” she says.
“The way that society approaches weight is very disrespectful to people’s autonomy,” Goldstein adds. By respecting a patient’s wishes, a provider sends the message that they’re safe to talk to in the future. “Just because it’s a ‘no’ for now, it doesn’t mean it’s a ‘no’ forever,” she says.
“I won’t offer unsolicited weight goals,” says Stephanie Catanese RES’14, MD, the associate director of the General Internal Medicine Residency Program at Rhode Island Hospital. Instead she asks patients what their health goals are, “and then I let them define what healthy means to them and where they want to be.”
Patient-led conversations about their goals are critical whether or not someone wants to lose weight. “It’s so ingrained that weight is the problem—which really means, how I look is the problem,” Lillis says, “and that the solution is weight loss.”
In an effort to undo some of that stigma, he uses his acceptance and commitment therapy research as sort of a “Trojan horse”: he draws participants to his studies with weight loss, and then hones in on their values, to shift their focus “from the scale to something more meaningful.” He has them imagine they reach their goal weight, and asks them: “Now what do you want to do? Because surely the goal isn’t to reach this specific weight and then sit in front of a mirror all day and admire what you see.”
Cohen has these conversations too. People come to him for bariatric endoscopic therapies after trying intensive lifestyle changes and even weight loss medications. Before moving forward, he asks each potential patient why they’re there. He gets answers like, “‘My knees are hurting me,’ or, ‘I want to be more active with my grandchildren,’” Cohen says. “Those are motivating factors that help them.”
That’s important because “these procedures are not done in isolation,” he adds. After an endoscopy, a patient works for a year with a dietitian to develop and maintain healthy habits. “It’s not like you walk in, you get your oil change, and you’re done,” Cohen says. “It’s a substantial commitment and a lifelong process.”
No matter how hard people work, many weight loss attempts—even surgeries—fail, and virtually no intervention can (permanently) produce the transformations touted on reality TV and in supermarket tabloids. And while patients may say their goal is to get healthier, it’s extraordinarily difficult to unravel that from the deep-seated belief that “healthy” means “thin.”
When Roullard sees patients who are “dead set” on weight loss surgery, she tries to be “supportive and understanding,” she says, because “as someone who lives in a fat body, it’s nonstop. It’s every day, from every angle, everywhere you look, every time you sit in a chair, get on a plane, walk through the mall, go shopping, read a magazine. So I get it.”
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That’s why some providers are finding liberation by deemphasizing weight in their patient encounters. The residents Goldstein talks to “are generally really open to it because they’re frustrated,” she says, “and they’re ready for something different.”
Sara Delaporta RES’11, MD, a primary care physician at Thundermist, says the size-inclusive health initiative and her conversations with Handfield have allowed her to focus on healthy behaviors like nutrition, exercise, sleep, and reducing stress.
“One empowering thing that I’ve said to a lot of patients is that no matter their body size, their healthy habits still count,” says Delaporta, a clinical assistant professor of family medicine. “That’s been something I’ve enjoyed being able to give to people as a gift.”
Graham says she used to recommend weight loss routinely, with a focus on BMI; now, Handfield’s size-inclusive health training “has changed the way I talk to people—to not vilify bodies, not vilify food, and really make it a conversation about health and how you take care of yourself,” she says.
Though Catanese’s clinic doesn’t follow a size-inclusive model, she shows trainees how to be allies to their patients, to remove the blame and stigma they may feel about their weight. “Patients are so hard on themselves sometimes,” Catanese says. She tries to reassure them: “Hey, weight is just a number. My job is just to make sure you are as healthy as you can be. … The weight doesn’t always reflect that you’re doing all those things successfully.”
She, like Goldstein, says many trainees are interested in taking a new approach. “They are hyper-aware,” Catanese says. “This new generation is even more attuned to asking things in a sensitive way that’s not stigmatizing.” But skepticism remains, among physicians of all ages, that not talking about weight could be good for their patients’ health.
According to Delaporta, that’s true even at Thundermist, where, despite Handfield’s strong advocacy and enthusiasm, providers have been slow to take up the size-inclusive practice model. Taking the focus off weight is “so at odds with people’s training that it is hard to buy in without some really big conversations,” Delaporta says. That takes time, which few providers have—not only for continuing education, but the longer and more frequent appointments patients may need when treating them calls for intensive lifestyle changes.
Roullard, who as a resident at Thundermist worked with Handfield to spearhead and lead the size-inclusive track among residents, admits all those challenges will lie ahead. But investing in trusting, longitudinal relationships with her patients has yielded big benefits for them and for her. She tells her colleagues: “Try it and see what happens. You will be pleasantly surprised.”
“My patients come back to see me more often, because they don’t feel judged or stigmatized,” she says. “They never miss appointments, they take all their meds, they do all their labs. They’re so good about everything, because they trust me. … I’ve had patients cry in my office, saying that they’ve been looking for someone like me. And that makes it all worth it.”
