On fat patients

By: Umangjot Bharaj

There is significant controversy when it comes to physicians commenting on their patients’ weight and lifestyle choices. Not only is weight loss especially difficult to achieve, and even more difficult to sustain; repeatedly telling patients to loose weight often hinders weight loss. Existing in a society that constantly shames and vilifies fatness, and often treats fat people as second-class citizens, fat patients become hypersensitive about their weight and any comments about it. In this context, a physician telling a fat patient to lose weight, when done without nuance and as a cursory addition to management plans, can have a very negative impact on the patient.

The Body Positivity Movement and Physicians

Cue the body positivity movement. Body positivity is essential for the society we live in: it represents and advocates for the idea that our worth is not determined by our size or our health status, and that to discriminate, shame, and vilify people based on their size, is unacceptable. Where body positivity loses its focus, however, is if it suggests that physicians should not tell their patients to lose weight ever.

While I agree that health cannot be defined and constrained to something as simple as body size alone, and that each individual has a right to define health for themselves, I think that physicians still have a right to encourage, motivate, and influence their patients toward healthier habits. HIV patients are stigmatized, but doctors don’t stop encouraging healthy sexual practices to HIV patients. Similarly, fat stigma does not mean that excess weight does not have a correlation with bad health outcomes. Excess weight complicates pregnancies, deliveries, and surgeries in general, making them riskier, and has been linked to many conditions such as metabolic syndrome, sleep apnea, and osteoarthritis of the knees. Thus, to suggest that a physician never comment on weight as a relevant factor in causing or exacerbating a patient’s condition is too simplistic and does fat patients a disservice.

It is however, important to accept that physicians are in a unique place to comment on the lifestyle choices of an individual. As a society, we don’t comment on people who choose to smoke, but as physicians(-to-be), it is our role to influence and motivate our patients toward healthier habits. Similarly, physicians have a responsibility toward their fat patients to talk about healthier life choices if they, in their clinical judgement, think that a patient’s weight or health is being affected by their lifestyle choices.

This is not to say that doctors have done no wrong to their fat patients. Research indicates that primary care providers do not build rapport and emotional bonds as strongly with their fat patients as they would with their non-fat patients. Another study found that physicians are more likely to prescribe more tests while spending less time with the patients themselves. There is a tendency to blame patients’ weight for all of their symptoms and in the process not recognizing other diagnoses or undertreating the other recognized diagnoses. Often, weight loss is prescribed as the treatment for all of their symptoms, even though patients would benefit from other medical interventions for their comorbid conditions.

A Patient’s Experience

One patient experience can illustrate what patients face when they go to see their doctor. This patient recounts myriad experiences of mistreatment and discrimination from health care providers: from being told that it was not possible for her to have a normal blood pressure (and having it re-taken 4 times), to being told to lose weight as a remedy for her anxiety and even her ear infection. There are even examples of doctors putting weight limits on patients they would accept: more than 250lbs and you wouldn’t be accepted by certain OBGYN. Fat patients recount experiences where doctors wouldn’t touch them, wouldn’t examine them, wouldn’t ask questions, or would refuse to order tests, refer to specialists, or write prescriptions.

These factors significantly complicate the discussion surrounding weight loss reduction. However, these are not reasons to justify that discussing weight reduction is always detrimental. Instead, they are reasons to introduce the idea of discretion and nuance in handling sensitive conversations such as those surrounding weight reduction.

In caring so deeply about our patients’ physical health, we cannot forget about their mental well-being and sanity, especially because the two are so interconnected and intertwined. For patients’ that live in a society that constantly reminds them that their weight makes them inadequate, physicians reiterating that only reinforces a vicious cycle of self-loathing, fuelling feelings of worthlessness. In patients that are battling mental health issues such as depression, anxiety, eating disorders, and substance abuse disorders, feelings of worthlessness and self-loathing can fuel into and exacerbate their mental health conditions. Perhaps most disturbing is that it discourages patients from seeking health care services at all.

Moving Forward Together

Weight loss discussions are discussions that need to happen in the context of a longitudinal relationship, or in the context where the support of a longitudinal relationship is possible. As well, these discussions require participation from the patient, and should empower and give control back to patients who likely feel disenfranchised by their inability to lose weight. There needs to be discretion as to when and how to approach the subject. This means that if a lot of times you have to ignore your patient’s weight problem because it’s not the right time or setting, then so be it. Finally, these discussions must take into account that simply prescribing patients with lifestyle changes often underestimates the influence of other contextual factors that can impact weight loss.

There is some discussion from practicing physicians about the need to reframe the conversation: instead of being preoccupied by a patient’s weight, physicians can simply encourage all patients to develop healthy lifestyle habits and behaviours. There is research to support this as well. In one study comparing the effectiveness of a weight-normative approach to a weight-inclusive approach, the latter was found to be much more effective and have better health outcomes in all domains, ranging from physical to behavioural to psychological.

Part of the challenge of being an effective physician is the art of difficult conversations. Running away from a conversation because it is difficult is neither productive nor useful to our patients. But by finding ways to have important conversations in a productive manner, we are able to better serve our (future) patients and be better physicians.  

Author: Umangjot Bharaj

Umangjot completed her Bachelor in Health Sciences from McMaster University. In recent years, she has gotten quite involved with social justice work, and has a significant interest in advocating for marginalized populations whenever possible. She loves reading and writing in her free time, and enjoys creating healthy versions of traditional recipes.
Photo Credits: Keto HC, Creative Commons