When Dani Donovan stepped into her doctor’s waiting room in Omaha, she was surprised and pleased to see a stack of cards with bold black letters stating: “Please Don’t Weigh Me Unless It’s (Really) Medically Necessary.”
“I didn’t even know that saying ‘no’ to being weighed was a thing you could do,” said Donovan, 30, an attention-deficit/hyperactivity disorder advocate who has a binge-eating disorder and often avoided doctor’s appointments because being weighed was so stressful. The card led to a good conversation with her doctor, Donovan said, that helped build trust and make her feel empowered.
She posted a picture of the card on Twitter, explaining that “saying ‘no’ when you’re asked to step on the scale at the doctor’s office can feel so intimidating.” More than 26,000 people noticed her post, with comments ranging from supportive to flat-out cruel.
The cards are a tool created by an eating disorder advocacy group that believes most health conditions can be addressed without weight numbers, and doctors’ constant focus on weight, no matter why the patient is there, is shameful, not helpful. Some doctors agreed, saying that they welcomed the chance to let the patient lead nutrition and weight discussions. Others emphatically said it’s a necessary data point and needs to be taken every time, no matter what.
Bias against people with obesity
There have been many studies showing that the medical world — and the world in general — has a bias against people who have obesity. One piece published in the British Medical Journal found that weight stigma actually led to increased mortality and other chronic diseases and “most ironically, (weight stigma) actually begets heightened risk of obesity.”
Umbereen S. Nehal, a former chief medical officer for Community Healthcare Network in New York and a board-certified pediatrician, strongly believes patients need to be weighed every time, regardless of when they were last weighed or why they are in the doctor’s office.
She said there’s no question that studies have shown the prevalence of weight stigma in the medical community, and she has a lot of sympathy and empathy for the intention behind the cards. But she would like to see data on how this particular intervention results in better outcomes before allowing patients to opt-out of the scale.
“Is the hypothesis that somebody who is obese, let’s say, if we don’t weigh them, fatphobia will go away? Those visual cues will not go away,” said Nehal. “So my beef with this is that it disrupts processes in the system for efficient data collection and that data are used for a variety of things.”
The cards were created in 2019 by Ginny Jones, 46, a Los Angeles-based eating disorder coach who works with the parents of children with eating disorders.
Jones, a survivor of several eating disorders including anorexia and bulimia, said the cards are a response to experiences she had at doctors’ offices. She was praised when she lost weight, even when her chart clearly stated that she had an eating disorder, Jones said.
Scale may be necessary at times
She said the cards — which are for sale on her website — clearly say that if a weight is needed, to just tell the patient, and that patients recognize there are situations when the scale is necessary.
“I wish I could say I was surprised by the ‘controversy’ around the cards,” Jones said. “I created them to address weight stigma, and it’s basically fatphobia to jump to conclusions and say blanketly that asking not to be weighed is unhealthy.”
At Element Primary Care in Omaha, where Donovan found the cards, the medical partners decided to ask patients if they wanted to get weighed when the practice opened about 18 months ago, said Ann Wieseler, a nurse practitioner trained in family practice. About half of patients decline, she said, but often weigh themselves at home and give their weight that way. Some open up later if they have concerns about nutrition or weight.
There are some situations which require monitoring weight, such as checking for fluid retention with heart failure, or before surgery for anesthesia purposes, but they talk about those situations with the clients, and they can step on the scale backward.
“It’s not like we’re never going to obtain their weight and get that measurement, it’s just on the patient’s terms,” Wieseler said. “The cards help patients feel safe and empowered with their health, and help them be an advocate for themselves.”
Weight gain during the pandemic
She said these discussions about weight are particularly sensitive now, when many people have gained pounds while stuck at home during the pandemic. Often, there are other issues such as anxiety and depression that are underlying factors, something that needs a discussion, not a lecture.
Fatima Cody Stanford, an internist and a specialist in obesity medicine at Massachusetts General Hospital who teaches at Harvard Medical School, emphasized that weight is an important measurement. Many people don’t go to the doctor that often, she said, so when they do, getting on the scale is a way to see changes.
Stanford also mentioned that, in her experience, some patients don’t want to accept that weight and it can sometimes have consequences on their health. For example, she said, someone might point out that they are concerned about diabetes because it runs in their family, but when the doctor asks if everyone in the family also has obesity, the patient doesn’t want to see the connection.
She emphasized that the cards don’t change the explicit and implicit biases that physicians have toward people who have obesity, and they don’t address that medical schools do a poor job of teaching about weight. In one 2020 study, she found that there are “literally zero countries” who have stellar programs for medical schools or residents to address weight. Stanford said she herself was mocked by a former program director for going into “fat” medicine.
All of these factors can make addressing weight a fraught situation for the entire eating disorder spectrum, from people who have anorexia to people who have obesity.
“What winds up happening is the biases that these physicians have, due to their lack of knowledge about this disease that we call obesity, yields very negative, explicit and implicit bias toward those that have obesity, right? So patients come in, I’m exaggerating here, but say they have a hangnail, and it’s like: ‘Well, you know, if you got that weight under control …’ ” said Stanford. “They may have excess weight that is contributing to other things, but the way it’s approached and the judgment that comes along with it, is why people are probably requesting these cards.”
Stanford suggested a card that said “I’m happy to get weighed but please do not provide any negative or derogatory comments associated with my weight.” That way, the doctor gets their data point but also a pointed reminder.
“So then the doctor gets that card,” she said, “and they might think, ‘Oh, I need to really think about what I’m saying and be more mindful.’”