My patient is in her early 30s, soft-spoken, soft-bodied and determined. She was diagnosed with prediabetes at a work health screening.
At her next appointment, she is crestfallen and withdrawn. She has gained seven pounds. I print out packets with information on the Mediterranean diet, and she glances at them, defeated. Sensing her hesitation, I suggest that we start her on metformin, a medication used to treat prediabetes, but she declines. “Weight loss is hard,” I say.
She doesn’t return to my clinic after that.
I think often about how I failed that patient, how physicians fail patients like her all the time. The training that I and most other physicians have received dictates that weight loss is as simple as calories in, calories out; eat less, move more. The underlying message, delivered to halls full of mostly thin medical students, is that weight is a matter of willpower, something that fat people evidently lack.
I am considered midsize, but I have a body mass index (BMI) that marks me firmly as a part of the roughly 70 percent of Americans who are overweight. Even I remember ducking my head in shame during these lectures, which rarely touched on the truth: that weight gain is governed by hormonal and metabolic dysregulation often out of patients’ control.
The truth is, doctors aren’t taught much about nutrition or weight management, and the lack of education means that the fatphobia that persists outside the clinic is amplified within it.
And the consequences are dire: In my short time as a physician, I have taken care of several patients who went to their doctors with symptoms that warranted a standard work-up, but instead they were dismissed and told to lose weight.
By the time I saw them, whether in the emergency room or the clinic, their symptoms had usually progressed. One patient who was told to lose weight after complaining of shortness of breath actually had blood clots in her lungs. Another overweight patient with stomach pain was found to have inflammatory bowel disease.
The doctors they had seen had paid more attention to the number on the scale than their symptoms, and now they had complications or were traumatized by extended delays in their diagnoses.
Doctors treat overweight patients differently
Obesity is attached to significant discrimination. Studies show that doctors treat overweight patients differently, often perceiving them as less adherent, less motivated and, in all, less deserving of empathy.
Over the past few years, I have made an effort to educate myself by reading books and following social media accounts that discuss body neutrality and fatphobia. I found myself facing the same truth over and over: that many people with obesity associate doctors’ visits with great harm.
A friend who got access to her childhood medical records learns that her beloved physician needlessly described her as “pudgy” in a note. Several accounts discuss avoiding doctor visits on purpose to avoid being dismissed and repudiated for existing in their bodies.
Among them is Susanne Johnson, a nurse practitioner who describes herself as a “fat-positive harm reductionist.”
“The medical establishment loves to equate weight gain to poor health outcomes, yet never seems to consider what it is like to be on the receiving end of that,” she says.
She describes the consequences of fat-shaming in medicine, such as how implying that chronic illness is always a function of weight can send a person into a “shame spiral that detracts from the goal of actually treating them.” It also makes it less likely that they will return for ongoing care, she says.
Patients should feel empowered to skip the scale
For patients who have obesity, navigating doctors’ visits can feel like navigating a minefield. First and foremost, patients should feel empowered to question routine weigh-ins at appointments, which are often stigmatizing. There are certain conditions for which tracking weight is important and has little to do with weight-loss management, and in those cases, shared decision-making can be employed.
Second, patients who want to lose weight should ask their doctors about options, including new medications that, in some cases, can be covered by insurance. These drugs, known as GLP-1 agonists, have been shown to have additional benefits regarding diabetes, as well as kidney, cardiovascular and liver diseases. If doctors are not knowledgeable about weight-loss options, ask for them to do some research or seek a referral.
Third, no patient should be dehumanized during interactions with a health-care team. Should patients feel judged or as if their medical care is being unduly influenced by their weight, they should try to find more empathetic care elsewhere.
And finally, we as a society — as well as doctors and even patients — must stop framing obesity as an issue of willpower.
I only learned about the complexities of weight management after starting my cardiology fellowship, four years after graduating from medical school.
Silvana Pannain is an endocrinologist and the director of Chicago Weight, a weight-loss program and support group at the University of Chicago Medicine. As part of my elective in cardiovascular prevention, I rotate through her weight-management clinic.
When I describe a patient as “obese,” she gives me the verbal equivalent of a rap on the wrist. “They have obesity, they are not obese,” Pannain chides.
“Obesity,” she later explains, “is the new hypertension.” Like hypertension, it is a complex, chronic, relapsing, progressive condition that is associated with, but not dependent on, lifestyle, a definition that has been supported by multiple prominent medical associations such as the Centers for Disease Control and Prevention, the American Medical Association and the Obesity Medicine Association.
A new patient who doesn’t want to talk about weight
Even before meeting Pannain, I knew I needed to change my approach to caring for patients with obesity.
In my final year of internal medicine residency, I met a patient who asked me for help managing her high blood pressure.
The medical assistant for my clinic informed me, with some annoyance, that the patient had declined a weigh-in before the visit.
But instead of insisting that she get on the scale, I used this as a springboard to connect with her. She described herself as fat and told me outright that she didn’t want to discuss her weight.
Instead, we talked about her sleep quality, healthy foods and additional physical activity that could keep her from needing additional blood pressure medications. Given my limited education on nutrition, I also referred her to a dietitian.
Over the course of the year, my patient went from not being able to walk more than two blocks to doing four laps a day around a track. By respecting her autonomy and not pathologizing her body, I was able to help her work toward a better quality of life.
Shirlene Obuobi is a second-year cardiology fellow at University of Chicago medical center. Her comics about navigating health care appear on her Instagram @ShirlywhirlMD. She is the author of “On Rotation,” a novel about a Ghanaian American medical student.
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