The Obesity Talk: Acknowledging Weight Stigma

By Cari Wade Gervin
Friday, September 10, 2021

While maintaining a healthy weight is important to managing many health conditions, three recent studies suggest increased prevalence of weight stigma toward patients leads to worse health outcomes. How can physicians achieve a balanced approach to conversations about weight?

In 2016, Kim was struggling with disordered eating and exercising. She was the thinnest she had been in years, but because she had just turned 40, she was told she would need a biometric screening before receiving a rate quote for a stopgap health insurance plan.

“I was literally underweight [for my height and age], and they told me that based on my BMI, I was medically obese,” Kim, now 45, says. “They didn’t deny me coverage, but they doubled the quote on what the insurance would cost because I was now ‘high-risk.’ And then I couldn’t afford insurance.”

After years of therapy, Kim has recovered from her disordered eating. But after numerous painful incidents surrounding her weight, Kim still experiences negative side effects of weight-related conversations.

“I absolutely will not go to the doctor unless I really have to, because it’s so fraught,” Kim says.

Weight Stigma Is Frequent

Patient experiences like Kim’s are quite common, according to three recent studies. In a survey of 14,000 members of WW (formerly known as Weight Watchers) across six countries published in PLOS ONE in June, over half the respondents said they had experienced weight stigma in their life in general. Of that cohort, around two-thirds said they felt they had experienced discrimination or poor treatment due to their weight from physicians.

A study in International Journal of Obesity in August found that “weight stigma is associated with poorer health behaviors, independent of BMI,” including disordered eating, comfort eating, sleep disturbance and alcohol use. But correlation is not causation, cautions study author Jeffrey Hunger, PhD, assistant professor of social psychology at Miami University of Ohio.

“One very plausible argument is that when we see a relationship between weight and health (which is not nearly as consistent as many assume or have argued), that relationship exists because of weight stigma,” Hunger says. “So it is not that weight has a direct impact on health but instead is associated with greater experienced (and anticipated) weight stigma, which as we found in the present study is associated with a host of behaviors that have implications for long-term health.”

A meta-analysis of recent topical research published in Obesity Science and Practice concluded that people who are told they are overweight have worse health outcomes than people who may have BMIs considered to be overweight but do not consider themselves to be so.

“There’s pretty convincing evidence amongst the people who realize that they are overweight, that appears to be worse for their mental health,” says study author Eric Robinson, PhD, reader, Institute of Population Health, University of Liverpool. “The study suggests ... they go on to gain more weight than people who don’t realize that they’re overweight. … And the most convincing explanation at the moment is that it’s likely to do with the stigma attached.”

Changing Approaches to Patients Can Help

For patients like Kim, simply knowing she will be weighed is a reason to postpone visits to healthcare providers.

“No one likes going to the doctor, especially if you’re worried something’s wrong,” Kim says. “But if I know I’m going to have to fight about the scale again, it’s just added anxiety.”

Eliminating mandatory weigh-ins is one way physicians can help reduce weight stigma. But the most important way is simply to be careful how they talk to patients.

Compassionate conversations

Jen Brull, MD, FAAFP, CEO and owner of Prairie Star Family Practice in Plainville, Kan., is a member of the board of directors of the American Academy of Family Physicians. She’s been in practice for 28 years, but remembers early on telling a patient that she needed to lose weight in what she thought was a fact-based manner. The patient postponed a return visit to Dr. Brull for far too long; when she did return, she said it was because she felt Dr. Brull was being judgemental about her weight.

“And it just really took me aback,” Dr. Brull said.

So Dr. Brull asked her patient how she would prefer to discuss the patient’s health issues, a practice she now maintains.

“I approach every conversation with a sense of partnership, which is, I know they want to be healthier,” Dr. Brull says. “You really don’t have to tell people that they are overweight. People know.”

And although it may be complicated for insurance reasons, some physicians may also want to question their reliance on BMI.

“To think that we can capture a person’s health simply by scaling their height against their weight is misguided at best,” says Hunger. “Moving away from weight-related metrics like BMI can work to reduce weight stigma because doing so recognizes that individuals can be healthy across the weight spectrum.”

Weight Talk Best Practices

Researchers, along with the physician and patient interviewed, suggest these approaches to weight-related patient interactions.

  • Ask permission to talk to a patient about their weight. If they give it, ask about any history of disordered eating before advancing the conversation.
  • Don’t assume a patient is unhealthy or has poor eating habits based on their weight.
  • Invest in training your staff about ways to sensitively talk about weight — and when to avoid it.
  • Make weigh-ins optional (unless needed for medical reasons like anesthesia), and ask patients their preferences about getting weighed.
  • Offer concrete reasons as to how losing a certain number of pounds could help a patient, and offer specific solutions (i.e., don’t simply say, “Avoid sugar and junk food.”)
  • Provide size-inclusive seating in waiting areas and patient rooms.
  • Keep a range of sizes of medical gowns in stock.