Cardiorespiratory fitness is a strong predictor of morbidity and mortality for individuals of all weights, yet clinicians, researchers, and the public tend to focus more on weight and body mass index (BMI) than the importance of good nutrition and physical activity.^1–4

This reflects a national culture of weight stigmatization and bias expressed through discrimination, stereotypes, and negative attitudes/beliefs about those who are overweight or obese. Those who are overweight or obese report experiencing weight stigma throughout all areas of life, including health care.^5–7 Physicians and other providers sometimes perceive those with obesity as noncompliant, overindulgent, lazy, and unsuccessful. They are less respected than patients who are not overweight, and some doctors report they would rather not care for those who are overweight.⁶ An inverse relationship has been reported between patient BMI and primary care physicians' patience, job satisfaction, and willingness to assist the patient.⁸ Doctors choose to spend less time with patients with obesity and order fewer preventive and diagnostic tests for them.⁶ Furthermore, some physicians report feeling they do not have the comfort, knowledge, time, or skill set to effectively counsel patients on issues related to weight.⁹

Focusing too much on weight rather than taking a more holistic approach can be detrimental to the care of all patients, whether overweight or not. Prioritizing a number on a scale over patients' individual characteristics and concerns increases the risk of “false negatives” (failing to diagnose a problem, such as type 2 diabetes, because the patient is not overweight) or “false positives” (incorrectly diagnosing a healthy person as unhealthy due to a higher weight). It can also be harder for patients who are overweight to receive proper care for concerns unrelated to weight. For example, if a patient who is overweight or obese seeks an appointment for a sinus infection or seasonal allergies and is given unsolicited advice to lose weight, this can lead to feelings of shame and delay in seeking care in the future.⁶

Clinicians can lessen weight stigma and improve health outcomes by communicating more productively with patients who are overweight or obese.¹⁰ This article offers five recommendations for more compassionate care, reviewed by a panel of patients in the University of South Carolina's Patient Engagement Studio, whose mission is to provide patient perspectives in scientific research and health system innovations.

1. SEE, ACKNOWLEDGE, AND TREAT THE WHOLE PERSON

Nearly 70% of people of who are overweight report feeling stigmatized by physicians.¹¹ Multiple studies have documented that patients (women in particular) tend to delay seeking health care to avoid being shamed due to their weight or because they fear their physician will attribute all health concerns solely to their weight.^6,12

To lessen stigmatization, clinicians can focus on each patient's holistic well-being rather than weight, and help patients develop sustainable lifestyle habits rather than just pursuing weight loss.¹³ Consider emotional, physical, nutritional, social, and spiritual health, and focus on process rather than a weight-loss end goal (even when patients ask for help achieving a weight-loss goal). Guide patients to notice what behaviors promote restfulness and energy (e.g., regular physical activity, regular intake of nutritious foods, adequate sleep and rest, and adequate hydration), and help them make those behaviors routine.

Treating the whole person also means evaluating patients with obesity for emotional distress. Look for signs of disordered, emotional, or binge eating by tracking weight trajectories over time and noting unusual gains or losses. You can provide treatment (pharmacological and nonpharmacological) and resources as needed, referring patients to mental health professionals who have a weight-inclusive approach. Be aware of how words may influence patients with disordered eating. Praising weight loss, or addressing weight gain by immediately and automatically recommending weight loss, can unintentionally reinforce disordered eating behaviors.

When conversations about weight and lifestyle are warranted, it is important to consider social determinants of health — socioeconomic factors that can account for up to 80% of health outcomes (see “Screening for Social Determinants of Health in Daily Practice”). Lower education levels, food and housing insecurity, and poverty increase the risk for overweight and obesity.¹⁴ Along with genetics, these factors limit how much patients can alter their body weight. For those with low socioeconomic status, public health recommendations to “maintain a healthy weight” can seem out of touch and unfair.¹³ Evidence suggests that accounting for social determinants of health may make clinicians more successful in helping patients reduce weight. In one recent study, intensive lifestyle intervention (e.g., nutrition, behavior change, and physical activity counseling) provided in primary care clinics helped underserved, low-income patients reduce weight by an average of 5% over 24 months compared to usual care.¹⁵

Adverse childhood events and traumatic experiences are other often-overlooked factors for patients who are overweight or obese.¹⁶ Being aware of the impact of traumatic experiences on weight and health and finding ways to implement trauma-informed care can help these patients. More information and resources are available at the Trauma-Informed Care Implementation Resource Center.

2. IDENTIFY BIAS AND ASSUMPTIONS

The number of documented health consequences of weight bias are staggering. They include but are not limited to the following:^17,18

1. Unhealthy eating behaviors, binge eating, increased caloric intake, inability to lose weight or maintain weight loss, and lower motivation for exercise,

2. Physiological reactions including increases in blood pressure, blood sugar, hypothalamic-pituitary-adrenocortical axis activation, and levels of the stress hormone cortisol,

3. Reduced engagement with health care services, including less trust of physicians and other providers and poor adherence to treatment,

4. Psychological distress, including depression, anxiety, substance use disorder, and suicidal tendency,

5. Long-term health effects including more advanced and poorly controlled chronic disease, low health-related quality of life, and increased risk of mortality.

Additionally, there is extensive evidence that long-term weight loss is not sustainable for most people, and weight cycling (i.e., “yo-yo dieting”) is associated with poorer health.¹³ The enormity of health-related consequences associated with weight bias indicates grave damage being done to people with obesity.

Implicit and explicit weight bias should be recognized as a social determinant of health that contributes to health disparities.¹⁹ Although recognition of racial, ethnic, and other biases and the need to counteract them is growing, there has been relatively little acknowledgment of weight bias. On the contrary, many people feel justified in externalizing weight bias because they assume individuals are fully responsible for their weight despite research demonstrating that biological, psychological, social, environmental, maternal, economic, and genetic factors contribute more to body weight than voluntary lifestyle choices.¹³

It is useful for clinicians to examine and address their own biases. For example, they can ask themselves, “When I see patients who are overweight, do I automatically assume they are inactive, have a poor diet, or are uneducated or lazy?” These assumptions lead to miscommunications and lack of trust between clinicians and patients.

Harvard University's Implicit Association Test on weight can help clinicians identify their biases. Other tools are available as well (see “Resources for creating a bias-free clinic”).

3. PRACTICE PATIENT-CENTERED COMMUNICATION

Any conversation about weight-related issues should begin with asking the patient's permission to discuss the topic (e.g., “Would it be OK to talk about your weight today?”). You can then transition to questions about the patient's goals, values, motivations, lifestyle, and challenges or barriers to change. Only by understanding these things can a clinician provide individualized, patient-centered education and work with the patient to set appropriate, realistic health and wellness goals.

Motivational interviewing techniques can be used to respectfully help patients understand health risks (e.g., after discussing diet, say, “Your eating habits, I believe, are putting you at risk for heart disease and type 2 diabetes”), emphasize patient autonomy (“It's up to you to decide if you are ready to make lifestyle changes. Whatever you choose, I'm here to support you”), explore ambivalence for lifestyle changes (“What is one advantage of modifying your eating habits? What's one downside?”), and instill optimism and self-efficacy for making change (“I know you can do this”).²⁰ Empathy and reflective listening during these conversations will help patients feel heard and understood.

Clinicians should also be mindful of the words they use to discuss weight with patients. For example, terms like “diet” or “exercise” can be replaced with more positive terms like “nutritious food choices” and “physical activity.” Terms like “fat,” “large size,” “heaviness,” “ideal weight,” “morbidly obese,” and “weight problem” are generally off-putting. It may be helpful to ask patients how they prefer you to refer to weight. The aim is not simply to be kind while trying to get a patient to lose weight. Rather, the goal is to change the focus from an external critique of weight and size to a partnership working toward health and wellness, as well as detecting and preventing the progression of disease.¹²

4. CREATE A WELCOMING ENVIRONMENT

A comfortable and welcoming clinical environment for everyone signals that patients' health care needs will be met without shame or discrimination.²¹ Practices should have furniture in waiting and exam rooms that is comfortable for patients of higher weight and use appropriately sized equipment, including scales, blood pressure cuffs, specula for female exams, and gowns. Choose reading materials that feature average (rather than idealized) bodies and healthy lifestyles. Weigh patients in private and only when medically indicated.

Special care should be taken to help patients with obesity feel comfortable during pelvic, genitourinary, rectal, and prostate exams. Be gentle and do not rush. Be friendly but thoughtful about humor or comments that could be interpreted as offensive. Avoid any display of frustration.

All practice staff can be included in sensitivity training focused on obesity, the challenges of weight management, and weight bias. The book Health at Every Size, by Lindo Bacon, PhD, is a resource for this. Clinicians can also help decrease discrimination among colleagues, staff, and trainees by modeling professional behavior and treating all patients with the same respect, regardless of weight. Comments reflecting bias toward higher-weight individuals should not be tolerated.

5. PURSUE LIFELONG LEARNING

Consider pursuing further education and knowledge on the topic of obesity and its treatment. The American Board of Obesity Medicine (https://www.abom.org/), the Obesity Action Coalition (https://www.obesityaction.org/), The Obesity Society (https://www.obesity.org/), and the Association for Size Diversity and Health (https://asdah.org) are excellent resources.

CREATING POSITIVE CHANGE FOR PATIENTS

Bias, stigma, and shame faced by those who are overweight or obese can lead to a reduction of healthy lifestyle behaviors and avoidance of health care.

Through holistic patient care, bias awareness and reduction, patient-centered communication, a welcoming clinic environment, and continuing education, clinicians may be able to reduce weight stigma and the shame it provokes in patients. This compassionate approach to caring for patients who are overweight or obese will “positively impact the health of this population even if a pound is never lost.”²¹