Last month, three American medical organizations drafted a series of guidelines to help doctors treat obese and overweight patients. The American Heart Association, the American College of Cardiology, and the Obesity Society worked together to create recommendations that include instructions to calculate patients’ body mass index (BMI) at least once a year and to consider recommending weight-loss surgery for patients with a BMI of 40 or higher. The guidelines were released the same week as a survey co-sponsored by the Obesity Action Coalition (an obesity advocacy nonprofit) that found many patients don’t discuss weight with their physicians. Although all doctors surveyed said they talk to their patients about managing their weight, only 40 percent of patients said their doctor had ever instructed them to lose weight.
While the guidelines and the survey were published independently, they point to an increasing problem in American healthcare: As a society, we seem to be growing more resistant to judging people based on (or even acknowledging) their weight. That resistance appears to have carried over into the medical sphere, causing doctors to avoid broaching the topic of weight so as not to insult patients. As a result, patients often leave the doctor’s office without learning important medical information.
Is it possible that doctors are too concerned about bruising egos to provide their patients with appropriate medical care? And are we moving toward a future in which doctors and patients can speak frankly but respectfully about the health risks associated with being overweight — or one in which these topics are even more taboo and confusing?
Fraught Fat: The Complicated Conversation Around Weight
In the last few years, as the number of overweight and obese American adults has skyrocketed to at least 69 percent, weight and body image have become increasingly polarizing topics. News anchor Jennifer Livingston garnered tremendous support when she stood up to the man who called her a poor role model because she is overweight. On the other hand, Maria Kang (aka the “fit Facebook mom”) provoked controversy across the Internet when she wrote that when we accept people who are overweight, we’re “normaliz[ing] being unhealthy.”
Even among health professionals, topics such as weight and body image are no less contentious. Earlier this year, the American Medical Association (AMA) officially declared obesity a disease, a ruling that may have significant implications for the way health insurance companies cover obesity treatments. But health experts seem uncertain as to whether being overweight is an automatic medical risk. A few years ago, the consensus seemed to be that someone could be “fit and fat”— meaning that as long as he/she exercised enough and showed no signs of adverse medical conditions, being overweight was okay. That kind of thinking has spurred the growth of the Health at Every Size (HAES) movement, which promotes the idea that good health and being overweight aren’t necessarily mutually exclusive. A group of researchers seemed to confirm that possibility when they found that — contrary to popular belief — having a higher BMI was associated with a longer lifespan. More recently, though, a review of studies suggested that overweight people were significantly more likely to die from heart disease than their thinner peers Are Metabolically Healthy Overweight and Obesity Benign Conditions? A Systematic Review and Meta-analysis. Kramer, C.K., Zinman, B., Retnakaran, R. Annals of Internal Medicine 2013 December 3;159(11):758-69..
Medical Missteps: Why Doctors Are Afraid to Address Their Patients’ Weight
One possible (and important) consequence to all of this confusion may be that doctors don’t even know how to start talking about patients’ weight in the first place. Several new studies have found that only about a third of doctors compute their patients’ BMI on a regular basis, and that most primary care physicians have no training in nutrition or weight management.
Moreover, some doctors claim that patients dislike talking about their weight because it can be upsetting and frustrating — even if starting that conversation could improve overall health. “Some people take offense when you talk to them about [their weight],” said Greatist Expert and pulmonary specialist Dr. James Hardeman. “Even though this should be really about your health and not the social aspects of being overweight or obese.”
Greatist Expert and cardiologist Dr. John Mandrola has had similar experiences. “[One] reason docs don’t talk about obesity with their patients is that they are concerned about hurting their patients’ feelings,” he wrote in an email. However, doctors who do bring up patients’ weight sometimes receive an indifferent response. Having heard the whole spiel before (and possibly having attempted to lose weight in the past), patients may not want to hear about their health problems yet again. “A common reaction [to being told to lose weight] is like, ‘Well, I know,’ like if I told them the sky was blue or something,” Hardeman said.
It’s particularly unfortunate that these conversations aren’t happening at the doctor’s office, since research suggests that patients who discuss their weight with physicians are more inclined to lose weight The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Post, R.E., Mainus A.G. 3rd, Gregorie, S.H., et al. Department of Family Medicine, Medical University of South Carolina, Charleston, USA. Archives of Internal Medicine 2011 Feb 28;171(4):316-21. Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial. ter Bogt, N.C., Bemelmans, W.J., Beltman, F.W., et al. Department of General Practice, University Medical Center Groningen, the Netherlands. Archives of Internal Medicine 2011 Feb 28;171(4):306-313. Physician weight loss advice and patient weight loss behavior change: a literature review and metaanalysis of survey data. Rose, S.A., Poynter, P.S., Anderson, J.W., et al. University of Kentucky College of Medicine, Department of General Internal Medicine and Geriatrics, Lexington, KY, USA. International Journal of Obesity (London) 2013 Jan;37(1):118-28.. The question that remains is whether physicians’ ability to help with weight management will be overshadowed by their fear of offending patients.
A Sensitive Subject: Can Doctors Learn to Talk About Obesity the Right Way?
So how will recent developments — such as the new guidelines for helping patients manage their weight — affect the conversations that happen in healthcare settings? Hardeman predicts that all the publicity surrounding the recommendations will ultimately have a positive impact: Once people realize that doctors are supposed to be talking to them about their weight, they’ll be less likely to take offense when the topic comes up. Discussing weight is “not just going to be like an out of the blue sort of thing where they get harassed again,” he said.
Hopefully, in the future, physicians will not only recognize the importance of discussing patients’ weight, but will learn to do so in a respectful, non-judgmental way. “Professionals need to be trained on how to bring up the conversation of weight,” said James Zervios, Director of Communications at the OAC. In particular, he added that offices should be “weight-friendly,” meaning that they have scales placed in discreet locations that accommodate individuals who might weigh 400 pounds and hospital gowns large enough to cover even severely obese people.
It’s harder to measure the psychological and emotional impact of feeling that your healthcare provider is judging you negatively based on your size. But by now it’s well known that weight bias exists in the healthcare community, even among those who specialize in treating obesity and eating disorders. A more weight-friendly doctor (and doctor’s office) can help patients be more proactive about discussing health concerns.
“The next decades will be about helping people help themselves,” Mandrola said, noting that doctors and patients alike will focus more on preventing avoidable health issues. Recently, the OAC launched a campaign called “Your Weight Matters,” in which people sign a pledge to reach for a healthy weight. Once they pledge, participants receive a packet that prepares them to discuss their weight with their doctor. Even back in 2011 (after researchers published findings suggesting that talking to a doctor about weight management could help people stay healthy), articles appeared on websites including Dr. Oz and the Huffington Post advising patients on how to broach the subject with their healthcare providers.
Overcoming Hurdles: The Takeaway
The next few years hold tremendous challenges for the medical community as well as for the general public. Somehow, doctors need to find effective ways to diagnose someone as overweight or obese (and address the potential negative health implications that follow) without seeming judgmental or disrespectful. If the number of obese Americans increases as predicted, overcoming all these obstacles will be crucial for our long-term physical, mental, and emotional wellbeing.
Have you ever talked to your healthcare provider about managing your weight? Let us know in the comments below or tweet the author at @ShanaDLebowitz.
Special thanks to James Zervios of the Obesity Action Coalition for his contributions to this article.