Shannon just got a reminder from her primary care office: “It’s been over a year since you’ve had an annual physical exam. Consider scheduling one today!”
Shannon actually does have a few health issues she’d like to address — an old knee injury has been flaring up and she’s got a few moles that should probably be checked out — but still, she hesitates to make the appointment.
The last time she had a visit with a care provider, she left in tears. She came in with a carefully prepared list of questions, but all the doctor wanted to talk about was her weight. He lectured her but didn’t offer any advice beyond telling her to go to the gym and avoid fast food. She felt frustrated, humiliated and unheard, because she has really tried to eat healthy and maintain an active lifestyle. She made up her mind not to go back to the doctor unless she absolutely needed to.
What Shannon experienced in her doctor’s office is known as weight bias. According to the World Health Organization, weight bias is negative attitudes toward, and beliefs about, others because of their weight.
As an endocrinologist and expert in diabetes, nutrition, obesity and metabolism, I know that weight plays an important role in health. But how we talk about weight matters. I’ve built my practice around a principle voiced by author and activist Maya Angelou: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
Whether intentional or unintentional, weight bias can cause real harm. It’s a serious issue that can impact how health care is experienced and used by people like Shannon.
What is weight bias?
Unfortunately, weight bias is prevalent and often socially acceptable. It’s seen as okay to make fun of larger people in movies and TV shows because, well, their weight is their fault.
But weight bias has documented negative effects on health and quality of life. It often starts with teasing in school. It negatively affects self-esteem and self-confidence, and can be a factor in anxiety, depression and eating disorders. It can even act as a barrier to employment or to career advancement if a person doesn’t have the right “look” for the company.
Unfortunately, weight bias also exists in health care. If a person is judged or shamed for their weight in the doctor’s office as Shannon was, they might not want to come back.
Some examples of weight bias in health care:
- Not being able to use medical equipment, such as a blood pressure cuff, because it’s too small. If you walked into a store and found they only had clothes in small sizes and had to special-order all larger sizes, would you ever go back? The health care system should be set up to serve everyone.
- Some comments about weight. While many health conditions, including high cholesterol and arthritis, can improve with weight loss, not all comments about weight are productive and some even demonstrate bias. Being told, “You look great,” after working to lose weight can be meant as a positive but also suggests you didn’t look as great with the additional weight. Alternatively, the physician could have said, “What an accomplishment. And do your knees hurt less now?”
- Simple “Eat less, move more” advice. It’s hard to imagine someone unaware of the correlation between what you eat and what you weigh, but the relationship between the two is neither simple nor straightforward. If your doctor is unwilling to move beyond “Cut your calories,” then you are not receiving optimal advice for weight management. There are specialists, evaluations for underlying causes of excess weight, medications and surgical options that can help.
Where does the weight bias come from?
Bias develops from the residue that popular culture leaves on your brain as you go through life. It comes from what you see on television and online, what you hear, and the ways your peer group and family talk. In the U.S. and much of the Western world, attractiveness is often based on a thin, Eurocentric idea of beauty. These ideas are so prevalent and accepted that biased thoughts and actions often occur unintentionally.
Weight bias is rooted in the idea that each person is 100% in control of their weight. There is a pervasive cultural belief that people only carry excess weight because they lack self-discipline, eat poorly or don’t exercise enough. A failure to get rid of excess weight is seen as a personal and moral failing.
But that is an extremely simplistic view of how weight works. In reality, weight is the result of a complex interplay between your genes, age, sex, hormones, sleep patterns, the food industry, your environment — and your choices.
If you ask 1,000 people with excess weight to participate in a structured intensive lifestyle change program, a lot of those people will lose weight early on but the number of people able to maintain their weight dwindles with time. The reasons behind weight regain are complex and include an interplay between changes in fat, muscle and hormones that control body weight and appetite.
The better you understand that weight is complicated, the less you will be inclined to blame and shame others — or yourself — for weight.
Challenging bias in the world around you
If you carry excess weight, a visit to the doctor’s office can be a stressful experience. The following strategies may be helpful.
- If a provider tells you that you need to lose weight to solve another health condition, understand why. Perhaps you’ve scheduled a medical appointment for a condition that is unrelated to weight and received advice to lose weight. It’s understandable if you then shut down and disengage from the conversation. If this is happening, try to ask your doctor how the condition is related to weight. Sometimes, there actually is a connection, such as losing weight to relieve knee pain from arthritis.
- If you have a negative experience with your health care team, let your physician or the health care facility know. It can be very difficult to challenge a health care professional during an appointment, particularly if you feel ashamed. Other options include sending them a note afterward — either handwritten or in your portal — asking for a call back to discuss something personal, writing out your thoughts in a patient satisfaction survey or discussing the incident with the patient experience office. It can be a hard choice to speak up and might make you feel like you’re “telling” on someone, but because bias is often unintentional, the person receiving your feedback might not be aware that they said something hurtful and may be grateful to understand why — so they can modify the message in the future.
- If you’re able, find a primary care physician who takes a compassionate, whole-person approach. Your doctor should display a desire to understand where you’re coming from. If you want to or should lose weight, your care provider must know what you’ve tried in the past, including what has and hasn’t worked. Using this information, they should create a multipronged strategy that incorporates your history and experience.
Challenging your own bias
No matter your weight, you probably also hold some weight bias. I think it’s important for everyone to ask themselves three questions:
- What do I believe about why people gain weight? Be frank with yourself: Do you tend to assume that when someone can’t lose weight, it’s their “fault”? If so, challenge that idea with some facts: We all know people who eat everything in sight and don’t gain a pound. Similarly, we all know people who try very, very hard to get rid of extra body weight and either can’t lose the weight or can’t keep it off. Certain medications and health conditions can cause weight gain. Major life changes such as childbirth and menopause can affect weight. All of these examples point to the fact that there are many factors beyond “willpower” that affect weight.
- Do I believe the common stereotypes shown in movies/culture? In popular media, larger people may be portrayed as clumsy, ridiculous or undeserving of romance. The next time you see someone with excess weight in a movie or TV show, ask yourself: How is this person being portrayed? Do I agree with that portrayal?
- What assumptions do I make when I interact with somebody who is a different size than I am? Do I make assumptions about a person’s competence, work ethic or intelligence based on their size? Do I see certain people as more or less deserving of praise based on their size? Do I avoid spending time with people of a certain body size?
Once you truly answer those questions, you’ll be better prepared to engage with people of all sizes.