How to Talk to Higher-Weight Patients About Behavior-Based Treatment Options

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!

I recently wrote two different pieces. In one I discussed mistakes doctors make when prescribing health supporting behaviors and in another I mentioned that it can help to come from questions rather than assumptions. I received the following reader question:

My name is Mary and I’m a family doc (you can use my first name if you print this.) I wouldn’t say that I’m fully onboard with being weight inclusive but I’ve been reading your work and I can’t deny that what you are writing makes sense and is grounded in research (some of which I had never heard of in any of my training.) I have been thinking about what you wrote when you said how important it is that we ask our patients questions instead of making assumptions. I will admit to making assumptions about diet and exercise with patients who are what you would call higher weight. Thank you for helping me see that, but I’m having difficulty with what to do instead and how to ask the questions and I thought others might be as well. Is this something you would be interested in writing about?

Thanks for the introspection, the open-mindedness, and the great question, I’m happy to write about this.

These conversations can be fraught, sometimes in large part because of the weight stigma that your patient has experienced in previous healthcare interactions. A common (valid!) reaction to this is for higher-weight patients to be very guarded and to assume that the healthcare provider is not acting in good faith, even when the provider is clear that they are coming from a weight-neutral perspective (and that this is not about claiming to be weight-neutral but secretly trying to make the patient lose weight, or yet another generic, harmful “eat less and exercise more” conversation).

Before we get into this I also want to acknowledge that often, through no fault of their own, providers are under a time crunch with patients so modify the scripts as needed for time and/or to put this into your own words (being careful to consider if those words might be coming from a place of unexamined weight stigma, and feel free to reach out if I can help ragen at weightandhealthcare dot com.) The bracketed sections are sections where you’ll want to be specific to the patient’s situation.

Before you consider these scripts, I recommend checking out this piece where I talk about common pitfalls that happen when providers recommend behavior-based interventions to patients.

EDIT: I was trying not to be redundant but based on a number of commenters who were (rightly!) concerned about these conversations, I wanted to reinforce reading the piece linked above before using these scripts.

Consider starting with an explanation and a list of the options, then ask permission, acknowledge the possible situation, and then lather, rinse, repeat. So something like:

Let’s talk about options for moving forward. My goal is to give you the categories of options, explore any of the options that you are interested in including the possible benefits and the possible risks, answer any questions that you have, and give you whatever support I can to help you make the best decision for you, because you know your body and your life best. Know that you can make a decision today and then change your mind later.

Based on your [diagnosis/symptomatology/goals] there are options that include [behaviors/medications/surgeries - this list will change based on the situation]. Which of those categories of options would you like to talk about?

(Note: In this piece we are only talking about the behavior-based options)

If they acknowledge that they want to talk about behaviors, whether as an intervention for a specific health issue and/or general health support, give another list of categories. For example:

Ok, let’s talk about behaviors.

Option 1: What have your experiences been with these types of conversations with healthcare providers? Do you have any concerns before we get started?

Option 2: I want to start by saying that some people have had negative experiences in these conversations because the focus wasn’t actually on behaviors but on weight. I just want to assure you that when I talk about behaviors, I’m talking about them in a weight-neutral way. Do you have any questions about that?

Listen to the answers, address the concerns, then move forward with more categorical options (and remember again we are just discussing behaviors here)

In [your situation] there are options including around [sleep, stress management, food, physical movement etc.] Which of those would you like to talk more about?

After they give the list of options, you can say something like:

“I’m going to go over each of the options briefly, feel free to ask for more information on any of these that interest you and remember it’s ok to decide against an option if it doesn’t sound like something that you can realistically do or if it doesn’t sound like something that you want to do. Even if none of these sound good, that’s fine too, we have more options and remember you can try something and then change your mind.”

At any point in this process you can ask the patient about their past experiences with this specific option to gather more information to help you construct a dialog that is helpful, avoids past provider mistakes that the patient has endured, and creates a patient-centered, shared decision-making conversation.

Continuously address any fears/concerns and offer more personalized recommendations.

Also, if it is an accessible option for your patient, you might also recommend a professional whose area of expertise is the specific behavior(s) you are recommending.

In general this process is about asking questions and having a patient-led conversation that combines the patient’s expertise with the providers expertise, to find the best option for this patient.

This month’s online workshop is Weight-Neutral Reproductive Care with Dr. Anna Whelan, MD FACOG. There is a pay-what-you-can-afford option and all registrants get a video. Details and Registration are here!

If you appreciate the content here, you can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter (and the work that goes into it!) and get special benefits! Click the Subscribe button below for details:

Liked the piece? Share the piece!

More research
The Research Post

More resources
The Resource Post

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.