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Patient Quick Guide To Talking About Weight with Healthcare Providers
A very common issue for higher-weight people who are trying to access healthcare is healthcare providers (HCPs) who want to focus on weight and weight loss. Today I’ll give some tips that I’ve learned both from personal experience and as a patient advocate for navigating what I call Provider Weight Distraction.
Before I say anything, I want to point out that weight stigma in healthcare often becomes higher-weight patients’ problem, but it is not higher-weight patient’s fault. We should not need to read articles and take workshops and gear up to try to get ethical, evidence-based, weight-neutral care.
I also want to point out that HPCs are often very well-intentioned and are relying on the training that they received. Much of healthcare education focuses on the idea of higher-weight patients as walking, talking pathologies, with the idea that “Occam’s razor”(that, essentially the simplest explanation is typically the right one) tells them that since being higher-weight is correlated (however spuriously) to health issues (often expressed as a condition being “weight-related,”) then if someone is both higher-weight and has a health issue or health issues, the focus should be on their weight to solve all of their issues. Unfortunately, however well-meaning, this attitude does tremendous harm to fat people. Additionally, there can be an imperative (often tied to compensation) to offer “weight management counseling.” That said, a patient’s right to informed consent/refusal is absolute, even if providing patient-centered care impacts the provider’s compensation.
Provider weight distraction can take a lot of forms. Some examples include:
The patient is presenting with something that couldn’t possibly be termed “weight-related” (ie: strep throat, sprained wrist, broken finger) and the HCP wants to focus on weight/weight loss
The patient has a health issue that gets labeled as “weight-related” even though people of all sizes get it (elevated blood pressure, elevated blood sugar, joint pain etc.) and instead of giving the patient the various options that would be given to a thinner person the practitioner focuses myopically on weight loss
The patient has been clear that they want weight-neutral care but the provider continues to recommend weight loss
Before we get into this, I also want to point out that in conversations with HCPs, privilege always comes into play. That means that those at the highest weights and/or those with multiple marginalized identities are likely to be afforded less respect and to be treated with greater paternalism than those with more privilege. I want to acknowledge that, as someone who is white, cisgender, currently able-bodied and neurotypical among other privileges I benefit from this.
That said, here are some options for navigating these discussions with your healthcare provider.
Explain Your Reasoning
One option is to explain your reasons to your HCP. This can sound like “My understanding is that about 95% of intentional weight loss attempts fail” or “I understand that weight loss surgery takes my currently perfectly healthy digestive system and puts it into a disease state, has serious side effects that risk my life and quality of life, and has almost no data after 10 years.”
This can be tough for a lot of reasons (and tougher for those with less privilege) because there can be multiple power imbalances. From a cultural perspective, there can be a belief that the HCP is an expert who is not to be questioned by the patient. There can also be situations where the patient absolutely needs something from the HCP (a prescription refill, a referral, a diagnostic exam etc.) and so can’t afford to upset or alienate the practitioner. Similarly, if a patient doesn’t have access to a wide network of doctors because of their insurance coverage or lack thereof, they may have to be careful not to create an adversarial relationship with this provider.
It can also be complicated because often providers are fully aware of the evidence, but they think it’s worth risking our physical and/or psychological health in an effort to make us thin. Even if we express that we don’t, weight bias (either explicit or implicit) can lead them to believe that the fact that we are fat proves that we aren’t capable of making, or don’t deserve to make, choices for ourselves.
Shift the burden of proof
When discussing evidence it can be easy to feel like the burden of proof is on you to quote studies and statistics. But if your HCP is the one recommending weight loss, then it’s completely reasonable to put the burden of proof on them. Something like “My understanding is that 95% of people who attempt weight loss end up regaining the weight, can you give me the name of a study where at least a majority of the subjects were able to lose a significant amount of weight and keep it off for at least five years?”
This is also not a sure thing. I said this to a doctor once and she responded “there are lots of them.” When I asked “Okay, can you give me the name of one?” she responded “I don’t want to debate this with you.” Luckily, I was in a situation where I could find another doctor, which is what I did.
Bypass the weight discussion
Another option is to try to bypass the weight discussion altogether. My favorite trick for this is to ask something like “What do you do for thin people with this health issue/symptom?” and then say “Let’s try that.”
You can also put the weight discussion off by saying something like “I know we have a limited time today so I’d like to focus on my [sprained wrist], I’ll make a separate appointment to talk to you about weight.“
You can also say “I’m exercising my right of informed refusal for weight loss as an intervention, what are the other options.”
This one is definitely a harm reduction option, which is to say it’s not ideal but sometimes we have to do what we have to do in order to navigate a system that is full of weight stigma. So, if your HCP simply won’t let the weight loss conversation go, you can say something like “Sure, I’ll start that diet, but in the meantime, I think that thin people also get knee pain, what options do you give them?...I’d like to start those now as well.” Then you don’t start the diet and do start the weight-neutral recommendations.
One last thing - if you try these things and the results aren’t what you were hoping for, please know - that is not your fault. Considering the amount of weight stigma that exists in the healthcare system, and all of the factors that go into a doctor’s reaction, we can never be sure that we will get the response and treatment that we need and deserve. Again, while that becomes our problem, it is not our fault.
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*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.