Reader Question – Top Thing Healthcare Providers Should Do When Working With Higher-Weight Patients

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Reader Danni sent in the following question:

I know that you give a lot of talks to doctors about working with larger bodied patients. I’m wondering, what is one thing that doctors could do that you think would make a really big difference right away?

This is an interesting question because there are certainly a lot of things that a healthcare provider (and I’m going to extend the original question from doctors to all HCPs,) could do, but one of those that I definitely think could make a big difference is to stop making assumptions about patients based on their size.

You know the old saying, right – “when you assume you make as ass out of you and me”

Well, when a healthcare provider assumes they can make an ass out of themselves and they can do serious physical and/or psychological harm to their patients and damage their patients trust in them and in the healthcare system as a whole.

Some common examples of assumptions that healthcare providers make based on a patients weight:

Assuming how much someone exercises

Assuming what and how much someone eats

Assuming what health conditions someone has or doesn’t have

Assuming whether someone has basic health/self-care knowledge

There are also more complicated scenarios that are often more about systemic assumptions (in lieu of actual research that includes higher-weight people) but they can also be individual like assuming how well someone will tolerate anesthesia and assuming how well someone will recover from surgery. For today I’m going to talk about the first group.

These assumptions can harm people of all sizes. The assumptions themselves are harmful – they can perpetuate weight stigma, they can mean missed preventative health screenings (for example, a lack of screening for type 2 diabetes in a thin patients or a lack of screening for cancer in a fat* patient.) They can result in patients losing trust in that specific provider and their recommendations. They can also lead to the patient getting frustrated and disengaging from care.

Perhaps even more dangerous is when provider recommendations are based on these assumptions. A simple example is when higher-weight patients are told to “eat less and exercise more” by a provider who has no idea what they eat, how much they currently exercise, their eating disorder history, or if they have contraindications for any/additional exercise (I wrote about this one in-depth here.)  Another example is telling a higher-weight person with Type 2 Diabetes to eat less carbs without any information about how many carbs they are eating (I wrote about this on in-depth here.)

I personally had a doctor make a big deal about how he wanted me to do something and that “it’s going to be hard, but if you can do it, it will change your life.” His recommendation? Start walking 10 minutes a day. I was at the end of training for my first marathon at the time and had walked 18 miles the night before the appointment. Talk about making an ass out of you…

I got an email (with permission to share anonymously) from a higher-weight patient who had to take a powder mixed into 6 ounces of liquid. She had found that apple juice worked best for her. Her doctor chided her that apple juice was “horrible for her diabetes.” The patient doesn’t have diabetes or blood sugar issues of any kind.

For higher-weight patients, this can often mean “diagnosis fat, prescription weight loss” No matter what’s wrong with higher-weight patients, the assumption can be that it will probably get better with weight loss and, if not, then it can be dealt with when the patient is thin (the “occam’s razor” theory of treating fat patients.)

It can also mean that issues are missed. For example, if a fat person has a sudden onset symptom but the provider assumes it’s their normal state (like they present at the emergency room with high blood pressure,) but they assumed that it’s chronic and not part of the emergent situation, then the provider can miss important symptomatology and diagnostic information.

This list goes on, but you get the idea (if you’ve experienced this, feel free to share your experiences in the comments.)

Ending this behavior can be more difficult than it sounds. Often these assumptions aren’t mean-spirited or even conscious – they are driven by implicit bias. These are biases that we have and work from subconsciously. In a world that is rife with weight stigma, implicit bias isn’t a surprise.  So it’s often not just about what the provider is doing, it’s about them noticing that they are doing it, understanding that they are doing it, making an immediate change, and then doing the lifelong work to uncover and dismantle their weight bias (and, of course, it’s not just weight bias, it’s also racism, ableism, ageism, homophobia, transphobia, and more.)  

One way to work on this is to ask questions before making suggestions (particularly those around so-called “lifestyle interventions”) and work hard to be clear that there are no wrong answers and that you aren’t making judgments.

So instead of “If you get more exercise, you’ll lower your blood sugar” maybe “Movement (sometimes called exercise or fitness) can sometimes help with blood sugar. If that’s something you’d like to talk about, do you mind starting by telling me if you are currently doing any kind of movement? If you’re not that’s fine and if it’s not something you want to talk about that’s also fine, there are lots of options to help manage blood sugar.”

If you are assuming that a symptom (let’s say high blood pressure) is chronic rather than a new/acute symptom, check the chart, or ask the patient “do you know what your blood pressure is typically” and/or “have you ever been diagnosed with high blood pressure”

In general this can require a provider to get in the habit of questioning if what they are thinking/saying/recommending or using as a basis for what they are thinking/saying/recommending is based on an assumption they are making about the patient based on their size (and, if so, finding a way to check that assumption – whether it’s checking the chart, asking the patient, or something else.)  

For higher-weight patients, assumptions are an enemy of ethical, evidence-based healthcare.

If you want some help navigating healthcare, my monthly online workshop this month is How To Be Your Own Medical Advocate. There is a pay-what-you-can option and a video of the talk and Q&A is provided to all registrants. Details and registration are here!

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More research and resources:
https://haeshealthsheets.com/resources/

*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.