The dangers of giving unsolicited health advice to higher-weight people - Part 2

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In part 1, I offered a framework of questions for healthcare providers (or others) to ask themselves before they offer unsolicited health advice to a higher-weight person (or, really, any person.)

I received this email from a doctor who asked to remain anonymous but gave me permission to quote what he wrote:

I’m a family medicine physician and a member of our practice sent your article about questions to ask before giving advice to [higher-weight] patients to our practice group. I will be vulnerable with you and say that it never before occurred to me that a doctor’s advice would be “unsolicited.” Prior to reading your article I would’ve said that when someone comes to see me as their doctor they are "soliciting" my advice. I’ve spent alot of time thinking about what you wrote and realizing that patients should have the right to decide what advice they want to be given, even by their physician. I’m close to retirement and I’m reckoning with the fact that I’ve been making this mistake for a long career, but it’s also nice to think that I can learn something new even at this stage. I’m looking into what you said about the issues with suggesting weight loss. I’m not as convinced about this as I am about making sure my advice is “solicited” yet, but I have more to read and you’ve already opened my mind about something that I would previously have said was a closed subject. Thank you for your work. If you print this publicly, please sign me as “Old doc with new tricks”

First of all, that is a top notch sign off if I’ve ever seen one. Thank you for reading and for being vulnerable and sharing your experience and insights.

Before I get into the original content I had planned for today, I want to discuss this a bit. As this doctor noted it IS, in fact, possible for doctors (and other healthcare providers) to give unsolicited advice. A patient who shows up and wants to know if a mole is cancerous did NOT sign up for a lecture about eating vegetables or even, (perhaps more arguably,) sun protection. Now, that doesn’t mean that the provider doesn’t have possibly helpful information, nor does it mean that the patient does not necessarily want to hear it. So what is a provider to do?

That is where the consent piece from question number 4 in Part 1 comes in. Asking the patient if they are interested in hearing the advice/having the conversation moves the conversation from unsolicited to solicited advice!

But what happens if the provider doesn’t bridge that gap, especially as it relates to giving unsolicited health advice to higher-weight patients? Well, it can do a lot of harm.

Waste (already limited) time/cause treatment delays

Many healthcare providers are under tremendous pressure to limit the time they spend with any given patient. This is neither the provider’s nor the patient’s fault. Where the provider can go wrong is by hijacking the time they do have with the patient to give unsolicited advice. In doing so, they take away the patient’s right and time to talk about what they actually made the appointment to discuss. Doing that without permission is apt to leave the patient not just frustrated, but also possibly untreated. Given the state of healthcare in the US, the patient may not be able to afford another appointment and/or may have to wait months to get one.

Create/exacerbate disordered relationships with food, movement, body

Higher-weight people are subjected to often relentless negative/stereotype-based messages and assumptions about their bodies, their knowledge, and their behaviors. When doctors make these assumptions and then give advice based on them, it can create harm by interfering with the patient’s relationships with food, movement, and/or their bodies. For example, it can give the impression that no amount of exercise is enough for a patient living in a larger body. This can cause over-exercise which can lead to everything from injuries to disordered exercise behaviors. Again, I cannot ethically support weight loss recommendations based on the evidence, but even if someone thinks this is a good idea, unsolicited advice to restrict food and/or increase movement can perpetuate or even create disordered relationships with food/movement and eating disorders.

Drive disengagement from healthcare

I cannot count the number of times a higher-weight person told me that they waited until a healthcare issue was an emergency/much worse than when they noticed it because they had repeatedly experienced having their reason for going to the doctor ignored in lieu of a lecture about their weight/eating vegetable/exercise.

Drive disengagement from self-care

When healthcare providers harp on weight loss, or deny healthcare unless or until someone gets to a certain size, they give the clear message that higher-weight bodies aren’t valid or worthy of care. Sometimes patients internalize this, disengaging not just from healthcare but also from self-care.

This is also a danger with advice around health-supporting behaviors. Health is not an obligation, barometer of worthiness, or entirely within our control. That said, when healthcare providers make assumptions that higher-weight people don’t know about/aren’t participating in/universally should be participating in specific health supporting behaviors, it can create frustration that leads people to, again, disconnect for both healthcare and self-care.

Gaslight the patient

The provider/patient relationship often comes with a power imbalance. When a healthcare provider perpetuates stereotypes and assumptions, it’s always possible that the patient will think that, no matter their actual knowledge and/or behaviors, they must be wrong or not doing “enough” since the provider says so. For example, a provider tells a higher-weight patient to exercise more without learning that the person exercises quite a bit already. Given the power imbalance, this can weaken/steal patient agency and can lead to harm. In our example, it might lead the person to exercising even more, creating over-exercising and/or sport injuries that keep the person from participating in the movement they want to do.

Lose credibility

Remember in part 1 when I mentioned the doctor who, very solemnly, told me that if I started walking 10 minutes a day it would change my life, when I was near the end of training for a marathon? In case you are wondering, I did not leave that appointment thinking “what an astute provider, I’m going to get excellent care from him.” I changed doctors. I asked my vegan friend her reaction to the doctor telling her she should replace meat in her diet and she wrote “I thought oh my god, this doctor is a total dud, I can’t get out of here fast enough.’

Not everyone has the privilege that I did to change doctors, but when you give unsolicited advice, especially when it’s based on your assumptions/stereotypes of the patient, you risk looking like you don’t know what you are doing. This can lead to patients being less likely to take other recommendations seriously. It can also make it clear that you are operating from a place of stigma, in his case weight stigma, which means that the patient has to wonder with every recommendation if you are actually trying to support their health as they have requested, or if you are surreptitiously trying to induce weight loss. Then, even when your recommendations are based on sound evidence, rather than stereotypes, the patient may end up rejecting prescriptions/referrals/advice that could have helped them.

Again, it is possible for healthcare providers to give unsolicited advice, and in doing so they can (however unintentionally,) do so much harm to so many patients (and much of that harm the provider may never even know about.) This can be avoided by using the four question framework that we discussed in part 1, and also through the providers doing their own work to address explicit bias and uncover and dismantle implicit bias.

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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.