Things to Stop Saying and Doing in Front of Higher-Weight Patients

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Every single day I hear from people who have had terrible experiences with healthcare providers. I often write about issues with overt weight stigma and the weight-loss paradigm in working higher-weight with patients/clients. Today I’d like to discuss things that often get said in front of these patients, but not to them. These things can cause significant harm, including damaging the relationship between the provider and the patient, making the patient less likely to be open and honest, and driving patient disengagement from care.

I want to preface this by saying that many of these things are incredibly common and considered part of “healthcare culture” or just common culture, so if you work in healthcare and you’ve done them, that’s not a huge surprise. Many are mistakes I made back when I was duped by diet culture. We can’t un-harm (and sometimes can’t even apologize to) anyone that we’ve harmed, but we can recognize it and make the change now that we know better. If you’re not sure about something that you or someone else does/says, feel free to email me and I’ll do my best to help. If you want to talk to co-workers about this, I have a guide here to help. If you’re looking for more information like this, I have a guide for what not to say at the beginning of appointments with higher-weight patients here and alternatives to common weight-stigma-based phrases here.

The items below are things that should not happen in front of patients of any size (at least without consent) but they happen more often and/or tend to be more damaging to higher-weight patients. As always, those of the highest weights and those with multiple marginalized identities face the greatest harm. Also, all of the stories that I share here are shared with permission. Note that the examples, in italics, contain true stories of weight stigma in healthcare practice that may be difficult to read so please take care of yourself.

Alright, let’s get into this:

Weight Loss Talk/Food Talk

Weight loss and food talk without patient consent have no place in healthcare settings. What you are eating. What you aren’t eating. Why you are or aren’t eating those things. What you are going to eat etc. Food talk and, even more so, weight loss talk, can be damaging to patients (and your co-workers) in many ways. You never know who has a predisposition toward, actively has, or is in recovery from an eating disorder. Patients may be fasting, on a specific diet, or on all clears for a procedure or lab and the last thing they want to hear about is the delicious meal you had or are about to have. A higher-weight patient may be in recovery from diet culture and working on a weight-neutral path and hearing diet talk can be damaging, as can hearing people (often people much thinner than you) explain the efforts they are making not to look like you. You are allowed eat what you want and to attempt weight loss, but talking about it in front of your patients can be seriously harmful.

Example: Recently a friend of mine was being prepped for surgery. One nurse said to the other that she was “fasting again” to “look good” for a cruise. As my friend was much fatter than the nurse there is, of course, the implication that my friend doesn’t look good, but her deeper concern was that someone who was responsible for getting her through surgery (and, in that moment, was struggling to place in IV) was purposefully doing so undernourished. A 2023 study found that intermittent fasting caused side effects including headache (61.3%), lethargy (68%), mood swings (57.8%), and lastly dizziness (55.8%)  and polyuria 46.2%). None of these are things you want someone in charge of your healthcare to be experiencing.

Negative Body Talk

This one goes hand in hand with weight loss talk. Any negative feelings you have about any part of your body are not best shared in front of your patients.

Example: A reader shared with me that they were sitting in the hallway at a new provider, waiting for someone to find the correct size blood pressure cuff that they had insisted upon  (which, by the way, should never have happened because the blood pressure cuff should have been readily available,) and two doctors were standing in the same hall, talking loudly to each other. One grabbed her leg and said “Ugh, the Corona 15 is all on my thighs” and the other said “I know, look at my ass, if I gain another pound I’ll have to go back into quarantine so nobody has to look at me!” They both laughed. Both doctors were roughly half the size of the patient. After getting her blood pressure taken and proceeding to the treatment room, the doctor who walked in was the second doctor from the conversation. The patient, thinking quickly, looked down at their phone and said that they had an unexpected emergency and would have to reschedule. Instead, they found another doctor and never went back.

Difficulties/challenges

The idea of calling higher-weight patients “difficult” or “challenging” is extremely problematic on its face. First of all, the existence of higher-weight patients isn’t the issue. The failure of the healthcare system to have tools and techniques for those who are higher-weight is the problem. Blaming the negative outcomes of that failure on higher-weight patients is stacking weight stigma on top of weight stigma. This is a mistake that is made in talking to patients, and even in research (sometimes, horrifyingly, research about weight stigma) but that’s a topic for another day. Today what I’m talking about is referring to a patient as “difficult” or “challenging” because they are higher-weight in front of them. Unfortunately, the failure of healthcare to accommodate higher-weight people can also create difficulties for healthcare practitioners who don’t have what they need to care for these patients. That’s a valid grievance, but it’s not the patient’s fault or the patient’s weight’s fault, and so it’s important to take care not to blame them, especially since they are the ones whose healthcare is being compromised. Be on the same team with your higher-weight patients, and against the weight stigma that is harming you both.

Example: A reader was in the hospital post-surgery to remove an ovarian mass. She was doing well and had been able to get up and walk around the evening of her procedure. The nurses had all been great and her mass was benign, so her spirits were up. When the doctors came by for early morning rounds the day after surgery they walked into the room and the doctor leading rounds turned his back on the patient and told the rest of the group ”ob*se” patients like this are more difficult from start to finish – more challenging in surgery and more challenging while they recover, between weight and laziness it’s almost impossible to get them up and walking.”  She said almost nothing to the doctors, just trying to hold back her tears. When the nurse came in after rounds the patient burst into tears and apologized profusely to the nurse for being so much trouble. After asking what had happened and listening empathetically, the nurse assured her that she wasn’t trouble at all and mentioned that that particular doctor was known for “poor bedside manner.” For the rest of her hospital stay the patient was worried that she was a burden.

Movement and Repositioning

It’s possible that, with patients of any size, you may need to have a discussion about the best way to move or reposition them, what’s not ok is having that discussion in front of the patient like they aren’t there. Talk out of earshot of the patient or, better yet, talk with the patient, explain what needs to happen.  Ask them questions rather than making assumptions about their abilities/capacities. Here again, the lack of equipment (like Hoyer lifts) can mean that both the patient and the provider are being harmed by the healthcare system’s failure to support and accommodate higher-weight patients, and here again stay on the team with your patient and against weight stigma.

Example: The WRISK project interviewed thousands of pregnant people and found that “The main thing that came out [of 7,000 interviews] for us was a routine dehumanization and depersonalization within the maternity care system.” Multiple women had been told they were at an increased risk of becoming incapacitated during labor and were then present for conversations where medical staff talked about how they would handle their body should they become incapacitated. “The participants acknowledged that that may need to be discussed, between staff, but not necessarily in front of them."

Blaming Their Body

We never want to blame higher-weight people’s bodies for the failings of healthcare. The patient isn’t too big – the gown, blood pressure cuff, MRI, etc. are too small. Healthcare should accommodate people of all sizes. People shouldn’t be asked to change themselves in order to get care, and they certainly shouldn’t be blamed when they can’t.

Example: A patient told me about going to get an MRI and finding out that the MRI failed to accommodate her. She asked the tech if they knew a facility that might have a machine with a larger bore. The tech opened the door and yelled up to the front desk staff “She’s too big for our machine, do you know where they might have a bigger one?” The patient, who was fully fat-affirming, realized that this was absolutely wrong and did lodge a complaint, but was still made incredibly uncomfortable and even more stressed than she had been upon learning that she couldn’t get the MRI she needed because the machine failed to accommodate her.

In general remember that higher-weight patients may be coming to you with a history of negative, weight-stigma-driven interactions with healthcare providers, and may also be dealing with internalized oppression. So take care to speak in ways that will create a positive, supportive interaction.

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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.