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Physicians must work to break this cycle of bias
by
Mengyi (Zed) Zha, MD
July 4, 2024
Zha is a physician and a nonfiction writer.
It’s summer 2024, yet Lady Gaga still had to fight rumors about her “looking pregnant.”
“Can we all agree that it’s invasive & irresponsible to comment on a woman’s body,” Taylor Swift responded, coming to her defense.
Superstars are far from the only ones who face body shaming. It’s incredibly prevalent in the health field too. Ask any patient who lives in a larger body, and they will tell you: weight stigma is bad medicine.
Weight Stigma Is Prevalent in Healthcare
Being shamed by physicians is not uncommon. In a 2009 survey study, 50% recalled at least one interaction with physicians where they left feeling ashamed — and weight was the most common shame-inducing topic. In 2022, I polled over 300 people on X and found the numbers were even worse: 70% said they had been shamed by their healthcare teams. Though weight stigma is equally as prevalent in the general population, physicians aren’t merely another component of the general population. Our actions can have far worse consequences for those who seek our care.
Studies have demonstrated that physicians show less respect and make less effort to build a rapport with patients living with higher weight. This effort deficit goes beyond emotional connection. Mothers living with obesity, for instance, are less likely to receive support for breastfeeding from healthcare professionals, which can negatively impact infants’ health. Even for weight loss, those who experience weight stigma from their physicians are less likely to succeed in losing weight than those who don’t feel judged.
Perhaps the worst outcome of patient-shaming is the loss of a therapeutic relationship. In the 2009 study, 45% of those who felt shamed by the physician left, avoided, or lied to the physician. Even anticipated weight stigma can prevent patients from seeking care. This begs the question: if weight stigma prevents people from getting cancer screenings and prenatal care, and patients living with obesity have higher cancer rates and worse obstetric outcomes, is obesity the risk factor or could weight stigma play a role too?
To be clear, addressing excess weight is important and does not by itself constitute weight stigma. But when we make weight the sole focus for all health-related issues, we embody weight stigma by gatekeeping access to care.
I’ve worked extensively with women suffering from hidradenitis suppurativa (HS), a chronic, recurrent skin condition that causes painful sores, often in private areas. Obesity has been identified as a comorbidity. Children who suffer from HS are over twice as likely to be overweight than children without HS. As a result, many patients have told me that “the doctor told me to go lose weight without even looking at my skin.” This inability and refusal to “see past fat” are not only perceived by patients as “annoying” and “wrong,” but can also do real harm, such as missing diagnosis and delaying care. Moreover, this stigma is often baseless, as in HS, where there is no strong evidence that weight loss consistently leads to clinical improvement in HS; on the contrary, rapid weight loss after bariatric surgery may lead to worsening symptoms in up to 69% of patients.
In other words, we can become blind to our own biases and fail to do our jobs. Patients living with obesity, who already suffer higher all-cause mortality, now face the consequences of inadequate medical care. The vicious cycle continues.
What Can We Do?
First, medicine, as a science and a service, must include people of all sizes. Currently, people living with obesity are not required to be included in U.S. clinical trials. Drug dosing in larger bodies, therefore, becomes an unknown territory. In cases such as infections, blood clots, and cancer, this can be life-threatening.
But there are many clinical settings where the weight of the patient is not important. When a patient comes in for an atypical mole, is it really necessary to know their exact weight? As BMI is exceedingly questioned as a “vital sign,” we should ask patients for consent before weighing them whenever possible. Additionally, all healthcare environments should adapt facilities, equipment, and policies that are large size appropriate.
There was a joke during my training that “XXX was so large we had to use the elephant MRI in the zoo for their scan.” Let me be clear: fat jokes have no place in medicine. And the failure to accommodate larger bodies in healthcare is not funny.
Second, health should be addressed at every size in a non-judgmental manner. Health At Every Size is a framework to combat the oppression people who are overweight or obese face in healthcare. It teaches that healthcare is a human right for people of all sizes and the refusal to provide care until arbitrary weight loss criteria is met could constitute a violation of the patient’s bodily autonomy. Additionally, after obtaining permission to discuss weight, the language used matters. It should be person-centered, collaborative, non-judgmental, non-blaming, respectful, evidence-based, and without assumptions.
Lastly, training to combat anti-fat biases must be provided early in medical training. In a telling 2010 randomized control trial for a patient presenting with shortness of breath, medical students were more likely to recommend lifestyle changes and less likely to prescribe symptom relieving medications for patients living with obesity. By residency, an alarming level of anti-fat biases exist across all specialties. This means either medical education cultivates weight stigma or does a terrible job correcting it (or both).
Breaking the Cycle
“Your weight did not cause your HS.”
When I meet a new patient living with HS, I slow down to emphasize this point. Many cry when they hear these words. Weight stigma creates so much trauma outside of our exam rooms. We must break the cycle in the one place where people expect care and compassion.
Every body should have a place in medicine. And every body deserves to heal.
Mengyi (Zed) Zha, MD, is a physician in Washington and an agented nonfiction writer.
