Patients who are overweight face "fat shaming" from health care providers, which can be harmful to physical and mental health—and even lead patients to avoid the doctor altogether, an anonymous blogger who calls herself "Your Fat Friend" writes for Self Magazine.
According to CDC data, about one-third of U.S. residents are obese. Further, a recent study in JAMA showed the rate of severe obesity has risen in recent years, from 5.7% in 2007-2008 to 7.7% in 2015-2016.
Although obesity is becoming more common in the United States, stigma about being overweight is pervasive—including among health care providers, the Self Magazine article notes. For instance, research indicates that primary care providers do not build emotional bonds as strongly with patients who are obese as with non-obese patients. Another study found physicians may prescribe more tests for "heavier" patient yet spend less time with these patients and regard them more negatively.
Nurses hold biases, too. For instance, a 2009 study of 352 nursing students and 198 registered nurses found a majority of respondents thought fat patients "liked food, overate, and were shapeless, slow, and unattractive."
These biases can have clinical consequences. The American Psychological Association (APA) last year announced that a research review found "[m]edical discrimination based on people's size and negative stereotypes of overweight people can take a toll on people's physical health and well-being."
Joan Chrisler, a professor of psychology at Connecticut College who presented the research review last year, said, "Disrespectful treatment and medical fat shaming, in an attempt to motivate people to change their behavior, is stressful and can cause patients to delay health care seeking or avoid interacting with providers." In particular, a study in Body Image found an association between a higher body mass index and avoiding health care.
Writing in Self Magazine, "Your Fat Friend" shares how health care providers' attitudes toward her weight deterred her from seeking health care for eight years.
The patient, who had "good insurance and plenty of doctors nearby," writes, "I didn't see a doctor for eight years," because "there was … one problem: I was fat, and I couldn't seem to find a doctor who would take my symptoms seriously."
The patient shares "many little moments that led" her to avoid medical care. For instance, she describes an annual checkup during which the physician "recoiled at the sight of" of her. The patient writes that the physician "quickly told me I'd need to lose weight … then left the exam room." She continues, "My body was never touched, never examined. I learned nothing new about my health, and was left only with the searing shame of believing that even a professional couldn't bear to touch my body."
In another instance, she writes, "[A] nurse took my blood pressure four times. When I asked her if I was OK, she told me my blood pressure must be wrong. 'Obese patients don't usually have low blood pressure,' she said." The patient notes, "Even my health was impossible to believe."
The patient writes, "I expected to discuss my weight with my doctor in certain situations, but I faced a monologue … regardless of the condition that brought me to the office, the response to every question was the same: 'Just lose some weight. Cut out junk food. Drink more water.'" For instance, the patient describes a visit to a doctor for an ear infection during which the doctor answered her question about follow-up care with advice to "'lose some weight.'" The patient writes, "As if I had never considered weight loss."
The patient states, "Doctors stopped seeing me. So I stopped seeing them."
In her efforts to lose weight, the patient became fixated on "meal prep and portion control, nutrition apps and food journals." She describes her eating habits as "meticulous and restricted, falling into the casual orthorexia of "clean eating" and rigorous food journaling." She writes, "It took months for me to recognize the soft shadows of disordered eating in my behavior."
Meanwhile, the patient discovered stories online that "offered a crushing kind of validation" about her experience with the health care system. The patient stumbled on a blog post by Rebecca Hiles, who waited 11 years before a doctor looked beyond her weight and correctly diagnosed her with cancer.
These anecdotes and the relevant clinical research, the patient writes, together "pain[t] a pretty clear picture." She explains, "As one study concludes, for fat patients, anti-fat bias 'poses serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts.'" She adds, "I realize that I could be one tumor or one missed diagnosis away from becoming another cautionary tale."
The writer shares that she has "returned to medical care" and offers advice for countering weight stigma in health care settings. She notes, "The staggering evidence of anti-fat bias is disheartening, but it offers action for each of us. Fat or thin, doctors or patients, there are things we can all do to begin to chip away at this omnipresent stigma and the harrowing implications:"
1. Advocate for overweight people.
Patients can ask their physicians whether they are trained to provide health care using the "health at every size" approach, and they can share this information with family members or friends who are providers to raise awareness.
2. Believe overweight people when they share their experiences.
The patient writes that family and friends often doubt or question the experiences of overweight people, dismissing what they said has happened to them, but research shows overweight "people aren't 'just imagining' medical bias."
3. Do not use 'tough love' with people who are overweight.According to the patient, overweight people are often told it is their fault that they are overweight and that if they simply used self-control they would lose weight. But that, the patient writes, "leads many of us to eating disorders and other coping behaviors that put our health at risk." The patient writes that "'tough love' approaches isolate fat people, teach us to stay silent, and push us to avoid contact with those who perpetuate those negative stereotypes—including doctors, family, and friends" (SELF Magazine, 6/26; Rapaport, Reuters, 6/19; APA release, 8/3/2017).
Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.
Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they're all driven by the physician as the "Influencer in Chief."
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