In a treatment team setting, I was recently working with a medical doctor (MD) whom I very much respect. She deeply cares about patients’ mental and physical wellness. Because our mutual patient, who was considered “obese” according to BMI, had not shared their weight history of struggles with their size and diets, the MD had not known that the use of medical terms related to weight and fat were triggering to the patient. The doctor’s medical attention (aimed at improving the patient’s health and safety) was simultaneously getting in the way of the patient improving their health and safety.
I could hear the MD’s care. She said, “I struggle with this,” meaning how to discuss “overweight,” “obesity,” “weight loss,” and other diagnoses and medical recommendations with patients who may get activated by them.
This is a complicated area probably for many MDs. Nowadays, terms such as diabetes, high cholesterol, fatty liver, obesity, etc. have become paired with shame and self-blame. Many patients will not automatically disclose their histories of previous dieting and weight loss attempts. Suggesting weight loss to people in larger bodies can, in many cases, intensify their restriction, bingeing, or even atypical anorexia (a condition proving itself to be as mentally and physically dangerous as typical anorexia nervosa).
This doctor pointed out that even if she uses none of the emotionally-packed terms during the appointment, the follow-up documentation contains the words anyway. So she could do great patient-empowering work, and then the Visit Summary paperwork could undo it.
I felt for her, her patients, and the Catch-22, which got me thinking… What can help MDs who recognize this predicament: They have a patient in a higher-weight body, and they feel they need to talk about improving the patient’s health, which might include weight references?
I know this beautiful-hearted MD is not alone in wanting not to cause her patients to feel worse about themselves or to increase unhealthy or dangerous practices to lose weight. I have met so many genuinely caring medical professionals throughout my years as a mental health clinician. So, on that note, I write this.
Letter to MDs.
Dear Doctors:
I am thankful for you who do this hard and complicated work of supporting diverse people—of any size—who come into your office. You often won’t know their full psychological histories. So hopefully these thoughts feel supportive to you. Please discard what doesn’t feel a fit for you. And if something does feel helpful to you and potentially to your patients, fantastic! I think you already do an incredibly challenging job and appreciate you; my own MD changed my life for the better.
Thank you to any medical professionals who take the time to read the following.
Respectfully,
Alli
Discussing the Body Mass Index (BMI) and Weight Categories.
Before discussing the patient’s BMI status and using labels such as “overweight” or “obese,” prepare the patient by explaining the BMI’s fallibility. Not all bodies will fit into the BMI range of normal, and it doesn’t necessarily mean the patient is unhealthy. For example:
- Many elite athletes will also be considered “overweight” or “obese.” Are they unhealthy? No.
- Bones and musculature matter. People who are born with birdlike, tiny bones or have difficulty building muscles will probably have an easier time staying in the “healthy” BMI range throughout the years versus those who are born with sturdier, thicker bones and/or who easily muscle.
- There is a video by the Association of Size Diversity and Health called “The Problem with Poodle Science.” (https://youtu.be/H89QQfXtc-k). The piece brings to light that under the umbrella of “dogs,” there are different breeds. In a charming and scientifically backed way, it shows that making all breeds fit the weight range of a poodle is not good policy or science. A Chihuahua or Great Dane is probably not going to be healthy when either finally, after working really hard to get there, reaches the Poodle’s weight range.
Let your patients know that bodies can be healthy at different sizes—outside of the BMI’s “healthy” range, too. In my experience, this can mean a lot to clients and can help motivate them to make changes that may benefit them.
If you don’t know a patient’s weight/dieting history, you may be speaking to someone who tried to lose weight so well and so diligently that they messed up their own metabolisms. So discuss current BMI with the knowledge that your higher-weight patient may have been—or be—someone who chronically diets. Focusing on weight loss could actually harm this patient.
Discussing Laboratory Results and Illnesses.
Unless it has been proven that adipose tissue is the actual, direct cause and culprit of a diagnosis or a skewed laboratory test result, don’t suggest solving their problems via mainly weight loss. Please consider treating all patients equally; advise larger patients in the same way you would thinner patients.
- What else, not weight loss-related, can help improve the patient’s labs or keep them safe?
- Could there also be other majorly influencing factors causing or contributing to the malady such as genetics, other disorders, past choices that now have consequences for the patient, the body expressing mental/emotional struggles, or effects of stress?
Share those.
Educating your patients about the various possible cures and causes besides weight can be empowering for them.
Imagine if you personally already struggled with your weight and your doctor understood that weight loss, for you, is like having to move a whole mountain with a forklift. Imagine, instead, hearing something like, “OK, so your body is already working to fix or manage itself. So let’s look at what you can do to help. Options [X, Y, and Z] have been shown to be helpful. Do any of those options sound like something you’d be willing to work on? OK. Pick one or two that are the easiest for you to accomplish by the next time we meet.”
Also, check if your patient in a higher-weight body has a history of or has currently been doing any fad diets or tweaking their nutritional intake (e.g., eliminating whole groups, restricting, eating desserts or drinking alcohol instead of meals, compensating for missing nutrients with supplements). A person of any size can throw off their wellness in these kinds of ways, which I have repeatedly witnessed. Many patients:
- will not know that eliminating whole food groups in the name of health can actually cause malnutrition and weird laboratory results.
- will not know that a pattern of skipping or minimizing a well-balanced meal (so they can have something less nutritious that they want, such as sugary soda, glass of wine, or dessert) can eventually result in unbalanced nutrition.
- will think that taking vitamins and “natural” supplements do not matter, need monitoring, or contain potential danger. Therefore, they may not mention their supplements, diet teas, etc.
If patients have been engaging in any of the above or similar behaviors, improving their health may be directly and primarily related to fixing these practices.
Offering options that your patient can do, realistically, to improve their health may help to reach both your goals of improving their health and keeping them safe.
Before any Weight or Weight Loss Discussions Happen.
Ask about their current ways of eating in a curious manner. You may discover, for example, they skip breakfast and lunch and then binge in the evening. This gives you an opportunity to help them accurately; educate about overeating/bingeing caused by not eating enough throughout the day. Help them understand regular eating so they can work to correct any patterns of restriction that can cause bingeing and likely excess weight.
Ask patients about their dieting histories. This can let you know if they:
- might already struggle with restriction, yo-yo dieting, etc.
- are already aware of their weight, which most people are.
Many patients have fat bias themselves—against themselves. They probably don’t need to be told they are “overweight;” they know they have a larger body. These labels are often experienced as shaming and counterproductive to the intention of helping.
If needed, educate patients that current weight does not necessarily equal lack of willpower. In fact, if a history of chronic dieting is present, their strong willpower may have gotten them here and with fat (ironic, huh?).
- Spans of dieting, weight suppression, and yo-yo dieting can make a person’s weight higher eventually. Many patients won’t know that lowering their caloric intake can result in the patient having to live on fewer and fewer calories to NOT gain weight. In other words, eating like a normal human being is supposed to eat—regularly, at predictable intervals, and well-balanced—can pack on pounds after years of dieting and yo-yoing.
- Since patients often regard MDs as knowing what is best and right, get ready for your patient’s brain to potentially explode when they hear this from you!
You can empower your patients of any weight to improve their overall health, without stressing weight loss.
Discussing Health in General.
When and where possible, deemphasize weight as the guiding force of their health. (A thin person with a perfect BMI can be just as unhealthy as an unhealthy fat person.) Possible helpful, health-improving conversation-starters might include:
- “How do you feel about your own health? Is there anything you’d change to live a healthier lifestyle?”
- “If this was someone you love (daughter, son, cousin, friend), what would you want them to change to improve or manage their health?”
When it comes to helping patients in larger bodies improve their health, it may be the most helpful to spend some time defining health in a broad sense. What do you, as a medical professional, think constitutes true health and wellness? Here are some domains that I think of:
- energy level;
- quality of relationships;
- steadiness of moods;
- quality and regularity of sleep;
- management of daily stress;
- work/pleasure balance;
- eating for both nutrients and satisfaction (to prevent restriction-driven bingeing or overeating);
- enjoyable movement (which is more sustainable than required exercise they don’t enjoy doing);
- labs within healthy ranges?
Maybe ask your patients to rate their wellness in the categories you, as a medical professional, find most important. Offer your recommendations (not weight loss-related) for improving their health (increase nutrient intake, sleep more, learn relaxation techniques, strengthen the body via physical therapy or strength training, see a mental health therapist, etc.).
In Conclusion.
Many people (of any weight) experience or have experienced bias and discrimination related to their size or shape. Sadly, whether the bias and discrimination were imagined or real, the effects can be deleterious. A body of evidence shows that experiencing oppression can result in diagnoses that are also linked to overweight/obesity—for example, weight gain, metabolic dysregulation, issues with cortisol, diabetes, and more.
Let’s imagine that research eventually concludes that experiencing stigma, bias, discrimination, or oppression was more often the cause of the obesity-paired ailments than the adipose tissue. It’s possible!
I can think of quite a few examples that remind of the following: Current science presented as the truth may not be the ultimate truth. Information about health continues to evolve. So the best any of us mental health and medical health professionals can do is to proceed with compassion and respect for our patients.
Personal Reflection.
Though this may go against the grain of how our Western medical system is organized, I invite a personal question of you as a medical professional. Ask yourself if you believe that adipose tissue is really the primary cause of the different ailments it has been paired with. Not correlation, but cause. If you see space for other possible explanations or contributors, please help your patients in larger bodies to stop blaming their bodies and to instead empower themselves to take realistic steps towards improving their health and safety.
*Should you wish to explore treating from a more weight-neutral/weight-inclusive position, here are some references.
Association for Size Diversity and Health
NAAFA: the National Association to Advance Fat Acceptance, Guidelines for Healthcare Providers with Fat Patients – brochure
What to Say at the Doctor’s Office (Dances with Fat blog)
note TO READERS who have reactions to this blog’s vocabulary or concepts.
I recognize that I used some potentially activating words in this blog. This piece is for and to doctors. I am aware that the research does not support weight loss being beneficial for most and is more often harmful rather than helpful. AND MDs are still trained to recommend it in various cases as standard of care. So instead of making the term off limits, which is realistically likely not possible in Western medicine, my intention is to help MDs discuss weight and think about weight loss in different ways than before reading this. All of our goals are optimal health, and so I hope to support in that.
My ways may not seem appropriate to those who prefer I eliminate the word “loss” (paired with weight) entirely from this blog. I understand, and you are welcome to voice your opinion online or email me at Alli@TherapyHelps.Us. You matter, and my way may not be the “right” way. I’m doing my best.
