About five years ago, Sarah Barak severely tore a ligament in her thumb and needed surgery to reattach it.
But when he went for the operation, he received unsolicited advice: The surgeon told him he should lose weight, suggesting his size and his injured thumb were related.
“I was arguing that my posture was affecting my arm pain and that my posture was made worse by my size, all of which could be true,” Barak says. “But I still had a disconnected thumb, and even if I had lost 100 pounds, the thumb wouldn’t have reattached itself.”
Barak says she is steadfast in advocating for the care she needs, but it is exhausting.
“It’s terribly exhausting,” he says. “And, frankly, not everyone can do it.”
For years, weight has been used as a measure of health in doctors’ offices. Having a higher body mass index is correlated with heart disease, diabetes, certain types of cancer, and other conditions.
But in recent years, research has shown that when doctors focus on weight, it can lead patients to avoid or delay medical care, including recommended cancer screenings. People with larger bodies often report that when they go to the doctor, their problems are ignored or dismissed as an inevitable result of their weight. Without asking questions, they say, health care providers suggest diets they’ve already tried and lifestyle changes they’ve already made.
Providers sometimes miss important health problems, both in people with larger bodies and those with smaller bodies, when they focus too much on the patient’s weight, says Dr. Lisa Erlanger, who practices weight medicine. neutral and is a clinical professor at the University of Washington. Medicine in Seattle.
“There are so many horror stories… of diagnoses that were missed because the focus was on weight,” Erlanger says.
Seattle clinic tries weight-neutral approach
Evidence that focusing solely on weight can harm patients has led some health professionals to examine their approach.
In June, the American Medical Association began recommending that doctors look beyond body mass index to understand a patient’s health. The new policy says factors such as genetics, blood sugar levels and where fat is on the patient’s body should be considered.
But a growing number of providers are going further: They practice what they call inclusive or weight-neutral care. Some subscribe to a set of principles called “health at every size.”
“In most cases, the care given should be the same no matter what the number on the scale is,” says Tess Moore, a family medicine physician in Seattle who has made her practice weight-neutral. .
Moore began by trying to make her clinic comfortable for patients of all sizes. Each exam room has a variety of arm blood pressure cuffs of different sizes, as well as gowns and specula of various sizes. The chairs and examination tables adapt to all patients.
But it’s Moore’s approach to talking about weight that’s most different from a more traditional practice.
“We don’t recommend weight loss as a way to treat medical conditions,” Moore says.
Instead, he tells his patients that exercise and nutritious foods are good for them. Nonetheless whether they lose weight or not.
“We recommend moving your body in a way that’s sustainable, that’s hopefully joyful,” she says, and “eating food in a way that’s nourishing.”
Moore says emphasizing the inherent benefits of exercise can help people start and stick to a routine. She points to research showing that even well-intentioned comments about weight from family members and doctors can increase exercise avoidance and that people with more internalized anti-fat attitudes are more likely to avoid exercise when they experience weight stigma.
“If after that discussion, a patient is still pretty sure they want to focus on weight loss,” Moore says, “I tell them they’re likely to fail in the long term.”
For example, a meta-analysis of 29 studies on long-term weight loss found that, on average, for people with obesity, more than half of the weight lost was regained within two years and that more than 80% was regained within five years. .
“When someone loses weight, it triggers a series of hormonal changes that tend to increase appetite and slow metabolism,” says Ellen Schur, an obesity doctor and researcher at UW Medicine.
Moore says his goal is ultimately to focus on the patient’s long-term health and make “recommendations that are much more likely to be sustainable.”
“Making the decision not to recommend weight loss opens a door rather than closing it,” he says.
If done in a “respectful” way, weight loss tips still matter
Schur and other obesity medicine specialists say they recognize the need for a new approach when talking to patients about their weight, but say it’s still possible to encourage weight loss when appropriate.
“For some people who have a condition like diabetes, weight loss in combination with some lifestyle changes might be an option they would choose,” Schur says.
She agrees with weight-neutral providers like Moore that encouraging patients to exercise and eat nutritious foods has obvious benefits. Still, for some patients, weight loss may have additional benefits, she says.
For example, studies have shown that even a relatively small amount of weight loss (in the range of 3% to 7%) reduces the chance of developing type 2 diabetes in those at risk and improves blood sugar. among those who suffer from diabetes.
And Schur says that when weight loss can help, doctors should say so.
While there is a long history of weight bias in American society, including in healthcare, Schur says it is possible to have conversations about weight loss that are sensitive and respectful.
“When a doctor approaches it without judgment and without assuming that a person has not made changes, it can be discussed as a treatment option in a supportive way,” he says.
Schur says that increasingly, weight-loss medications like Wegovy are his primary tool for managing patients’ weight.
“To be completely honest, what we’ve been asking them to do, you know, just with the lifestyle hasn’t been realistic,” she says.
Critics of the newer weight-loss drugs point out their limitations: They are expensive and scarce, and their long-term effects are still unknown.
And weight-neutral providers say that even in a world with these new medications, people with larger bodies still need to feel heard and respected in the doctor’s office and have their biggest health concerns addressed.