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‘Size-inclusive medicine’ opens doors for patients | Expert Opinion

People who are overweight face stigma even at the doctor's office. Here are some practical steps you can take to demand better care.

Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories. (Lydia Zuraw/Kaiser Health News/TNS)
Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories. (Lydia Zuraw/Kaiser Health News/TNS)Read moreLydia Zuraw / MCT

If you live in a plus-size body, going to see the doctor can be a uniquely stressful experience.

Over and over again, my patients tell me how stigmatized they feel when visiting the physician’s office. “If you’re overweight, doctors automatically start telling you to lose weight — even if I’m there to talk about a cold!” my patients say.

I’m a primary care physician, and I practice what I call “size-inclusive medicine.” That means I don’t pressure my patients into conversations about weight loss, and I don’t bring up their weight unless it’s something they ask to talk about. Through education and advocacy work, I’m trying to make health care more equitable for everyone, regardless of their body size.

(Like many activists, I also am working to reclaim the word “fat.” You’ll hear me use it in my writing as a neutral term, like being “tall” or having brown hair. It can still be a stigmatizing word, however, so I only use it with my patients if they use it themselves.)

We doctors have a lot of work to do. Health-care settings are some of the least welcoming places for people who have been classified in the overweight or obese categories under the body mass index, which is a measure of weight for height. Historically, BMI has been used to identify risk of disease, but doctors increasingly realize it’s not a good measure of an individual’s health. Still, people with higher BMIs often experience discrimination. And in research on obesity stigma, doctors and nurses are frequently described as some of the worst offenders.

One survey of professionals attending an obesity medicine conference — the very doctors who are supposed to be helping patients with obesity! — found very high-levels of pro-thin, anti-fat bias. And this kind of bias has very real health consequences. In one study, women whose weights would be flagged as obese in medical settings were found to routinely put off gynecologic care, including screening for cervical cancer. A major reason for these delays, researchers found, was feeling disrespected by doctors and nurses about their weight.

It’s clear we need to do better. I know it can be challenging and even scary to question your doctor. But as a physician who is fed up with anti-fat discrimination in health care, I wanted to offer some practical steps that you can take to demand better from your doctors.

  1. Do some research. When picking a primary care physician or other doctor, ask around. Do friends and family have recommendations for physicians who are size-inclusive? Some doctors will highlight their commitment to fat-friendly care on their online profiles. You can also search for “health at every size” or “size-inclusive medicine,” both of which are terms providers will use to describe this welcoming approach.

  2. Call ahead. Before your first appointment, call ahead to ask some basic questions about the doctor you’ll be seeing. Do they have experience making people of all body sizes feel welcome? You may not be able to get the doctor on the phone, but the staff members you speak with should be able to answer these questions.

  3. Skip the scale. Many size-inclusive physicians don’t require that their patients get weighed at every visit, since it can trigger disordered thinking about body image. You can tell the medical assistant doing your intake that you’d prefer to not be weighed. If the doctor does need your weight — there are some medical circumstances where having an accurate weight is important — the provider should be willing to talk with you about why. If an updated weight is necessary, you can turn around while being weighed so you don’t see the number, and you can ask the doctor to avoid discussing it.

  4. Lose the gown. Those flimsy paper gowns you’re sometimes asked to wear don’t fit anybody well, but can be particularly stigmatizing if they’re too small for your body. Many times, they aren’t necessary at all. You should feel empowered to continue wearing your normal clothes until the doctor comes in. If undressing for an exam is necessary, you can discuss together the best way to navigate it. Most offices have different sized sheets that can be used to preserve privacy.

  5. Speak up. If you don’t want to talk about weight or body size, tell your doctor. Most doctors will be respectful of your wishes. There can be a power differential between doctor and patient, and communicating your needs can sometimes feel daunting. But I’d like to think that most doctors will be receptive. If they aren’t, time to find someone new.

Obesity stigma is deeply entrenched in the culture of health care, and I appreciate how much courage it takes to speak up for a more thoughtful approach to care. I’m heartened by how grateful my patients are to discover a less weight-focused approach when we work together. We focus on metrics that are more meaningful than BMI, like blood pressure, glucose tolerance, and finding ways to fit in regular exercise. No matter your body size, you deserve a doctor who doesn’t make you feel shamed, and instead empowers you to discover more expansive definitions of health and well-being.

Mara Gordon is an assistant professor of family medicine at Cooper Medical School of Rowan University.