Thursday, February 7, 2013

The Repercussions of Weight Bullying

all images from
I'm concerned about the increasing trend towards Weight Bullying among some healthcare providers.

As the pressure on providers to "do something" about the Obeeeesity Epidemic increases, so does the pressure for them to participate in weight bullying at appointments.

What is "weight bullying"?  Weight bullying is the unrelenting, negative focus on a patient's weight during medical appointments to the detriment of all other issues.

It is the constant harassment to lose weight ─ not just work on healthy habits, but actually put the primary focus on losing weight ─ by whatever means necessary, even radical ones.

It is blaming the patient's weight for everything that is wrong with that patient, even when such a connection is dubious.

It is overlooking other possible causes because the care provider cannot see anything besides the patient's weight ("fat distraction," also known as "size profiling").

It is limiting access to tests and treatments, based only on a patient's weight (or willingness to pursue losing weight).  It is denying treatment until a patient acquiesces and loses weight.

Sometimes this pressure for weight bullying comes from the insurance companies that providers have to answer to, sometimes from colleagues within the profession, sometimes from research articles that contend that care providers aren't doing enough to combat the  "obesity problem," etc.

Many articles in the popular media and in the medical research claim that doctors are rarely engaging in "obesity screening" or "weight loss counseling."  Funny how that doesn't seem to jibe with the experiences of most "obese" people, who report that the harassment over their weight and pressure for weight loss is unrelenting at most appointments.

Whatever the source of the pressure, care providers need to start recognizing that weight bullying is causing more harm than good for many obese people.

The Dreaded "Weight Talk"

There was a great article about this called "Dear Doctors, Quit It With The Weight Bullying" and it's by "Jess." It can be found here.

The topic of the  post, as you might guess, is weight bullying.  Specifically, "the weight talk" and pressure to lose weight, often without regard to why you're really at the doctor in the first place, and usually without even asking about your habits first (because you're only going to lie about them, right?).

Jess pointed out that when a routine health check-up becomes an exercise in shame, it tends to have a chilling effect on future doctor visits.  

And that is one of the most ominous effects of weight bullying at the doctor's, because putting off regular appointments can result in serious conditions going overlooked or undertreated, and thereby irreparably harming a person's health.

Here is what Jess experienced.  She was at her doctor's for a regular pap smear. Here's part of what happened:
...he asked what I ate, but he didn't wait for an answer. I had to exercise more, he said, having no idea how much I was exercising. I also needed to eat less than whatever it was I was eating which I hadn't gotten a chance to tell him. 
Dear god, what cutting-edge medical research! I certainly never thought of “eat less and exercise more,” especially not when I was bulimic, which incidentally is in that file of papers you’re holding which we like to call “records.” 
“I’m not concerned about it,” I said tightly, “and if it comes up again I’m going to have to find another doctor.”

“Any other doctor would tell you the same,” he said, as though I hadn't been coming to him, just as fat as now, for several years. 
“Well, I prefer a doctor who at least waits to hear what I eat before telling me to eat less." 
He looked exasperated. “There’s no possible way you’re not eating too much.”
Even though she fought back and fired this doctor, she found herself putting off her next yearly exam because she dreaded finding a new doctor who might put her through all that again.

When fat people get bullied, not believed, or made to feel like crap at the doctor's office, they tend not to not return. 

What a surprise. Imagine not being keen to keep going back for repeated harassment and derision.

Worse yet, they often lose trust in being able to get reasonable health care from other providers, and so tend to put off a return to ANY provider, not just the fat-phobic one.

Then doctors whine about how obese people avoid the doctor, and gees, how can we get fat people to be compliant with the recommended doctor visits?  How can we get them to improve their health?  How can we get them to regularly undergo tests and see specialists as needed?


Weight Bullying Repercussions

Care providers greatly underestimate the negative impact of weight bullying.  It rebounds in so many harmful ways.

Weight bullying results in people trying over and over again to lose weight, even though research clearly shows that permanent success is very unlikely.  It results in weight cycling, which can increase the chances for gallstones, kidney cancer, further weight gain, and potentially many other issues.

Weight bullying results in fat people resorting to ever-escalating steps to try and lose weight.  When the usual recommendation of "eat less and exercise more" doesn't do enough, most dieters try to eat even less or exercise even more.  If that doesn't work, they go even further, sometimes to dangerous levels.

When that doesn't work, they try fasting, meal-replacement drinks, herbal supplements, or weight-loss drugs that have significant risks and which may do permanent harm to their systems.

When the weight loss doesn't last, many resort to surgery, maiming perfectly healthy organ systems in a desperate attempt to achieve thinness and "health," only to find other, unexpected complications instead. And still, even with stomach amputations and gut bypasses, most don't lose enough weight to achieve a "normal" BMI.  Does that really sound like a purely behavioral problem?  Or could something more be going on to cause their obesity?

With such poor results, so many negative side effects, and the extreme unlikelihood of achieving a "normal" BMI, does this sound like a goal worth pursuing?

Weight bullying also results in people (especially women) developing low self-esteem and poor body image.  Some develop eating disorders because of the shame and disapproval they have internalized.

Even when a full-on eating disorder does not occur, many people have developed harmful habits like overeating or binge-eating, and have internalized toxic attitudes about food and body image.

And, as we have seen, weight bullying discourages fat people from making regular doctor visits and makes them less likely to get tests that might help prevent/diagnose various diseases early.  In the end, this has far greater negative impact on fat people's health than choosing not to go on the latest diet.

In particular, fat people LOATHE:
  • being lectured about weight/pressured to diet when they are at the doctor's about something completely unrelated to weight
  • having every condition they experience blamed on their weight, even when it is clearly unrelated
  • being told they are liars (either to others or to themselves) when they try to share that they eat normally or are already exercising
  • being told that they just haven't tried "hard enough" or with the "right" program yet
  • having to have The Weight Discussion over and over again, every time they visit the doctor, despite previously explaining patiently why they have reservations about weight loss/dieting and why they are exercising their right to patient autonomy by declining this treatment
  • having weight loss promoted as the only treatment choice for whatever ails them, even when their condition has nothing to do with weight or there are alternative treatments to consider
  • having the risks associated with obesity exaggerated in order to scare them into losing weight ("You won't live to see 40!" "You'll never see your child grow up!"
  • not being given access to tests that people of "normal weight" would automatically receive with the same symptoms because the care provider has concluded that weight is the main issue
  • not being allowed access to needed treatment without having to lose weight first
But, but, but.....!

I know, I know.  Many doctors view it as part of their job to promote healthy behaviors, and that bringing up uncomfortable topics is part of good care. I understand that and I truly respect the difficult line that care providers walk when trying to treat all groups with respect and yet also promote better health.

However, there is a difference between promoting good nutrition/exercise and browbeating someone about their weight.

Providers need a better sense of when they cross the line between encouraging health and harassing someone about weight.  It's not that weight cannot ever be brought up, but rather that it should be a respectful and dynamic dialogue, not a one-sided lecture full of assumptions about what the fat person "must" or "must not" be doing, or pressure to lose weight no matter what extreme tactics must be used to do so.

Too many times, fat people try to share their concerns about the health downsides of yo-yo dieting, extreme restrictions, or the eating-disordered behaviors that dieting and weigh-ins can trigger, only to have their concerns completely dismissed or cut off.

Providers need to realize that many people who have opted out of the weight-loss paradigm have done so for very legitimate reasons, not out of laziness, gluttony, or lack of knowledge about the risks of obesity, but because it makes better sense for their body and their life and they feel healthier overall doing so.

Providers also need to understand that patient autonomy means respecting people's right to decline a recommended treatment (weight loss) and still receive respectful, considerate care.

Providers need to understand that repeatedly challenging a person's decision not to pursue weight loss and harassing them about their weight can result in the person avoiding  healthcare altogether until an emergency presents, and this certainly does not improve that person's health.

Furthermore, providers need to realize that promoting healthy habits doesn't have to involve weight loss or a weight discussion at all. 

Providers need to understand that promoting healthy habits can result in health improvements without significant weight loss, and that promoting weight loss as a goal at any cost often backfires and can result in extremely unhealthy behaviors.

By all means, promote more exercise and movement for patients...but don't tie it to weight loss as a goal. We know that exercise is beneficial, even when it doesn't lead to weight loss.  But if exercise is seen only as a means to weight loss, it is rarely sustained.

Exercise should be promoted as a goal in and of itself, not just as a weight loss tool.  

And don't forget to promote healthy habits for all your patients, not just the fat ones.  Don't make it about weight control, make it about lowering the risk for health complications.  Fitness is the best predictor of health, whatever a person's BMI, and may be the most efficient way to improve health for those who have difficulty losing weight.

Don't assume that a fat person never exercises, or that thin ones are exercising plenty.  The truth is that you can't tell how much a person exercises just by looking at them.

ASK THEM their habits and then advise them based on what you are told.  Find out what barriers there are to improvement of habits, and then help them strategize how to overcome those barriers.

Providers can and should encourage healthy behaviors ─ but it is more effective to do so without tying it to weight, without assumptions about what a person's habits "must" be (based only on their BMI), and without indulging in shaming and blaming.

As Deb Burgard says, "Listen to your public health messages with the ears of your fat loved one or colleague...Tease out the hate [speech] from the health speech."

Or as Ragen Chastain says, "People don't hate themselves healthy....We need to take weight out of the equation and make public health about public health and not public thinness."


I believe that most providers mean well, but they need to understand just how much weight loss pressure/weight bullying backfires in terms of a person's overall health.

Health care avoidance is a REAL issue for many people of size, and many have darn good reasons for doing so, based on past experiences.

One of the most important things that care providers can do for people of size is to build trust about the care they will receive ─ independent of weight ─ so that fat patients will not avoid the doctor and will utilize all the tools available to improve/monitor their health long-term.  

Providers, please divorce weight loss from the promotion of health.  By all means, encourage healthy habits, but don't keep tying it to weight loss.

Bringing up weight constantly, shaming patients about it, or harassing them to lose weight doesn't work. Instead, it alienates the very people it is trying to help, often discouraging them from seeking care at all.  And that certainly does not improve their health.  


Anonymous said...

Oh my goodness...just experienced this last night. Went to my Gyn for my annual exam. I'm 5'6" and weigh about 179 pounds. I finally gave up dieting (and disordered eating) after twenty years and so I've put on about twenty pounds as I try to relearn how to eat. Anyway, the doctor never ONCE mentioned anything having to do with the reason for my visit. He spent the entire time talking about how I was obese and how I just needed to eat less and exercise more. Then, while lying on the table getting a breast exam, he notices I have a skin condition called vitiligo (basically, my body destroys its own pigment in large spots, leaving me with large pale spots). He goes on to say "well, well, well, you're just a factory second aren't you?" I sat there stunned. He basically said I was defective. I'm so mad at myself for not jumping off that table and giving him a piece of my mind! But I was shocked. Left in tears. Today, I'm just mad. I'm calling the office at nine and giving him a piece of my mind, even if it's just through voicemail.

Nancy Lebovitz said...

I've read a few accounts from very thin people who've been told to just gain weight.

Diagnosis by BMI is the modern version of phrenology.

Giulia said...

Nancy, so true !

Not only that, but also when a psychiatrist tries to diagnose someone with an ED only based on BMI.

I went to a psychiatrist because I suffer from ADHD. I am 1.52m for 42-43 kilos (so, a mere thin person, and I let someone convert because I am not good at such an exercise).
No matter the appointments to a RD, psychologists, blood samples... the psychiatrist diagnosed an ED.
RD said that my behavior with food is far from being disordered. Psychologist said that hyperacousia and hypersensitivity to tastes is not an ED.
But that psychiatrist maintained her "diagnosis" no matter what. At the same time, she gave me Ritalin because my mom pushed her to stop with the ED game.

FYI, I am a constitutional thin, therefore I am thin because I've always been thin, even as a child.
Even my GP was stunned that my ex-psychiatrist diagnosed me with an ED.
Needless to say, I fired her and it was a mess to find someone who accepts ADHD as a valid diagnosis, without telling that my parents must have terminated their parental rights if they wanted me to heal from ADHD.

So, not only I had to take the ED-crap from my ex-psychiatrist (one of the rare psychiatrists in my country treating adults with ADHD), but I also have to take the crap from docs telling me that my parents created my ADHD because they have chosen to have a child with a criminal record.
Oddly enough, I have no criminal record.
They really need to learn not only bedside manners, but also asking instead of assuming !!

I have the thin privilege, but it does not make me immune of bias from the medical practitioners.

Kmom, can you make a printable version that I can give to my neighbor, a GP full of prejudice ? I am in the mood to give him some education about bias, assumption and medical practice.
I am proud to have been able to ask him eyes in the eyes : "Did I choose my ADHD ?" and he did not know what to say. I hope it'll make him think twice instead of once.

Anonymous said...

Anonymous, I'm so sorry. I also have a skin condition and know what it's like to feel self conscious, but to have a doctor say that to you, I'm left without words. He should have his license revoked or at least be mocked until he cries or something. That just makes me sick.

Emerald said...

There was a study the other week that claimed that the reason UK rates of death from cancer are higher than the rest of Europe may be our 'stiff upper lip' - i.e. the tendency, particular in older British people, to just suffer symptoms and 'not want to bother' a doctor about them. I wonder, though, how much of some people's reluctance to visit a healthcare provider is actually down to the increase in fat hate in this area. I've been lucky with my own doctors (my current GP surgery, which I've been with for thirteen years now, has never even weighed me - I'm an in-betweenie, so maybe they think I don't look 'obese', which is telling in itself) - but I've heard some horror stories, especially from women. My guess is that if they accounted for a) medical mistreatment, and b) the proven physical effects of societal stigma, the supposed negative health effects of being fat in itself would mysteriously evaporate.

Moose said...

I'm not a parent nor will I ever be one, but THIS is why I follow this site.

I run the fa-diab mailing list (for talking about treating diabetes without the 'weight loss is required' nonsense), and I've been reading medical research for years because of all the bullshit out there.

I've personally experienced this -- it's hard to not meet a fat person who hasn't. And I've heard tales worse than what I've experienced. The one that sticks in my mind the most is the person who had a doctor try to put them on a very low calorie diet and said "I won't treat your diabetes until you've lost 50 lbs."

I also read a bunch of medical-related "blogs". If I could just go through a week without stumbling upon some medical professional ranting about how "gross" fat people are, I could die happy. I especially love the posts that claim that "every" fat diabetic is out of control, because "every" out of control diabetic they see at their ED is fat. Gee, I'm sure it has nothing to do with socio-economic situations nor the prejudice of doctors. It couldn't be that fat diabetics struggle to get proper treatment free of "If you don't lose weight you're going to die" nonsense.

(There's a term for predicting death like that, it's called "voodoo medicine." I was told I would die before 30. Then I was told "nobody as fat as you could live until 40". I'm pushing 50.)

Many doctors quote things that are pseudoscience, which typically start with "Everyone Knows" or "In My Practice I See". Try, just try, going to the NSF and getting a research grant using either of those for a scientific basis. Real science is not generated just by the things you think you see. This is why we no longer believe the Sun goes around the Earth and that bleeding cures diseases. And let's not forget the granddaddy, correlations and other logic failures. You can tell me that because every out-of-control diabetic you see is fat, all fat diabetics must be out of control. Someone once mapped stock market changes per day based on what Vanna White wore on Wheel of Fortune the night before. [I am not making that up.]

There is research that shows that doctors have a bias against fat people, written about here:

Hanne Blank wrote a letter to her doctor which others have copied and used since (with her permission), found here:

The comments on Jess's post are filled with the typical idiots. "You eat less and exercise more -- THAT IS HOW YOU LOSE WEIGHT!"

Sure it is. THAT IS WHY PEOPLE FAIL. Because they believe this nonsense. Because while the simple mechanics of calorie intake / calorie burned works when you're 20 yrs old and have a fast metabolism, the truth is that by the time you're over 30 there are a thousand and one more things in play. Hormones, foods, genetics, disease, metabolism, these and lots more determine what happens to every drop of food or drink that you put in your mouth. Add to that the fact that your body adapts -- if you're living on 800 calories for a year, your body learns to believe that 1200 calories is a ton of food and you'll rapidly gain weight. If you're not already dead from malnutrition, that is.

Yes, I know. I'm preaching to the choir. The mass mind belief that being fat is BAD, is DEADLY, causes DISEASE (it doesn't cause diabetes OR heart disease, people!), and that people rightfully should be bullied to lose weight makes me so sad and angry.

DeskDiva said...

Anonymous #1, I am SO SORRY for that horrid comment your so-called medical professional made. What a vile thing to say. I don't know where you live, but if I were you, I'd find whatever regulating or licensing board exists and make a formal complaint. That is unacceptable across the board. *hugs* You deserve so much better than that.

I am so thankful for this article. I would love to turn it into a brochure that can be presented to doctors who do this. I'd be happy to work on that. Might take a little time, but it would be SO worth the effort. Then I can carry a handy little brochure in my wallet when headed to doctor visits. Let me know, please. :)

Excellent post.

Anonymous said...

I'm Anonymous #1 in these comments and I just want to say thanks for the support I found here. I'm new to the whole fa thing and I'm touched by everyone's kindness. And I just wanted to update that my angry (but controlled!) call to the doctor's office turned out pretty well. I thought I would just leave my voicemail, have my say and no one would call me back. But the manager of the office called, heard more details of my visit, apologized profusely, and said the offending doctor was going to be sent my voicemail and a meeting would be held. She also said no patient should ever be spoken to like that and she was sure that the doctor would no longer be talking to patients like that after their meeting. So a happy ending at least, and I just wanted to pass it along because from what I read, these happy endings don't seem to happen as frequently as they need to. Thanks again!

Anonymous said...

So I went to the doctor the other day for my annual "yes, you can have another year's worth of BCP" checkup. My blood pressure is in the "slightly elevated" range for the second year in a row. Since I am past 40 and I haven't had the chance to exercise the way I used to, I am going to accept that this is an ongoing thing and not whitecoat syndrome--especially since my reading is higher this year than last year.

So. Can anybody who reads here point me to tips for managing my blood pressure that don't start with dire warnings that my fat butt is somehow going to strangle my heart?

I am giving up caffeine for Lent. Hopefully it will stick this time. I have laid the groundwork by figuring out how I ended up depending on my morning cup of caffeinated stuff in the first place and taking steps to fix the issues.

I have found ways to fit more aerobic exercise into my day, not in order to lose weight, but in an attempt to get my resting heart rate to go lower. I'm not back up to my old standard of 30 minutes on the bike 3 times per week, but I'm shooting for it.

Anybody have more ideas?

Well-Rounded Mama said...

More regular exercise, watching the salt, cutting out caffeine....those are the traditional ways to address BP concerns. They have success for some people and not for others. Worth a try for sure. And exercise will be good for you regardless.

Acupuncture is pretty good at lowering BP in the short term. If you really have chronic hypertension developing, however, it may not be as effective long-term. However, it might help for now, along with the exercise.

You might want to buy a home BP monitor and keep a log of your BPs over time. Amplestuff has one made for larger folks, or you can sometimes find a cheaper one via medical supply companies. Just be sure it has a LARGE cuff, not just a regular cuff. Then you can monitor yourself and know if there's a problem on a daily basis.

Many people develop hypertension after 40, fat or skinny. If you find you are one of them, don't hesitate to take medicine for it. The most important thing is to treat it. Give lifestyle and acupuncture a shot, but if that doesn't adequately address the issue, then that's what medications are for. It can be hard on your pride to accept this, but it really is important for your long-term health.

K said...

Yes! I have a teenage niece who gained a lot of weight in a short period of time for no apparent reason and also suffers from depression severe enough that she's been hospitalized twice. Both times when she was hospitalized they limited her diet and made her exercise (walking on the treadmill) assuming that the weight was a cause rather than a symptom. I'm the one who finally told their mother (my sister) that I thought both of her girls might have PCOS (they have other symptoms like irregular periods and dark facial hair). Thankfully she actually listened to me and talked to a gynecologist who agrees so they're able to get the help they need.

Anonymous said...

Magnesium may help lower BP.