The Repercussions of Weight Bullying

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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?

The answer is, STOP THE WEIGHT BULLYING.

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."

Summary

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.  

You Have The Right To Decline To Be Weighed

A while ago there was a discussion over at the blog "Fat Positive Femin[IS]m" about getting weighed at routine doctor appointments. This is one of my hot buttons, so I started commenting, then realized I should probably save it for a post here.

Here's the bottom line: You really can decline to be weighed. You do NOT have to submit to being weighed at every appointment.

I decline being weighed all the time. Sometimes I get hassled for it, but most of the time I don't anymore. I make it clear that this is NOT negotiable. I do keep track of my own weight, informally, at home, but I don't agree to weigh-ins at the doctor's office unless there is a clear, pressing need for it. 

Some people don't have a problem being weighed routinely at the doctor; some do.  Some people weigh themselves regularly at home if they don't at the doctor; some don't. I'm not telling you what you should or should not do; I'm just reminding people that they have a right to decline being weighed at the doctor's if they prefer to avoid it.  This is something that some people of size don't realize.

Your Right To Informed Refusal

As a patient, you have the RIGHT TO DECLINE ANY MEDICAL TEST OR PROCEDURE at any time. It's your body, and you have the final say.

We don't think of weighing as a medical test, but it is a form of one. And you always have the right to informed refusal of a test or medical procedure. So no, you do NOT need to be weighed every time you go to the doctor. It is a test or procedure that you can refuse.

If you do plan to refuse weigh-ins, use strong, clear language when declining; don't be unpleasant, just polite and firm. I usually say something along the way of, "I don't do weigh-ins, thanks" if I'm not anticipating trouble.

If you meet resistance, use stronger language than "I'd rather not" or "I'd prefer not to." That leaves arguing room and sooner or later you'll get arguments. Just state clearly and categorically "I decline to be weighed" or something similar.

If they press it or claim it's necessary, remind them that you have the right to decline any test or procedure at any time and you are declining this one. If they really push (I've had it happen), use legal language, like "I DO NOT CONSENT." Any medical person worth their salt knows that this carries legal heft and that carrying out a procedure on someone after a phrase like this could potentially be construed as assault.

If it gets unpleasant, ask to speak to the office manager, the care provider, or just leave. A letter of complaint afterwards, reminding them of your legal right to informed refusal of any test or procedure, can also help change their tune.

The Power of Complaint

Complaining can be powerful. As I've mentioned before, I once visited an urgent care facility whose large blood pressure cuff was "out for repair." I declined to have my BP taken with a too-small cuff (which can strongly elevate BP readings). Long story short, they manipulated/badgered me into agreeing, the numbers were very high, and I was furious that those inaccurate numbers were now in my medical record.

So I wrote a letter of complaint to the clinic, to my insurance company, and to the head of medicine. I reminded them that I had the right to refuse any medical test or procedure, I included research that showed how much BP can be altered with a too-small cuff, and I quoted the American Heart Association's policy on cuff size. I demanded that they get a working large cuff, that they train their staff on the importance of its use, and that they remind staff of the right of patients to decline testing. Boy, did THAT get results.

So I'm just saying, if this is an important issue to you, feel free to resist being badgered into it. Start by politely refusing to be weighed.  Try to keep things low-key whenever possible.....but if pushed it can be very effective to complain verbally, to ask to see a superior, or even to write a letter afterwards and remind them of your LEGAL RIGHT to informed refusal.

I've had a couple of tussles with med techs who insisted I had to get weighed routinely.  One tried the excuse that the insurance companies were really cracking down and everyone had to be weighed now at every visit.  I noted that they might be trying to encourage that, but it was still my right to decline it. She kept arguing, so I asked whether I was going to need to talk to the office manager.  At that point she backed down, and my nurse-practitioner noted wryly afterwards that no one could ever accuse me of not being able to stand up for myself.  No one in that office bugs me about it now. We do a little dance out of formality; they take me to the scale every time, I politely remind them that I decline to be weighed, and we go on our merry way without any more hassle.

Sometimes, you might find a provider will not keep you as a patient if you decline being weighed.  I haven't found that yet, but I'm sure it could happen.  In that instance, you have to decide if avoiding weigh-ins is worth it or not to stay with that particular provider. Generally speaking, my view is that if they don't recognize that routine weighings are a fairly meaningless measurement and that you always have the right to decline such things, they're not worth having as a care provider anyhow.  I would worry what other medical procedures or interventions they might try to bully me into, and I would not want to stay with a provider who tried such strong-arm tactics.

When Weighing is Appropriate

Most med techs have been matter-of-fact about it when I decline to be weighed, but occasionally one will fight me. I have no doubt that regular weighing is encouraged but the fact is that they cannot "require" it because legally you can always refuse tests or procedures.

That said, sometimes I'll pacify them by telling them that I'd be happy to weigh later in the appointment IF there is something in the appointment that requires an accurate weight. Examples of that might be:

• Certain types of prescription drugs (although most drugs do not use weight-based dosing, some do and an accurate weight would be important for these)
• Before a surgical procedure (anesthesiologists need an accurate weight for anesthesia dosing)
• Prenatal blood tests for birth defects (an accurate weight is very important for these tests)
• If the doctor has reason to be concerned about something like Congestive Heart Failure (weight gain from fluid retention can be a marker for worsening CHF)

These are all legitimate reasons for weighing at certain appointments, and a history of CHF would be a legit reason for weighing on a regular basis.  No doubt there are other reasons that could justify weighing too, but these are the ones that spring to mind most readily.

Sometimes they will tell you they need to track your weight so that if there is a big increase or decrease, they know to look for possible problems like diabetes (which often causes a sudden, unexplained weight loss), etc.  This is an accurate point. As Living ~400 lbs. notes, it certainly is true that a big change in weight can indicate problems, and there are certainly advantages to tracking your weight trends. I'm not opposed to that, and in fact I track my own weight for just that reason. 

However, it's your choice whether you prefer to do that for yourself or have your doctor do that for you.  Personally, I prefer to track my own weight trends and stop being a slave to the medical weigh-ins. I simply reassure my healthcare providers that I am perfectly capable of watching for any alarming patterns myself and that I will report in if there are any concerns.  They know me well enough to know that I care very much about my health and that I really will follow up on it if there is a problem.

Because there may be other situations in which weighing really is important medically, be open to listening to reasons. If it seems reasonable and in your best interests, do it. If you don't mind routine weighings and it's no big deal to you, it's probably easier to just go along with it; there's no law that says that if you are into fat-acceptance you have to decline being weighed.

But think through your feelings so you are making a conscious decision about routine weighing; if it doesn't seem reasonable, if it's just routine and you prefer to keep track on your own, or if you find being weighed triggering or judgmental, feel free to decline it.

Remember, you have the power to refuse or acquiesce.

Conclusion

Weighing every time you go to most doctors is not a requirement. If it bothers you to be weighed, if it's triggering to you, or if you just refuse to be constantly subjected to scale scrutiny, just say no.

Personally, I always agree to be weighed the first time I visit a new care provider, so they have a ballpark figure on record for med dosing or whatever. I think that's a reasonable request.  But after that, I decline to be weighed routinely. Some days it's a battle to have that decision honored, but I don't ever back down.

I do consider circumstances individually; if there is a justifiable reason to get an accurate weight, then I agree to it gracefully and without making it into a big deal.  But only if there's a real reason for it.

I do have a scale at home and I do weigh regularly in order to watch for any alarming trends. I find that just relying on the fit of your clothes is not enough to really monitor your weight trends and that a closer watch than that can be useful, so I do weigh.

However, I don't need to rely on a doctor's office for that; I'm perfectly capable of monitoring my own weight trends. It doesn't take a medical degree to weigh yourself and keep track of those numbers.

I am in a place emotionally where I don't fear seeing the number on the scale....it's more a matter of principle.  I was a slave to the scale for many many years and I lived and died emotionally about what the damn thing said and on the reactions of the people weighing me.  I refuse to go to that place anymore.  I know what I weigh and I don't have a problem with that number, but I don't need to submit that number to public review unless I choose to or there's a compelling medical reason to do so.

Most of the time, it's just routine to weigh people, not truly necessary. And it's ALWAYS your right to accept or decline.

What do you choose to do in your life?  Do you agree to routine weighings at the doctor's office, or do you refuse?  Do you keep track of your weight at home, or do you find simply monitoring the fit of your clothes is enough?  Why do you make these choices?

*Coming Soon:  The Debate Over Routine Weighing During Pregnancy