I think you're absolutely right that people have come to expect medical weight stigma and may even try to get ahead of it by disparaging their body before the doctor can make a comment.
I imagine the GLP-1s have made this dynamic even more complicated, and people may want to have the drug offered to them (so they can say "my doctor recommend this"—at least in part because there is stigma around using these medications).
But I think you also touch on the larger point that we've been trained in our culture to blame ourselves and our bodies when things in our lives aren't going well. It can be a coping mechanism, especially when we feel powerless to change the systemic issues contributing to our suffering, but focusing on trying to shrink ourselves also serves to keep us from resisting and doing things that might actually help effect change (or least keeps us from experiencing as much joy and connection, which are forms of resistance, too). It's no coincidence that ultra-thinness is "in" again for women at the same time as so many rights are being stripped away.
I just moved and am establishing care relationships in my new city. And every time I'm readying myself for a weight conversation. So far, I've been pleasantly surprised: PCP, gastro NP both let me decline the weigh in (though once the gastro and I agreed it was a good age to schedule my first colonoscopy, I did get weighed for anesthesia purposes, which is totally fine). Ortho surgeon's office did insist on a weigh in ("since it was my first visit") not considering it was just a post-shoulder surgery follow up (surgery performed in my former hometown) I couldn't really see why they would care. Didn't come up in the visit at all (I mean why should it, we were looking at X-rays and testing strength and ROM, which has zero to do with my body weight, but providers have done stranger things before).
Maybe it's getting better, maybe I'm establishing some boundary by declining the weigh in? 🤷♀️ But I still hate that because I'm fat, I always have to be prepared for the conversation to go sideways.
It must be so hard to navigate respect for bodily autonomy when patients want to try to lose some weight alongside the science on diets and their associated health risks. Nevermind trying to loosen the tangles of their many assumptions about bodies, goodness, and worth as you do. Many many kudos to you for always being so thoughtful in this space.
Somewhat related, I've had some challenges eating since early February because of a dental issue. I'm still eating, but just less, and it reminds me of my (thankfully limited) past efforts at dieting and how freaking hungry I felt all the time. Stripped of any "willpower" element, it just makes so crystal clear what we do to our bodies when we restrict eating --it's the last thing I'd want anyone to do (anyway, but especially) when going through other trauma! Thank you for connecting those dots here.
Mara, another wonderful piece! Two things really stood out for me:
1. The concern about the slipperiness of problem vs preventative visits is an extremely real one - would you advise patients to try to book two same-day sequential slots, one for the problem visit and one for the healthcare maintenance? I want patients to be able to get care for both without having to take more time/resources to see their doctor again. Every practice likely addresses this differently but curious about your thoughts.
2. I think the doctor/patient relationship is so fractured, generally, that even beyond fatphobia I think patients show up expecting to be shamed.
I sure do! I show up at the dentist, eye doctor, and my PMD (all of whom I like!) expecting to be shamed (rarely disappointed, there's always something). Even when there's nothing to be shamed about, like with my gyn who is both a colleague and a friend - I still brace myself for shame and the hangdog feeling of being a patient, wearing a paper crop top, confessing some sin of being human.
I can see it my patients' eyes every day - I ask them how they plan to feed their baby and I can see them brace themselves in anticipation of my reaction about formula or breast milk long before I've said anything.
So much of going to the doctor and the vulnerability happens before the provider even walks into the room. We bring all of our hangups and fears with us. It's so hard to be a patient.
#1: It depends. I can easily squeeze in a prescription for an allergy med in a “preventive visit.” I’m not a monster.
And I realize people often take off work to come see me. And of course, ugh, because people almost always have more than 20 minutes worth of stuff to discuss, I’m always running late, which means a visit to our clinic takes all afternoon, further compounding the problem and making me feel guilty for asking people to come back.
But sometimes it truly is too much for a 20-minute slot to have an in-depth discussion about mood or irregular vaginal bleeding or anticoagulation risks/benefits…
Sometimes I’ll try to give my patients “homework” (like, read about this medication I might recommend) so that they feel prepared for the next visit. Or order labs that might help inform the discussion. At least to get the ball rolling.
#2: Shame is everywhere, and shame is the worst. It is incredibly counterproductive to being healthy and engaging in medical care. Thanks for sharing your thoughts about this. <3
This is beautifully written...it's really not about weight but perhaps self-reckoning and the true intimacy of the relationship between patients and physicians. As often as we hear about negative perceptions, the exam room is where people feel safe to confide their innermost anxieties and take stock of their lives. I can't help to think how right you are that losing weight is no fix and how much need there is for us collectively to relieve stressors like low living wages, food costs, long work hours, inaccessible housing. Beautifully written.
Yes. It doesn't even seem like a conscious connection people are making - just kind of a stream of consciousness connection... "Oh if I lose weight then everything will be easier..."
This is a powerful post coming from a medical practitioner. I think the answer to your question is: both. Especially for those of us in larger bodies: We expect to be chastised about our weight. It’s on you all to change that and I’m very happy that at least you are taking steps.
Thank you so much for this article. I’m really struggling with a new endocrinologist who is definitely blaming me and my weight for everything I have going on (when my A1C went up she asked me how much weight I had gained). I agree so much with your observation that we expect doctor visits to be judgment about weight. Because it happens so often. For me at least this is the main reason o don’t feel like doctors offices are a safe place to share everything. I hope that more doctors will listen to peers like you and make healthcare better for their patients.
This was lovely to read from a PCP. I was especially touched by the story of your patient who was too anxious to eat the bread that reminds him of his daughter. That being said, I'm a little stuck on a small point. I'm curious as to why you mentioned your patient's BMI. Would you have given different advice (instead of "you should eat the bread" - which I love!) if it were a different value?
Totally fair! I actually wrote and deleted an explanation for why I was providing that context - I think it was to illustrate that this kind of thinking affects people of all body sizes, including this thin person. But yes, anyone can eat bread, anytime, no caveats needed. ❤️
I also think BMI is hard to rid ourselves of because it is incorporated everywhere, especially in medical records and can serve as a useful (not good, but useful, those are not the same) shorthand that many providers understand (and which guidelines reference). Other measures of metabolic health or body composition tell a much clearer story of patient health, but until a better alternative metric is well disseminated in the literature and in daily practice, it's hard to get rid of it.
So much of it is laziness - BMI is easy to calculate, while interpreting a complex clinical portrait of insulin resistance, BP, adipose tissue in the liver, etc is so much harder to automate.
Heartbreaking. Diet culture has succeeded in infecting every aspect of life. Its devastating effects—physically, emotionally, spiritually, and socially constitute a syndrome worthy of inclusion in the DSM-5 (whatever version we are up to).
I am sorry, I got stuck on your parenthetical (As a brief aside, insurance companies...) This blew my mind. I had no idea this was the case. AND it explains why I spent two weeks trying to straighten out a doctor bill. Per the insurance company, the annual checkup was billed as a problem. They wanted me to call the doctor to have them change it. Which I did. But they didn't. I won't pay that bill and I don't care. Sorry it's off topic but thank you for inadvertently explaining why this happened.
This is an odd thought, but I wonder if people feel safe in a weight loss conversation? That conversation is "normal" and doesn't involve any of the acute stressors of their current "abnormal" challenges.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.
I think you're absolutely right that people have come to expect medical weight stigma and may even try to get ahead of it by disparaging their body before the doctor can make a comment.
I imagine the GLP-1s have made this dynamic even more complicated, and people may want to have the drug offered to them (so they can say "my doctor recommend this"—at least in part because there is stigma around using these medications).
But I think you also touch on the larger point that we've been trained in our culture to blame ourselves and our bodies when things in our lives aren't going well. It can be a coping mechanism, especially when we feel powerless to change the systemic issues contributing to our suffering, but focusing on trying to shrink ourselves also serves to keep us from resisting and doing things that might actually help effect change (or least keeps us from experiencing as much joy and connection, which are forms of resistance, too). It's no coincidence that ultra-thinness is "in" again for women at the same time as so many rights are being stripped away.
Absolutely. Beautifully said, Oona. These are deep and complex issues.
I just moved and am establishing care relationships in my new city. And every time I'm readying myself for a weight conversation. So far, I've been pleasantly surprised: PCP, gastro NP both let me decline the weigh in (though once the gastro and I agreed it was a good age to schedule my first colonoscopy, I did get weighed for anesthesia purposes, which is totally fine). Ortho surgeon's office did insist on a weigh in ("since it was my first visit") not considering it was just a post-shoulder surgery follow up (surgery performed in my former hometown) I couldn't really see why they would care. Didn't come up in the visit at all (I mean why should it, we were looking at X-rays and testing strength and ROM, which has zero to do with my body weight, but providers have done stranger things before).
Maybe it's getting better, maybe I'm establishing some boundary by declining the weigh in? 🤷♀️ But I still hate that because I'm fat, I always have to be prepared for the conversation to go sideways.
YES. It sounds like you're doing awesome.
It must be so hard to navigate respect for bodily autonomy when patients want to try to lose some weight alongside the science on diets and their associated health risks. Nevermind trying to loosen the tangles of their many assumptions about bodies, goodness, and worth as you do. Many many kudos to you for always being so thoughtful in this space.
Somewhat related, I've had some challenges eating since early February because of a dental issue. I'm still eating, but just less, and it reminds me of my (thankfully limited) past efforts at dieting and how freaking hungry I felt all the time. Stripped of any "willpower" element, it just makes so crystal clear what we do to our bodies when we restrict eating --it's the last thing I'd want anyone to do (anyway, but especially) when going through other trauma! Thank you for connecting those dots here.
Thanks for sharing this, Meghan. So sorry about the dental stuff -- the worst!! :(
Mara, another wonderful piece! Two things really stood out for me:
1. The concern about the slipperiness of problem vs preventative visits is an extremely real one - would you advise patients to try to book two same-day sequential slots, one for the problem visit and one for the healthcare maintenance? I want patients to be able to get care for both without having to take more time/resources to see their doctor again. Every practice likely addresses this differently but curious about your thoughts.
2. I think the doctor/patient relationship is so fractured, generally, that even beyond fatphobia I think patients show up expecting to be shamed.
I sure do! I show up at the dentist, eye doctor, and my PMD (all of whom I like!) expecting to be shamed (rarely disappointed, there's always something). Even when there's nothing to be shamed about, like with my gyn who is both a colleague and a friend - I still brace myself for shame and the hangdog feeling of being a patient, wearing a paper crop top, confessing some sin of being human.
I can see it my patients' eyes every day - I ask them how they plan to feed their baby and I can see them brace themselves in anticipation of my reaction about formula or breast milk long before I've said anything.
So much of going to the doctor and the vulnerability happens before the provider even walks into the room. We bring all of our hangups and fears with us. It's so hard to be a patient.
Vicky: Thanks for these thoughtful comments.
#1: It depends. I can easily squeeze in a prescription for an allergy med in a “preventive visit.” I’m not a monster.
And I realize people often take off work to come see me. And of course, ugh, because people almost always have more than 20 minutes worth of stuff to discuss, I’m always running late, which means a visit to our clinic takes all afternoon, further compounding the problem and making me feel guilty for asking people to come back.
But sometimes it truly is too much for a 20-minute slot to have an in-depth discussion about mood or irregular vaginal bleeding or anticoagulation risks/benefits…
Sometimes I’ll try to give my patients “homework” (like, read about this medication I might recommend) so that they feel prepared for the next visit. Or order labs that might help inform the discussion. At least to get the ball rolling.
#2: Shame is everywhere, and shame is the worst. It is incredibly counterproductive to being healthy and engaging in medical care. Thanks for sharing your thoughts about this. <3
This is beautifully written...it's really not about weight but perhaps self-reckoning and the true intimacy of the relationship between patients and physicians. As often as we hear about negative perceptions, the exam room is where people feel safe to confide their innermost anxieties and take stock of their lives. I can't help to think how right you are that losing weight is no fix and how much need there is for us collectively to relieve stressors like low living wages, food costs, long work hours, inaccessible housing. Beautifully written.
Yes. It doesn't even seem like a conscious connection people are making - just kind of a stream of consciousness connection... "Oh if I lose weight then everything will be easier..."
Kate Harding used to call this “The fantasy of being thin.” It’s insidious, and even folks who’ve been HAES believers for years can be subject to it.
Truth
I'm a little confused why a size-inclusive doctor would cite BMI.
Fair critique!
This is a powerful post coming from a medical practitioner. I think the answer to your question is: both. Especially for those of us in larger bodies: We expect to be chastised about our weight. It’s on you all to change that and I’m very happy that at least you are taking steps.
Thank you, Rebecca.
Thank you so much for this article. I’m really struggling with a new endocrinologist who is definitely blaming me and my weight for everything I have going on (when my A1C went up she asked me how much weight I had gained). I agree so much with your observation that we expect doctor visits to be judgment about weight. Because it happens so often. For me at least this is the main reason o don’t feel like doctors offices are a safe place to share everything. I hope that more doctors will listen to peers like you and make healthcare better for their patients.
So sorry to hear this. Thanks for sharing.
This was lovely to read from a PCP. I was especially touched by the story of your patient who was too anxious to eat the bread that reminds him of his daughter. That being said, I'm a little stuck on a small point. I'm curious as to why you mentioned your patient's BMI. Would you have given different advice (instead of "you should eat the bread" - which I love!) if it were a different value?
Totally fair! I actually wrote and deleted an explanation for why I was providing that context - I think it was to illustrate that this kind of thinking affects people of all body sizes, including this thin person. But yes, anyone can eat bread, anytime, no caveats needed. ❤️
That makes sense, thanks for the explanation! :)
I also think BMI is hard to rid ourselves of because it is incorporated everywhere, especially in medical records and can serve as a useful (not good, but useful, those are not the same) shorthand that many providers understand (and which guidelines reference). Other measures of metabolic health or body composition tell a much clearer story of patient health, but until a better alternative metric is well disseminated in the literature and in daily practice, it's hard to get rid of it.
Absolutely.
So much of it is laziness - BMI is easy to calculate, while interpreting a complex clinical portrait of insulin resistance, BP, adipose tissue in the liver, etc is so much harder to automate.
Heartbreaking. Diet culture has succeeded in infecting every aspect of life. Its devastating effects—physically, emotionally, spiritually, and socially constitute a syndrome worthy of inclusion in the DSM-5 (whatever version we are up to).
I know. It's painful, for all of us.
I am sorry, I got stuck on your parenthetical (As a brief aside, insurance companies...) This blew my mind. I had no idea this was the case. AND it explains why I spent two weeks trying to straighten out a doctor bill. Per the insurance company, the annual checkup was billed as a problem. They wanted me to call the doctor to have them change it. Which I did. But they didn't. I won't pay that bill and I don't care. Sorry it's off topic but thank you for inadvertently explaining why this happened.
‼️‼️‼️
“We had a long and rambling conversation, in which I said very little. But she kept circling back to her body size.
“If I could just lose some weight, it might be easier,” she said.”
I feel that so deeply. I had a similar convo with my doctor and she was very supportive. We need more like her and you.
Thanks for sharing this. It's a hard thing to unlearn and grapple with! <3
This is an odd thought, but I wonder if people feel safe in a weight loss conversation? That conversation is "normal" and doesn't involve any of the acute stressors of their current "abnormal" challenges.
Exactly..like it's what you're "supposed" to discuss at the doctor.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.
I saw my NP (can't see PCP bc reasons) for a follow-up and it seemed it was ALL about my weight. They want to put me on weight loss drugs if I haven't lost some weight by the next visit in 3 months.
Context: I lost 40 lbs, healed my fatty liver, and dropped my A1-C to normal on healthy keto and intermittent fasting over 2.5 years. Then my father was diagnosed with acute leukemia and given 2 months to live, my mother passed away after 10 years of dementia with me as a caregiver along with my sister, and now I'm handling the estates, for which I was fired from my job.
Not a surprise that I started comfort eating and regained the weight I'd lost. Yes I'd like to be healthier again but maybe give me some time to decompress from trauma before chiding me about my response to stress and insisting I need drugs to fix it.