How Doctors and Patients Can Do Better

This is the third in a three-part series on the obesity crisis. Part one asks a complicated question: Why has the obesity rate continued to rise despite our efforts to stop it? Part two examines whether new weight loss drugs will finally end the crisis.  July 5, 2023 – After Mia O’Malley gave birth in 2018, she retained fluid in her legs – a common occurrence after giving birth. The swelling made walking, sitting, and caring for her newborn painful and uncomfortable. She went in for a check-up, and her doctor told her it would eventually go away with regular movement and elevating her legs.  Months passed and the painful swelling wouldn’t subside, so she saw a different primary care doctor. O’Malley said the second doctor didn’t examine her legs, but instead implored her to focus on one thing: losing weight. She left with information on which calorie-counting apps to download.  As time went by and the swelling persisted, she went back to the second doctor and asked for a water pill to flush out the fluids – something she had seen other new parents discuss online. The doctor obliged, and within days, O’Malley’s swelling was gone. She realized she could have avoided 6 months of potential health risks and pushing through pain if only her doctor had seen her as a person, not just a bigger body.  Weight bias, unfortunately, is nothing new.  Many studies over decades have shown that doctors sometimes look down on patients with obesity, and can have a hazy understanding of the condition overall. This makes it harder for bigger patients to receive proper care and achieve positive health outcomes, with previous negative experiences deterring some from seeing doctors at all. And so the cycle continues.  “There are a lot of things that happen in my body that I feel like I have to educate my [health care] providers on,” O’Malley said. “I wish that was different.” Weight Stigma in Health Care Runs Deep In some cases, like O’Malley’s, patients don’t feel heard because they doubt their doctors can see past their obesity. At the same time, the weight loss advice that doctors tend to give – eat less, move more – often doesn’t work. While some doctors do specialize in obesity treatment – obesity medicine has been  growing since the field was established in 2011 – most receive little training in how to talk about and treat obesity. Then there’s the fact that doctors are human and not immune to bias. Previous studies have shown weight stigma in patient-provider encounters, with a  2021 PLOS One study of nearly 14,000 people across six countries showing two-thirds of those who have experienced weight stigma also experienced it with doctors. The result: They perceived less listening and respect from doctors, more judgment due to body weight, and lower quality of health care. There’s more. The negativity of weight stigma can lead to more unhealthy behavior, including  disordered eating, more weight gain, and alcohol use , and it has been linked to  higher suicide risk . All this is bad news for people and for public health, as it leaves people living with obesity reluctant to seek help for any health issue, much less for weight management. In a country with skyrocketing obesity rates, that’s not good.  Obesity medicine specialist Fatima Stanford, MD, MPH, an educator and doctor at Harvard Medical School and Massachusetts General Hospital, sees patients from as young as 2 years old to upwards of 90. Among her diverse pool of patients emerges one common theme.  “Patients with obesity have been devalued and belittled,” she said. “They often seek treatment under cloak of secrecy. They don’t want people to know they’re being treated for obesity because it must be a sign of failure or of their inadequacy of not doing things the ‘hard’ or the ‘right’ way.”  When It Becomes Easier to Simply Not Go to the Doctor  For many larger-bodied patients, it’s common to news go years without seeing a doctor. Studies have shown that people with obesity are  less likely to be screened for certain cancers and more likely to  delay care , in large part due to the negative attitudes they experience in health care settings.  Research also shows that overweight patients shop for doctors 23% more often than their lower-weight counterparts. For patients with obesity, that jumps to 52%, showing just how hard it is for those patients to find a compassionate provider and stick with them.  “It’s not just about hurt feelings,” O’Malley said. “It’s about people avoiding preventative care appointments, avoiding getting injuries treated, avoiding their health issues because they don’t want to be shamed.”  This rings true for Jen McLellan, a plus-sized childbirth educator and author.  “Even though this is what I teach full-time, I didn’t go to the doctor for over 2 years, and during that time I gained weight already existing in a larger body,” she said. “I gained an additional 60 pounds, and it really affected my mental health.”  The long hiatus began pre-pandemic, after McLellan saw a doctor when she had a hard time breathing. A month before her appointment, she had completed a 5K and was in good health. She asked her provider for an inhaler but was told that would “hurt her heart.” The doctor ordered an EKG, which showed no abnormalities, but still refused to give McLellan a prescription for an inhaler.  As she was driving home, she nearly blacked out from lack of air. She ended up going to urgent care for an inhaler and was told she just had a restricted airway that needed help opening up after a bout with strep throat.  “I’ve basically had to say [to doctors]: Look at me , the human sitting in front of you that has been mistreated by the health care system,” McLellan said. “I am a person. I am not a BMI or a number on the scale. Treat me with dignity.”  A New Path to Better Results  Kristal Hartman, 45, is a member of the Obesity Action Coalition and has sought treatment for obesity throughout her life. She ultimately had bariatric surgery in her mid-30s. Before the surgery, she had given birth to twins, and her health had suffered due to polycystic ovary syndrome and thyroid issues.  “I had little kids, and I’d already tried every fad diet,” Hartman said. “My primary care physician, who has never experienced obesity herself, just kept telling me to ‘just walk a little more and put down the fork and eat a little less’ – that was pretty much the only advice I got from her about weight management.” Studies have shown that weight loss advice from doctors rarely includes effective methods, and typically falls into the generic “eat less, move more” variety.  This doctor was also an internal medicine specialist whose practice was said to be geared toward patients with more complicated health profiles, Hartman said. Eventually, Hartman’s endocrinologist recommended different treatment options, like medication and surgery.  “Even when researchers do very nice, controlled studies, only about 5% of people are able to lose 20% of their weight with lifestyle interventions alone. Forty-eight percent of people are able to lose 5% of their weight,” said Angela Fitch, MD, associate director of the Weight Center at Massachusetts General Hospital. “The biggest thing I tell people is that it’s not about your character; it’s about your chemistry.”  Getting regular exercise and eating a balanced diet are good lifestyle choices for everyone, not just those with obesity. But according to Fitch, patients usually need another intervention for successful weight management. At the Massachusetts General Hospital Weight Center, Stanford says, it’s about trying different therapies and seeing how patients respond. Successful treatment involves every part of a person: genetics, hormone levels, sleep patterns, food access, and mental health. And in her experience, this multidisciplinary approach works.  “A large majority of my patients – people I’ve been seeing for 10 or 12 years who have continued with care – probably an excess of 90% are successful in their treatment strategies,” she said.  A person’s weight management strategies often have to change over time. Even after Hartman lost significant weight from bariatric surgery, her weight began to creep back up (a  not uncommon experience ). She started taking a prescribed GLP-1 receptor agonist – a group of drugs that includes semaglutide (Ozempic, Wegovy) – to help her maintain her weight.  How Doctors and Patients Can Get Better Results Together For heavier people who don’t have access to a multidisciplinary, patient-focused weight center – and doctors who don’t provide those specialized services – there are still ways everyone can achieve better treatment results.  For doctors: You’re seeing patients with obesity, but do those patients feel “seen”? Is your practice set up to accept and accommodate heavier patients? McClellan suggests looking at areas you may not have thought about previously, such as gowns that fit larger bodies, larger chairs in the waiting room, and scales with higher weight limits. Education is key, said Maria Daniela Hurtado Andrade, MD, PhD, an obesity medicine doctor at the Mayo Clinic in Jacksonville, FL. Hurtado Andrade pointed out that new therapies are being developed to manage weight loss, and some (like semaglutide) have already been used for years to treat diabetes. “While some providers are willing to start using these medications, it is not enough,” she said. Remember: “We should be treating obesity as any other chronic disease, just like high blood pressure or diabetes.”  For patients: Check online for lists of “weight-neutral” or “size-friendly” providers endorsed by other larger-bodied patients. Lists like  these are places where patients can add the names and information of providers they’ve had positive experiences with.  Ask questions and advocate for yourself, McLellan urges, even if you’re not comfortable doing so. “Am I going to be given a sheet or a gown that fits my body? Are they using a blood pressure cuff with the correct size? Are they taking your blood pressure the minute you’re hurried back to a room?” (According to the  CDC , a patient must be seated with their back supported for at least 5 minutes with their feet flat on the ground in order to get an accurate blood pressure reading.)  But what’s made the biggest difference for her is being clear with doctors and nurses about how she’s feeling in the moment, and how her previous experiences in health care have contributed to that.  Since incorporating these strategies, McLellan said she has finally been able to receive the care she deserves from a compassionate provider.  “I told [my doctor], ‘I want to be healthy,’” she recalled. “And we went through my lab results together. I had done a full blood panel, and he scooted his chair toward me and looked me straight in the eye and said, ‘You are healthy.’”