Weight has long been a cultural fixation, and more so than ever, it seems, what with our current feverish interest in semaglutides like Ozempic. But an increasing number of size-inclusive doctors are making a concerted effort to not center weight in conversations with their patients.
“My practice is to not focus on my patient’s weight and instead focus on more holistic measures of health, including metrics like blood pressure, glucose control, mood and pain,” says Mara Gordon, MD, a primary care physician in Camden, NJ. Gordon says that this approach helps patients feel more comfortable and less stigmatized, and allows her to work in tandem with them on their health goals. Lisa Erlanger, MD, a family physician in Seattle affiliated with UW Medicine, zeroes in on how her patients feel and function, asking them, setting weight aside, what they think has the biggest impact on their health and how she can support them. “We know that many things can have a huge impact on both wellbeing and health; for example social connections, community involvement, amount and quality of sleep, mindfulness activities, stress reduction, mental healthcare, and appropriate medical care all can improve longevity, blood pressure control and blood sugar levels,” she says.
Weight discrimination and bias in healthcare is rampant, so it’s imperative for doctors to engage in patient-centered, non-judgmental communication. What that looks like, says Rebecca Puhl, PhD, deputy director for the Rudd Center for Food Policy Obesity, is doctors asking patients for permission to discuss weight, actively listening to their views about health behaviors and being mindful of their word preferences for describing their weight. “The words doctors use matter,” says Puhl. “Certain words or phrases can lead patients to feel stigmatized, judged and blamed, which can jeopardize important discussions about health.” Also it’s critical to consider whether weight even needs to be part of a particular conversation at all. “Doctors should address the chief complaint first and offer treatments that would be offered to a person in a smaller body before discussing weight or weight loss,” says Erlanger.
Just as more doctors need to be mindful about how they talk about weight in their practice, the public at large needs to do the same. Fat-shaming has a long and sordid history, but now, as use of semaglutides becomes more commonplace, a new chapter in the blame and shame game has opened up, with judgment applied to people who choose to use these medicines. As a society we’re not OK with bigger-size bodies and we’re also not OK with people deciding that they no longer want to be in those bodies, unless it’s by a certain means, i.e., exercise and dieting.
Oprah Winfrey, who recently shared that she is using weight loss drugs, admits that she was beholden for years to the notion of willpower, believing that a lack of it played a role in her inability to shed pounds. “When we start to recognize that this isn’t about me doing something right or wrong we begin to realize that it’s really about our inherent biology,” says Fatima Stanford, MD, an obesity medicine physician at Mass General Hospital and associate professor at Harvard Medical School in Boston. Winfrey’s willpower viewpoint is shared by many people whose weight struggles mirror hers. This veneration of willpower is due for the dustbin, Puhl says. “At the foundation of weight stigma are false, inaccurate, and oversimplified beliefs that body weight is an issue of personal control, that it’s a simple issue of not working hard enough. That viewpoint is inaccurate and only fuels societal bias.” Which makes life that much more challenging for people living in bigger bodies. “Weight is not a behavior, although it’s often seen as one in our society,” adds Erlanger.
Many doctors now agree that weight is also simply not a good measure of overall health, though culturally we remain fixated on it. For those of us accustomed to hearing about “goal weights” and “target sizes,” concepts symptomatic of our toxic diet culture, the notion that the number on the scale is not a sole determinant of health is big. “Weight is only one piece of information and by itself is insufficient to determine a person’s health status,” says Puhl, adding that thinness doesn’t equate to health, nor does a higher body weight equate to illness. Same goes for BMI, an antiquated measure of adiposity (amount of fat) and health risk that the American Medical Association recently acknowledged the limitations of. But this doesn’t mean we just need a better measure of adiposity.
“What it means is that surveilling fatness and trying to reduce it has not, over more than 100 years, been shown to improve the health or lower the body size of our population,” says Erlanger, adding that increased health problems associated with higher body size is a correlation, not a causation. “It’s time to look beyond body size as a measure of health or as a target of interventions.” In Stanford’s office there are no goal numbers to hit; the target, she says, is to get to each individual’s happiest, healthiest weight. For her that means where blood pressure, blood sugar, and liver function are normal; where cholesterol isn’t elevated; where you’re able to walk up a flight of stairs without getting winded. “What is the weight when all those things are good in your body,” she posits. “That number may be 300 for one person, and 150 for another.”
