“I THINK YOU JUST NEED TO LOSE THIS BABY WEIGHT,” the kidney specialist said. Jen Curran had given birth to her daughter, Rose, a few weeks earlier, and she was following up with the specialist after a routine test during her pregnancy found excess protein in her urine. She listened as the doctor shared some platitudes about not eating processed foods, but the 38-year-old had lingering doubts.
Curran’s OB-GYN had been concerned enough about the abnormal findings to call Curran after the birth to remind her to see a specialist. She found one near her home in Los Angeles who confirmed that the protein levels were still high and climbing. But the specialist gave Curran the same advice she had heard throughout her life, at different ages and different sizes, no matter what health problem brought her in: Try losing weight.
After weeks of dieting, Curran decided to trust her intuition and asked her OB-GYN for a referral to another specialist. The new doctor confirmed her worries. She told Curran that her weight would not explain the lab results. The doctor ran more tests that led to a multiple myeloma diagnosis that, “in retrospect, looking at my lab work, is almost obvious,” Curran says. The diagnosis “was missed because I’m young, and it’s just not what people expect, especially if there’s another quote-unquote issue, which they thought there was in my case, which was that I needed to lose weight.”
Messages about weight are ubiquitous in the U.S. Advertisements promise the benefits of diet plans and gyms, magazines exactingly track the body changes of celebrities, debates about certain body types are continually fought across social media, and news reports frequently highlight a long and ongoing “obesity epidemic.”
Researchers and care providers wrestle with the health associations of having excess weight and how to manage the weight and its effects. Several organizations, including the American Association for Cancer Research (which publishes Cancer Today), have highlighted obesity as an important modifiable risk factor for cancer, and the American Academy of Pediatrics calls it one of the most common chronic childhood diseases. Even as these and other groups promote the fact that various factors contribute to a person’s size, it has proven difficult to dispel the misconception that larger bodies are simply the result of personal choices, and that shame is a way to encourage healthy behaviors.
For Curran, now 42, weight has been a regular topic at medical appointments since she was 12, even though she wasn’t overweight at the time. Over the course of her adult life, her size has varied; at one point, she lost more than 100 pounds. “I’ve been in and out of a lot of medical experiences over the years where that’s been something that they’ve mentioned. ‘It might help to lose a few pounds.’ ‘It might help to lose weight.’ ‘It might help to change your diet,’” she says. But she also perceived weight as a distraction from the problem that brought her to the doctor in the first place.
Her encounter with the kidney specialist was in line with a lifetime of well-intentioned advice she had received. The doctor suggested avoiding packaged foods and watching sodium content, generally good health suggestions, but they were overshadowed by the task of having to drop considerable weight.
Jeanne Ferrante, a health services researcher and family physician at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, says many health professionals see weight loss as a simple process of eating less and exercising more. “But obesity, as we know, is a chronic medical condition with a complex etiology,” she says. “It’s influenced by genetic, environmental, social, medical, economic, psychological and physiological determinants.”
Weight Stigma at the Clinic
Anna, who asked that her last name not be used, was diagnosed with breast cancer in late 2021. After treatment including a mastectomy and chemotherapy, she had a temporary expander placed in her chest but developed an infection at the site before they could place the permanent implant. Anna decided next to pursue surgery, called autologous tissue reconstruction, that would use tissue from another part of her body to rebuild the breast shape. Since her BMI was over 35, however, she wasn’t eligible for the surgery according to hospital policy.
Anna was not interested in discussing weight loss for the surgery. She had spent 10 years of her life trying to stay lean but achieved it only through disordered eating. She had missed out on the food of her family and culture; she had missed out on holiday meals. She had felt unfulfilled, and despite all of it, the weight started coming back anyway. She didn’t want to go on another diet that would end with her gaining the weight back, and she feared that dieting could tip her into disordered eating.
Weight Stigma’s Backfire Effect
Research shows that shaming people for their weight can encourage less healthy behaviors.
Not only is shaming people with larger bodies unhealthy in general, but it’s also counterproductive when it comes to promoting healthy habits.
Jeanne Ferrante, a health services researcher and a physician at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, says there is a common misconception that shaming people for their weight is justifiable to motivate them to eat healthier and exercise. But this justification has not been borne out by research. “On the contrary, studies have shown that experiencing weight stigma leads to psychological distress and unhealthy behaviors,” such as binge eating or avoiding exercise, she says.
In a May 2021 study published in the International Journal of Obesity, researchers found that weight stigma was associated with disordered eating, such as binge eating, and comfort eating, as well as alcohol use and sleep disturbance. They also found that even people with a lower body mass index showed more disordered eating and alcohol use when they experienced weight stigma. The researchers noted a person’s weight is largely a product of genetics and other factors, and they expressed concern that behaviors people have more direct control over—such as eating habits and alcohol use—are undermined by the continual focus on a person’s size.
Living in the Boston area, Anna found another nearby hospital that would consider her for the tissue reconstruction she wanted. The second visit at the new center started with a medical assistant asking to take Anna’s weight. She said no. As a rule, unless she is given a clinical reason, Anna asks not to be weighed. After a disagreement that included the medical assistant leaving to confer with a doctor, she agreed to be weighed for the sake of moving on. While taking a patient’s weight is considered by many to be a standard part of a health care appointment, some groups—including people recovering from eating disorders and those who feel uncomfortable being weighed in public or having their weight be at the center of health care discussions—ask that it not be part of their routine care.
Next, Anna spoke to a doctor in the practice. After their conversation, before even seeing her surgeon, Anna called her wife in tears. The conversation had gone poorly, and she was convinced by his questions and tone that they weren’t going to accept her for the tissue reconstruction. The doctor spoke about the dangers of excess weight, different weight loss programs and medical treatments, and the risks of going ahead with the surgery at her size. Anna told him about her history of disordered eating and about her relationship to her body and eating.
“It was as if we were having two different conversations, and he could not see where I was coming from or why, or even really fully understand my words,” Anna says.
“I understand there are actual risks. I don’t deny that,” Anna says about the surgery, but she wanted to have a say in her care. “Don’t fat people get to have two breasts too?”
Anna’s experiences reflect some of the many ways that people with obesity have negative experiences in health care. “Oftentimes we think about biases and stigma in the form of communication, which is definitely one of the mainstays. But there are other forms of this being found in health care,” says Amanda Velazquez, director of obesity management at the Center for Weight Management and Metabolic Health at Cedars-Sinai Medical Center in Los Angeles. The stigma can start in the waiting room with chairs that aren’t appropriate for larger people to sit in comfortably. Offices may not have gowns that fit or equipment that is appropriate to a patient’s size, leading to shaming experiences like trying to fit in a too-small blood pressure cuff or having to wait while someone finds a larger one.
Velazquez says there can be a negative feedback loop between people with weight concerns and the health care system. Excess weight is associated with more health problems, leading to more interactions with the health care system, but if weight stigma makes patients’ experiences negative, they may choose to avoid the system, leading to more serious weight issues and medical problems. “It’s doing truly physical and psychological harm to these individuals,” Velazquez says.
Understanding the Challenges
Medical professionals who regularly advise patients to lose weight need to understand that weight loss is not as simple as it’s often presented, Velazquez says. “Long-term sustained weight loss is really difficult to achieve,” she adds. “It’s not because individuals lack willpower. It’s because this is a chronic disease.”
Velazquez says that healthy diet and exercising, on average, can help achieve 3% to 5% weight loss over the long term. A 2019 meta-analysis of lifestyle programs for weight loss in BMJ Open showed that frequent and sustained lifestyle interventions resulted in an average sustained weight loss of less than 5% over three years. Velazquez stressed that weight loss even at these levels has numerous health benefits. But for many people, 5% weight loss, or even 15% to 30% weight loss seen with surgery or medication in conjunction with healthy lifestyle changes, will still leave them classified in the BMI range of obesity, a label they will carry with them every time they see a health care provider.
People who are diagnosed with cancer face additional obstacles to shedding pounds. Cancer medications can encourage weight gain, Ferrante says. For example, she says most breast cancer patients will gain weight during chemotherapy, and even those who don’t will usually gain weight in the three years following treatment. And cancer and treatments can affect appetite, taste and the ability to stay active.
“If there was something I was interested in eating, that was a good thing because I had really bad food aversion,” Anna says of the period when she was on chemotherapy. She couldn’t stand the taste of water and had mouth sores that made some foods intolerable. Finding a sugary coffee drink or having an ice pop that didn’t trigger a burning sensation counted as a success.
“It’s a bit of a Catch-22 [that] they are being counseled to lose weight and at the same time being treated for their cancer with weight gain-promoting medications,” Velazquez says.
Having excess weight has been associated with a number of health problems, including an increased risk for 15 different kinds of cancer. Ferrante from Rutgers Robert Wood Johnson Medical School notes that weight gain before and after treatment has been associated with decreased survival.
“It’s really important for patients who are diagnosed with cancer to maintain a healthy weight, increase [their] physical activity levels and maintain a healthy diet to have better quality of life, better physical function and hopefully increase their survival,” she says.
Ferrante says a common complaint from patients is that they go to a health care provider to get help with a specific problem, and the provider tells them it would go away if they lost weight. She points to conditions such as fatigue and joint pain that can be attributed to excess weight but are also common side effects of cancer treatment. “They don’t really help address the problems that the patient is going in for; they just focus on the weight,” Ferrante says.
“[Patients] want specific goals and support and specific treatments. When they just get generic weight loss advice, they feel like the physicians lack attention, concern and support,” Ferrante says.
But health care providers, especially primary care physicians, are also in a difficult position, Velazquez notes. Many are not trained to have conversations about weight, they may be blind to their biases about weight, or they may not have enough time to discuss the issue.
Taking considerate steps like asking for a patient’s permission to talk about weight and understanding their history could make for a more fruitful discussion between patient and doctor. Also, knowing if a patient who is in the BMI range of obesity is engaging in healthy eating and exercise or has recently lost weight will influence the interaction.
Velazquez emphasizes that goals around weight should focus on functionality and managing related conditions and risks. She says weight scales and BMI are tools, but not in themselves the goal, which is overall health. And when people avoid the health care system because they feel they are not getting the care or respect they need, she says, they are missing important and even lifesaving interventions like cancer screenings.
For patients, the road can be bumpy, but when doctors partner with them, it’s possible to discover ways forward. Curran found a doctor whose focus on the cancer, and not her weight, is reassuring. She knows that any advice will be specific and meaningful and help her chances for successfully managing her cancer. And at the same appointment where Anna felt sure she would be rejected for the breast reconstruction surgery, she finally spoke to her surgeon and had a reassuring conversation. “He got creative, and we brainstormed together,” Anna says. They discussed spreading the process over multiple smaller surgeries instead of one or two larger ones, an approach the surgeon thought would lower her risk.
For Anna, questions about weight and health touch on something extremely personal. She has thought a lot about how to best take care of herself and her body. Living through an eating disorder and cancer has changed her priorities and her understanding of being healthy, and she finds judgments about her health based solely on her size to be hollow.
“My body is me, but it’s also not me,” Anna says. “It’s the vessel that I live in, and I take care of it the best way that I can. And that might not look like how you would take care of yours or how someone else would take care of theirs.”
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