We’ve all heard stories of women with obesity who avoid healthcare because they dread being shamed or lectured about their weight. When they do seek care, many women prefer to avoid the topic of weight completely. Sadly, weight bias continues to be common in healthcare settings, and studies have documented the negative effects of this bias on health outcomes among individuals with obesity.
But some clinicians are also hesitant to discuss weight with their patients. Because obesity is so stigmatized and such a sensitive topic, many providers don’t want to offend anyone, so they don’t bring up weight at all, even when the patient’s long-term health is at risk. This is not uncommon as most providers receive inadequate training on what obesity is (a complex, chronic disease), how to treat it (medical intervention is generally indicated per guidelines) and how to discuss it appropriately with patients. Now that we have more effective treatments for obesity and access to care is slowly improving, however, patients in my obesity medicine practice have actually begun to lament that their primary care and women’s health providers are staying quiet.
Many women first experience difficulty losing weight in connection with pregnancy or menopause. But because obesity is associated with more than 200 health conditions (including type 2 diabetes, coronary disease, sleep apnea, urinary incontinence, breast cancer, osteoarthritis and depression, to name just a few), providers in virtually any context can find themselves wondering whether and how to talk to patients about their weight.
If the patient presents with an acute condition or a situation that’s not weight-related, it may not be an opportune time to bring up the subject; however, if weight is pertinent to the patient’s medical concern, gently raising the issue in the context of that condition could be appropriate and even welcome. The following are tips to help make that discussion more fruitful.
- Ask permission
Address the patient’s concerns first, and then ask permission to talk about her weight, explaining why it’s relevant.
If the patient doesn’t want to address the issue, respect her wishes and simply let her know that you’ll be there to provide support when she’s ready.
- Think about language and tone
With regard to terminology, weight experts recommend putting people first, to avoid defining them by their disease. In the same way that we would refer to “people with schizophrenia” rather than “schizophrenics,” we say “people with obesity” rather than “obese people.” We also try to avoid euphemisms (like “people of size” or “curvy women”) as well as terms that suggest victimhood (“she suffers from obesity”).
Although obesity is widely recognized as a complex chronic disease, and many people find it extremely liberating to realize that their inability to lose weight is due to biology rather than a lack of willpower, the terms “obesity” and “disease” themselves can be off-putting. I find that most patients tend to respond better to “excess weight” and “medical condition.”
The essential thing, in every interaction, is to be empathetic and respectful. Individuals with obesity are more than pounds on a scale, and they are not lazy or lacking in willpower. They are fighting a multifactorial disease. Whatever their weight, they deserve the best in compassionate, evidence-based care — just like patients with any other condition.
- Assess without making assumptions
Always assess the situation before telling patients what to do. While it’s true that obesity can cause or compound a wide variety of health issues, excess weight isn’t always the source of these problems. Providers who immediately tell their patients to lose weight, without considering all the potential causes and conducting a thorough assessment, risk overlooking other serious conditions.
It’s also possible that the patient has already lost considerable weight; insisting she do more without acknowledging this achievement may be demoralizing. Relatively small amounts of weight loss (5%-10% of body weight) can bring significant health benefits over time, even if the individual’s BMI isn’t within the normal range, so knowing the patient’s weight history is key.
Or maybe the patient has already made all the recommended lifestyle changes but her efforts are being thwarted by medications that promote weight gain. Drug-induced weight gain is common with some forms of birth control and antidepressants, for example, and this issue should be taken into account when evaluating the risks and benefits of any medication. If a woman needs hormonal treatments for breast cancer, for instance, it’s obviously most important to treat the cancer first, but when equivalent weight-neutral medications are available in any given situation, they should be considered first.
In short, it’s critical to get the full picture and listen carefully to the patient’s story to understand what factors have contributed to her weight gain and what barriers might be preventing weight loss. Specific factors and barriers are associated with each weight-related health condition, and these factors depend on the woman’s stage of life, comorbidities and other variables. An effective individualized treatment plan requires a thorough assessment.
- Provide support
If the patient agrees that she’s ready to make changes, simply telling her to eat less and exercise more is unlikely to be helpful. Obesity is a medical condition that needs to be addressed with a comprehensive medical approach, with ongoing support and regular follow-up.
Lifestyle changes are the cornerstone of any weight-management program, so focus first on collaboratively setting realistic goals for healthy eating and physical activity. If you don’t have the time or expertise to provide the necessary guidance, you can connect your patients with outside resources such as dietitians, behavioral therapists, health coaches, and community or telehealth programs.
When lifestyle interventions have been optimized or aren’t working, consider referring patients to an obesity medicine specialist to discuss adding anti-obesity medications to the mix. These agents can help overcome metabolic adaptation (our bodies’ anti-starvation responses to weight loss that push weight back up) and allow patients to lose significant weight.
- Offer hope
Most women with obesity have tried to lose weight many times, only to gain it back. This pattern often leads not only to feelings of shame and personal failure, but also to a sense of futility. To give these women hope, it’s important to emphasize, first, that their inability to lose weight is not their fault — the body has evolved many complex hormonal, metabolic, and neurobehavioral mechanisms to actively fight weight loss — and second, that excess weight is a treatable condition.
Every day we’re learning more about this complex disease, and although only 2% of eligible patients are currently receiving medical weight management according to guidelines, telemedicine and data-driven tools are expanding access to evidence-based obesity treatment, new anti-obesity medications offer increasingly effective pharmacotherapy options, and insurance coverage of obesity treatment is improving. Now is not the time to give up!
If we as women’s healthcare providers can help our patients overcome the discomfort of bringing up a difficult topic, we can help more women with obesity achieve better health and well-being.