We’re all aware of the dangers of obesity, which include increased risk for mortality, type 2 diabetes, coronary heart disease, and stroke, among others. But talking with your patient about their obesity is a delicate matter, and your concern for their health might be misconstrued as fat shaming. Make no mistake: perceived fat shaming by doctors and HCPs is quite common, according to recent research. And while some people argue that fat shaming can push some overweight patients to lose weight, fat shaming has genuine and serious consequences for patients’ mental and physical health. Here’s what we know about fat shaming and how you can better approach this sensitive topic.

‍How Common Is Fat Shaming?

A research team led by Rebecca Puhl, deputy director at the Rudd Center for Food Policy and Obesity at the University of Connecticut, tackled the topic of fat shaming in a pair of recent studies.

In one study published in June in the International Journal of Obesity, Puhl and her colleagues surveyed nearly 14,000 people in WW (formerly Weight Watchers) across Australia, Canada, France, Germany, the U.K., and the U.S. These surveys touched on questions about participants’ history of experiencing weight stigma, when it occurred and how it caused distress, and who were the fat shamers.

The researchers found that 56–61% of participants experienced fat shaming, and 22–30% experienced their first weight stigmatization by age 10. The participants experienced fat shaming in every aspect of their social lives:

• 76–88% were fat-shamed by family
• 72–81% by classmates
• 63–74% by doctors or healthcare providers
• 54–62% by coworkers
• 49–66% by their friends

In a second study published in June in PLOS ONE, Puhl and her team used the same WW dataset to look at fat shaming in the healthcare setting. The questions in this study investigated the experience that participants have with their HCPs and their views about their weight. The participants rated various statements and questions, such as:

• I avoid seeing my doctor because I feel uncomfortable when my body is being examined.
• During the past 12 months, how often did doctors or other health providers listen carefully to you?
• My weight is a significant way I judge my value as a person.

They found that participants with higher internalized weight bias reported more healthcare avoidance, increased perceived judgment from HCPs due to body weight, lower frequency of routine checkups, less frequent listening and respect from providers, and lower healthcare quality.

Though the research talks about “perceived judgment,” past studies suggest that some HCPs treat heavier patients worse. For example, one study found that physicians spend less time educating obese patients about their health and more time discussing exercise, while another found that physicians prescribed more tests for heavier patients but purposefully spent less time with them. One study even found that some physicians are more reluctant to perform pelvic exams on obese women.

Research also suggests that fat shaming is making people sicker and heavier. The more people are exposed to weight bias and discrimination, the more likely they are to gain weight and become obese (even if they’re thin to being with) as well as to die from any cause (regardless of their BMI).

Other effects of fat shaming include:

• Depression
• Anxiety
• Low self-esteem
• Eating disorders
• Exercise avoidance
• Increased risk of metabolic syndrome
• Increased stress and cortisol levels

And in one study of more than 300 autopsy reports, researchers found that obese patients were 1.65 times more likely than normal weight or underweight people combined to have undiagnosed medical conditions, including endocarditis, ischemic bowel disease, and lung cancer.

‍A Different Approach

Fat shaming can take various forms. For example, aside from verbally fat shaming patients, HCPs might show weight biases by:

• Recommending different treatments for patients with the same condition, such as advising weight loss for heavier patients while recommending CAT scans or physical therapy for average weight patients
• Being reluctant to touch a heavy patient or shake their hands
• Wincing or making a “tsk” noise while noting a patient’s weight in the chart

This kind of shaming is often intended to guilt patients into losing weight, but experts argue that other approaches are more effective and less damaging.

A personalized approach in which HPCs listen at length to patients’ issues before giving advice is key. To start, determine the patient’s expectations, knowledge, and preconceptions about weight and weight loss. Next, help patients understand the risks of certain behaviors and inform them about the impact of a healthy lifestyle to treat and prevent diseases. Focusing on reducing risk factors and improving overall wellness is a healthier goal than targeting a specific weight loss number.

Word choice is critical when talking about weight loss with obese patients. Avoid saying things like obesity, heaviness, large size, and excess fat; instead, use terms like weight, BMI (and unhealthy BMI), weight problems, and excess weight. Also, avoid assigning blame, and validate patients’ worth outside their weight and body size. You can even offer the option for them not to view their weight or BMI in every visit, reducing weight-related anxiety and decreasing the emphasis on weight.

If a patient appears to have internalized weight bias, encourage self-forgiveness and teach them how these biases are harmful. Encourage them to adopt a proactive philosophy by anticipating failures and relapses as part of the weight loss process.

Use motivational interviewing techniques, which allow patients to express their desire for change. For example, you can ask patient-centered and non-threatening questions like “How important is your health to you?” “What are your biggest barriers to self-care?” and “What are your hopes for the future if you become healthier?” Reflective listening techniques can also help and include questions and statements like:

• You’re thinking about losing weight but aren’t sure you’re ready yet. Would you be willing to talk about this again during your appointment?
• It can be hard to make changes in your life. Thank you for talking with me about this today.
• It’s great that you feel good about making some lifestyle changes! You are taking important steps to improve your health.

Finally, note that while these suggestions are targeted toward patients, you can also use these recommendations to help family and friends.