“ One of the real challenges with weight loss studies is disentangling improvements in quality of dietary intake and increased physical activity from the weight loss ,” Olson adds . “ The scope of the literature documenting that weight loss can , in randomized trials , lead to health benefits is very compelling . The question comes back to that individual variability . You have the science in large groups . And then you have a patient sitting in front of you . And the degree to which you can promise that health benefit is , of course , not the same as talking about large groups .”
ONCE A YEAR , GOLDSTEIN TALKS TO INTERNAL MEDICINE RESIDENTS at Rhode Island Hospital about weight stigma and how to address weight loss with patients . Her first rule : ask permission to even talk about weight . “ If someone says ‘ no ,’ then that needs to be the end of that conversation ,” she says .
“ The way that society approaches weight is very disrespectful to people ’ s autonomy ,” Goldstein adds . By respecting a patient ’ s wishes , a provider sends the message that they ’ re safe to talk to in the future . “ Just because it ’ s a ‘ no ’ for now , it doesn ’ t mean it ’ s a ‘ no ’ forever ,” she says .
“ I won ’ t offer unsolicited weight goals ,” says Stephanie Catanese , MD , the associate director of the General Internal Medicine Residency Program at the hospital . Instead she asks patients what their health goals are , “ and then I let them define what healthy means to them and where they want to be .”
Patient-led conversations about their goals are critical whether or not someone wants to lose weight . “ It ’ s so ingrained that weight is the problem — which really means , how I look is the problem ,” Lillis says , “ and that the solution is weight loss .”
In an effort to undo some of that stigma , he uses his acceptance and commitment therapy research as sort of a “ Trojan horse ”: he draws volunteers to his studies with weight loss , and then hones in on their values , to shift their focus “ from the scale to something more meaningful .” He has them imagine they reach their goal weight , and asks them : “ Now what do you want to do ? Because surely the goal isn ’ t to reach this specific weight and then sit in front of a mirror all day and admire what you see .”
No matter how hard people work , many weight loss attempts — even surgeries — fail , and virtually no intervention can ( permanently ) produce the transformations touted on reality TV and in supermarket tabloids . And while patients may say their goal is to get healthier , it ’ s extraordinarily difficult to unravel that from the deep-seated belief that “ healthy ” means “ thin .”
When Roullard sees patients who are “ dead set ” on weight loss surgery , she tries to be “ supportive and understanding ,” she says , because “ as someone who lives in a fat body , it ’ s nonstop . It ’ s every day , from every angle , everywhere you look , every time you sit in a chair , get on a plane , walk through the mall , go shopping , read a magazine . So I get it .”
THAT ’ S WHY SOME PROVIDERS ARE FINDING LIBERATION BY deemphasizing weight in their patient encounters . The medical residents Goldstein talks to “ are generally really open to it because they ’ re frustrated ,” she says , “ and they ’ re ready for something different .”
Sara Delaporta , MD , a primary care physician at Thundermist , says the size-inclusive health initiative and her conversations with Handfield have allowed her to focus on healthy behaviors like nutrition , exercise , sleep , and reducing stress .
“ One empowering thing that I ’ ve said to a lot of patients is that no matter their body size , their healthy habits still count ,” says Delaporta , a clinical assistant professor of family medicine . “ That ’ s been something I ’ ve enjoyed being able to give to people as a gift .”
Graham says she used to recommend weight loss routinely , with a focus on BMI ; now , Handfield ’ s size-inclusive health training “ has changed the way I talk to people — to not vilify bodies , not vilify food , and really make it a conversation about health and how you take care of yourself ,” she says .
“ Patients are so hard on themselves sometimes ,” Catanese adds . She tries to reassure them : “ Hey , weight is just a number . My job is just to make sure you are as healthy as you can be . ... The weight doesn ’ t always reflect that you ’ re doing all those things successfully .”
Roullard , who completed her residency at Thundermist , says practices that want to be more welcoming to people of all sizes should take an opt-in approach by asking every patient whether they want to be weighed . Patients should also feel empowered to ask not to be weighed , either verbally or by handing “ don ’ t weigh me ” cards ( order online at more-love . org ) to their providers .
Knowing a patient ’ s weight shouldn ’ t change how they ’ re treated , Roullard says — from checking other metrics , like blood pressure and blood work , to asking questions about exercise , food , sleep , and stress . Taking the emphasis off the scale not only relieves some patients ’ worries about going to the doctor , she says ; it also makes her better at her job .
“ I ’ m not providing poor care to my patients because of this . In fact , it ’ s probably better care ,” Roullard says . “ My patients come back to see me more often , because they don ’ t feel judged or stigmatized .” HD
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