What rational basis is there for people — any people — to be biased against other people because of adipose tissue?
Dr. David Katz asks this provocative question in his recent Huff Post Blog, Obesity, Bias and Bedrock. While the question is meant for everyone, doctors and other health professionals are the primary target. Dr. Katz takes his cue from Tara Parker-Pope’s piece in the New York Times, Are Doctors Nicer to Thinner Patients? The dark truth is that patients of size have faced medical bias and worse for decades, certainly longer than the 26 years I have been in private practice.
Dr Katz mentions biology, suggests a role for anthropology, but fails to ask his colleagues to look in the mirror. From my perspective one of the biggest reasons patients experience weight bias is because medicine pretends weight has much more to do with health and disease than it actually does.
WEIGHT IS A POOR SURROGATE MEASURE FOR HEALTH
Measuring weight and calculating BMI scores is fast, easy, and inaccurate. Metabolic health is the critical indicator, but more time consuming and expensive to assess. So, doctors continue to measure weight, remark about weight and lament when patients don’t lose weight despite evidence that says weight doesn’t accurately assess health status. In addition, preoccupation with a number on the scale completely ignores the fact that how you lose weight matters.
Patients lose weight but cholesterol doesn’t drop, blood sugars don’t get better, blood pressure doesn’t decrease. It is a myth that a 10 pound weight loss improves health. The truth is that lifestyle changes help the body to use fat more effectively for fuel. A healthier metabolism improves health status and weight loss is the result of better metabolic health, not the cause.
FOCUS ON WHAT REALLY MATTERS
Maybe medicine needs to stop pretending that weight is an indicator of health. It isn’t. If health care professionals are serious about decreasing weight bias, they can focus on what really matters:
- Ask your patient if anything about their metabolism is of concern or keeping them from living the life they would like to enjoy. Keep the focus on metabolic health and resist using weight as short hand.
- Discuss what kind of activity patients enjoy, or if they have time to be active. What holds them back? Give them an opportunity to consider what they could do. The more patients own the plan, the more likely they will make an earnest effort to follow through. If they can’t, there is more to be discussed.
- Ask patients about their diet. Resist leaning on one or two soundbites of advice. Be ready to listen without judgment. Give your patients a safe place to discuss what is not working. Ask them if they are interested in getting some help with that. Then if you don’t have the time or expertise to take it further, refer them to a registered dietitian or qualified nutritionist.
- Consider what else could be getting in the way of effective energy metabolism. Stress plays a powerful role, so does lack of sleep. Medications often interfere with energy metabolism; some cause dramatic weight gain and even diabetes.
- Stay open to the concept of healthy at every size. (HAES) There are many people who are living large– and are metabolically healthy.
- Scrutinize your own beliefs and values. We are fast evolving from the simplistic notion that a larger body just eats too much. A sympathetic and non-judgmental ear is far more encouraging than even the slightest hint of shame or blame.
It is clear to me that weight bias exists because too much value is given to the number on the scale. If doctors are serious about eradicating weight bias, they need to figure out a more accurate and honest way to assess health. Have you been treated differently because of your weight?