Giving patients weight advice

Ms Sinead Lay, Case Manager at Medical Protection, offers advice on conversations around a patient’s weight and suggests why it is likely to become more commonplace in future.

The World Health Organisation (WHO) reports that worldwide obesity has nearly tripled since 1975. According to an Irish Times article based on a new WHO report, Ireland ranks ninth of 53 European countries for obesity in adults and eleventh for overweight and obesity. Children between five and nine years old rank ninth for overweight and obesity, while 10-to-19 year-olds rank 10th. It may be alarming to know that most of the world’s population live in countries where being overweight and obesity kills more people than being underweight or malnourished. 

At the forefront of the obesity epidemic, obesity bias and stigma (also known as ‘fat shaming’) is an under-recognised and widely prevalent barrier to optimal care of patients living with obesity. 

What is weight bias? 

Internalised weight bias means holding negative beliefs about oneself due to weight or size. These internalised negative self-beliefs can be bolstered by external influences such as other people’s negative attitudes towards, and beliefs about, a person because of their weight. These negative attitudes may be manifested by stereotypes and/or prejudice towards people who are overweight. Medical professionals are not always an exception to this. 

Patients who are overweight or obese can find using the healthcare system daunting. Patients who feel they are experiencing obesity bias from healthcare professionals may cancel or delay appointments as well as avoid preventative healthcare and screenings. Sometimes doctors can be guilty of holding negative attitudes, both explicit and implicit, about patients with excess weight. This weight bias could potentially lead to delays in care and other downstream health consequences as seen in the following case study. 

Case study 

Mr Z, a patient living with obesity, twisted his right ankle whilst out for a walk one evening through a muddy field. Mr Z attended his GP, Dr F, who examined him and advised he had a soft tissue injury. Mr Z’s symptoms worsened over the next two weeks and he returned to Dr F, who advised Mr Z that the strain he suffered whilst out walking and the pain associated with it were greatly exacerbated by his obesity. Dr F weighed Mr Z and advised that he needed to lose a significant amount of weight and this would alleviate the pain he was experiencing. 

A month later, Mr Z’s worsening pain led him to, the emergency department in his local hospital. An x-ray of his ankle revealed a displaced posterior malleolus fracture, which required surgical treatment. 

Mr Z and his wife filed a complaint against Dr F with the Medical Council. The preliminary proceedings committee (PPC) looked into the complaint on the grounds of poor professional performance. Following the PPC’s investigation, it made the decision that no further action be taken. However, the months taken to investigate the complaint had been incredibly stressful for Dr F and the matter was not resolved. 

The patient went on to pursue a medical negligence claim against Dr F, alleging that failure to diagnose the ankle fracture had led to a delay in surgical treatment and unnecessary pain and suffering. It was also alleged that Mr Z had experienced psychological distress as a result of Dr F attributing his symptoms solely to his weight. 

An expert witness report, provided for Mr Z, concluded that Dr F had breached his duty to his patient by failing to refer him for an x-ray when his symptoms did not settle within a reasonable timeframe. Had the patient been referred for an x-ray sooner, the fracture would have been diagnosed and possibly would have been displaced, which may have meant that surgery could have been avoided. The case was settled for an undisclosed sum. 

Avoiding weight bias 

Approaching the subject of weight with someone can be challenging in everyday life, let alone in a healthcare setting. Asking for permission from a patient to discuss their weight is always a good start. Psychologically speaking, this makes patients feel more in control of the conversation and its direction from the offset. Questions such as “Could we talk about your weight today?” or “How do you feel about your weight?” are always good conversational starting points when discussing weight. 

If the patient declines to discuss their weight, doctors should respect that decision. The conversation could end by letting the patient know that you are available to discuss the issue whenever they feel the time is right for them. 

When discussing the topic of weight with patients, it is important for doctors to choose their words wisely and steer away from any language that places blame. Stigmatising or blaming words, such as ‘fat’, ‘morbidly obese’, and ‘chubby’ should be replaced with words such as ‘weight’, ‘unhealthy weight’, and ‘high BMI’. Adopting a people-first language – by not labelling a patient by their health condition – can be beneficial, especially when it comes to weight concerns. It would be better to identify a patient as having obesity rather than an ‘obese patient’. 

Practical strategies for healthcare professionals when managing patients with obesity: 

• Recognise the complex causes of obesity and communicate this to colleagues and patients, thus dispelling the stereotype that obesity is solely attributable to personal willpower or lack thereof. 
• Although weight may be contributing to a patient’s symptoms, do not rule out other causes. Ensure that when they are presenting with symptoms, they are afforded proper and adequate assessment and/ or specialist referral to rule-out all causes of presenting problems. 
• Be mindful that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity. 
• Recognise that many patients have unsuccessfully tried to lose weight repeatedly. 
• Discuss holistic approaches to weight loss with the patient, including behavioural and lifestyle adjustments, ensuring to not focus solely on the number on the scale. Emphasise to patients that even small weight losses can result in significant health gains. 
• Offer practical suggestions such as advising the patient to take up an exercise programme or eat at home, rather than simply saying, “You need to lose weight.” 
• Acknowledge the difficulty that patients living with obesity may have with adopting new lifestyle changes. 
• First impressions count so consider creating a supportive healthcare environment from the offset. Implementing large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and friendly patient reading material in the waiting area may be helpful in reducing patient anxiety prior to a consultation. 
• Researching reputable patient advocacy groups within your local community or nationwide, and encouraging patients to engage in such support groups is another way to ensure a patient leaves a consultation feeling informed and supported. 

The European Coalition for People living with Obesity (ECPO) helps the European scientific and clinical community better understand the patient experience. The group regularly holds online workshops for patients and clinicians alike, encouraging open and frank conversations around the topic of obesity bias and stigma in healthcare settings. 

A very useful online tool healthcare professionals may consider using to assist in overcoming obesity bias is The Rudd Centre’s eight-module toolkit self-assessment course. The toolkit offers easy-to-implement solutions and resources to improve delivery of care for patients who are overweight or obese. The resources include ways to improve doctor-patient communication, ways to make positive changes in the clinical environment, and self-examination of personal biases. 

Fighting obesity bias as clinicians 

Healthcare professionals can make a huge difference with the obesity epidemic by initially striving to overcome any personal obesity bias and discrimination they may hold within themselves. They can also lead the way by addressing obesity bias in their interactions with their patients. By becoming knowledgeable about evidence-based obesity care, they can make a big difference to the way patients manage their own health. 

The education of current and future healthcare professionals should focus on raising awareness of attitudes and bias toward obesity as well as addressing the development of empathy for the struggle of patients who are living with obesity. Doctors should be mindful of the fact that most individuals with excess weight are very much aware of their weight and will have tried repeatedly to lose weight, and many of these individuals may have had previous negative experiences regarding their weight. Creating a supportive environment will help patients living with obesity feel comfortable when seeking medical care, and it could encourage patients to take on effective and tailored weight management.