Following our posting of the HBO short on weight stigma, we reached out to Keith Bachman, MD, clinical lead for the Kaiser Permanente Care Management Institute’s weight management initiative. Keith spoke with us about his thoughts on weight stigma, how it’s experienced in medical settings, and what care providers can do to address it.
CTH Blog:
What is weight stigma, and why is it such a serious concern?
Keith Bachman, MD:
You know, we all have burdens. But with heavier people, they wear it, and we can see it. When you start talking with heavier women, especially those with a BMI of 35 or higher (20% of the population), you realize how common stigma is. Everyone has at least one story of experiencing stigma, and each one is a punch to the gut.
As a society, we are frightened of obesity. Children as young as three years old are already identifying obese people as being funny or people they don’t want to be around. And we know that out in the world, heavier people are not recognized as much for school accomplishments, they make less money, and they are promoted less often.
As health care providers, we need to keep in mind that by the time we see patients, they are probably already stigmatized within and outside the health care system.
CTH Blog:
Tell us about weight stigma in health care. It’s not something you hear about very often.
Bachman:
The health care system often stigmatizes obese people without even meaning to. When people enter a waiting room and chairs don’t fit their bodies, it’s a signal that they are not welcome. When staff has to scramble for a large blood pressure cuff or a larger hospital gown, it’s a signal that they are not normal and we are not set up for them. We know there are women who are struggling with their weight that choose to not come in for care because they don’t want to deal with being weighed.
You know, Rev. Dr. Martin Luther King, Jr., once said that, “of all the forms of inequality, injustice in health is the most shocking and inhumane.” As care providers, we need to think about that. And it all begins with listening to our patients. Until they feel listened to, we can’t even begin to address the issue.
I’ve heard stories of an obese person coming into the doctor’s office with a problem, and the health care provider looking only at the person’s weight. Someone might come in with foot pain, for example, and they know that it’s caused in part by their weight. But there are doctors who would focus only on their obesity—ignoring the issue specific to the foot pain—and tell them to lose weight. That is not providing them a service. We need to counsel them. Each person has different challenges, barriers, interests and motivations to becoming fit, and we need to tap into those. We know now that using things like shame, guilt or fear with patients is the wrong way to go. We must show compassion and support and help with problem solving.
CTH Blog:
You talk about the importance of listening, but what a doctor or nurse says is powerful, too, isn’t it?
Bachman:
Absolutely, and yet it’s not simply what we say, it’s how we say it. I once recommended to a patient that she focus on a reasonable weight loss goal of losing 5 percent of her body weight. I didn’t see her for two years after that, and when she did come back, she told me she didn’t feel comfortable coming in because she had failed at what I had characterized as a “reasonable” weight loss. Hearing her say that made me re-think how I speak with my patients. The last thing we want is for patients to avoid visiting the doctor, and we know there are people—women, especially—who do that, just because they don’t want to be weighed or they don’t want to feel they’ve failed.
CTH Blog:
So what can be done to reduce stigma in a medical setting?
Bachman:
First, it’s important to recognize that obesity is multifactorial. Genetics are part of it. Environment is important—what foods we are exposed to, are convenient and inexpensive). It’s not just about willpower and self-control.
And language is key. Our patients have told us how they want us to talk about weight. The way we speak should be non-judgmental. We can give them the data, compare it with past visits, and put them in control of how to deal with it, how to talk about it. Ultimately, it’s a matter of respect.
An important thing we can do is to always focus on behavior rather than the weight. Don’t make the number on the scale the goal. Because the bottom line is this: Whatever your weight, if you are inactive and you increase your activity, you will make improvements.
