Tipping the Scales
Doctors are some of the biggest offenders in terms of making patients feel ashamed of their weight.
It might be a doctor’s headshake, wince, or “tsk, tsk” as weight is recorded in a patient’s medical chart. Or it’s a medical lecture about being overweight during an appointment for a sore throat. Or it’s a reluctance to touch a patient because that patient is obese.
“Medical fat shaming” has serious health implications, said Joan C. Chrisler, the Class of ’43 Professor of Psychology.
“Fat people experience sizeism and microaggressions all of the time, but your doctor is supposed to be someone who has your best interests at heart, so it is more painful and even more shocking,” Chrisler said.
Negative attitudes toward overweight people permeate American culture, and the healthcare field is no exception. However, when patients are shamed and embarrassed in a clinical setting, they are often reluctant to schedule return visits, which leads to incomplete follow up care, missed screenings and delays in treatment for new health problems.
Some patients avoid going to the doctor completely.
“Doctors are always lamenting that people don’t come see them when they need to. What they don’t realize is the way they treat fat people has a lot to do with it,” Chrisler said.
Chrisler and Angela Barney MA’16 recently conducted a comprehensive review of research related to sizeism in the healthcare field. They published their results in the journal Fat Studies, and Chrisler presented on the topic at the American Psychological Association’s annual convention in August.
The problem is widespread. Chrisler points out that more than half of 2,000 participants in a 2006 Yale University study reported hearing disparaging comments from their doctors about weight. Women in the study reported physicians as second only to family members as the most frequent sources of weight stigma.
Doctors might think that their critical comments about a patient’s weight will motivate that person to lose weight. But that rarely—if ever—works, because there are mitigating factors to obesity, such as genetics, Chrisler said.
“When the doctor tells a fat person, ‘You are fat,’ the person already knows it. Disrespectful treatment, in an attempt to motivate people to change their behavior, is stressful and can cause patients to avoid interacting with providers.”
In their Fat Studies article, Chrisler and Barney also cite studies that show when an overweight patient seeks care, that patient is often told to lose weight—regardless of symptoms. In their research, Chrisler and Barney came across stories of patients who were lectured on weight during visits for broken toes, dislocated shoulders, strep throat, anemia and low libido.
“People have been told to lose weight to prevent them from getting colds,” Chrisler said. “A cold is a virus. Either you are exposed or you aren’t. It has nothing to do with weight.”
In fact, Chrisler says the link between being overweight and poor health is precarious at best. She argues that no research has shown how much weight is too much, and studies that do show weight as a predictor of chronic illness often confound weight with other variables that impact overall health, including diet, stress and poverty.
“There are healthy fat people and unhealthy thin people. You can’t determine someone’s health status simply by looking at their weight,” Chrisler said.
“Research has shown that doctors repeatedly advise weight loss for fat patients, while recommending CAT scans, blood work or physical therapy for other, average weight patients. Recommending different treatments for patients with the same condition based on their weight is unethical and a form of malpractice.”
It can also be deadly. In a 2006 study, researchers from Drexel University College of Medicine analyzed more than 300 autopsy reports and found obese patients were 1.65 times more likely than average weight or underweight patients to have a significant undiagnosed medical condition, such as endocarditis, ischemic bowel disease or lung cancer.
While some might argue the study indicates obese people have more health problems, Chrisler says that these conditions were undiagnosed, meaning that doctors either misdiagnosed the problem, or the obese patients never sought or received medical care at all.
“Too often, doctors will say to a patient, ‘It’s because you weigh too much,’ instead of looking for an underlying condition.”
One area where attention should be paid to weight is drug dosage. Yet overweight patients are often excluded from medical research and drug trials because of assumptions about their health status, so standard dosages are calculated based on midrange weights.
Even when there are guidelines for adjusting dosages for overweight patients, studies show they are often ignored. In a 2012 study, researchers from Washington University School of Medicine reviewed nearly 2,000 emergency room prescriptions for three different kinds of antibiotics and found that overweight patients received the recommended dosages less than 10 percent of the time. Another study published by the Journal of Clinical Oncology found that up to 40 percent of overweight patients with breast, ovarian, colon and lung cancers received dosages of chemotherapy that were not appropriate for their body weights.
Under dosing of antibiotics can lead to treatment failure and bacterial resistance. Under dosing of chemotherapy can result in death.
If the scale isn’t going to be used to help medical providers determine the correct drug dosages, Chrisler wishes it would disappear from doctors’ offices altogether. Instead of worrying about weight, she says, doctors should be focused on good health habits, like regular physical activity, a nutritious diet and adequate sleep, for all patients.
To help combat sizeism in the healthcare system, Chrisler has joined a growing body of experts who advocate for better training for doctors and medical students about the importance of treating all patients fairly and respectfully.
“Doctors need training on all sorts of oppressions—racism, sexism, sizeism. They need to understand that it is unethical to treat patients differently, and you end up with poorer outcomes,” she said.
But she also suggests that patients become their own advocates whenever possible and consider switching doctors if they experience poor treatment.
“Women, especially, often have internalized shame about their weight. They think they are ‘bad,’ and that every doctor is going to treat them this way,”
she said.
“I want them to know they don’t have to put up with that.”