8 actions to build trust with patients at higher weights

When a patient at a higher weight visits Michigan Medicine for the first time, they may have already experienced mistreatment in a health care setting. If that sounds like an exaggeration, consider the conclusions of a 2019 research review of 21 studies about weight bias in medicine (1). The researchers found that patients at higher weights routinely experienced:

• Contemptuous, patronizing and disrespectful treatment
• Health care providers attributing all health issues to weight
• Health care providers making assumptions about patients’ behaviors and beliefs based on weight
• Avoidance or delay of health services because of fears of judgment about their weight

Michigan Medicine’s commitments to excellent patient care and health equity mean going the extra mile to build trust with all patients, especially those who may be at greater risk for discrimination.

Below are some actions health care providers can take to keep from unintentionally harming patients at higher weights.

• Create accessible spaces (2). Ensure that chairs, blood pressure cuffs, gowns and other equipment are large enough to accommodate patients at higher weights.
• Offer evidence-based medical interventions. Weight loss interventions do not lead to sustained weight loss and/or health improvement for the vast majority of people. In addition, dieting can put people at risk for health consequences related to weight cycling and disordered eating. Focusing on weight or weight loss in lieu of other evidence-based treatments (i.e., those you might offer to a patient at a lower weight who presents with the same complaints) may also contribute to health inequities.
• Do not require weigh-ins unless they are medically necessary. Do not automatically require patients to be weighed. If a patient refuses to be weighed at a routine appointment, respect that decision and move on to the rest of the appointment. If having an accurate weight is medically necessary (e.g., for medication dosing), explain to the patient why they need to be weighed, and offer blind weighing if that is what your patient prefers. 
• Do not make assumptions about a person’s health or behaviors based on their shape and size. Interventions and recommendations for behavior change should be individualized and based on your patient’s goals.
• Don’t use BMI as a proxy for health (3). Though widely used in health care settings, the Body Mass Index (BMI) was not created as a health care tool. It does not accurately measure health. As a simple ratio of weight to height, the BMI cannot determine how much fat a patient’s body has. And as a tool created using statistics based on a mostly-white population, the BMI is even less accurate for Black and Asian people.
• Believe what patients tell you. One particularly important way to earn trust is to believe what patients tell you about themselves. Do not act surprised if a patient in a larger body tells you they exercise regularly and/or eat a lot of fruits and vegetables. Similarly, do not be skeptical if a patient at a higher weight says they are experiencing disordered eating behaviors, such as extreme calorie restriction. Malnutrition can occur at any weight, and eating disorders are common in individuals with higher weights.
• Use inclusive language. Health care providers should not describe a patient’s shape and size to them (or to a colleague) unless it is medically necessary. In situations where such a description is medically necessary, consider using more neutral terms, such as “a patient at a higher weight” or “a patient in a larger body.” Though the terms “obese,” “obesity,” and “overweight” are accepted medical terms, they are not free from bias, and many people find them stigmatizing and offensive.
• Remember that you are powerful. Health care providers are in a position of power. The words you use with patients can stay with them for days, months, or years, and could affect their decision to reach out for healthcare in the future. Doing extra work to establish trust with your patients at higher weights could have a profoundly positive effect on their health and wellbeing for years to come.

Sources:

(1) Weight bias and health care utilization: a scoping review

(2) This recommendation is inspired by blogger, athlete, and fat activist Ragen Chastain’s article, “Things to Stop Saying/Doing to Fat Patients at the Start of Their Appointments.” 

(3) The history of the BMI described in this recommendation is based on “The Bizarre and Racist History of the BMI.”