‘Seeing’ Obesity: How Doctors and Patients Can Do Better

July 5, 2023 – After Mia O’Malley gave birth in 2018, she retained fluid in her legs – a common occurrence after giving birth. The swelling made walking, sitting, and caring for her newborn painful and uncomfortable. She went in for a check-up, and her doctor told her it would eventually go away with regular movement and elevating her legs.

Months passed and the painful swelling wouldn’t subside, so she saw a different primary care doctor. O’Malley said the second doctor didn’t examine her legs, but instead implored her to focus on one thing: losing weight. She left with information on which calorie-counting apps to download.

As time went by and the swelling persisted, she went back to the second doctor and asked for a water pill to flush out the fluids – something she had seen other new parents discuss online. The doctor obliged, and within days, O’Malley’s swelling was gone. She realized she could have avoided 6 months of potential health risks and pushing through pain if only her doctor had seen her as a person, not just a bigger body.

“There are a lot of things that happen in my body that I feel like I have to educate my [health care] providers on,” O’Malley said. “I wish that was different.”

Weight Stigma in Health Care Runs Deep

In some cases, like O’Malley’s, patients don’t feel heard because they doubt their doctors can see past their obesity. At the same time, the weight loss advice that doctors tend to give – eat less, move more – often doesn’t work. While some doctors do specialize in obesity treatment – obesity medicine has been growing since the field was established in 2011 – most receive little training in how to talk about and treat obesity.

There’s more. The negativity of weight stigma can lead to more unhealthy behavior, including disordered eating, more weight gain, and alcohol use, and it has been linked to higher suicide risk.

All this is bad news for people and for public health, as it leaves people living with obesity reluctant to seek help for any health issue, much less for weight management. In a country with skyrocketing obesity rates, that’s not good.

Obesity medicine specialist Fatima Stanford, MD, MPH, an educator and doctor at Harvard Medical School and Massachusetts General Hospital, sees patients from as young as 2 years old to upwards of 90. Among her diverse pool of patients emerges one common theme.

When It Becomes Easier to Simply Not Go to the Doctor 

For many larger-bodied patients, it’s common to go years without seeing a doctor. Studies have shown that people with obesity are less likely to be screened for certain cancers and more likely to delay care, in large part due to the negative attitudes they experience in health care settings.

Research also shows that overweight patients shop for doctors 23% more often than their lower-weight counterparts. For patients with obesity, that jumps to 52%, showing just how hard it is for those patients to find a compassionate provider and stick with them.

“Even though this is what I teach full-time, I didn’t go to the doctor for over 2 years, and during that time I gained weight already existing in a larger body,” she said. “I gained an additional 60 pounds, and it really affected my mental health.”

The long hiatus began pre-pandemic, after McLellan saw a doctor when she had a hard time breathing. A month before her appointment, she had completed a 5K and was in good health. She asked her provider for an inhaler but was told that would “hurt her heart.” The doctor ordered an EKG, which showed no abnormalities, but still refused to give McLellan a prescription for an inhaler.

As she was driving home, she nearly blacked out from lack of air. She ended up going to urgent care for an inhaler and was told she just had a restricted airway that needed help opening up after a bout with strep throat.

A New Path to Better Results 

Kristal Hartman, 45, is a member of the Obesity Action Coalition and has sought treatment for obesity throughout her life. She ultimately had bariatric surgery in her mid-30s.

Before the surgery, she had given birth to twins, and her health had suffered due to polycystic ovary syndrome and thyroid issues.

“I had little kids, and I’d already tried every fad diet,” Hartman said. “My primary care physician, who has never experienced obesity herself, just kept telling me to ‘just walk a little more and put down the fork and eat a little less’ – that was pretty much the only advice I got from her about weight management.”

This doctor was also an internal medicine specialist whose practice was said to be geared toward patients with more complicated health profiles, Hartman said. Eventually, Hartman’s endocrinologist recommended different treatment options, like medication and surgery.

“Even when researchers do very nice, controlled studies, only about 5% of people are able to lose 20% of their weight with lifestyle interventions alone. Forty-eight percent of people are able to lose 5% of their weight,” said Angela Fitch, MD, associate director of the Weight Center at Massachusetts General Hospital. “The biggest thing I tell people is that it’s not about your character; it’s about your chemistry.”

Getting regular exercise and eating a balanced diet are good lifestyle choices for everyone, not just those with obesity. But according to Fitch, patients usually need another intervention for successful weight management.

“A large majority of my patients – people I’ve been seeing for 10 or 12 years who have continued with care – probably an excess of 90% are successful in their treatment strategies,” she said.

A person’s weight management strategies often have to change over time. Even after Hartman lost significant weight from bariatric surgery, her weight began to creep back up (a not uncommon experience). She started taking a prescribed GLP-1 receptor agonist – a group of drugs that includes semaglutide (Ozempic, Wegovy) – to help her maintain her weight.

How Doctors and Patients Can Get Better Results Together

For heavier people who don’t have access to a multidisciplinary, patient-focused weight center – and doctors who don’t provide those specialized services – there are still ways everyone can achieve better treatment results.

For doctors: You’re seeing patients with obesity, but do those patients feel “seen”? Is your practice set up to accept and accommodate heavier patients? McClellan suggests looking at areas you may not have thought about previously, such as gowns that fit larger bodies, larger chairs in the waiting room, and scales with higher weight limits.

For patients: Check online for lists of “weight-neutral” or “size-friendly” providers endorsed by other larger-bodied patients. Lists like these are places where patients can add the names and information of providers they’ve had positive experiences with.

Ask questions and advocate for yourself, McLellan urges, even if you’re not comfortable doing so. “Am I going to be given a sheet or a gown that fits my body? Are they using a blood pressure cuff with the correct size? Are they taking your blood pressure the minute you’re hurried back to a room?” (According to the CDC, a patient must be seated with their back supported for at least 5 minutes with their feet flat on the ground in order to get an accurate blood pressure reading.)

Since incorporating these strategies, McLellan said she has finally been able to receive the care she deserves from a compassionate provider.

“I told [my doctor], ‘I want to be healthy,’” she recalled. “And we went through my lab results together. I had done a full blood panel, and he scooted his chair toward me and looked me straight in the eye and said, ‘You are healthy.’”