About five years ago, Sarah Barak badly tore a ligament in her thumb and needed surgery to get it reattached.
But when she went in for the operation, she got some unsolicited advice: The surgeon said she should lose weight, suggesting that her size and her injured thumb were connected.
"He was making the argument that my posture was affecting my arm pain and that my posture was made worse by my size, all of which could be true," Barak says. "But I still had a disconnected thumb, and even if I lost 100 pounds, the thumb would not have been reattached on its own."
Barak says she's assertive about advocating for the care she needs — but it's draining.
"It's freaking exhausting," she says. "And frankly, not everyone can do it."
For years, weight has been used as a measure of health in doctors' offices. Having a higher body mass index is correlated with heart disease, diabetes, certain types of cancer and other conditions.
But in recent years, research has shown that when clinicians focus on weight, it can lead patients to avoid or delay health care, including recommended cancer screenings. People with larger bodies often report that when they go to the doctor, their problems are ignored or written off as an inevitable result of their weight. Without asking questions, they say, health care providers suggest diets they've already tried and lifestyle changes they've already made.
Providers sometimes miss major health problems — in both people with larger bodies and those with smaller ones — when they're too laser focused on a patient's weight, says Dr. Lisa Erlanger, who practices weight-neutral medicine and is a clinical professor at UW Medicine in Seattle.
"There's so many horrible stories ... of diagnoses that were missed because the focus was on weight," Erlanger says.
A Seattle clinic tries a weight-neutral approach
The evidence that focusing solely on weight can harm patients has led some in health care to examine their approach.
In June, the American Medical Association started recommending that clinicians look beyond body mass index to understand a patient's health. The new policy says to consider factors like genetics, blood sugar levels and where there is fat on a patient's body.
But a growing number of providers are going further than that: practicing what they call weight-inclusive, or weight-neutral, care. Some subscribe to a set of principles called "health at every size."
"In most cases, the care that you're providing should be the same no matter what the number on the scale is," says Tess Moore, a family medicine physician in Seattle who has made her practice weight neutral.
Moore started by trying to make her clinic feel comfortable for patients of all sizes. Every exam room has an array of blood pressure cuffs for different-size arms, as well as gowns and speculums of various sizes. The chairs and exam tables fit all patients.
But it's Moore's approach to talking about weight that's most different from a more traditional practice.
"We don't recommend weight loss as a way of treating medical conditions," Moore says.
Instead, she tells her patients that exercise and nutritious food are good for them regardless of whether or not they lose weight.
"We recommend moving your body in a way that's sustainable, which hopefully is joyful," she says, and "eating food in a way that nourishes."
Moore says that emphasizing the inherent benefits of exercise can help people start, as well as stick with, a routine. She points to research showing that even well-meaning comments about weight from family members and doctors can increase exercise avoidance and that people with more internalized anti-fat attitudes are more likely to avoid exercise when they experience weight stigma.
"If after that discussion, a patient still is fairly certain that they want to focus on weight loss," Moore says, "I do tell them that it is likely to fail in the long term."
For example, a meta-analysis of 29 long-term weight loss studies found that, on average for people with obesity, more than half of the weight lost was regained within two years and that more than 80% was regained within five years.
"When someone loses weight, it kicks in a series of hormonal changes that tend to increase appetite and slow metabolism," says Ellen Schur, an obesity medicine doctor and researcher at UW Medicine.
Moore says ultimately her goal is to focus on a patient's long-term health and make "recommendations that are much more likely to be sustainable."
"By making the decision not to recommend weight loss, it opens a door rather than closes a door," she says.
If done in a "respectful" manner, weight loss advice still has a role
Schur and others who specialize in obesity medicine say they recognize the need for a new approach when talking to patients about their weight, but they say it's still possible to encourage weight loss when appropriate.
"For some folks who have a condition like diabetes, weight loss in combination with some lifestyle changes could be an option that they would choose," says Schur.
She agrees with weight-neutral providers like Moore that encouraging patients to exercise and eat nutritious food has obvious benefits. Still, for some patients, weight loss can have additional benefits, she says.
For example, studies have shown that even a relatively small amount of weight loss — in the range of 3% to 7% — cuts the chance of developing Type 2 diabetes for those at risk and improves blood sugar among those who do have diabetes.
And Schur says that when weight loss might help, doctors should say that.
While there's a long history of weight bias in American society, including in health care, Schur says it's possible to have conversations about weight loss that are sensitive and respectful.
"When a physician is approaching it in a nonjudgmental manner and not assuming that a person hasn't made changes, it can be discussed as a treatment option in a way that's supportive," she says.
Schur says that increasingly, weight loss drugs like Wegovy are her primary tool for managing patients' weight.
"To be totally honest, what we've been asking them to do, you know, with just lifestyle alone has been unrealistic," she says.
Critics of the newest weight loss drugs point to their limitations: They're expensive and in short supply, and their long-term effects are still unknown.
And weight-neutral providers say that even in a world with these new drugs, people with larger bodies still need to feel heard and respected in the doctor's office and have their primary health concerns addressed.
