Tipping the scale: How to make weight discussions more empathetic

On a beautiful Texas day, I settle in for a coaching appointment with my third patient of the day. As we discuss their success, obstacles and vision for health – I am nagged by a perpetual sensation that we are both distracted. And as I reflect later, I realize that our conversation was persistently leaning toward an object in the room that dominated the entire session – the scale.

I can’t help but wonder: is this really the best way for me to spend my counseling and education time with patients? My next patient enters the room and I watch their tightly coiled body relax when I do not even broach the subject of weight. We start an invigorating dialogue about their favorite places to walk and a recent recipe they found that finally provided a breakthrough for brussel sprouts in their diet.

I ended the day internally chafing at the “scale” small-talk patients feel forced to have with me: “I promise it is just my earrings weighing me down” (they always chuckle).

Somewhere in the haze of these encounters, I went on a journey that made me aware of the prevalence of diet culture, fat phobia, and weight stigma in the United States. A recent HuffPost piece summarizes this basic concept. Patients who do not fit the medically and socially constructed norms of weight are casted aside by our culture.

Much of this stigma comes from what Aaron and Stanford titled the ‘dispositionism epidemic’—we as a society distract ourselves from the structural issues that lead to the ‘obesity epidemic’ and instead blame the individual for lack of willpower and discipline. If I had a dollar for every time a patient told me that they “just need more willpower,” well, I would be writing this blog post from Tahiti.

The real problem with the weight stigma epidemic though, is that it disproportionately impacts BIPOC (Black, Indigenous, People of Color) communities and medicine’s insistence we focus on weight as a metric of health further marginalizes vulnerable folks and — even more troubling, may further social inequities and health disparities.

These issues have been crystallized in the pandemic; scholars point out the disproportionate impact of the pandemic on BIPOC communities is partially explained by the disproportionate impact of obesity. Rather than addressing the structural inequalities that exist, instead, we drill down on the individual and cause stress responses that further obesogenic processes, psychological distress, and delays in care.

At the very least we should be attuned to the stigma our patients may have experienced interacting with the healthcare system and society – and work to create empathetic, weight-neutral environments for health promotion. I use an acronym to frame this practice: E. A. T.

• “E” stands for empathy: Create empathy by empowering autonomy, asking open-ended questions, and demonstrating deep listening using reflections.
• “A” stands for asking: Ask permission before you council about health behavior.
• “T” stands for translating: Help patients translate weight-centric goals into health behaviors that really matter.

More importantly, we can reflect on our own contributions to a society that emphasizes a discourse centered around personal responsibility as a distraction from the structural issues that surround equity in pursuit of health.

-By Sarah-Ann Keyes MS, PA-C, assistant professor in the Physician Assistant Program, assistant professor, Education Innovation and Technology, and medical ethics scholar in the Center for Medical Ethics and Health Policy at Baylor College of Medicine