Time to look beyond the scale?

Bernie Salazar felt fine, as good as any healthy father of a 2-year-old. He only scheduled a doctor’s visit because he received a calendar alert reminding him it was time for his annual wellness checkup. Bernie and his relatively new doctor had already discussed his weight, dieting history and health status the previous year, and he’d gotten “all clear” after normal lab results. But this time, after he stepped off the scale with what he considered a scant four-pound increase on his 260-pound frame, the doctor suggested it was time to talk about weight-loss surgery.

“I felt a very familiar sense of defeat and shame. Why would my doctor recommend a highly invasive, irreversible surgery without knowing my [most] recent labs or discussing my habits? He didn’t ask if I was concerned about my weight or if was open to discussing weight loss at all,” says Salazar, 37.

As the at-home winner of the fifth season of NBC’s “The Biggest Loser,” Salazar knows what losing weight requires from him: hypervigilant eating and exercise, significant investment of time and money, and sacrifice to his mental health. “I’d exercise for hours on end, limit myself to small portions of food, and fight constant hunger. My mind was always worried if I was losing or gaining weight,” says Salazar, who appears as an occasional guest on my podcast, Body Kindness. In the years that followed the show, his weight rose again — like that of most other contestants.

About the time his daughter was born, Salazar decided to stop the weight cycling “yo-yo” and instead focus on good habits, such as getting enough sleep, exercising regularly (including taking his daughter on daily walks), and cooking more at home. Though he had previously avoided the doctor because he couldn’t bear any more negative judgments about his weight, he also vowed to get annual physicals. Salazar feels better physically and emotionally with this approach to health, even though it doesn’t produce significant weight loss. But his promise to himself to get a yearly physical was being tested by this new doctor.

This tension between Salazar and his doctor is common: In a review of research about weight stigma — discrimination based on weight — Rebecca Puhl and Chelsea Heuer noted that 69 percent of higher weight women reported feeling stigmatized by their physician. Furthermore, they said, research has shown that some health-care providers view their obese patients as lazy, noncompliant and undisciplined. A 2018 Drexel University study on health-care avoidance showed that one’s body mass index (BMI) was correlated with weight stigma, increased body shame, and rising health care stress. Some patients give up on doctor visits as an attempt to escape their stress and anxiety around health care encounters. Epidemiologist and biostatistician Janell Mensinger, the lead study author, says that makes it difficult for people to stay healthy. “Avoiding health care can result in the delay of important routine screenings, diagnosis and treatment for health issues.”

By weighing their patients, doctors are following guidelines. The U.S. Preventive Task Force recommends physicians screen all adults for obesity by weighing a patient, calculating BMI, and offering or referring patients to behavioral interventions if their BMI is 30 or greater. However, the recommendation does not acknowledge weight stigma as a possible harm of the screening, nor does it suggest asking the patient for consent to do the screening. Patients have the right to decline being weighed, as with any other medical screening.

What if doctors stopped using BMI as the trigger for conversations about behavior changes and instead collaborated with patients on the importance of healthy habits, regardless of their weight? This approach would probably reduce body shame and and improve health care.

Ana Paunovic, a Washington-based internist, has changed how she handles the issue of weight. “I delay weighing new patients so I can make sure doing so would not cause harm, like in the case of clients with eating disorders or a history of body shame,” she says. Paunovic suggests that patients who would prefer a weight- neutral approach bring a letter stating their desires to their appointment. She believes many providers are still unaware that they may be reinforcing weight stigma and will respect their patients’ boundaries. Paunovic doesn’t discount weighing patients at the doctor’s office as a matter of routine screening. “If there are sudden weight changes, physicians can look for signs of health problems, including malnutrition, which can happen at any size.”

It’s unclear how much health-care stress affects higher weight people when they do go to the doctor, but Mensinger wants to study it. “We need data to determine if stress over the health-care encounter is being expressed in the body with the overproduction of stress hormones, such as cortisol,” she said. The U.S. Preventive Task Force also suggests further research into what effect screening for obesity has on long-term health outcomes. Perhaps such studies will encourage the medical profession to examine its treatment of patients at higher weights. But for now, “the burden of reducing weight stigma at the doctor’s office currently falls primarily on the patient,” Paunovic says.

This is how Salazar says he will handle that challenge: He will return for a wellness visit next year, rather than let stigma keep him away. But he will be setting firmer boundaries around weight conversations with his doctor or finding a new provider who will respect his body no matter his size.