E71: Louise Metz on Weight Inclusive Medical Care
Weight stigma, bias and discrimination can have very profound impacts on individuals. Medical settings are a place where there are real opportunities to make change and today’s guest, Dr. Louise Metz is a change maker. She is passionate about providing weight-inclusive medical care, and committed to helping to change the paradigm surrounding the way we address weight and health.
So what do we know about weight bias in healthcare settings?
Weight bias again is negative weight related attitudes and beliefs that lead to bias and discrimination towards people in larger bodies. People in larger bodies experience weight bias at a very high rate in medical settings. We also know that physicians tend to associate people in larger body sizes with non-adherence to treatment and dishonesty and to make assumptions about behaviors and health based on body size. There was one study that looked at about 2,500 women who were overweight or obese and found that 69% of them reported experiencing weight bias by doctors, and 46% by nurses, and 37% by dieticians.
How we might see this play out in medical settings really pans out throughout a medical visit. So even the very first thing that happens when a patient goes to a medical visit is that their weight is often taken sort of in a public area of the clinic. So from the get go there’s a big focus on weight and sometimes there are comments made around that. Then you’ll find that sometimes the equipment, so the blood pressure cuffs, the chairs in a medical office, the gowns don’t accommodate people of all body sizes. Then as the visit goes on, you’ll see that the providers really focus on weight management as the main focus or sometimes many and all medical complaints that people come in to the doctor for.
You were mentioning negative attributes people who practice in medical settings may have against overweight people. Do you think that people who work in medical settings, is there something special about the way they’ve been trained or the way they have learned to practice that makes them different than people in general?
Yeah, I think that’s a good question. So healthcare providers, of course, we live in this society where weight bias is pervasive and so all of us carry that implicit weight bias. But once we get into healthcare and our education and training that weight bias is really reinforced throughout medical education and medical training. So I do think that that sort of heightens that weight bias, but a caveat there I would say is that healthcare providers, of course, we all mean well and believe we’re always acting in patient’s best interest. But unfortunately this kind of weight bias and stigma turns out to be harmful to people’s health.
So I’ve heard you mention the traditional weight-centric approach to health within the medical system. What do you mean by that and do you think research supports the use of that approach?
So the weight-centric approach is really the typical standard in our medical system in which the health care system prioritizes weight as the main or one of the main determinants of health. Therefore there’s a huge focus on weight management for the treatment and prevention of disease, but unfortunately this is really based on a lot of assumptions. So it’s based on the assumption that weight may actually be within our control, that weight loss could be maintained or sustained and that a higher weight equates to health risk. But we don’t really have good research to support those assumptions.
For instance, if you look at BMI, which tends to be considered a determinant or a measure of health, we find that the literature does not support this as a very good measure. So for instance, if you look at BMI as a measure of metabolic health, so we tend to think of higher BMI being associated with abnormal metabolic parameters like blood pressure, or cholesterol, insulin resistance. But one study from the archives of internal medicine looked at this question and found that if you use BMI as a measure of health, you will actually misdiagnose people in a high percentage of times.
So for instance, 23.5% of “normal weight people” have an abnormal metabolic profile. So if you assume they’re healthy based on their BMI, you may miss these folks who have abnormal metabolic conditions. Similarly, people who are overweight or obese, you will misdiagnose a high percentage of those. So 51% of those who are overweight or 32% of those who are obese will actually have a normal metabolic profile.
So then if you have somebody in a medical practice whose BMI would look to be treatable, that is they’re overweight or obese by traditional standards but they don’t have the adverse metabolic profile that you’ve mentioned, then what would be done normally in your practice?
So in our practice, we’re going to really take the focus of weight completely out of the equation. It appears that though in some cases there is an association between BMI and certain health conditions, this may be a correlation and not actually causation. So I think we’re really asking the wrong questions in healthcare and so we really need to start taking the weight out of the equation and focusing on behaviors, things that can lead to improvement in one’s health. If there is a correlation, what might be the mediators between BMI and certain health conditions like genetics, or cardiovascular fitness, or the effects of weight stigma or weight cycling on health.
And how do you think about interventions that would ordinarily be used to treat weight itself? So medications let’s say, or surgery?
Medications, they may decrease an individual’s weight in the short term, but not in the long term and that’s really what we see kind of across the board for weight loss interventions is that there will be short term decreases in weight, but in the long term people do regain that weight. So in fact, extensive literature will show us that over 95% of people who lose weight will gain it back and that two thirds of those folks will regain more than they lost. So I don’t find that treating with a medication is beneficial in the long term. And again, it’s targeting an outcome that I do not believe will improve one’s health. Similarly, I also have concerns about surgery and whether in the long run we can be harming people in certain ways due to the complications that occur with weight loss surgery.
So let’s get back to the issue of the stigma itself. So what does the medical literature show about how weight stigma affects health?
What we know is first that people who experience weight stigma in health care avoid seeking care. In fact, people in larger bodies are much less likely to go in for their preventive medical care. So for instance, we know that there are lower rates of women having pap smears, mammograms and people having colonoscopies due to the weight stigma experienced. So that’s a significant and a harmful effect on an individual’s health and there’s continuing emerging literature showing us that internalized weight stigma, so when people learn and adopt these negative attitudes about weight within themselves, that that is associated and can lead to health conditions.
So, for instance, internalized weight stigma is associated with hypertension, an increased risk of diabetes, metabolic syndrome, and also depression and eating disorders. And so we’re finding that weight stigma really is one of those mediators that could explain some of the association between BMI and health. So really some of the very conditions that doctors are blaming on weight may actually, at least in part, be caused by the weight stigma.
How do you figure stress fits into all of this?
Well I think stress is a big part of this. So experiencing weight stigma certainly is a stress on the body and other forms of trauma that we see also affecting the body in forms of stress. For instance, we know that experiencing weight stigma increases cortisol reactivity in the body and so that stress experience leads to spikes in cortisol levels, and that cortisol reactivity may be a mediator that leads to some of these metabolic conditions.
How do you do things differently than people might be doing in the normal practice?
We exclusively practice with a weight inclusive approach and so what that means is that we recognize size diversity, which means that people come in all sizes and there’s really a normal distribution on a bell curve of people’s sizes. So we do not pathologize body size and really recognize that diversity, that it’s really based on genetics as well as some social factors. We really try to bring that within our practice, starting from the spaces that people enter in the waiting room. We want to make sure that there is seating available for all body sizes and that there may be inclusive images on the walls and then kind of moving through a patient visit. We do not weigh patients when they come in. Patients kind of go straight into an exam room and have vitals taken without a weight.
Now there are a few indications, rare indications, in which we do check a weight and when we do need it, we do it blindly so where the patient can’t see the weight and we do it in the room in a private setting. But that would really only be for the very rare indications such as a weight-based medicine, a patient with an eating disorder who is in active treatment and is weight suppressed, or an adolescence for whom we’re measuring on a growth curve. So really we kind of take weight out of the equation and that decreases the shame experienced. And so then in the exam room we want to make sure that we have exam table chairs, blood pressure cuffs that come in all sizes. The equipment in the room is very important and then we really take the focus off of weight and that allows us to focus on patient-centered health goals, promoting behaviors and focus on evidence-based treatments for the conditions that they’re experiencing.
Is this kind of approach common? Do you see other medical practices doing this kind of thing?
So it is not. It’s actually a very rare approach and I hope that over time we will find a way to gradually change this paradigm, but it’s very uncommon and we believe that we are one of the only primary care practices that exclusively practice in this way. But we’re really finding that there’s a high demand from individuals who want to seek this care. We have folks coming from all over the state to see us, many of whom haven’t sought medical care in years because of their previous experiences with weight stigma. I really believe that this is the only ethical and evidence-based way to practice medicine and I’m really hopeful.
This may help the way families think about people in their family who struggle with weight issues. Have you had that experience?
Yes, definitely. Definitely. I think in particular as our patients kind of think about their children, we do talk to them a lot about that and thinking about approaching, talking about body size and food in a different way with their children. Weight inclusive care and health at every size care.
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Louise Metz is an Internal Medicine Physician specializing in the medical management of eating disorders and gender-related health care. She is the owner and founder of Mosaic Comprehensive Care, a medical practice in Chapel Hill, NC. She created Mosaic using a unique model of individualized and collaborative care with a focus on body diversity and complexities of health. She is passionate about providing weight-inclusive medical care, and committed to helping to change the paradigm surrounding the way we address weight and health. Metz holds an undergraduate degree in Biology and Women’s Studies at Duke University, and a doctorate in medicine from the University of North Carolina.