In recent years, several qualitative studies have given us field notes of patients describing their experiences having larger bodies and interacting with the health care system:
“I think that medical professionals will often cut people off about other medical concerns and blame everything on being overweight. Patients need to have their other concerns taken care of and not being ignored while their weight is the main focus.”
“I feel I have little control of my weight because of medical conditions so am embarrassed when I have to weigh in.”
“And like [sic] I was doing my best, it was probably the healthiest I had ever been […] and it still wasn't enough for me to be treated correctly. For me to be accepted as a human who needed help, instead of a fat person who needed help. It wasn't enough for him.”
“I was at the doctor for… chronic ear problems… and left with a diet… I think that probably started my [eating disorder] journey.”
These experiences are all too common for patients in larger bodies. Like all of us, health care providers have varying degrees of implicit and explicit bias against people in larger bodies. But this has a direct impact on patients: studies have shown that primary care providers have less respect for patients with a higher body mass index, which can result in less time spent with these patients in clinic. When presenting with a medical issue, patients in larger bodies experience a hyperfocus on weight and more frequent counseling on “lifestyle recommendations” than patients in smaller bodies, who may receive further testing or medication options.
This stigma in the medical environment leads to avoidance of the health system and delays in care. It is no surprise that the degree of weight stigma and discrimination faced by patients has been correlated with increased mortality, regardless of body size.
The goal of primary care physicians is to create a trusted relationship with patients to work towards an individualized and patient-centered idea of health. If our current practice of weight-centric management—focusing on body weight and BMI as treatment targets—is harming our relationships with our patients and contributing to poor health outcomes, is there an alternative?
In our practices, we have embraced another option for managing patients called weight-inclusive care, which focuses on changing health behaviors rather than changing weight. This approach to care puts modifiable behaviors such as movement, hunger and satiety, sleep, stress, pleasure, and body acceptance at the center while avoiding perpetuating stigma. Focusing on behaviors such as consumption of nutritious foods and physical activity can lead to improved metabolic fitness at any body size. In a systematic review and meta-analysis, improved fitness levels decreased cardiovascular and mortality risk regardless of BMI.
Weight-inclusive management has also been shown to improve depression and anxiety. This is in contrast to dieting for weight loss, which in some studies has been associated with higher rates of depression. Following weight-inclusive techniques also helps patients create more intuitive eating patterns associated with improved quality of life and metabolic fitness, again in contrast to weight loss attempts that are associated with more disordered eating patterns. Another added benefit is that because weight-inclusive care is individualized with a low risk of side effects, people are better able to engage in weight-inclusive care plans compared to those involving intentional weight loss.
How can clinicians implement weight-inclusive care in practice?
Clinicians can create trusted spaces in individual encounters with patients and in our communities while working to dismantle harmful structures that lead to health inequity:
- Clinicians should work to address their own structural biases learned from a weight-centric world and medical education. Instead of immediately jumping to weight loss, clinicians should ask themselves: how would we address this issue in someone who is not in a larger body?
- Clinicians can respect a patient’s bodily autonomy while still practicing weight-inclusive care. People in larger bodies may feel weight loss is the only way to achieve health, or they may feel that the benefit of reduced stigma outweighs the risks of weight loss. Clinicians can use the same shared decision-making approach as they would with any other intervention.
- Clinicians can educate colleagues and patients on meaningful ways to minimize harm and promote inclusive approaches to health. In our practice, we have created a “Health for Every Body” patient group, where patients can learn together about how to focus on their health without focusing on their weight, sharing and supporting each other in a safe environment.
- Clinicians can advocate for implementing weight-inclusive policies and structures within their institutions. This can come in many forms including updating facilities to be weight-inclusive, de-incentivizing coding for stigmatizing diagnoses like “morbid obesity,” and improving medical education regarding non-weight loss treatments such as Health At Every Size.
It is important to emphasize that this framework does not ignore conditions that require weight monitoring as a measure of disease status. For example, patients who have heart failure need to be weighed to assess fluid balance. Infants, children, and teenagers need to be weighed to assure appropriate growth and screen for disordered eating. The role of a clinician, which includes optimizing organ function, does not change with taking an approach that destigmatizes body size.
All medical doctors strive to live by the principle of doing no harm. Weight-inclusive care provides clinicians with an opportunity to enhance the health of our patients without causing further harm through stigmatization, body shaming, health care avoidance, and even missed diagnoses due to a preoccupation with body size. Using the tools of the weight-inclusive care model can help us lead our patients toward better, more equitable health—for everybody.
This article was published as part of a series for Obesity for World Obesity Day, March 4, 2025. View the full Special Series for more articles and messages from the editors regarding language and content.
Special Series
About the authors
Cortney Crespo, MD, MMedEd, is a Family Medicine physician at Cambridge Health Alliance, Associate Director of the Integrative Medicine Educator Fellowship and Clinical Faculty at the Tufts University Family Medicine Residency Program. She received her MD from Stony Brook University School of Medicine in New York, completed her residency and fellowship at Tufts University Family Medicine Residency, and received her Masters of Medical Education from the University of Dundee. Cortney enjoys teaching residents and medical students, and educating about integrative medicine and weight inclusive care as a path toward health equity.
Madhuri Rao, MD, is a Family Medicine physician at MGH Chelsea Healthcare Center and an Instructor in Medicine at Harvard Medical School. She completed her residency at Tufts University Family Medicine Residency program where she was a chief resident. She received her MD from George Washington University with a track in Clinical and Translational Research. She was the recipient of a Clinical Learning Environment Innovation grant with which she helped develop the “Wellness for Every Body group.” She enjoys using her academic time to research health equity issues including reproductive justice, LGBTQ health, weight inclusivity to help advocate for her patients.
Geraldine Malana, DO, MPH, is a Family Medicine Physician at Cambridge Health Alliance,Faculty of the Tufts Family Medicine Residency Program, Clinical Instructor at Tufts University School of Medicine, and Lecturer at Harvard Medical School. She received her DO/MPH from A.T. Still University in Arizona and completed her residency at Northwestern McGaw Family Medicine Residency at Humboldt Park in Chicago. Geraldine's professional interests include health equity, weight inclusive care, and osteopathic medicine in primary care.
**Feature photo obtained with a standard license on Shutterstock.
Interested in other articles like this? Subscribe to our newsletter.
Interested in contributing to Perspectives in Primary Care? Review our submission guidelines.
