Until she was in her mid-30s, Xanthia Walker rarely went to the doctor, even when she needed care. She didn’t want to step on the scale.
When she did go in — to treat sciatic nerve pain or get antibiotics — somehow the conversation always turned to her weight.
“Even when I went in about migraines, the response was, ‘Well, if you lost weight that would probably go away,’” she recalled.
That changed when Ms. Walker, 40, who lives in Phoenix, found a new physician. Dr. Natasha Bhuyan rejects what she calls the “weight-centric” model of medicine.
Instead, she favors a “weight-inclusive” approach recognizing that people come in different shapes and sizes, and that the number on the scale does not necessarily predict health status.
“When a person comes in, the first thing we do is not check their weight,” said Dr. Bhuyan, who is the vice president of in-office care and national medical director at One Medical, a primary care practice owned by Amazon.
“We bring them back, sit in the exam room, and just talk with them,” she said. “It’s a paradigm shift — if we do feel we need to check their weight, we get their permission.”
That approach is still controversial for many doctors. Medical school students are taught that a patient’s weight is one of the vital signs that should be checked at each medical encounter, like blood pressure.
And it runs headlong into the deeply ingrained belief that patients can control their weight if they put their minds to it.
Critics note that obesity is the top health concern in the United States, stoking Type 2 diabetes and hypertension, and contributing to heart disease, stroke and some cancers. They say physicians should address weight as the No. 1 priority.
Ignoring a patient’s weight is missing an opportunity, said Dr. Caroline M. Apovian, co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston.
“I can see doing this maybe 10 or 20 years ago, but now? Now that we have these great new treatments, why would you do this?” Dr. Apovian said, referring to powerful new weight-loss drugs and bariatric surgery.
If anything, she said, doctors should focus on the patient’s obesity before the medical conditions that often come with it.
“If primary care providers all over the country can address the obesity first and treat it, then in the long run we are going to reduce the incidence of all these other problems,” she said.
Body weight “is as much a vital sign as blood pressure and respiratory rate,” said Dr. Steven B. Heymsfield, a professor of metabolism and body composition at Louisiana State University’s Pennington Biomedical Research Center.
“Unless the patient is phobic around their weight for some reason, it makes no sense not to quantify it from the medical perspective,” he said.
While asking for a patient’s consent before weighing can foster “a more patient-centered approach,” said Dr. Fatima Cody Stanford, an obesity specialist at Harvard Medical School, “it is crucial that patients are informed about the options available to them, including weight management strategies, and that these discussions are approached with empathy and support.”
But doctors who eschew routine weigh-ins believe the link between excess weight and harmful chronic health conditions has been overemphasized in medical training.
Telling patients they are fat is almost guaranteed to drive them away from care while doing little to improve their health, they say.
And research shows that maintaining an optimal weight is not about willpower. A person’s weight is also the product of genetics, early childhood experiences and other environmental and social factors.
New medications like Ozempic are challenging the traditional mind-set among medical professionals by demonstrating that biology can matter more than willpower.
“At an annual physical, that is a definitely a time when I do want to know the patient’s weight, but what I’m looking for is a big fluctuation in one direction or another,” said Dr. Alexa Mieses Malchuk, speaking for the American Academy of Family Physicians.
A major swing could indicate nutritional deficits, an endocrine disorder or a malignancy, she added. But routine weigh-ins at every appointment are “a bad practice,” and something that “some medical practices are moving away from, and I hope all will move away from.”
The U.S. Preventive Services Task Force first recommended screening patients for obesity in 2012, saying that those with a body mass index of 30 or above should be treated with “intensive, multicomponent behavioral interventions.”
The task force, which prides itself on developing evidence-based guidelines, acknowledged at the time that there was not much evidence proving the interventions would have an impact on long-term health. The screening has nevertheless become enshrined in medical practice.
There have always been physicians who adhere to the “health at any size” approach. But recently, several larger practices have eliminated routine weigh-ins at all encounters for adult patients who aren’t pregnant.
One Medical, which has more than 200 offices around the country, is one of the groups that have moved away from weigh-ins. Its app was even developed in such a way that people can hide their weight if they do not want to see it, Dr. Bhuyan said. (Dr. Malchuk works for the group as well.)
The recent changes at One Medical, Dr. Bhuyan said, are motivated in part by a growing body of research indicating that routine weigh-ins elicit shame in many patients, increasing the likelihood that they will avoid future medical encounters.
One of the earliest such studies, in 2006, surveyed close to 500 white and African American women to find out what prevented them from getting screened for gynecological cancers.
Obese women reported the most delays in screenings, compared with those who were overweight, despite the increased risk of cancers associated with obesity. The percentage avoiding care increased in lockstep with rising body weight, according to the study, published in the International Journal of Obesity.
The women who avoided care reported embarrassment about being weighed, providers’ negative attitudes toward them and the likelihood of getting unsolicited advice about losing weight.
A more recent study of 384 women, published last year in the journal Annals of Family Medicine, found that almost one-third of participants said they had refused to be weighed by a physician or assistant because of the negative impact on their emotions, self-esteem or mental health.
“Folks are avoiding health care to avoid the scale, for a lot of reasons,” said Ginny Ramseyer Winter, the author of that study and an associate professor at the University of Minnesota.
“They don’t want to see the number. And they’re missing out sometimes on lifesaving preventive care just because they don’t want to be weighed,” she said.
The family medicine practice at the University of Rochester Medical Center in Rochester, N.Y., which serves some 26,000 patients, recently dropped routine weigh-ins. Dr. Holly A. Russell, an associate professor of family medicine at the university, said the new policy had brought thoughtfulness into weighing patients.
“It’s not that we have entirely stopped weighing patients, but we don’t do it for everybody without thinking,” Dr. Russell said.
“We only check people’s oxygen levels if they’re there for a complaint due to shortness of breath,” she added. “And we check their weight if they’re there for a concern related to their weight.”
More important, Dr. Russell said, patients have a say in the matter.
“Patients like not being weighed, but what’s remarked on more on is having the choice,” she said. “I think that gives them a little bit of power back around something that often makes them feel powerless.”
During discussions at the university about adopting the new policy, Dr. Russell said, some physicians confided that they were putting off their own annual physicals so they could lose weight before going in.
It’s not as if these patients don’t know that they are heavy and need to have it pointed out to them, said Dr. Emily A. Gordon, an internist with Rutgers Health and assistant professor of medicine at Rutgers-New Jersey Medical School.
“They may have trouble buying clothing or fitting into a seat on an airplane,” she said. “A blood pressure cuff may not fit. I don’t think I need to make people aware of it.”
While weight loss may sometimes help ameliorate conditions like Type 2 diabetes, high blood pressure or cholesterol, she said.
“There are so many other things that can also help with those medical problems, like decreasing stress, better sleep, access to green spaces to walk in. Focusing only on the weight is not something that’s definitely going to be in the patient’s control, and very shortsighted.”
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