When so many children and adults struggle with obesity, it’s easy to see why weight loss is often celebrated. Unfortunately, health care professionals sometimes apply those same social narratives to clinical decision-making, and the consequences can be dangerous.
I’ve developed two distinct clinical niches: metabolic dysfunction and tuberculosis. A colleague once asked me to review the chart of a patient with a history of obesity who had been admitted to an outside facility. The patient, who was epidemiologically at risk for tuberculosis, presented with a large neck mass and had lost roughly 20 pounds within the 4 months prior. The alarm bells rang appropriately for my colleague, but by the time the patient reached a higher level of care, the same alarm bells had fallen silent. The infectious disease specialist downplayed the weight loss, attributing it to increased physical activity from the patient’s new job at a grocery store.
Dismissing this weight loss was a clinical error. I knew immediately that the patient’s obesity was skewing the team’s perception of risk—and I was hit with a mix of emotions, none of them positive.
I wish this were an isolated case, but we’ve all seen it: clinicians letting society’s ideas about weight cloud their judgment. If it really was as simple as “eat less move more,” then maybe this ID physician wouldn’t be too far off base; but this is implicit bias, and it’s costing patients time, trust, and timely diagnosis.
The irony? Many health care workers themselves struggle with overweight or obesity—some studies suggest that nearly 50 percent of nurses fall into this category. Yet even within our own profession, weight stigma persists. Despite decades of research showing that obesity is a chronic, multifactorial disease, it’s still too often viewed as a failure of willpower or character.
Unintentional weight loss is typically defined as a loss of 5 percent or more of total body weight over 6 to 12 months. The reality? It’s often pathologic, and having obesity doesn’t change the definition. When a patient presents with a neck mass and unintentional weight loss, the differentials are broad. Notably, cancer becomes a glaring concern. Ignoring a symptom like this simply because the patient has excess weight can lead to serious diagnostic delays.
We already have robust research showing that weight bias leads to worse care, misattributed symptoms, and delays in seeking help. I’d argue there’s another consequence that hasn’t been named enough: the dismissal of unintentional weight loss in patients with overweight or obesity, and the missed or delayed diagnoses that follow.
As clinicians, we must stay vigilant. We should calculate how much weight has been lost and ask ourselves what it actually means. A single pound of fat lost reflects a 3,500-calorie deficit. If a patient has lost 8 to 10 pounds without trying, that’s tens of thousands of calories unaccounted for, which should raise red flags.
Most people have tried to lose weight at some point, regardless of their BMI. Think back to a time when you were intentionally trying to lose weight: changing your diet, exercising, watching the scale creep down, if at all. Weight loss doesn’t happen easily for most people.
Ask your patient directly: “I see that you’ve lost weight. Is that something you have been trying to do?” When someone happily attributes a 10 percent total body weight loss over the past year to a switch from regular to diet pop—whether their starting BMI is 22 or 42—you better believe I’m documenting “unintentional weight loss” in the chart and following up accordingly.
Health systems also need to address their role in weight bias and stigma. We need to name this specific form of weight bias and train providers to reassess their assumptions. Health care providers must challenge societal views of obesity (laziness, lack of self-discipline, and poor choices) and replace them with science.
This is a deeply rooted cultural issue in health care; and it demands reckoning. When we inappropriately celebrate pathological weight loss, patients lose far more than pounds. Obesity and metabolic dysfunction are conditions I’m trained to treat, and treatment never starts with a character assessment. Stigma and bias? That is another epidemic entirely, and medicine has yet to face it.
Samantha Malley is a nurse practitioner.
