Managing Anti-Fat Stigma in Primary Care: An Observational Study

ABSTRACT

In many wealthy countries, fatness is stigmatized as a sign of personal failure. Health care interactions can enact fat-related stigmatization, which can worsen health outcomes. The present analysis highlights how stigmatizing discourses about fat bodies emerge in primary care appointments, and examines immediate conversational effects. Methods: Observational study in three primary care clinics in Canada, using conversation and discourse analytic methods on transcripts of 29 audio-recorded appointments with adults. Talk about weight and blood pressure are contrasted. Results: During measurement and review of measurements, clinicians routinely interpreted the blood pressure result but rarely interpreted weight. Patients of varied ages and body sizes often filled the interpretative vacuum, and focused on behaviors. Overall, neither patients nor clinicians challenged the stigmatizing discourses associated with fat bodies, but sometimes agreed that the “personal failure” frame associated with fatness does not apply to the particular patient. Physicians rarely raised other determinants of weight, but often did so when talking about blood pressure. Conclusions: Across most body types and ages, weight-related talk spurred stigma management from adult patients. Patients’ interpretations were consistent with accepting or avoidant strategies to manage stigma. The findings challenge clinicians and researchers to frame patients’ defensiveness or sensitivity as a predictable response to mitigate stigma, and consider how clinical care might be better structured to avoid stigmatization. Recognizing the range of determinants of weight with interpretation of weight may help, particularly if combined with other methods to de-stigmatize care. The results have implications for clinical weight management and behavior change support.

Acknowledgments

The author thanks her PhD co-supervisors, Drs. Arthur Frank and Liza McCoy (University of Calgary), as well as Dr. Maeve O’Bierne for help with recruiting clinics, and the participants who allowed her to observe their appointments.

Notes

¹ Following conventions in fat and critical weight studies, I use the word fat as a neutral descriptor of bodies, similar to thinness. I opt not to use overweight or obese unless referring to an author’s usage, because these categorizations embed a normative judgement.

² I was unable to recruit a physician-centric clinic with a lower socio-economic status population within the study timeline constraints.

³ A rise in BP associated with anxiety.

⁴ I identify patients by their exemplar letter.

⁵ BMI results are known for 22 of 29 participating patients. BMI is a flawed and contested measure (Nicholls, 2013), so is used in limited ways in the present study. But BMI remains recommended (Brauer et al., 2015) and in use in clinics as a guide for clinical care.

⁶ I identify physicians as Dr1, Dr2, or Dr3. In this appointment, the physician did all the measures typical of RNs or MOAs due to scheduling.

⁷ The three exceptions were people with thin and visibly muscular bodies.

⁸ Summarized due to the length of the exchange.

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research and The Killam Trusts.