“I’m on a mission to put forth this message: Psychology is an integral part of obesity care, even though it’s often not mentioned,” said Robyn Pashby, PhD, research assistant professor of psychology at F. Edward Hebert School of Medicine at Uniformed Services University, Washington, DC, and member of the National Board of Directors at Obesity Action Coalition.

“I had a patient recently who was given a colonoscopy without anesthesia because upon arrival, she was told she didn’t meet the BMI cutoff the anesthesiologist was comfortable with,” Pashby said in an interview with Medscape Medical News. The interview followed her presentation in a Science Press Package team media briefing on GLP-1 drugs for obesity.

“Another client was told to go to the loading dock to be weighed because the office scale could not accommodate her weight,” she said. “Many clients have had to stand in a doctor’s waiting room because there was no chair to accommodate their body.”

“Clinicians need to understand that no person living with obesity is coming to an appointment neutrally,” she said. “They come in anticipating bias and stigma, and that’s the number one variable that leads to avoidance of healthcare.”

Therefore, clinicians treating people living with obesity need to normalize the fact that when they talk about physical health, they’re also talking about its interaction with mental health, said Pashby, who is also founder of Health Psychology Partners. “A quick screen for associated mental health conditions such as depression, anxiety, or disordered eating can go a long way toward helping the patient and fostering collaboration between doctors and mental health professionals.”

A Brain Disease

The mental health connection is clear when obesity is recognized as a brain-based disease with treatments that are also brain-based, Pashby said in her AAAS presentation. “Importantly, GLP-1 medications influence both.”

GLP-1s change the brain before they change the body, she said. “They influence brain function long before the scale moves, which is why some of the earliest responses we see tend to be psychological and neurologic, not just metabolic.”

Although GLPs act on neural circuits involved in appetite, they also act on circuits involved in learning, motivation, memory, sleep, and mood, as well as how the brain interprets reward cues and experiences pleasure, she said. “These neurologic changes can help explain why some patients experience changes in cravings and emotions well before any scale change.”

Patients also experience early reductions in food noise — ie, fewer intrusive thoughts and less internal negotiation around food. “This is the first profound relief, and often a stand-alone therapeutic benefit for my patients,” she noted.

“Physiology shifts within days, and weight can often change pretty quickly,” she added. “But for people with trauma histories or high internalized weight bias, that rapid weight change can actually outpace emotional readiness and create a psychological vulnerability. And fear of weight regain, grounded in real, live, and lived experiences, not irrational worry, can also heighten anxiety during this time.”

When biological and psychological timelines fall out of sync, she said, patients are vulnerable to psychological disruptions and to treatment discontinuation, and mental health support becomes essential for helping to keep treatment steady, sustainable, and doable.

On the other hand, the weight stigma people with obesity live with is a biological stressor as well as a psychological one, she said. “Stigma alone elevates glucose, activates chronic cortisol release, increases inflammation, and drives psychological and behavioral harm. Often, these effects accumulate over years. And while GLP-1s can certainly change physiology, they do not erase the psychological imprint of that stigma.”

For many patients, food has long served as a tool for managing emotions, she added. “When that tool is suddenly diminished or removed, a gap is created. The brain loses a predictable source of comfort, regulation, and reward, which can amplify distress, even as metabolic health improves.”

Trauma-Informed Care

Pashby advocates for “trauma-informed” care, following the recommendations of the US Substance Abuse and Mental Health Services Administration and adapting them for working with people living with obesity. “For many people, living with obesity is a chronic traumatic stressor. You’re living in a body that everyone you know — from your medical providers to your mom to the stranger in the grocery store — judges as wrong,” she said in Medscape Medical News interview. “Providers need to recognize that if we don’t adopt a trauma informed-care perspective, we’re going to lose patients or not give them the type of care they deserve.”

A key part of the trauma-informed approach is being transparent when communicating. For example, when prescribing a GLP-1, “simply say something like, ‘I’m going to give this medication to you, and there’s a chance that it will have meaningful impacts on your health, such as weight loss, lower blood pressure, and blood sugar control. There’s also a chance that it won’t have those effects, and it would not be your fault if that happened. You’re dealing with a biological condition.”

“What you say doesn’t need to be long and drawn out, just putting out there what we know in a transparent way, because patients often hang on every word,” she said.

Another helpful communication change would be to say, at the beginning of the visit, “it’s so nice to see you” rather than “wow, you look great” or “you’re doing great.” That’s because weight is a chronic and relapsing condition, and there’s still a chance the patient will experience a weight-gain recurrence. Then they’ll think, “The last time the doctor said I was doing great, and now I’m not. Now I’m failing.”

Assuming a history of traumatic stress around weight does no harm, Pashby explained. “Why not just assume there’s a level of traumatic stress associated with weight bias and stigma, and instead of approaching the patient with the mindset of ‘what’s wrong with you?’ ask ‘what’s happened to you?’ That’s a mindset shift every healthcare professional can make.”

What’s more, she added, emerging evidence suggests that when physicians use trauma-informed care, they report less burnout over time because it improves the healthcare experience for both them and their patients.

Ask Before Talking

Whether you’re working in private practice or an obesity treatment clinic, always ask consent before discussing weight with your patient, Pashby advised. That’s because a patient may make an appointment to see a gastroenterologist or an obesity medicine specialist because they feel ready to start a GLP-1, for example, and there may be a gap of weeks between the time the appointment was made and the time the patient comes in.

“Meanwhile, psychology has happened,” Pashby said. “They may have begun to feel nervous about what will happen. They’ve probably gotten weight goals into their head. Or their mother made a comment at Thanksgiving dinner about their fat body. If they haven’t canceled, they could be showing up for the appointment in a very different place from the moment they made the appointment.”

Because of this, clinicians need to assume that something psychologically damaging may have occurred in the interim, and say something like, “I know you’re here to talk about your weight, but are you still up for talking about it today?” This should be asked at every meeting, Pashby said.

“There will be times when patients say, ‘I don’t have it in me today. And doctors will get a patient for life if they say, ‘I understand. Let’s find another time to follow up. How else can we use our time together today?’”

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.