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In this story, average-weight people will walk in the footsteps of those who most assuredly are not.

In their shoes, you’ll have difficulty using a toilet in a public place or doctor’s office because the seat is too close to the wall. If chairs in these places have arms, standing will be your only option. If the doctor’s office scale is less than your weight, don’t be surprised if you’re escorted to a large-weight scale not meant for patients, like a freight loading dock. And these are just the public humiliations, the I-am-fat reminders. The private ones, like not reaching the floor to tie your shoes or pick up a toy, exist, too. If a family member witnesses these failings, expect teasing and humiliation. And you probably won’t blame the messenger.

It might have gotten to this point for various reasons: your overnight work schedule, the diabetes or psychiatric medications you take that pack on pounds, the culture you grew up in, the genes you inherited, and the life stresses you are under.

The weight gain does not happen in one day. Nor will it come off in one.

“It very much feels like a personal failure, but it’s not. At some point, it’s a medical issue,” said New Hampshire resident Christine Andre, 62. The weight gain “starts slowly. It’s insidious.”

Andre — a bike rider, hiker, and kayaker — tried on her own, in at least five different ways over 40 years, to trim her 5 ft 2 in frame to below 200 pounds. She said physicians in the seven states she lived in during this time disregarded her weight during exam visits, though no one said cruel things to her. “I’ve had people be rude but not medical staff,” said Andre. She’s faced diabetes, hypertension, and hypercholesterolemia. A prescribed GLP-1 made her nauseated. She has since undergone bariatric surgery.

Even though the American Medical Association declared obesity a disease 12 years ago, the obesity stigma exists. Most of the damage inflicted comes from family members, but not always. It’s been long known that patients who feel they are being judged for their weight will not lose it.

“We know so many patients have experienced stigma from healthcare professionals, and that behavior has contributed to self-stigma, avoidance of healthcare, reluctance to talk, and the lowering of trust,” said Rebecca Puhl, PhD, deputy director of the Rudd Center for Food Policy and Health, Hartford, and University of Connecticut, Storrs, both in Connecticut. “We want to see a shift in how providers communicate with patients,” acknowledging that “a lot of physicians feel frustrated in not knowing how to have this conversation.”

So here’s the pressing question: With so many people currently overweight or obese, what’s being done to erase the stigma and start the healing?

“From a medical standpoint, we are seeing a lot of change in terms of how medical associations are talking about weight,” said Rebecca Pearl, PhD, associate professor in the Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida.

This is a start. But the real challenge is convincing individual doctors’ offices to do the following: don’t focus on weight, don’t scold about blood pressure numbers or A1c levels, and don’t scare patients by sharing what a future with obesity looks like. Focus on a patient’s eating behavior and history. Teach them about good nutrition, which takes conversation and lots of time.

“A lot of physicians feel frustrated in not knowing how to have this conversation,” said Puhl. “I think some are aware of the stigma, and there is real interest in getting that information.”

For those who have had such conversations with patients, like Nida Latif, MD, family physician and obesity specialist in the Detroit suburb of Westland, Michigan, the results are positive. These patients, she said, have to know you care. They don’t want to hear “eat less, move more.”

“The biggest thing is making them feel they have taken the biggest step,” namely, looking for help. “They have to feel welcome, to know it is a disease. [It’s about] empathizing with them that they always faced a stigma and to get them out of that guilt, eat, guilt cycle,” said Latif.

Another good tactic for physicians: Ask if a patient’s weight is open for discussion. “This is about taking the emphasis on body size and putting it on health behavior,” said Puhl.

Steps to Success

Just recently, researchers surveyed individuals with obesity about what an ideal visit to a doctor’s office looked like. They essentially described Latif’s office.

In Latif’s office, patients sit in large chairs with no arms. They have two choices of reading material while they wait: literature from the Obesity Action Coalition and children’s books. The rest room has a wide door and plenty of space inside. Inside the waiting room, patients don’t change into a gown unless necessary. Latif keeps pictures of her patients on the wall for motivation — how they looked when they came for help and their pictures of progress. “They keep looking back at their picture to see how far they have come,” Latif said.

Latif doesn’t have an easy job. Half of her patients are on Medicaid, she said, so very few are taking GLP-1s. Her patients, many of whom found her through word of mouth, include whole families and teenagers. The majority are middle-aged women, who often come in groups to motivate each other. Do they do well? “It depends,” she said. “Some people are struggling so hard. When I can feel that it is a constant struggle, I bring in their spouse.” This way, the patient gets more intense support. Each week, she reviews patients’ food logs. “I have them do what [they ate] and how much,” Latif said. “On that, I give feedback. So I say, ‘change the timing for this or add a protein shake.’”

Latif learns about the patient’s life and the behaviors pushing the overeating. “If you can make patients understand how things work, compliance is better,” she said. Many of her patients work an overnight shift. “It’s a very different approach because their hormones are out of whack,” Latif said. “You have to get their hormones back on track.” For patients on psychiatric medications, and many are, she tells them that these medications will stimulate appetite, so patients are prescribed naltrexone to decrease the cravings. “It works beautifully,” she said. For patients on insulin, the goal is to get them off as soon as possible.

Latif ticks off her success stories: The patient who could finally ride a roller coaster, another a horse. The patients who reduced to 400 pounds so they could qualify for bariatric surgery. The few who no longer have diabetes. The two who reversed atrial fibrillation after losing 100 pounds.

She also learns from her patients. One told her how to make ice cream with either a protein shake or lactose-free milk in a Ninja CREAMi, “which was great to pass on!” Another patient, taking a GLP-1, was losing hair. The patient “made a high-protein probiotic yogurt,” said Latif. “Countless others have benefited from” that information.

Additional Tools and Resources

In 1906, A.C. Croftan wrote in JAMA that “the reduction of obesity is an important therapeutic task….a necessary step toward removing adipose tissue that is producing disagreeable or dangerous complications about important organs,” like the heart.

After 119 years, the study of obesity and nutrition is still not a uniformly taught subject in US medical colleges. In a statement, the Association of American Medical Colleges said that medical schools “typically embed obesity care across all 4 years of training.” In a recent survey on nutrition in curricula, all the schools reported including nutrition “in some form,” fewer than 45% in the current survey reported that nutrition was incorporated into numerous courses or rotations.

For physicians needing additional resources, there are many continuing medical education courses. Puhl’s Rudd Center offers quick-hit videos that can help physicians find the right words in having open-ended conversations with their patients.

An interdisciplinary team including a physiologist, mental health professional, and nutritionist would be ideal in helping someone lose weight, according to Pearl. But to keep it off, a physician would need “multiple tools, like behavioral interventions and medications and surgery,” Pearl said. “This is where, sometimes, doctors have a negative attitude, because [they feel weight loss] should be maintained through diet and exercise. They think it is a personal responsibility, just about eating less and moving more. This is simplistic.”