Trauma-informed Care Trauma-informed Care for Every Body (Part 1) Erika Roshanravan, MD, FAAFP

Trauma-Informed Family Medicine

Erika Roshanravan, MD, FAAFP

Trauma-informed Care for Every Body (Part 1)

This is the first installment of a two-part discussion on weight stigma, and how using trauma-informed care will improve care experience and engagement for patients of increased weight. Stay tuned for Part 2 in the Winter 2023 issue, where Dr. Roshanravan will discuss disordered eating, the relationship between trauma and weight, and what family physicians can! “Why would I go to the doctor? I really don’t want to hear again that I should lose weight.” “I bet the only thing they’d have to say about my symptoms is lose weight anyway.” “They say to lose weight, but nothing ever works anyway.” “I don’t want to get weighed all the time, so I just don’t go to the doctor.”

When we talk about trauma-informed care, we talk about creating safety, trustworthiness, empowerment for patients and staff. It is interesting and frankly alarming to realize that as a healthcare system, we seem to have a blind spot for this when it comes to patients with increased weight. Although well-intentioned, common workflows such as unasked weight checks at every visit or checking the box on “counseled about diet and exercise,” can create unease, and even make patients with increased weight feel unsafe, untrustworthy, and disempowered. What we were taught is the “right thing” is stigmatizing, and evidence shows our part in weight stigma encourages and increases disordered eating, low self-esteem and stress, and the likelihood that stigmatized patients avoid healthcare altogether (Alberga et al, 2019). Weight stigma is defined as “discriminatory acts and ideologies targeted towards individuals because of their weight and size.” Like other types of stigma, weight stigma is a form of trauma and can have devastating psychological and social effects for affected individuals.

Unlike other types of stigma, much of weight stigma is socially acceptable because of the common assumption— including by physicians—that increased weight is largely a choice. This assumption ignores that weight results from the complex interplay of heredity, epigenetics (remember how trauma changes epigenetics?), mental health, social determinants of health, and the prenatal and postnatal environment.

The thing is this: I don’t think we in the medical community have made a sweeping commitment to combatting weight stigma and its harms, and we do not acknowledge our role in it. Most of medicine still believe that “thinness” is objectively “better,” despite evidence that it is not necessarily healthier. Many of us may also feel some unease with supporting patients of all sizes and shapes. We may feel that allowing patients to “love their bodies just the way they are” ignores the risk we see in their weight, and so we impress the need to change and telegraph our disapproval of our patients’ bodies. Studies in adolescents at higher weights actually show our error: there is an association between better body image and lower future weight gain, improved mental wellness and much lower rates of disordered eating (Sonneville et al, 2012; Sonneville et al, 2015). To make matters worse, the traumatization of patients with weight stigma is pointless, because the advice we give day in and day out—"diet and exercise”—has proven largely ineffective. Very few people successfully lose weight, and many of those who do gain it right back (Fildes et al, 2015). Now to Body Mass Index (BMI). First of all, BMI is a terrible proxy for health. Besides its problematic roots in an entirely white European population, it also entirely ignores important indicators of health like cardiorespiratory/ cardiometabolic fitness, muscle mass and others. In fact, the AMA House of Delegates acknowledged this as an issue at their 2022 Annual Meeting and referred it to their Board of Trustees for further consideration.

Even accepting the conventional thinking about BMI, physicians tend to forget that the association of BMI and mortality is J shaped: lower BMI and higher BMI are both associated with an increase in mortality. In fact, a large study by Bhaskaran et al. (2018) in the Lancet showed that the mortality curve rises more sharply towards lower BMIs than towards higher BMIs, especially in women and the elderly. In women, for example, a BMI of 20 had about the same

mortality as a BMI of about 32. I have a BMI of 20, and despite these findings, my doctor has never told me that I should gain weight. Moreover, I am generally met with the assumption that I am fit without knowledge of my lifestyle habits or risk factors. Meanwhile, my patient with a BMI of 40 exercises at high intensity daily, eats a plant-based diet, has a hemoglobin A1c one percent lower than mine, and an enviable unmedicated LDL, yet she is routinely met with the assumption that she is lazy, non-compliant, and “just needs to start doing the right thing.” Unfortunately, this weight bias is all too common. I know this is complicated, but I also know we can do better. We will talk about how to do better for all patients of any size in next issue’s edition.

References Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review. Prim Health Care Res Dev. 2019 Jul 22;20:e116. doi: 10.1017/S1463423619000227. PMID: 32800008; PMCID: PMC6650789. Bhaskaran K, Dos-Santos-Silva I, Leon DA, Douglas IJ, Smeeth L. Association of BMI with overall and causespecific mortality: a population-based cohort study of 3·6 million adults in the UK. Lancet Diabetes Endocrinol. 2018 Dec;6(12):944-953. doi: 10.1016/S2213-8587(18)30288-2. Epub 2018 Oct 30. PMID: 30389323; PMCID: PMC6249991. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health. 2015 Sep;105(9):e54-9. doi: 10.2105/AJPH.2015.302773. Epub 2015 Jul 16. PMID: 26180980; PMCID: PMC4539812. Sonneville KR, Calzo JP, Horton NJ, Haines J, Austin SB, Field AE. Body satisfaction, weight gain and binge eating among overweight adolescent girls. Int J Obes (Lond). 2012 Jul;36(7):944-9. doi: 10.1038/ijo.2012.68. Epub 2012 May 8. PMID: 22565419; PMCID: PMC3394875 Report of Reference Committee D. June 2022 Meeting of the AMA House of Delegates. https://www.ama-assn.org/system/files/a22-resolutions.pdf. Accessed October 5, 2022. Sonneville KR, Thurston IB, Milliren CE, Kamody RC, Gooding HC, Richmond TK. Helpful or harmful? Prospective association between weight misperception and weight gain among overweight and obese adolescents and young adults. Int J Obes (Lond). 2016 Feb;40(2):328-32. doi: 10.1038/ijo.2015.166. Epub 2015 Aug 25. PMID: 26303350.

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