The woman, 60, had long-standing obesity and had consulted a new doctor for weight management help.
“Over the last 6-8 months, she told me, she was not able to keep up with her friends when walking,” said Alina Elperin, MD, FACP, DABOM, an internist and obesity medicine physician at Endeavor Health in Evanston, Illinois, who saw the patient. Hikes with her family, previously doable, were becoming a struggle, too.
On questioning, the patient also mentioned recent shortness of breath, which she was attributing to weight gain, but hearing the new symptom triggered concern for Elperin.
Instead of simply suggesting she lose weight and return when she had done so — advice many people with obesity are accustomed to hearing — Elperin tracked her patient’s weight history for the past year. It had not risen much, so Elperin ordered a stress test. Elperin ended up finding coronary artery disease, and the woman received two stents.
Although a new symptom, the shortness of breath was simply attributed to the woman’s obesity by other healthcare providers, Elperin suspected.
Whatever the symptom — shortness of breath, knee or other joint pain, fatigue, depression — physicians need to look beyond the weight of patients with obesity, a growing number of obesity experts advise, and stop sending patients with obesity home with curt advice to lose weight without investigating the new symptoms that brought them in.
Why are physicians so quick to zero in on weight loss as a one-stop fix for symptoms? Bias. For years, multiple studies have shown that physicians and other healthcare providers hold strong negative attitudes about patients with obesity, affecting judgment, communication, and decision-making.
“These internalized biases are triggered very quickly,” Elperin said.
Patients notice, and it can affect their healthcare long term. In a 2024 report, researchers who surveyed 395 patients of all weights and analyzed 73 substantive narrative comments found that weight stigma was perpetuated owing to, among other factors, what patients viewed as “excessively weight-centric medical counseling.”
Among the comments received was this from a 51-year-old woman with a BMI of 27.1 who went to a new doctor: “My BMI was only slightly over normal and that was ALL she talked about. No matter what issue I brought up it went back to my weight.” The woman said she never returned to that physician.
Passing off a patient’s concern about a symptom as simply a result of their obesity and potentially missing a new diagnosis is a common occurrence, obesity experts told Medscape Medical News. “This is an entity called attribution error or bias, and [it] occurs in many medical diseases and not just with obesity,” said Caroline Apovian, MD, professor of medicine at Harvard Medical School and co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital, Boston. “That is why doctors need always to ask themselves ‘What else could this be?’” Apovian said, citing the words of one of her mentors, Jerome Groopman, MD.
In his book How Doctors Think (Houghton Mifflin, 2007), Groopman defines attribution error as stereotyping patients based on their personal characteristics. And “What else could this be?” is a key question, he believes.
While attribution error can occur in other diseases, ignoring a new symptom and blaming it on excess weight is believed to be more common for patients with obesity than some others, according to Christopher Weber, MD, FAAP, FACP, CSCS, FOMA, DABOM, bariatric services medical director at Ascension Wisconsin and obesity medicine director at Ascension Columbia St. Mary’s Bariatric Center, Milwaukee, Wisconsin.
He cites many reasons. “There has been a spotlight on obesity the last few years, especially with our rapidly changing understanding of the pathophysiology and with the advent of such effective [antiobesity] medications.”
Experts have also learned that obesity can cause or exacerbate numerous other diseases, so managing it is clearly important for health and well-being, he said.
“Obesity in healthcare is now top of mind, and so doctors are more likely to discuss weight, but unfortunately often to the detriment of discussing other potential causes for symptoms.”
The bias that still exists, he said, “can unintentionally lead to doctors overemphasizing obesity as the sole cause for symptoms.”
Correcting the Course
“Symptoms in someone with obesity should be evaluated the same way they would be in someone without obesity,” Weber said, “but with the understanding that obesity increases the likelihood of developing certain conditions.”
Among them, according to the Centers for Disease Control and Prevention, are hypertension, hypercholesteremia, type 2 diabetes, asthma and other respiratory conditions, and joint problems.
“The first thing to remember is, obesity is a chronic condition and can result in multiple complications, but in itself is not a conclusive diagnosis,” said Elperin.
She emphasized the need to look for the underlying etiology for the symptom or symptoms of concern. Although obesity may have contributed to the development of the new symptom, she said, the new diagnosis is not obesity. “The diagnosis will remain whatever the underlying pathology that is found and that the patient initially presented with.”
“When a patient comes in with symptoms, we address the symptoms, no matter what their shape or size,” she said. “Obesity as a diagnosis for the patient’s [new] complaint is not appropriate.”
Tracking the Symptoms
“Our history and physical exam lead us towards a diagnosis, and tests and imaging can then be done to help confirm or refute our suspected diagnosis,” Weber said. “This stepwise approach can help us to accurately find the cause of the person’s symptoms, whether due to obesity or something else entirely,” Weber said.
“Thinking of obesity similarly to how we think about other chronic diseases can be very helpful,” Weber said.
For instance, when patients with depression complain to their doctors about being tired, the physician is likely to consider many causes, Weber said, such as anemia, thyroid disease or vitamin deficiencies, not just the depression.
The same approach should be taken for a patient with obesity, he said. As an example, he said, “obesity can directly cause knee pain, but so can osteoarthritis, tendonitis, ligament injury, and even more rare conditions like Lyme disease or autoimmune disease.” However, he added, ‘’Unfortunately, these other possible causes are too often ignored by simply blaming obesity.”
Only after thoroughly checking out the new symptom or symptoms, Elperin said, “If all else is normal, then maybe we can say, ‘Oh that extra weight is contributing.’”
But not as the first target.
Asking a patient with obesity for permission to address weight is a productive strategy, said Elisabeth (“Liesbeth”) van Rossum, MD, PhD, professor of medicine and head of the Obesity Center CGG (Centrum Gezond Gewicht) at Erasmus University Medical Center, Rotterdam, the Netherlands, who has published about a comprehensive approach to detect underlying causes of obesity.
For instance, she suggested this kind of approach: “While you are here for knee issues, is it okay to address your weight?”
Once a patient is open, she said, it’s important to explain to patients that a diagnosis of obesity involves low-grade inflammation. “We know inflammation from belly fat goes all over the body.”
And that inflammation can be a gateway to numerous diseases. That education may help those with obesity understand the interplay of obesity with other disease. For instance, van Rossum said, “if people have rheumatoid arthritis [RA] and obesity, the chance of getting the RA into remission is more than 50% lower when obesity is present.”
Van Rossum’s center recently published a free online screening tool, CheckCausesObesity.com, to look for causes, contributing factors and comorbidities of obesity.
Apovian, Elperin, and van Rossum have no relevant disclosures. Weber is on the Novo Nordisk obesity speakers bureau, was on a 2024 obesity advisory board for Lilly, and is a faculty presenter for CCO Obesity CME seminar.
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