Weight Stigma Remains a Barrier to Patient Care體重污名仍是患者診療一大障礙

Obesity has historically been regarded as a moral failing， and people with obesity describe being seen as deficient， lazy， and/or undeserving of respect， lacking willpower and self-discipline， and gluttonous1.

把肥胖看成品德問題由來已久，肥胖者稱他們被指有缺陷、懶惰、不配受到尊重、意志薄弱、缺乏自律，還貪吃。

These views contribute to weight bias （negative ideologies2 associated with obesity）， which can lead to weight stigma3 （discriminatory acts and ideologies targeted toward individuals because of their weight and size）.

這些看法助長了體重偏見（涉及肥胖的負面思想），進而形成了體重污名（針對個體體重和身材的歧視性行為和觀念）。

Paradoxically， research suggested an association between weight stigma and increased food intake， eating without being hungry， emotional eating， binge4 eating， and long-term weight gain.

矛盾的是，研究表明，體重污名與進食量增加、非饑餓性進食、情緒化進食、暴飲暴食和長期體重增長之間存在關聯。

The medical community is working to address the problem， and there are practical steps physicians can take to make their practices weight inclusive.

醫學界正在努力解決這個問題，也有了一些切實可行的辦法，醫生加以采用就可使其診療過程具有體重包容性。

Impact of weight stigma

體重污名的影響

Weight stigma in healthcare settings is communicated to patients verbally and nonverbally. Patients reported being “fat shamed，” as described in a recent article in Fortune magazine.

醫療場景中的體重污名是通過口頭和非口頭方式傳達給患者的。正如《財富》雜志最近一篇文章所述，患者吐槽他們“因肥受辱”。

“I always go in [to medical appointments] with my guard up5，” one patient said in the article. That patient was told by an obstetrician/gynecologist that she was “too fat” and that the physician couldn’t treat people like her after the doctor tried and failed to insert an intrauterine device6.

文章中有位病人這樣說：“我就診時總是防備心很重。”曾有一位婦產科醫生試圖給這個病人放置宮內節育器，失敗之后反倒怪她“太胖了”，說醫生沒法給這么胖的病人看病。

Nonverbal shaming can include looks of disgust or contempt， discussions that lack warmth， and a demonstrated unwillingness to touch the patient.

非言語性羞辱包括厭惡或輕蔑的神態、冷冰冰的問診，以及明顯不愿觸碰病人。

Weight discrimination can have serious consequences for patient health. Patients who have experienced weight bias in a medical setting are more likely to cancel appointments and avoid preventive care， which increases their medical risk. For example， women with obesity are less likely to be up-to-date7 on Pap smears8 and screening mammograms9， often due to perceived weight stigma and lack of appropriately sized examination equipment.

體重歧視會嚴重影響患者的健康。在醫療服務中體驗過體重偏見的患者更有可能取消預約并回避預防性治療，其醫療風險也因此而增大。例如，肥胖婦女很少會接受宮頸涂片檢查和乳腺X光篩查，通常都是因為感受到體重污名，以及缺少尺寸合適的檢查設備。

“Weight stigma is a major concern that needs to be addressed in clinical practice and medical education，” Kathleen Robinson， MD， PhD， assistant professor of internal medicine-endocrinology and metabolism， Iowa Carver College of Medicine， Iowa City， Iowa， told Medscape Medical News10.

“體重污名是臨床實踐和醫學教育中需要解決的重要問題。”艾奧瓦州艾奧瓦市卡佛醫學院內科-內分泌與代謝學助理教授、醫學博士、哲學博士凱瑟琳·魯賓遜博士接受“醫景網醫療新聞專欄”采訪時說。

Robinson and colleagues surveyed 395 individuals who were asked about their experiences related to weight stigma and healthcare. Of these， 73 provided narrative responses， some of which included experiences of being shamed.

魯賓遜及其同事調查了395人，問他們與體重污名和就診相關的經歷。受訪者中，有73位提供了敘事性回復，其中就有遭受羞辱的切身經歷。

“We found ongoing tension between the framing11 of weight as solely a result of personal responsibility vs weight as a multifactorial12 condition with an array of uncontrollable aspects，” Robinson reported.

“我們發現，有兩種觀點持續對立——一種觀點把體重問題完全歸因于個人責任，另一種則認為體重受多因素支配且很多因素難以控制。”魯濱遜指出。

“And we found healthcare providers made assumptions about patients based on body size， such as what they were eating or whether they were exercising， and didn’t necessary ask about or acknowledge the patient’s previous experiences with losing weight or what their actual lifestyle was，” she said. Advice was often “trite and dismissive，” rather than addressing the patient’s specific needs and history.

“我們還發現，提供醫療服務的機構根據患者的身材臆斷他們常吃什么或是否常鍛煉，認為沒必要詢問或確認患者以前的減肥經歷或他們的實際生活方式。”她說。診療建議往往也是“老生常談外帶敷衍了事”，而不是按患者的需求及病史進行有針對性的治療。

Weight stigma can result in physicians dismissing patients’ non-weight-related concerns， refusing care， or attributing health problems to obesity without considering other causes.

體重污名會導致醫生忽視患者與體重不相關的訴求，拒絕施治，或不考慮其他成因就把健康問題歸咎于肥胖。

“If a patient with obesity presents with knee pain， for example， it’s all too often attributed to excess weight，” Kasuen Mauldin， PhD， RD， professor and director of the Dietetic Internship Program， San Jose State University， San Jose， California， told Medscape Medical News. “But there are many causes of knee pain， of which mechanical weight-related stress is only one. So， before you attribute the knee pain to the patient’s weight， ask yourself how you would handle the same complaint13 in someone of lower body weight and size and if you would conduct the same workup14.”

“舉例來說，肥胖癥患者如果出現膝關節疼痛，這種癥狀往往都被歸因于過度肥胖。”加利福尼亞州圣何塞市圣何塞州立大學教授及臨床營養學實習項目主任、博士、注冊營養師卡蘇恩·莫爾丁接受“醫景網醫療新聞專欄”采訪時說，“但造成膝關節疼痛的原因有很多，與體重相關的機械性壓力只是其中之一。因此，在將膝關節疼痛歸咎于患者體重之前，請先自問，你會如何診治主訴相同但體重較輕、身材適中的患者，是否也會做相同的診斷檢查。”

Evolution in thinking

思想觀念演變

Stigmatizing attitudes in healthcare arise from a lack of education and the mistaken belief that weight is a primary indicator of health.

醫療服務中對肥胖的污名化源于相關知識的缺失和把體重當成主要健康指標的錯誤觀念。

David Strain， MD， PhD， associate professor of cardiometabolic15 health， the University of Exeter Medical School in Exeter， England， said the “dogma” he learned in medical training was that obesity “is a pure function16 of eating too much and exercising too little， so the treatment was simply ‘eat less， move more.’”

英國埃克塞特大學醫學院心臟代謝健康副教授、醫學博士、哲學博士戴維·斯特雷思說，他在醫學培訓中學到的“教條 ”是：肥胖“純粹是吃得太多、運動太少造成的，因此治療方法就是‘少吃多動’”。

In this weight-centric approach to health， lower weight is regarded as healthier than higher weight， Amanda Velazquez， MD， director of Obesity Medicine， Cedars-Sinai Center17 for Weight Management and Metabolic Health， Los Angeles， told Medscape Medical News. And weight—typically measured as body mass index （BMI）—is generally viewed as being within the patient’s control.

洛杉磯西達賽奈醫療中心體重管理與代謝健康中心肥胖醫學部主任、醫學博士阿曼達·貝拉斯克斯接受“醫景網醫療新聞專欄”采訪時說，按照這種以體重為中心的健康觀念，瘦一點比胖一點要健康。此外，體重——通常以身體質量指數衡量——被普遍認為是患者自身可控制的。

However， obesity isn’t a single entity but a “complex， multicausal， chronic disease with variable clinical phenotypes defined by abnormal or excessive adiposity18，” according to a 2023 consensus statement of the American Association of Clinical Endocrinology （AACE）.

然而，根據美國臨床內分泌學會2023 年的一份共識聲明，肥胖癥并非單獨存在的實體，而是一種 “復雜的多病因慢性疾病，有多種臨床表型，以異常或過度的脂肪蓄積為主要特征”。

The association recommends complication-centric staging19 that facilitates personalized interventions. Therapy should include not only percent weight-loss goals but also alleviation of obesity-related complications， rather than weight loss per se. This approach is “consistent with the medical model for treatment of chronic disease and may help reduce weight stigma and weight bias.”

該學會建議采用以并發癥為中心的分級法，以便進行個性化干預。治療方案不僅應著眼于減重百分比目標，還應緩解肥胖相關并發癥，而非局限于減重本身。這種做法“符合慢性病治療的醫學模式，且有助于減少體重污名和體重偏見”。

Tips for a weight-inclusive practice

體重包容性方法小貼士

Addressing weight stigma in healthcare involves changing the clinical approach to patients with obesity.

要解決醫療服務中的體重污名問題，就必須改變對肥胖癥患者的臨床治療方法。

Physicians should focus on helping patients set and work on behavioral goals rather than on losing weight， Mauldin said. “If you go to a financial planner， you won’t be told， ‘Get rich.’ Instead， you’ll be given concrete， practical steps， such as diversifying investments or saving money every month. Similarly， instead of focusing on weight， it’s better to focus on actionable items， such as food substitutions， filling the plate with vegetables， or increasing movement.”

莫爾丁說，醫生應該重視幫助患者制定和實現行為目標，而不只是減重。“如果你去找理財顧問咨詢，對方不會說‘去發財吧’，而是會教給你切實可行的致富方法，比如多樣化投資或每月存錢。同理，與其只關心體重，不如關注可操作事項，比如更換食譜、多吃蔬菜或增加運動量。

Measuring and discussing a patient’s weight may not always be necessary at every appointment and may perpetuate20 the weight-centric model—especially when a person is presenting with an unrelated concern， Mauldin said. A weight-centric approach can contribute to the notion that obesity drives all illness， leading to potential neglect of other etiologies21.

莫爾丁說，每次就診并不總需要測量和討論患者體重，那樣只會延續以體重為中心的錯誤模式——特別是在就診者所擔心的問題與體重無關時。以體重為中心的做法會讓人認為一切疾病皆因肥胖而起，可能造成對其他病因的忽視。

Mauldin emphasized that a weight-inclusive approach means treating patients “holistically， in a nondiscriminatory way， in line with22 the patient’s internal cues， such as whether they’re hungry， and away from weight being just a number on the scale， which is a weight-centric approach.”

莫爾丁強調，體重包容性診療意味著“采用整體性方案、以非歧視態度對待患者，依據其內在信號（如是否饑餓）施治，避免以體重為中心（將體重僅看作秤上的一個數字）的做法”。

Physicians also can address weight stigma by making sure they have equipment that accommodates patients of all sizes.

醫生還可確保所配設備適用于各種身材的患者，以此應對體重污名問題。

Examination tables， scales， MRI machines， and similar equipment should be able to accommodate individuals of all sizes and weights. And don’t keep the scale in the hallway23. “Being weighed in such a public place might be uncomfortable， not only for patients with larger bodies but for other patients， too，” Mauldin said.

檢查臺、體重秤、核磁共振成像儀以及類似設備應當能適應各種身材和體重的人。還有，不要在門廳和過道放置體重秤。“在這樣的公共場合稱體重可能讓人不自在，對身材胖大的患者是這樣，對其他病人也是如此。”莫爾丁指出。

Additional tips include having a split lavatory seat and properly mounted grab bars to help the patient get up more easily， floor-mounted toilets and well-supported toilet bowls， urine specimen collector cups with handles， extra-long phlebotomy24 needles and tourniquets25， and a large vaginal speculum26.

另外，建議配備便于患者起身的分體式馬桶座與正確安裝的扶手、落地式馬桶和穩固承重的馬桶基座、帶手柄的尿樣收集杯、加長的靜脈采血針頭和止血帶以及大號陰道內窺鏡。

（譯者為“《英語世界》杯”翻譯大賽獲獎者）

1 gluttonous貪吃的。" 2 ideology思想（體系），思想意識。" 3 stigma污名，恥辱（常因社會或人們對某事物懷有偏見而造成）。" 4 binge無節制，狂歡。

5 with guard up提高戒備心。" 6 intrauterine device即intrauterine contraceptive device，簡稱IUD，宮內節育器。" 7 up-to-date掌握最新信息的。" 8 Pap smear = Pap test （Papanicolaou test），即（宮頸）涂片試驗。" 9 mammogram（用于篩查乳腺癌的）乳房X線照相檢查。

10 Medscape譯為“醫景網”，美國著名醫學網站，1995年投入運營，是面向全球醫療專業人士（如醫生、護士、藥師等）的醫療在線平臺，提供最新的臨床研究、疾病管理指南、醫學新聞、藥物信息等。" 11 frame（以某種方式）表達。" 12 multifactorial受多因素所支配的。

13 complaint疾病或小毛病，病癥。" 14 workup為診斷而做的細致檢查。

15 cardiometabolic心臟代謝，心血管代謝。" 16 function應變量，函數。" 17 位于美國加州，是非營利性導向的綜合專業健康科學中心。" 18 adiposity多脂，肥胖，肥胖癥。" 19 staging分期法，分級法。

20 perpetuate使（本該被終止的東西，如錯誤的想法或糟糕的情況）持續。" 21 etiology病原，病因，病因學。

22 in line with按照，與……相符。" 23 hallway過道，走廊。" 24 phlebotomy靜脈切開術，放血術。" 25 tourniquets止血帶；壓脈器。" 26 vaginal speculum陰道窺器，陰道鏡。