Pregnancy and weight bias with Taniya Nagpal, PhD

– Welcome back to the “Scale Up Your Practice” podcast from Obesity Canada. I’m Dr. Roshan Abraham, a family physician and associate professor at the University of Alberta.

– And I’m Michelle McMillan, a lived experience expert with Obesity Canada. This podcast is where we have honest conversations about how we can improve obesity care that’s grounded in both evidence and empathy.

– Pregnancy is a time of frequent interactions with the healthcare system. Checkups, screenings, advice, support. But for many women and birthing people living with obesity or in larger bodies, those interactions can be clouded by stigma and bias.

– And not only that, as someone who has experienced pregnancy twice in a larger body, pregnancy is such a personal and joyful time, but it’s also a really vulnerable and scary time. You’re preparing for a major change in your life. Your body is changing in ways that you didn’t ask it to, and it doesn’t want to listen to you. And the other thing is it happens kind of younger in our years. And so this might be the first time in our lives that we’re regularly visiting healthcare professionals. Now, if we combine into that people living in larger bodies, sometimes those appointments can come with added layers of judgment, bias, stress, that has nothing to do actually with their actual health. So today’s conversation is about what happens when those biases go unchecked and how we can start to do better and show up differently.

– We’re excited to be joined by Dr. Taniya Nagpal, whose research work focuses on maternal health, physical activity, and the ways bias shows up in care settings for women and birthing people living with obesity. Dr. Nagpal, thank you so much for being here and welcome to the podcast.

– Thank you so much for having me.

– So research suggests that nearly one in five women experience weight stigma in healthcare settings, which we know can lead to patients delaying or avoiding healthcare due to negative experiences.

– And we know that weight bias in healthcare is real and well documented, but when it interacts with pregnancy, the impact can be even deeper. Dr. Nagpal, your work zooms in on the intersection between larger bodies and pregnancy. Before we get into the data and stories, I know you and I have met in various settings, but for our podcast listeners, can you tell us a little bit about what brought you to this area of research?

– Yeah, absolutely. Thank you again for having me. And I love answering this question because it allows me to go back into my research path. And initially, this was not the area that I actually did my thesis work in. My PhD work was looking at physical activity during pregnancy. And I come from a health psychology background. I was looking at various behavior change strategies to help individuals in pregnancy meet physical activity recommendations. And then I was also looking at measuring how being active in pregnancy impacts downstream outcomes in the newborn. And during my thesis work, I was working quite closely with pregnant individuals. One on one, I would meet them at 12 weeks of pregnancy and follow them all the way through until their babies were born. And then I measured them six hours after they were born. So I got to really know my participants. And throughout my thesis work I was very actively involved with Obesity Canada as a student volunteer. And my very first conference that I attended through Obesity Canada was their summit in 2017. And the very first session I attended was by a lived experience expert who was sharing their story. And they were talking about weight bias and stigma and how that impacted them through their childhood years into adulthood. And I realized that there are so many elements in my thesis work that does not even acknowledge weight bias or stigma. But it could be something my patients tend to be experiencing. For example, I weighed them every single week during my study, but I never actually asked if they wanted to be weighed. I was taking a look at tracking their gestational weight throughout pregnancy and I would be putting it on a chart, but I wasn’t talking about how that maybe made them feel. I was very much coming at it from an objective standpoint of this is how much you gained last week or over the week. And I started questioning myself and my thesis work and how I was using body mass index in my studies as well. And again, this was something at the summit that was brought up a few times, the limitations of BMI. And although weight stigma wasn’t a part of my dissertation work, I couldn’t stop thinking about it. And the more I stayed involved with OC, it was always something that we talked about. And so I decided for my postdoc that’s what I wanted to learn more about. And so for my postdoc I worked with Dr. Kristi Adamo at the University of Ottawa where, through through my tax funding, I did a few qualitative studies, I wanted to learn qualitative research methods as well, on just getting, capturing experience of having obesity in pregnancy. And I really wanted to not use BMI to define obesity. So we worked with obstetricians who worked in high-risk obstetric clinics to identify individuals with larger bodies and severe levels of obesity which would be clinically diagnosed. And I interviewed these participants, and honestly, there was just no turning back from there. From that study, I knew this was the area of research that I wanted to continue to go deeper into and learn from lived experience and essentially hopefully build a research program that was focused on reducing weight bias and stigma in pregnancy. And the other piece that sort of kept me going is that pregnancy is very unique in that bodies are changing over that 40-week period. Irrespective of what your body size was before pregnancy, you will experience change. And one of those changes is likely gestational weight gain. So it’s very unique to study weight stigma and bias in this period of time where possibly for many individuals this might be the first time no one is saying, “You need to go lose weight.” This is, we’re talking about weight gain and weight change and not so much weight loss. And so just that that nuance, I guess, of pregnancy keeps me going as a researcher to want to study weight bias and stigma as well.

– So you’ve interviewed and worked closely with women and people navigating pregnancy while living with obesity or in a larger body. What are some of the most common assumptions being made about people’s bodies in perinatal care settings? And how are these assumptions shaping care?

– Yeah, so similar to I think the non-pregnant period, some of the stereotypical assumptions that individuals with larger bodies or obesity face is that you’re likely not eating well during your pregnancy or you’re likely not engaging in physical activity or are not interested in physical activity. So those are probably as the common obesity stereotypes are, they apply in pregnancy as well. But it goes one step further in pregnancy, in my opinion, where now it’s saying, “You’re not doing these things and it’s affecting your baby.” And that, I think that blame, that shame and guilt is so amplified in pregnancy anyways for individuals going through pregnancy that it’s, I would argue it’s just so much worse for somebody living in a larger body having to face these stereotypes and now being blamed for the next generation, essentially. So those I would say are probably the two most common narratives. The other piece of that we’ve seen in the research is that for a lot of individuals, they may have been advised, if they went through any sort of preconception counseling, that you should have lost weight before your pregnancy. And so now when pregnant, they’re also being the assumption is that they didn’t try beforehand or that they didn’t listen to the recommendations. And now here we are in your pregnancy. So when Michelle was talking about in the intro pregnancy is sometimes often meant to be this joyful experience. A lot of individuals that I’ve interviewed have shared that sometimes they’re not given that traditional pregnancy experience, because they’re constantly faced with these assumptions that they, quote, unquote, don’t care as much about their body or don’t care about their pregnancy.

– Yeah, I mean, that’s one of the challenges with living in a larger body and being pregnant is that all people who are pregnant, you know, we want to have healthy children. That’s the goal, right? But there is a whole underlying assumption that if you didn’t lose the weight before, do you really care about how healthy this baby is? And there’s a whole guilt that comes with it, which is, I mean, once you’re pregnant, like, we’ve kind of like, as we would say out here in the west, the horse has left the barn.

– Yes.

– Yeah, absolutely. And I think moms or moms to be already there’s so much pressure in pregnancy of like, this is what you should do, this is what you should not eat. This is what, like, it’s just adding to that list of do’s and don’ts. And when you’re saying, “Well, you should have lost weight before pregnancy,” but now you’re pregnant. So that added guilt is only going to impact maternal well-being. There’s no other impact it’s going to have by talking about what should have been done before.

– So thank you for getting us started into this discussion because I do think this is important for us to explore, and I’m so glad you’re here. Let’s step back for a moment and look at what the evidence is telling us. What are some of the most consistent patterns or themes you’ve seen when it comes to weight bias in perinatal care?

– So I think some of the consistent patterns would be, firstly, the communication with healthcare providers comes more with assumption rather than allowing the patient to lead appointments. So if I use the example of physical activity and eating, a lot of our participants have shared stories of the provider not necessarily asking them about their physical activity or asking them about their nutrition, just assuming they’re not doing those behaviors or interested in those behaviors. So assumption is sort of a common theme. Another common theme that we’ve seen is that sometimes pregnant individuals, they may come to their pregnancy care with previous experience of weight bias and stigma. And so they themselves come into appointments sort of on guard and ready to defend, especially if they maybe went through any fertility counseling or preconception care where they had to advocate for their bodies maybe for quite a while. And now they’ve come in to their prenatal appointments sort of always ready to talk about weight or to try and avoid talking about weight. And that seems to be a common theme. And what’s interesting is we’ve done some work also looking at the healthcare provider perspective and we’ve also seen that healthcare providers feel that they have to sort of beat around the bush when it comes to talking about weight in pregnancy. And the patient feels that the beating around the bush is an example of weight bias as well. So that’s another common theme. So I would say the assumption as well as coming in kind of on guard.

– Yeah, I mean, it’s one of those things. It’s like I have great sympathy for healthcare providers because you’re kind of damned if you do, damned if you don’t, kind of, you know. And maybe Roshan, you would know this. Well, I imagine that you see many patients just in the early stages of their pregnancy as they’re coming to their family physician.

– Yeah. I actually completely agree with that. And despite the experience that I’ve gained by working with Obesity Canada and learning from a lot of different amazing people in this space, this is a challenging part for me just in terms of trying not to beat around the bush, because I recognize that there’s considerable weight bias in stigma. I do my best to try to ask those open-ended questions and not make assumptions. But then still having a really good conversation as well in a shorter amount of time, because it’s usually booked for shorter visits. That’s the other thing too is that prenatal visits, I mean in family practice it ends up being 10 to 15 minutes. But man, when I was going through my obstetrics and gynecology rotations, they were five minutes. So having those conversations in such a short amount of time leaves very little to actually explore the patient experience. And so weight bias is going to come in regardless just by how you’ve structured your appointment. So I think there’s so many things about the, even the structure of prenatal visits and prenatal care that ultimately lead to more weight bias and stigma and potentially even thinking about what follow up looks like. We usually look at follow up in the first stages of pregnancy every four weeks. Well, why not actually book something over the phone or something a little bit less, a little bit more casual if you will, for us to follow up on in between if we do want to actually have those conversations, or after getting permission, of course, but actually having those Conversations as opposed to, well, this is your next prenatal visit is in four weeks. Let’s do this again or try to do this again in four weeks. So there’s kind of the structure of it as well that kind of forces you along this path. The horse having left the barn, if you will, continuing that analogy, it kind of, it’s not just for the patients but it’s also for the providers as well where you’re kind of put on this conveyor belt, and it’s sort of like a single brushstroke to sort of describe everyone or paint everyone is just not really appropriate.

– Yeah, and I completely agree with that. And even because the appointments are so short, there’s sort of a lot of procedures that perhaps are done with the nurse prior to the OB coming in to speak to you. So for example, having your blood pressure checked or even being weighed is sometimes done very quickly sort of outside the room potentially as well as a way to streamline these appointments so that when the provider sees you they’ve just got the number on the chart and they’re going to go through it very quickly and get to kind of all of the checklists that they have to get through in pregnancy. So we do actually hear quite a few patients saying that they feel their appointments are rushed or they don’t have the time to be heard. And like you said, Roshan, that it could actually be a function of just how the structure of the healthcare system is for obstetric appointments.

– And you mentioned the pre-visit stuff that’s done, and you just kind of put a thought in my head about, so of course that weight is taken outside usually the examining room, and I can’t tell you the number of times that a nurse, whether I was pregnant or not, announced that number to me.

– Ooh.

– So everyone in the hallway could hear the number. I can see the number on the scale! You don’t have to read it to me! I can read. But that kind of brings me to my thoughts about, we’ve kind of talked about some overt ways we’re seeing the bias and the stigma. But what are some subtle ways like language and tone? You’ve talked a little bit about assumptions, but you know, in your research, what strikes you as those subtle ways that people are experiencing bias without maybe even the providers even realizing what’s happening?

– So first thing that comes to mind is a story of one of my participants that she shared with me and it’s in one of our publications, her quotes where she went for one of her standard obstetric appointments and they were going to use the Doppler to listen to baby’s heartbeat. And they just, the doctor just said, “Can you hold your fat up for me?” And the way she described that interaction was that it was very quick. She right away reached the exactly how the doctor was advising her, and left the appointment, and then thought about it for the rest of her pregnancy. And so every time she came in, she quickly, for a Doppler exam, would right away hold her body the way that she was instructed so she didn’t have to hear that language again. And the way she described that interaction as well was that the doctor wasn’t being malicious or saying it in a rude tone. It was just kind of very casual like, “Can you just do this?” But didn’t realize that the language they were using was harmful. And a similar example was provided by another participant, this time in labor and delivery where they were getting a C-section. And they could hear sort of the mumblings of the team saying that, it must have been a doctor advising to a nurse or someone saying like, “Can you hold the fat up?” And that again, language that was being used. Perhaps the doctor didn’t realize they were saying that. It’s usually a high-stress, quick situation when you’re going through a C-section. But that stayed with the participant. So language is incredibly important. And for healthcare providers, you might be going through a quick appointment, but what you say will stay with that patient once they walk out of your doors. That’s an example of maybe some of those unconscious or implicit biases coming into play. Other examples that participants have shared are things like you said in the scale being outside. And that could be a function of how that clinic is set up to sort of streamline appointments and just get people going, but that in and of itself could impact a patient and could make them feel a certain way, especially based on what their pre-pregnancy history might be with being weighed and weight stigma and bias, and even things like I had a story and again from a participant where they had some of those older scales that are like kind of the clunky things that you take across. And she described to me that every time she got on the scale, it’s all towards the zero. And the provider would scale the smaller piece and then the bigger piece. And it’s like, why can’t you just go to the number that was there last week and move accordingly? And from the provider side, maybe they’re they’re following the rules on how to get the best measure objectively. But this is how you’re making your patient feel in that moment. So some of these examples that you might just not even notice that they’re happening, but they’re staying with your patient.

– I think this brings up a really important part, or, sorry, a really important point, especially in primary care, that there are a lot of subtle ways, not just from a prenatal standpoint, but even the regular visit of somebody coming into the office and how somebody actually moves through the clinic setting and how weight bias and stigma influences the movement, whether it’s their interaction with the front desk, how they are weighed, where they are weighed, if they need, if we get permission to actually weigh them, which we’ve tried at our clinic somewhat successfully. Although, again when you’ve been taught a certain way that this is just what happens, and I hear it in the background while I’m in my office, that they’re just being weighed without actually getting permission for it. I try my best to avoid doing that until I’ve actually spoken with the patient. And same thing goes for the prenatal assessment, too. I think there’s so many aspects of that when we talk about our multidisciplinary teams, to have those conversations and have them frequently to counteract a lot of the education that we’ve done where this is just sort of a, it’s just a mandatory part of your visit today without realizing the, I guess the harmful effects that are totally, they’re not malicious, as you mentioned, but this is where weight bias and stigma persists in one of the more egregious ways within our health care system.

– Yeah, yeah. And it’s interesting, another story that just came to mind as you were talking about sort of just the second structure of clinical appointments. One story that stuck with me that I didn’t even think about was a participant shared with me that she ended up missing her obstetric appointment and she was seen at a high-risk clinic simply because she couldn’t find a parking spot, and she was 37 weeks pregnant, where she could get out of the car. And when she called the clinic to say, “I missed my appointment,” she felt that there was this assumption that you just don’t care, but that was actually an issue with physical infrastructure.

– Wow.

– And if you take a look at our parking lots, like they’re pretty cramped and only getting smaller. So now you have this individual who’s 37 weeks pregnant, maybe they need some space to be able to exit their car and she just couldn’t find that. But then because she’s somebody who’s living with obesity or somebody with a larger body, she was met with this assumption of, well, you don’t care. And that’s just not fair overall.

– What are some of those downstream effects you’ve seen in terms of how weight bias can influence things like access to prenatal education, provider recommendations, or birth planning? I think that’s something that is that we don’t talk nearly enough about. We don’t talk about a lot of this, but this is one area that I wish we talked about a lot more.

– Yeah. So similar to, again, in non-pregnant situations, there’s going to be that reduced level of trust with your healthcare provider if you perceive them as somebody who has weight-stigmatizing attitudes. And then that can trickle down into not being open about the concerns that you’d like to share. And in pregnancy that’s, well, anytime, but in pregnancy it’s very important to feel comfortable with your healthcare provider to share some of the things that you’re worried about. There’s just so many unknowns in pregnancy, and the Internet can make that even more scary for you. So it would be helpful to have a trusted source that you know you can go speak to. But if you perceive that trusted source as someone who carries those negative attitudes, you won’t ask your questions, and you won’t seek the support that you have all the right to have. So that’s a big one is that mistrust with your healthcare provider. Not so much the missed appointments that we see in non-pregnancy. And I think that would be because, as Michelle mentioned, in pregnancy you tend to have more frequent health care provider interaction. There’s also this desire to want a healthy pregnancy, to want to know how baby is doing and you need to go to a clinical setting to do that. But once in that environment, just not openly sharing your concerns is probably the biggest issue. And then we also see that sort of follow into the postpartum period that if you have concerns postpartum, you won’t share them for fear of what you experienced in pregnancy. And in postpartum we see that individuals with larger bodies or obesity, if they had a C-section, for example, they may need support for wound care and they may need support for something like urinary incontinence, which in and of itself those issues are sometimes stigmatizing and difficult to talk about. And now you’ve added the layer of obesity or the layer of having a larger body and weight stigma. So I think communication is what’s harmed the most in my opinion. And then we also see that in the research we’ve seen in associations with experiencing weight bias and higher levels of maternal anxiety and maternal depressive symptoms. And although this hasn’t necessarily been tested in the context of weight bias, experiencing anxiety or depression in pregnancy is going to have an effect on the newborn, and it’s going to have an effect on mom’s mental health postpartum them as well.

– Wow. So a lot of longer term effects for things that healthcare practitioners may not even realize that they’re doing, right? Can you hold this fat out of the way? Like they’re just like, I’m trying to do my job as quickly as efficiently I can, without thinking of those longer term things, which also makes me, I’m wondering if any of your research has involved people having these experiences and then internalizing that weight bias, and then how that’s impacting them and the health practitioners they’re interacting with going in the future.

– Yeah, yeah. We actually, with Obesity Canada, we modified the adult weight bias internalization scale to be specific to weight change in pregnancy. And in that study we found similar findings to the adult, the general adult population, that internalized weight bias appears to be higher among individuals who have larger bodies or obesity and also amongst those who may have been experiencing gestational weight gain at a rapid pace or exceeding sort of recommended amounts. And there have been some recent works also showing that internalized weight bias is linked with reduced breastfeeding, and so a lot of associative work and a lot of work using scales and surveys. But I do think in the pregnancy and postpartum research space we need to dive deeper, perhaps from more of a qualitative or a lived experience perspective on that internalization to understand how that impacts decision making and just processes, especially postpartum. I think, because now you’ve added that responsibility of childcare and all that goes into having a newborn. And so certainly we do see with internalization though there is a negative impact on mom’s overall well-being and mental health outcomes. And we just actually started a study, so I hope to share the findings in the future where we’re looking at how internalized weight bias actually changes across the life course of women in particular and through these milestones of preconception, pregnancy, and post postpartum, and then the impact on outcomes like mental health outcomes, but also behavioral changes like physical activity or stress reducing activities. Again, drawing from sort of non-pregnant work to see how that then impacts pregnancy.

– That’s fantastic. I really think that we need more exploration of the impacts of pregnancy on health and specifically around obesity and how that changes over time. When I’ve done my assessments for people living with obesity who are living in a larger body, definitely pregnancy stands out, right? As a time in their lives where there’s, as Michelle mentioned, it can be one of the most joyful times in your life. But due to either conflicting information from family members, from healthcare practitioners, or just the way that you view yourself, it changes you irreparably to the point that biological females as opposed to biological males, there’s a huge difference. Like as a biological male, there’s a pretty good chance I’m never actually going to experience that. And that has changes to our health that are long lasting. And so having that exploration from a research standpoint across the time spectrum I think is really critical and I’m so glad that that’s actually being explored.

– Yeah, yeah. And it’s, it’ll be a tough and long study to do. But what we’re really interested in is trying to understand how, in this particular study we’re working with individuals who identify as women specifically, but looking at how your relationship with weight possibly changes as you go through the life course. So we’re looking at experiences in adolescence and then preconception, pregnancy, postpartum. Like you said, Roshan, that that timeframe actually could impact the rest of your life. There’s quite a bit of research looking at postpartum weight retention where you don’t, and so this is the weight after you’ve had baby, and current recommendations indicate that you should lose your postpartum weight before you have your next child. And if you don’t, the idea is that it’ll continue to add up and it increases your chance for obesity or increased weight after having children. And we want to explore the implication of postpartum weight retention on things like internalization of weight bias where now women are bombarded with messaging, especially through mediums like social media, that you should bounce back to your pre-pregnancy weight, if not less in a couple of weeks or whatever and that impact that it has on you for the rest of your life. And we’re also even interested in going further into spaces like menopause where now biologically your body is going to fluctuate when it comes to weight, irrespective of if you’ve had obesity or not. And so what does that mean in terms of your experiences of weight bias or your internalization of weight bias? So, yeah, women’s bodies, female bodies are amazing and they’re constantly changing. And there’s so many biological milestones that will impact hormones and impact the way your body regulates weight. But we need to now take that one step further and think about, well, how does that affect you psychologically?

– I’m sure just like with a lot of our guests, we could spend hours talking about this, and especially for me, when I see the breadth of patients in my practice, that to talk about health across the spectrum is something that I wish we could do more of, so I appreciate the work that you’re doing. Before we continue, we wanted to pause for our bias break. As a lot of our listeners are aware, it’s a moment to bring this conversation into real life moments.

– So, Dr. Nagpal, we’ve heard several stories from you already because so many women have shared their stories with you. And this is an unfair ask, but I’m going to ask it anyway. Can you share one experience, it could be even a personal experience of yourself, where you’ve experienced or observed weight bias and share it with our listeners.

– Am I allowed to share two, one personal and one from a participant?

– Of course, of course!

– So I will share the participant experience first. So this is a story that I got to hear when I was a postdoc doing some of my first qualitative work. And this was an experience that a participant shared with me at one of their routine ultrasound checks that they had. And it was an example of we were chatting about unconscious bias or those subtle moments that one wouldn’t recognize. And so they were at their ultrasound appointment and the technician was kind of getting set up and looking for, listening into baby’s heartbeat. And they just said, “Oh, I can’t find the heartbeat.” And that’s what they said and continued with their assessment. And she said in about 15 minutes, all things were all set, and they were able to find the heartbeat, continue with the exam. But what she said is that those were the worst 15 minutes of her life. And that 15 minutes stayed with her for the rest of her pregnancy. And every appointment, she walked in terrified. And she talked about how that made it so that she had prenatal anxiety, and it terrified her for the rest of her pregnancy. And it was just a quick comment by the tech, possibly just an objective comment of why they were taking long with the Doppler. She doesn’t know. She didn’t ask any questions of the tech, but she always says, 15 minutes, worst 15 minutes of her life. And they stayed for the rest of pregnancy. And so that was, and where the obesity piece comes in or the weight piece comes in is she was told earlier on by a healthy provider that often if you have a larger body or if you have obesity, we sometimes need to do multiple appointments for these ultrasounds. So she knew that going into the appointment, and so she left feeling that it’s because of her obesity something happened to baby, and she internalized that and blamed herself. And so that is a story that even when she shared that with me, it was is a qualitative interview over Zoom, and I didn’t even know how to proceed with the rest of my questions. It was just a moment where we had to stop and think. And she just kept saying, she’s like, “I felt like it’s my fault.” And that’s a common narrative we see. We did a study with a team in the United Kingdom where we looked at their newspaper representation of maternal obesity, and UK media tabloid culture is quite different than maybe our tabloid culture. And it was just the way that maternal obesity is essentially presented as like this, like catastrophe, or like this, like warlike language that’s used, and the person internalizes that and blames themselves, and that’s extremely harmful. So that’s one of my examples. And then I wanted to share a personal example because it’s kind of the opposite side of what I’ve been talking about. And I mentioned earlier that pregnancy is unique because all bodies are changing in some way. So I experienced my first pregnancy very recently. So my daughter is now 14 months old. During my pregnancy I actually experienced intrauterine growth restriction. So what that means is that the placenta was possibly not functioning optimally and baby was not receiving an adequate amount of nutrients. And I have been a pregnancy researcher for I don’t know how long. And I did the things that I thought you’re supposed to do to prevent all the complications, the things that I’ve written about or been a part of guidelines for. And so when I found out I had IUGR, I sat there thinking, “What did I do wrong? What did I do wrong?” I’m in this field. And I could not shake that question. And when my daughter was being born, the OB made a comment just along the lines of like, “Oh my God, you don’t even look pregnant!” And you might think that someone will take that as a compliment. And I took that as, oh my God, I didn’t eat enough, I didn’t gain enough, I didn’t do enough, and that’s why my daughter experienced this. And even though now we’re at 14 months postpartum, and you know, it’s in the past, I sometimes still have that moment of like, oh, she told me I didn’t gain enough, like I did something wrong. So that made me realize in sort of the weight research that we do, these types of comments, moms take it, and they don’t take it objectively as I gained nine kilograms or whatever the guidelines are. They take it as, what did I do wrong? And that’s an issue in pregnancy that we have to address and we have to prevent.

– Yeah, definitely. I mean, I think a lot of pregnant people experience it in different ways. But like, yeah, that internalizing that, because we all feel guilty. You know, we’re trying to do everything so that the baby is perfect. And if the slightest comment seems to imply that we’re not doing what we should do, you know, that that’s just like a dagger in the heart, right?

– And weight is just, it’s so visible in pregnancy, if that makes sense. And for some reason in pregnancy there’s this social idea that it’s okay to talk about weight, whether it’s your family talking about it. You know, a lot of our participants will share stories of family members saying things like, “You need to eat more,” or, “Eat less,” and it just seems like it’s as if it’s like socially acceptable to make those comments during this 40-week period.

– Yes, yes. I’m laughing because it’s like it’s normal where people also feel like they can, family feels like they can comment on what you eat and what your body size is, but it’s just so much under a microscope when you’re pregnant. Yeah, it’s such a challenge. We’ve talked a lot about individual experiences. But I might like to shift things a little bit towards the larger systems, right? Because a lot of our listeners have to work in the system which they don’t control, except in small amounts. And I’d like your thoughts about pregnancy care in a larger body and how our larger medical systems help or impede that being a successful experience.

– I think we sort of talked about this earlier as Roshan mentioned that a lot of the experiences that individuals have may be a function of our constraint healthcare system and limited appointment times. You know, there’s actually been a lot of research to show that individuals who maybe go through midwifery care have fewer instances of weight bias and stigma. And that could really be a function of the fact that in midwifery there’s longer appointment times, often maybe more time to build a rapport or a relationship with your healthcare provider. And a lot of the work that we’ve also done is healthcare providers, they want to do good. I would like to say optimistically, most of them want to do good and most of them are also aware that weight stigma exists in the healthcare system, whether very overtly or not. So I think overall at a systems level, I think we need to possibly integrate more educational opportunities for healthcare providers to be able to recognize those sort of subtle or unconscious weight biases. And oftentimes with weight bias, how do you reduce it is by improving self-reflection practices. And so it’s very difficult to buy you a tool or something like that, like a clinical piece of equipment to reduce weight bias. It’s more you. And so it’s important to, I think, to have healthcare providers understand what is weight bias, how it may have impacted your patients before they even came to you. And through your own sort of self-reflective practices, you can engage in trying to understand how to improve your language, your communication style, to just overall improve the experience of the patient. So I think with weight bias in prenatal care and in general, the way to address it at that system level is to integrate more education for healthcare providers.

– On that note, are there examples anywhere in Canada or internationally of systems or clinics doing this better?

– I mean, I think so. I think within Alberta we’ve got quite a few obesity-specific clinics and it is possible that you might earlier in your pregnancy be seen at these clinics. But there are quite a few clinics across Canada that are specifically for individuals who have high risk obesity in pregnancy. And in those clinics, at least some of the providers that I get to interact with, have done sort of the work to have that background knowledge on weight bias and stigma and how it implicates their patients. The most recent obesity and pregnancy guideline that was published by the Society of Obstetricians and Gynecologists of Canada did have a section on weight stigma, which I think is a step in the right direction and we can certainly do more. So I think it is recognized that this is something that needs to be addressed in this population and also recognize that it’s going to be unique in pregnancy, where, again, we’re weighing participants more often. Gestational weight gain is a change they’ll experience. I was recently a part of a study with a team in Australia where they developed some resources for clinics, such as just sort of memory cards for anybody in the clinic on remembering to ask the patient before they ask them to step on the scale. They haven’t done necessarily work to see if the tool’s been working, but those types of things are being implemented in Canada and outside of Canada.

– See, there’s hope. In our podcast, there is always hope. There’s hope for change. There is hope for a difference. That’s what I love about it.

– That’s awesome.

– So I seem to ask all the impossible questions today. I do it to the guests all the time. But you know, for our listeners, is there one thing that you could impart your wisdom about that they could take to their practice tomorrow or Monday morning that you think is simple to implement but would make a big difference with their patients?

– Oh, that is such a tough question, Michelle. You know, I think, I really think most maternal healthcare providers probably already know this, but I’m going to say it anyways. Is that like you said earlier, Michelle, pregnancy can be a joyful time, but it can be an extremely stressful time. And in the day and age that we live in, where we have information overload and you can ask AI to diagnose you with absolutely anything, pregnant people have a lot of questions about their bodies, they’re changing bodies, they have a lot of worries and concerns about this developing newborn. And individuals living with obesity or a larger body and specific to obesity, if you have a clinical diagnosis of obesity and perhaps you went through preconception care or fertility care, they come into this experience nervous and anxious and really excited that perhaps they’re going to be growing their family, but those nerves and that anxiety exists and you as a healthcare provider are in this incredibly powerful space where you could reduce some of that anxiety. And I think that’s the message I want to give them, that you have this ability to reduce that feeling of being scared or nervous. And weight stigma and weight bias takes that power away from you, so don’t let it. So participate in learning about what weight bias and stigma is, how it could have impacted your patients before they even came to see you, and engage in those active self-reflective practices on what you can do to reduce some of those anxieties. And you know, a participant shared once with me that it could be as simple as before you ask your participant to go on the scale, you do the Doppler exam first so they get to hear baby’s heartbeat. It could be something as simple as just switching around the order, or like she was saying, she’s like, “Why can’t they just weigh me on my way out?” Or something like that. And so as a healthcare provider, you are so you can do those things. And the other piece is to remember that in that patient-provider relationship, it’s a collaborative relationship. So to give that patient that space to be empowered over their own health, and especially in pregnancy, where now you’re constantly thinking, even though it’s about your own health, you’re constantly thinking about baby’s health. So to empower the patient to be in control of their health.

– I think that’s really, really powerful. It’s something I think about all the time in prenatal counseling, of the stress that and the burden of information expectations on the patient as soon as they walk in the door. I think what I’m going to take out of this podcast, this discussion that we had today, is the importance of the collaboration work that we can do as a team. I know we didn’t discuss it at length, but it’s definitely what’s come out for me in my primary care practice, how is it that each component of our team can help facilitate a better experience for patients, but primarily a reminder that we are still there for them and that we’re not trying, at least not intentionally, to rehash a lot of old wounds or bring out a lot of the trauma that’s potentially been there from the healthcare system, because it’s a prenatal visit and we just have to do these things anyways, right? Because it’s just part of the way that we’re going to do things. Let’s be intentional about it. Let’s reflect as a group, not just as an individual, but as a group, as to how we can provide really optimized patient care for patients living with obesity or living in a larger body.

– Absolutely.

– And that sums it up so well. I mean, so much of what we talked about today comes back to empathy, right? Slow down, listen, and see the whole person in front of you.

– Dr. Nagpal, thank you for sharing your insights and for the incredible work you’re doing to help us do better. We’ve got a lot to reflect on.

– Thank you so much for having me.

– If this episode got you thinking about how weight bias shows up in your practice or your institution, share this podcast with a colleague, have a conversation. That’s how change starts.

– And don’t forget to follow or subscribe so you don’t miss upcoming episodes. Until next time, stay curious, stay kind, and keep scaling up your practice. This podcast is intended for informational and educational purposes only and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you are listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient-client relationship.