He Said
Examples of weight stigma are prevalent and run the gamut: clothing and airline seats designed for smaller bodies, cyber bullying, verbal insults, physical attacks, and social exclusion. Even our own government has declared war on fat people. Unfortunately, weight stigma also infiltrates and inflicts harm in a space that is supposed to promote health: the doctor’s office.
Obesity is associated with a number of health woes, and, clinically, your doctor probably finds more problems in heavier patients than in thinner ones. Consequently, your doctor might recommend weight loss as a supposed path to better health. On the surface, such well-intentioned advice sounds reasonable, but it is problematic for a multitude of reasons.
Correlation does not equal causation. In other words, just because two factors tend to occur together does not mean that one necessarily causes the other. The diseases blamed on obesity could be due to other factors that tend to co-occur with increased body weight.
- Cardiovascular disease, which is often blamed on obesity, is also associated with stress. In fact, research has suggested that many of the health woes blamed on obesity might actually be due to the stress of weight stigma.
- Heavier people are also most likely to embark on weight loss endeavors, which are likely to result in weight cycling, which in and of itself is associated with worsened morbidity and mortality.
- Some doctors spend less time with obese patients, fail to order diagnostic testing, and have less patience and get more annoyed the heavier a patient is, meaning that heavier people are subjected to worse medical care than thinner people receive.
- Wary of being fat shamed, heavier individuals are less likely to seek regular medical care, so their diseases may be more severe by the time they are detected, as opposed to illnesses that are nipped in the bud and therefore have a better prognosis.
In other words, the causal factor might not be your weight, but rather one or a multitude of other factors associated with your weight.
Your doctor may have heard of the National Weight Control Registry, a database of “over 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.” Some doctors believe that if their patients adopt the behaviors exhibited by people in the Registry, their patients are likely to achieve similar weight loss.
Unfortunately, presenting these behaviors as the key to long-term weight loss makes little sense when so many other people perform the same actions without achieving similar outcomes. The lottery crowns new millionaires every single day, and a quick study of the winners reveals that a behavior common to all of them is that they bought tickets, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball.
Even if a causal relationship exists between body weight and your medical condition, endeavoring to lose weight is still not the answer. In light of the research showing the prevalence of weight regain that often surpasses baseline weight, we can only assume that the condition you are trying to improve by losing weight would actually worsen in the most likely scenario that you end up heavier than you are now.
For these reasons, many healthcare providers – including us – believe it is unethical to recommend weight loss to patients as a path to better health.
Weight stigma in healthcare can also negatively impact thinner individuals. For example, binge eating disorder is a condition stereotypically associated with larger people, but the reality is that it can affect people of all sizes. Doctors may dismiss or overlook red flags in individuals who do not look the part. Furthermore, just as doctors sometimes make incorrect assumptions about the behaviors of larger individuals, doctors may assume that thinner patients are leading healthier lifestyles than they really are.
On a personal note, as someone with a relatively thin body, I have certainly had my share of doctors make assumptions about my eating behaviors – without asking me a single question about my feeding habits or my relationship with food – because of my body. Typically, their assessment is along the lines of, “Clearly, your nutrition is fine,” as they glance down at me. How often do you think people labeled “overweight” or “obese” hear such a sentiment from their doctors?
In hopes of freeing themselves from weight stigma, some people resolve to change their body to a size and shape that our society deems more acceptable. While we firmly support a patient’s right to choose for themselves the approach to healthcare that feels most appropriate for them at any given time, we also believe in disclosure and informed consent so patients can make educated decisions. After knowing the facts regarding the failures of weight loss endeavors, you may still decide to travel that road. Know, however, that you have a choice. For more information regarding how to tackle weight stigma and pursue better health in a weight-neutral fashion, please see our Weight Loss FAQ.
She Said
Weight stigma. People living in larger bodies are often treated as less than and discriminated against in many different contexts. This goes double for those people of size who are also people of color, LGBT, and/or disabled. From being body shamed at the doctor’s office to earning less money than their thinner counterparts to being ridiculed by the media and told they are a problem that is to be solved, fat people have it tough in our society.
While it is neither unexpected nor surprising when weight stigma is exhibited in all of the above situations, it is simply mind-boggling how it is displayed in certain “woke” spaces. Take, for instance, the eating disorder (ED) treatment community. Here is a group of professionals whose job is to help individuals heal their relationships with food and their bodies. One would think that this help should be offered to ED patients in all different body sizes. Unfortunately, this is rarely the case.
I have a number of patients who clearly exhibit ED behaviors, such as restriction, bingeing and purging, or excessive exercise, yet their higher weight precludes them from meeting the criteria for an ED like anorexia nervosa or bulimia nervosa. Instead, these patients fall into the catchall category of “ED NOS” (eating disorder not otherwise specified), also known as “OSFED” (otherwise specified feeding and eating disorders). This means that even if someone is heavily restricting their intake, no longer menstruating, and severely malnourished, but their BMI falls in the “normal,” “overweight,” or “obese” categories, they are not seen as “sick” as those who are “underweight.”
Never is this more clear than in inpatient or residential treatment for EDs. While the emaciated patients are refed aggressively to help them regain weight, those in larger bodies are often fed just enough to sustain them because it is assumed that they do not need to regain any weight. In some cases, I have heard of ED facilities actually trying to help the larger ED patients lose weight, as “clearly they could stand to lose a few pounds.”
This difference in how patients are treated is not only disturbing, it is also quite damaging to ED patients who live in larger bodies. Many of my larger patients have actually become more symptomatic after being discharged from treatment because they felt they needed to be even “sicker” to receive adequate help. I specifically remember one such patient who, even though she was eating only 200 calories per day and was exercising for hours on end,would only get to stay at a program for a couple of weeks and then be discharged for outpatient care as her weight was not concerning enough.
This has got to stop. EDs are found in people with all different body types. Just because someone does not appear to be emaciated does not mean that he or she is not suffering from a debilitating ED. The ED treatment community needs to start treating ED patients who are living in larger bodies with the same care and concern as those living in smaller bodies. Hopefully, someday there will be an end to weight stigma in ED treatment as well as in other areas of our society.