Weight Stigma in Healthcare Harms Us All

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The following is a guest blog written by Deirdre, who has given us permission to use her real name.

All my life, I’ve been sick. I can remember being five years old and waking up in the morning sobbing because my eyes were swollen shut, I could not breathe, I was always tired, and had severe skin conditions and rashes all the time. I had to go on nasal sprays, steroids, oral allergy medicines, and eye drops almost year-round from that age. Around the age of 14, I started to present with vomiting up bile every single solitary morning before proceeding with my day. Despite complaining to doctors all my life about all these things, I was ALWAYS considered healthy. The number one indicator for doctors? I was thin. I always had a “healthy” BMI, and all my bloodwork looked good, so nobody ever took me seriously.

Fast forward another decade. At this point, my body was so inflamed from consuming gluten – a protein which I later found out I was severely allergic to all along – that I had gained a significant amount of weight. I was 24 years old at this point, vomiting and having diarrhea after every single meal, suffering with mental illness (depression and anxiety, some from trauma but also largely because I *never* felt well and had no choice but to press on), smoking cigarettes constantly to suppress my appetite, abusing Adderall to suppress my appetite, exercising excessively (3-5 mile runs, 10 on weekends, and 2-hour workouts daily). Doctors still would not listen to me.

When I was thin, my health complaints were ignored because I was thin. When I was big, my health complaints were ignored because I was big. This is how weight stigma harms people of all sizes. When doctors are trained to view the BMI as such a strong indicator of our health, they tend to miss out on treating the whole patient and the concerns they are actually presenting. In this way, fatphobia continues to dominate our medical fields in the most insidious ways, regardless of a patient’s size.

When I was younger, I felt like my only sustainable solution was to put restrictions on my eating. I felt like I needed to do everything in my power to just not really eat. The only thing that ever felt good to me was mint chocolate chip ice cream. It was the one food that never made me sick. I ate a pint of it nightly, then would feel guilty, throw up the next morning involuntarily, feel good about that because I was disordered in my eating habits by then, and the cycle of “weight management” continued to wreak havoc on my life and destroy my gut health, self-esteem, and brain chemistry.

At 25, I was accepted to my dream graduate school for my health degree, and thus I was always in Boston. This meant finally seeking out primary care at Fenway Health and getting a fat-positive, conscious, and compassionate doctor for the first time in my life. Dr. Karen Kelly literally saved my life, as I know I would have attempted suicide that year if I had not met her. I was at my wit’s end.

Karen’s team allowed me to face away from the scale when they took my weight. I told Karen all the symptoms I’ve always had. She referred me to an incredible gastroenterologist who finally listened to me and tested me for a bunch of autoimmune gastroenterological diseases.

Notice that only now, because I finally was seeing a fat-positive doctor, was my weight looked past in order for me to receive the care I truly needed. My current health care team, including Karen, is amazing. It is a shame that all the doctors I ever saw prior assumed that being thin meant I was healthy. That mentality destroys a doctor’s ability to see clearly, and my chronic autoimmune disease was completely missed for 25 years as a result. If my celiac disease had been caught sooner, it could have meant avoiding severe damage to my organs, and possibly even reduced my chances of long-term health implications. Now I have to live with whatever damage has been done.

More and more public health research is finally showing that fat people can be healthier than thin people. More and more people are catching on that the BMI as a marker of health is a limited, archaic, outdated, weak, inaccurate, and frankly incredibly lazy way to approach medicine. It is a way for doctors to not do their jobs. All doctors should first and foremost be researchers and scientists listening, looking, and hypothesizing with open minds. I am almost the heaviest I have ever been now, yet my cholesterol, blood pressure, oxygen, etc., are all fantastic.

The concept of weight management is a barbaric and inhumane way for any doctor to practice. One hundred years from now, we will look back at the ways we tried to force mutilation on humans through diets and bariatric surgeries and see the oppressive reality of that kind of hatred of fatness. Doctors that focus on “weight management” and miss what is really going on need to start being held accountable – sued and fired by their patients.

I think that numbers are detrimental, and so is excessive monitoring of size and shape. We came here to live in these sacks of skin as vessels for our non-physical selves, our souls, and nothing more. The BMI is bullshit and was invented by an astronomer in the 1800s who only used white Anglo-Saxon males in his sample size. BMI does not account for muscle mass, bone density, or genetics. It does not leave room for all the boobs and butts and hips our bodies create to cushion us or to grow or feed our babies.

Someday I will have chapters in a book titled “the BMI is racist,” and “the BMI is sexist.” Once I am a doctor or nurse practitioner, I will create a new tool for epidemiologists to test that will actually be inclusive of all sexes, genders, races, etc., without poisoning our minds with self-doubt and self-mutilation.

If I had unbiased doctors all my life, I may have been diagnosed with celiac disease much earlier on and could have potentially saved myself from having cancer or infertility someday. I hope to live a long life and to have children and grandchildren, and I hope to leave them in a world with less weight stigma and more active listening, especially in the field of medicine.

Here Comes Mr. Greedy

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When I ask my patients to look into their pasts and tell me about the origins of their weight stigma, they can sometimes trace back and point to influential entities, such as a parent, teacher, doctor, or coach. In relatively rare cases, they can recall specific interactions, such as Joanne’s doctor telling her to “get skinny,” or my neurologist cautioning me that if I ever thought about “slacking off” in my exercise routine, I should remember the conversation we were having right then.

Most typically though, patients cannot point to anything. They look at me befuddled, as if I asked a Red Sox fan how they came to know that the Yankees suck. Like, aren’t Bostonians just born knowing that? No, they are not; nor are we born prejudiced against fat people. Both mindsets are learned.

Just as dislike of the Red Sox’s longtime rival is ubiquitous throughout the metropolitan area, so is weight stigma in our culture at large. We develop sports team allegiances from a young age via various sources – jerseys in elementary school, endorsements, televised games, familial preferences passed down – and the biases that we hold against people of higher weights were shaped from so many sources that no singular one tends to stand out in our memories.

And these sources get to us when we are young. Our daughter loves books and has an extensive library of reading material geared towards toddlers her age. In a boxed set of children’s books from the late Roger Hargreaves, Joanne intercepted one entitled Here Comes Mr. Greedy, which shows a cartoon of a fat man on the cover. Subsequent pages describe this rotund individual as “the greediest person I’ve ever met,” that he constantly thinks about food, and he is so “greedy” that he throws a birthday party for himself every week so he can regularly have his favorite food: birthday cake.

This is just one book that Mr. Hargreaves wrote that features his Mr. Greedy character. Another one reads in part, “In fact, Mr. Greedy loved to eat, and the more he ate, the fatter he became. And the trouble was, the fatter he became the more hungry he became. And the more hungry he became the more he ate. And the more he ate the fatter he became. And so it went on.”

Nothing against Mr. Hargreaves, who seemingly dedicated his professional life to creating content for children. Like most of us, he was an apparent victim of a fatphobic culture. Mr. Hargreaves presumably absorbed erroneous stereotypes about eating behavior and body size and repackaged them for preschoolers, thereby perpetuating the generational cycle of fat hate.

Sparing our offspring from weight stigma is certainly an uphill battle, but parents have the ability to take mitigating actions.

For starters, parents can minimize exposure. Just as Joanne spotted Mr. Greedy in our daughter’s new book collection and removed it, we can be vigilant in other ways. Change the channel when ads for weight loss programs and products come on, set appropriate boundaries with those who talk about their diets on family Zoom calls, and find a pediatrician who provides weight-neutral healthcare.

When children inevitably encounter weight stigma, address it head-on and help them process it. Teach them that bias against body size is as erroneous and problematic as any of the other stereotypes and prejudices that infect our world.

Most importantly, even though what happens out of the house is largely out of our control, make sure to keep a body positive environment at home. Avoid leaving problematic magazines on the coffee table (or better yet, do not keep them in the house at all), get rid of the scale, do not go on diets (or embark on “lifestyle changes” that are diets in disguise), and refrain from offering disparaging comments regarding anyone’s bodies, including our own.

Crime and Punishment

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Michael Felger, a sports radio host in Boston, received national attention last week for his extended rant in reaction to the death of Roy Halladay, the former pitcher who was killed when the plane he was piloting crashed into the Gulf of Mexico.

“It just sort of angers me,” Felger said. “You care that little about your life? About the life of your family? Your little joyride is that important to you that you’re going to risk just dying. You’re a multimillionaire with a loving family, and to you, you have to go get that thing where you can dive-bomb from 100 feet to five above the water with your single-engine plane with your hand out the window. ‘Wheee! Wheee! Yeah, man, look at the G-force on this! I’m Maverick! Pew pew pew! Yeah, man, look at this, this is so cool.’ And you die! Splat! If I die helicopter skiing, you have the right to do the exact same thing I’m doing to Roy Halladay. He got what he deserved.’’

Felger took it too far and he knows it. “In a nutshell, I would say that I feel bad about what happened on a lot of levels,” he said the next day in his on-air apology. “I feel bad about what I said and how I conducted myself. To say it was over the top and insensitive is really stating the obvious.”

However, Felger limited his contrition to the poor timing and distasteful nature in which he communicated his points, but he held firm to his core arguments. “I believe what I believe,” he noted, a sentiment to which he returned over the course of the four-hour show to emphasize that he was not apologizing for his feelings, but only for how he conveyed them.

That is unfortunate, for as much credit as I give Felger for taking responsibility for his tone and tactlessness, going out of his way to double down on his stated beliefs suggests a failure to understand the inherent dangers of condemning someone else for making a choice or engaging in an activity that subjectively feels too risky to the person passing judgment.

Stunt flying, as Halladay was reportedly doing at the time of his crash, is inherently dangerous, but all choices exist on a risk continuum that never quite reaches zero. Every single one of us makes decisions on a daily basis that someone else might deem too risky, but we weigh the pros and cons and ultimately take the risks that in balance feel worth it. Some of us cross busy streets, gather in crowds, work stressful jobs, play contact sports, get behind the wheel, mount bicycles, undergo elective medical procedures, attend protests, testify against violent defendants, and yes, some of us stunt fly. We all draw a line somewhere regarding what we, personally, feel is too risky, but who is to say that our placement is any more right or wrong than where someone else draws their own?

For another example of a choice that could be considered too risky, Felger need not look any farther than the chair next to him. His co-host, Tony Massarotti, elected to pursue a weight-loss treatment plan at a local diet center and pitches the program via radio spots every afternoon. Hopefully he knew going into it that he is unlikely to sustain his lower weight and that weight cycling, regardless of one’s baseline weight, is associated with a higher overall death rate and twice the normal risk of dying from heart disease.

Hopefully, nobody will claim, “He got what he deserved,” if Massarotti dies of a heart attack, yet some do just that. A fervent raw vegan that I used to run against once suggested that we should treat omnivores who die of myocardial infarctions as suicide victims because, in his eyes, their deaths were self-induced by years of consuming cooked foods and animal products. They are shooting themselves, he explained metaphorically, they are just pulling the trigger really, really slowly.

To suggest that people who follow a diet other than his own are killing themselves is to pass quite a judgment, one that is particularly curious since other restrictive diets have their own staunch followers who similarly believe that raw vegans are bringing about their own demise. Ours is the path to salvation, extremists believe, while others are deservedly damned for worshiping another dietary God.

Across the street from the radio station, a related story of crime and punishment is apparently unfolding at New Balance, where, according to someone I know who works there, the company has started measuring employee body mass index (BMI) annually and now charges fat workers more for health insurance than their leaner colleagues.

Perhaps New Balance’s intent is to encourage employee engagement in behaviors subjectively considered healthy and/or to financially demand more of the individuals who are seen as the greatest burden on the healthcare system. In either case, the company is erroneously conflating behaviors, health, and anthropometrics. To charge heavier people more for health insurance is to issue a stiff sentence after an unjust conviction.

The policy is a clear case of discrimination that exacerbates weight stigma and risks worsening the health of fat people, in part by encouraging them to pursue weight loss, sometimes by very dangerous means, in order to be treated, both financially and otherwise, like everyone else. Such a policy also negatively impacts thinner people. One of my patients, the child of a New Balance employee, is working to recover from a restrictive eating disorder and exercise bulimia that were triggered by – get this – a fear of becoming fat. Given how heavier people are treated, including by New Balance, who can blame this kid for wanting to avoid such torment?

The accumulation of insurance payouts for this patient to attend regular and ongoing appointments with me and the rest of the treatment team is certainly expensive. With this child representing just one small twig on the tree that survives on the light that is New Balance’s insurance coverage, perhaps this reprehensible policy will increase, not decrease, the totality of the company’s financial healthcare burden. If that possibility comes to fruition, I will borrow a line from Felger and decree:

They got what they deserved.

David Bowie

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David Bowie and Duran Duran are the only two artists I have been listening to virtually my entire life, and somewhere in an unpacked moving box in our basement sits my tape copy of the former’s Let’s Dance album that I got in kindergarten.

Although I do not care for everything Bowie released, I greatly respected his ability to oscillate between styles so drastically that I was left enjoying only parts of his catalog, as opposed to those of artists whose sound is so consistent that I can accurately base my impression of their body of work on a single song.

His versatility, I expected, would form the basis of the numerous tributes that poured in via social media yesterday as the shocking news of his illness and death became public. While some of them certainly did, several centered around the profound impact Bowie had on many individuals and our culture as a whole in terms of empowerment, self-acceptance, and tolerance for diversity and differences.

Nobody said it better than Richey Rose, a guitarist living in New York City, in the following tribute he posted yesterday:

“I had my Bowie phase a little over 10 years ago, when I was a sophomore in college. I had just gotten my first record player and found Hunky Dory at Pop’s (best used record store in my hometown of Lexington, KY). Of course I’d always known Bowie, especially because I’d just gone through a massive Velvets/Warhol/60’s & 70’s NYC discovery the year before… but that record was my first effort into becoming properly acquainted with him as an artist. Needless to say it opened Pandora’s box. I became obsessed and fully engrossed in everything he’d done. A friend gifted me an original pressing of Ziggy and I promptly wore it out; teaching myself all the guitar parts along the way. YouTube was just starting and there were interviews, videos, concert footage – it was my own personal archive into David’s creations and contributions to the world. I was beyond inspired. I’d always been self-conscious about being too skinny, too ‘pretty’ if you will, and had grown up being mercilessly teased because of it. Bowie was literally the first artist/person/thing to make me feel strong and powerful because of my body instead of feeling the total opposite, which I’d done for so many years before. I thought he was a total fucking badass; I thought he was God. Reading everyone’s stories today I realize that Bowie touched EVERY one of us on so many different levels… but not just musically. Sure his records taught me an invaluable amount about songwriting, melody, production, etc. but furthermore Bowie inspired and forever changed my perspective on life. For that I am eternally indebted and grateful. There’s certainly a bit of Bowie inside us all… RIP.

The bold face used above was my own doing in order to emphasize the passage that I expect most universally resonates and relates to our work as dietitians. Joanne and I do a great deal of activism in the size acceptance movement because on a daily basis we see the consequences of people living under the oppression of weight stigma: eating disorders, shoddy medical care, failing weight-loss pursuits, bullying, weight cycling, disordered eating, and other conditions, approaches, and consequences that only serve to worsen health, not improve it.

In an era when another celebrity gained our trust only to abuse it and built us up until it was personally and financially advantageous to tear us down, Bowie’s lessons of acceptance and being true to ourselves juxtapose in even greater contrast and feel that much more important to reinforce. No matter which Bowie era is your favorite, whether you are a Starman, Ziggy Stardust, Young Americans, Scary Monsters, Modern Love, Heart’s Filthy Lesson, Reality, or Lazarus fan, or even if none of those are your cup of tea, we can all recognize that he impacted our world in a way that extended well beyond his music.