Thank you for the work that you are doing with your patients, in the medical community, and here on Substack. You've made so many important points here and the ending "Either medical education cultivates anti-fatness or it does a terrible job correcting it. Or both." cuts right to the heart of the issue (and, for the record, in my experience it is most definitely both.) I'm so glad that your patients get to have you on their healthcare team and grateful that you are doing this work more widely and that you are modeling how we can do our own work to uncover and dismantle anti-fat bias in healthcare!
Nearly all of my classmates in medical school class was a thin-bodied person, as well as the educators. I didn't see it during the time when I was in training, because at that point I definitely was embracing the diet culture. Now, looking back, it feels so wrong to sit in a classroom of people in thin bodies blaming people in large bodies. (It feels...cult-ish.) Gives me chills, actually, not the good kind.
Thank you for your comment and your openness to collaborate and be a resource! I wonder if Anti-Fatness in Med-Ed would be something we could collaborate on. I am also open to other ideas! I will email you soon to connect.
Thank you for writing this. I remember in my early twenties, I went to the doctor for hives on my arm, and the nurse talked to me about my weight. I was filled with shame and guilt. Several years later, while seeing a doctor for follow up on an unrelated condition, she talked to me about I need to do something about my obesity. Turns out her MA put my height into the computer wrong -- even though he hadn't even checked my height.
Since then, I've learned that I have lipedema, a rare adipose disorder that doesn't respond to diet, exercise, or even bariatric surgery. I feel much more able to advocate for myself and partner with my doctors to learn together about a diagnosis that gets no air time in residency. I feel fortunate to say that in the last several years, I've never had a doctor bring up my size or weight in a way that's unrelated to the matter at hand. I think it's doctors like you, Zed, who are helping to transform that medical culture, so thank you.
You are a great self-advocate! Though I wish you didn't have to be....Imagine if people living with lipedema are urged to undergo bariatric surgery and the harms that might come along with it!
Many years ago I went to a small village in south China to do some health screening. The villagers farmed from sunrise to sunset -- everybody walked everywhere, all able bodied. Yet when I measured their BMI (I didn't know better back then lol), everyone was "overweight" or "ob*se"!! Turns out when you arbitrarily divide your weight by your height twice, short people (or anyone who isn't a able bodied white male astronaut) has irrelevant and "abnormal" numbers!!!
What a strange medical world we live in (invented by those who don't look like us) lol.
Whoa, that’s such a great example of how this metric is meaningless! I have a friend who is a professional basketball player - 6’4, all muscle - and according to her BMI, she’s ob*se. This metric is trash, and so is the concept of weight=health.
I went to urgent care after breaking my kneecap in a very silly dance party injury in February. The instructions I was sent home with included "join a gym to lose some weight." I was in a full leg brace for 2 months and could barely go downstairs to leave my apartment. That fully crossed the line from unhelpful to insulting.
You mentioned, "I have learned by now that I must always have a box of tissues ready when I do because almost everybody cries when they hear these words." After reading your essay, I nearly had to reach for my own tissues! I am so glad, at age 83, to finally ready such an eloquent essay on this topic by an MD. I have had individual MD's apologize to me about their colleagues' insensitivity toward fat patients (such as my friends and my female family members have experienced for countless years). But your essay is the first I have seen with these sentiments in the written word. Thank you so much. For your own reference, I have been active in size acceptance since 1969. My worst experience, that helped make me into an activist, came when my late first wife needed to get a blood test and was ushered in to see a new doctor in Great Neck, NY. When he asked her why she wanted a blood test, she showed him the form that the State of NY required in order to get a marriage license. (It was required in those days.) He looked at her fat body with astonishment, and asked "Who would want to marry you?"
Wow, Bill!! Honored you read the piece and liked it. Thank you for the important work you have done (since 1969! you are the OG) and are still doing (though I hear real retirement is nice, too lol).
I have so many questions....
1. what was the reason why NY required blood work for marriage license? I image and read it was to help prevent syphilis? It's kind of crazy as we have penicillin now....I was required to be tested for syphilis as well as an immigrant. And the healthcare professional I encountered explained to me that was because, "you know, to prevent people from coming to the US and spread diseases, like what happened to Covid!"
Does she really think that's what caused the pandemic? Some US-trained Chinese physician hopped on a plane and started the pandemic? What ignorance.
2. 😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤 What did your late first wife say to this????
First, back in 1964, which is when we married, NY State was, indeed, looking for syphilis. Perhaps the law was a legacy of the old pre-penicillin days. My theory is that they left the law in place to slow down impulsive wedding license applications. It surely slowed us down!
Second, my fiance was very sad that this happened. She knew that it would not deter me from marrying her, but was afraid of my angry reaction. I just filed it away in my memory, and it surfaced five years later when I became an activist. As a husband of a large woman, I personally witnessed countless examples in which she was discriminated against--including the NY Times being unwilling to publish her engagement photo. In those days, they had an official policy of not picturing fat women, even though she had a socially prominent father. (Around 1995, they revised the policy.)
Thank you for this. I have found, in my work as a medical historian and bioethicist who has written about fat, that MD voices — and especially the voices of thin MDs — are far more likely to be listened to than any of the fat people, myself included, doing this work and saying these things.
This comment is so rich. It points to many things that disempower fat patients: physicians' words hold more value, thin-bodied people hold more value, and the two combined, not surprisingly, even more. To me this speaks to the important of allyship as a person who has these two privilege. I'm curious to learn how do you (really) feel about it?
Also, I totally see a future collab with you! I love medical history and took 10 weeks off last year from clinical practice to do a medical history fellowship. <3
As for how I feel about it: it's infuriating, of course. I imagine you can appreciate how galling it is to be a person who has taught medical, nursing, and MPH students, and who is trusted as having the credentials/background to do so, and then having my credibility dismissed when I say something heterodox about fat because I am fat. My thin colleagues, especially the MDs, can say the same things and usually at least get a hearing. I often can't.
(Let us draw a discreet curtain over how much more galling this dismissal of my credibility is when I'm a patient!)
Such and important topic! Patient shaming for any reason is unacceptable and fat shaming or “anti-fatness” is so prevalent. Admittedly, I felt called out in the article because I’ve definitely been guilty of thinking those shaming thoughts about others and about myself. Fortunately (an odd choice of words in this dysfunctional context! 😅), I’m only vocal about those directed inward at myself.
Me too! I still have so much shaming thoughts toward myself. I have (I think) stopped doing that to others. Perhaps self compassion is harder than other compassion...
Have emailed this to myself to read when I have enough time to absorb it thoroughly. I haven't run into much of this, carrying 20 lbs. I'd be healthier without, but I have a family member with PCOS (polycystic ovary syndrome), messing with both her insulin and hormones. PCOS, for the non-medical people here, makes it very easy to gain weight and very difficult to lose it.
So many people in our society are quick to say, "'just' stop eating so much and get exercise," which is about as helpful as telling my Type 1 diabetic husband, "if you'd just try harder, your body would make the insulin you need." His body doesn't make insulin, period.
Hard to believe that people were told to lose weight for all of the reasons listed. That alone, from only skimming this at the moment, nearly broke my brain.
I have always been overweight, even when I was eating well and very active.
At 24, I slipped a disc that didn't go away. It affected my entire life and I had to stop exercising because it was too painful.
I went to the doctor and the nurse congratulated me on losing 10 pounds. I immediately told her that this was nothing to celebrate. I went up a pants size and my weight loss was due to losing a bunch of muscle. I may have weighed less, but my health was incontrovertibly worse.
Thank you for sharing this. That moment you describe, being congratulated while your body was actually failing you, is such a clear example of how medicine confuses weight with health, numbers with reality.
Dr. Zha, I feel like I'm commenting on all of your posts, but they seem to all hit a nerve! I've felt fat my entire life because my mom always felt fat even though she was skinny and I was pretty normal to a bit overweight. Family of origin issues are strong! In medical school and residency, I imbibed all the anti-fat bias that was there in the early 90s, and I am sure that I fat-shamed some of my patients, although I was very "nice" about it.
When my chronic migraine showed up, I was on multiple courses of steroids and ballooned up from my usual 180 pounds to 240. I ended up leaving the practice of medicine because we couldn't get the migraine disease under control. Thankfully, I had doctors who were very good at not fat-shaming me. But, they didn't have to. I did it all to myself, all the time. I knew that there was an association between chronic migraine and obesity, so I "knew" that if I lost weight I would get better. Finally, about 6 or 8 years ago, I went on a ketogenic diet to try to help the migraine disease. It did help the migraines for a month. But, I lost 60 pounds and kept it off until about a year ago. But weight loss didn't cure the migraine disease. But, my labs (glucose and lipids) looked great!
Unfortunately, starting a year ago, my GI tract didn't seem to like the low-carb thing anymore, so I had to start eating some carbs. And between that and another couple of rounds of steroids this year, my weight is back up over 200 which is messing with all my psych stuff. But, when I see my doc in a couple of weeks, I'm confident that we'll deal with my medical issues, not fat-shaming. I know that I'm fortunate. I hate reading these stories of other people's experiences. I hate knowing that I was part of a dysfunctional system and participated in it.
Thank you for doing better and for making others aware.
First of all, I’m honored you read my stuff and that you take the time to comment!! And thank you for sharing your experiences. It will make someone else who’s reading it feel so much less alone. And reading what you wrote made me realize that we are all temporarily able bodied and all the other privileges we enjoy are almost always temporary. I just hope the culture is such that being human with each other is the norm no matter where we are in our life’s journey. But I guess that’s why we are here. To make the changes. 🥹
My personal stories for anti-fat bias in medical spaces can go on and on, but three are pretty poignant:
My mother spent 30 years asking for doctor's to address debilitating joint pain throughout her body. The response was always to lose weight. Finally, at age 60, she was diagnosed with psoriatic arthritis and other autoimmune conditions that were the main culprits behind her pain. She suffered for years because no one would look further than her obesity.
I went to a doctor a few years ago with issues of extreme fatigue like I had never felt in my life and difficult losing weight/weight gain no matter what I tried. I was scolded into a sleep study for sleep apnea that cost me 900 dollars out of pocket, even though I was sure I was not having any issues sleeping. The test concluded I had no apnea. This year, under a new doctor, I finally got bloodwork for my thyroid, including an antibody test. I have Hashimoto's and hypothyroidism, which is pretty unsurprising when you look at my family history. I'm glad I didn't have to wait 30 years like my mother.
Finally, my husband went to a clinic for an infection on his finger caused by a deep puncture wound from a cat we fostered. He was told he was obese and needed to lose weight, which did not relate at all to the abcess on his finger.
Thank you for writing this piece and doing the work you do! It is so important that we try to shift doctors and other healthcare providers away from fixating on weight as the only issue when it comes to treating fat people. My heart aches for all the people like my mom who have had their problems grossly overlooked. We know better and we can do better. <3 Great piece!
I still remember my first regular gynecologist appointment after having had a baby some months before. The provider was confused as she looked at me and then looked at my chart. Apparently someone else in the practice had deemed me “morbidly obese.” First of all, to the extent that that’s a technical diagnosis, I never met it. Second, I had been PREGNANT at the time. WTF. I don’t go there anymore.
We can be "against" a disease, but we don't want to be against people with that disease. Instead of labeling someone as obese, we need to reframe our concepts and see them as a person who has obesity. In other words, we need to see people as people, not as their disease. Which makes me wonder if referring to a person who sees a doctor as a "patient" might be doing them a disservice?
I have an awesome and accepting PCP who treated my obesity is something other than a moral failure, And it is sad to me how many people don't have that access. Thanks for writing this.
Thank you for the work that you are doing with your patients, in the medical community, and here on Substack. You've made so many important points here and the ending "Either medical education cultivates anti-fatness or it does a terrible job correcting it. Or both." cuts right to the heart of the issue (and, for the record, in my experience it is most definitely both.) I'm so glad that your patients get to have you on their healthcare team and grateful that you are doing this work more widely and that you are modeling how we can do our own work to uncover and dismantle anti-fat bias in healthcare!
I agree, it's definitely both.
Nearly all of my classmates in medical school class was a thin-bodied person, as well as the educators. I didn't see it during the time when I was in training, because at that point I definitely was embracing the diet culture. Now, looking back, it feels so wrong to sit in a classroom of people in thin bodies blaming people in large bodies. (It feels...cult-ish.) Gives me chills, actually, not the good kind.
Thank you for your comment and your openness to collaborate and be a resource! I wonder if Anti-Fatness in Med-Ed would be something we could collaborate on. I am also open to other ideas! I will email you soon to connect.
Thank you for writing this. I remember in my early twenties, I went to the doctor for hives on my arm, and the nurse talked to me about my weight. I was filled with shame and guilt. Several years later, while seeing a doctor for follow up on an unrelated condition, she talked to me about I need to do something about my obesity. Turns out her MA put my height into the computer wrong -- even though he hadn't even checked my height.
Since then, I've learned that I have lipedema, a rare adipose disorder that doesn't respond to diet, exercise, or even bariatric surgery. I feel much more able to advocate for myself and partner with my doctors to learn together about a diagnosis that gets no air time in residency. I feel fortunate to say that in the last several years, I've never had a doctor bring up my size or weight in a way that's unrelated to the matter at hand. I think it's doctors like you, Zed, who are helping to transform that medical culture, so thank you.
You are a great self-advocate! Though I wish you didn't have to be....Imagine if people living with lipedema are urged to undergo bariatric surgery and the harms that might come along with it!
Many years ago I went to a small village in south China to do some health screening. The villagers farmed from sunrise to sunset -- everybody walked everywhere, all able bodied. Yet when I measured their BMI (I didn't know better back then lol), everyone was "overweight" or "ob*se"!! Turns out when you arbitrarily divide your weight by your height twice, short people (or anyone who isn't a able bodied white male astronaut) has irrelevant and "abnormal" numbers!!!
What a strange medical world we live in (invented by those who don't look like us) lol.
Whoa, that’s such a great example of how this metric is meaningless! I have a friend who is a professional basketball player - 6’4, all muscle - and according to her BMI, she’s ob*se. This metric is trash, and so is the concept of weight=health.
👆👆👆👆👆👆👆👆👆👆👆👆
I had a student who referred to BMI as "Bogus Medical Information."
Are they very muscular? I would have thought the typical genetic southern Chinese would be more like me. Delicately framed with a low BMI.
I went to urgent care after breaking my kneecap in a very silly dance party injury in February. The instructions I was sent home with included "join a gym to lose some weight." I was in a full leg brace for 2 months and could barely go downstairs to leave my apartment. That fully crossed the line from unhelpful to insulting.
Wait but have you tried lifestyle changes?? 🫠🫠🫠🫠🫠🫠🫠(I’m being sarcastic.)
😆
Gaaaahhh!
You mentioned, "I have learned by now that I must always have a box of tissues ready when I do because almost everybody cries when they hear these words." After reading your essay, I nearly had to reach for my own tissues! I am so glad, at age 83, to finally ready such an eloquent essay on this topic by an MD. I have had individual MD's apologize to me about their colleagues' insensitivity toward fat patients (such as my friends and my female family members have experienced for countless years). But your essay is the first I have seen with these sentiments in the written word. Thank you so much. For your own reference, I have been active in size acceptance since 1969. My worst experience, that helped make me into an activist, came when my late first wife needed to get a blood test and was ushered in to see a new doctor in Great Neck, NY. When he asked her why she wanted a blood test, she showed him the form that the State of NY required in order to get a marriage license. (It was required in those days.) He looked at her fat body with astonishment, and asked "Who would want to marry you?"
Wow, Bill!! Honored you read the piece and liked it. Thank you for the important work you have done (since 1969! you are the OG) and are still doing (though I hear real retirement is nice, too lol).
I have so many questions....
1. what was the reason why NY required blood work for marriage license? I image and read it was to help prevent syphilis? It's kind of crazy as we have penicillin now....I was required to be tested for syphilis as well as an immigrant. And the healthcare professional I encountered explained to me that was because, "you know, to prevent people from coming to the US and spread diseases, like what happened to Covid!"
Does she really think that's what caused the pandemic? Some US-trained Chinese physician hopped on a plane and started the pandemic? What ignorance.
2. 😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤😤 What did your late first wife say to this????
First, back in 1964, which is when we married, NY State was, indeed, looking for syphilis. Perhaps the law was a legacy of the old pre-penicillin days. My theory is that they left the law in place to slow down impulsive wedding license applications. It surely slowed us down!
Second, my fiance was very sad that this happened. She knew that it would not deter me from marrying her, but was afraid of my angry reaction. I just filed it away in my memory, and it surfaced five years later when I became an activist. As a husband of a large woman, I personally witnessed countless examples in which she was discriminated against--including the NY Times being unwilling to publish her engagement photo. In those days, they had an official policy of not picturing fat women, even though she had a socially prominent father. (Around 1995, they revised the policy.)
🤯🤯🤯🤯🤯
Thank you for this. I have found, in my work as a medical historian and bioethicist who has written about fat, that MD voices — and especially the voices of thin MDs — are far more likely to be listened to than any of the fat people, myself included, doing this work and saying these things.
This comment is so rich. It points to many things that disempower fat patients: physicians' words hold more value, thin-bodied people hold more value, and the two combined, not surprisingly, even more. To me this speaks to the important of allyship as a person who has these two privilege. I'm curious to learn how do you (really) feel about it?
Also, I totally see a future collab with you! I love medical history and took 10 weeks off last year from clinical practice to do a medical history fellowship. <3
That's exactly why allyship is so important.
As for how I feel about it: it's infuriating, of course. I imagine you can appreciate how galling it is to be a person who has taught medical, nursing, and MPH students, and who is trusted as having the credentials/background to do so, and then having my credibility dismissed when I say something heterodox about fat because I am fat. My thin colleagues, especially the MDs, can say the same things and usually at least get a hearing. I often can't.
(Let us draw a discreet curtain over how much more galling this dismissal of my credibility is when I'm a patient!)
I'd love to explore collaboration sometime. If you aren't familiar with my little book on fat, you might like to check it out. https://www.bloomsbury.com/us/fat-9781501333286/
Such and important topic! Patient shaming for any reason is unacceptable and fat shaming or “anti-fatness” is so prevalent. Admittedly, I felt called out in the article because I’ve definitely been guilty of thinking those shaming thoughts about others and about myself. Fortunately (an odd choice of words in this dysfunctional context! 😅), I’m only vocal about those directed inward at myself.
Thank you for being so forthright in sharing!
Me too! I still have so much shaming thoughts toward myself. I have (I think) stopped doing that to others. Perhaps self compassion is harder than other compassion...
Have emailed this to myself to read when I have enough time to absorb it thoroughly. I haven't run into much of this, carrying 20 lbs. I'd be healthier without, but I have a family member with PCOS (polycystic ovary syndrome), messing with both her insulin and hormones. PCOS, for the non-medical people here, makes it very easy to gain weight and very difficult to lose it.
So many people in our society are quick to say, "'just' stop eating so much and get exercise," which is about as helpful as telling my Type 1 diabetic husband, "if you'd just try harder, your body would make the insulin you need." His body doesn't make insulin, period.
Hard to believe that people were told to lose weight for all of the reasons listed. That alone, from only skimming this at the moment, nearly broke my brain.
Thank you. It gives me hope to see a doctor write this. Please keep speaking and sharing loudly.
Thank you Megha! It gives me hope to have my writing read, haha!
I have always been overweight, even when I was eating well and very active.
At 24, I slipped a disc that didn't go away. It affected my entire life and I had to stop exercising because it was too painful.
I went to the doctor and the nurse congratulated me on losing 10 pounds. I immediately told her that this was nothing to celebrate. I went up a pants size and my weight loss was due to losing a bunch of muscle. I may have weighed less, but my health was incontrovertibly worse.
She didn't say anything after that.
Thank you for sharing this. That moment you describe, being congratulated while your body was actually failing you, is such a clear example of how medicine confuses weight with health, numbers with reality.
Dr. Zha, I feel like I'm commenting on all of your posts, but they seem to all hit a nerve! I've felt fat my entire life because my mom always felt fat even though she was skinny and I was pretty normal to a bit overweight. Family of origin issues are strong! In medical school and residency, I imbibed all the anti-fat bias that was there in the early 90s, and I am sure that I fat-shamed some of my patients, although I was very "nice" about it.
When my chronic migraine showed up, I was on multiple courses of steroids and ballooned up from my usual 180 pounds to 240. I ended up leaving the practice of medicine because we couldn't get the migraine disease under control. Thankfully, I had doctors who were very good at not fat-shaming me. But, they didn't have to. I did it all to myself, all the time. I knew that there was an association between chronic migraine and obesity, so I "knew" that if I lost weight I would get better. Finally, about 6 or 8 years ago, I went on a ketogenic diet to try to help the migraine disease. It did help the migraines for a month. But, I lost 60 pounds and kept it off until about a year ago. But weight loss didn't cure the migraine disease. But, my labs (glucose and lipids) looked great!
Unfortunately, starting a year ago, my GI tract didn't seem to like the low-carb thing anymore, so I had to start eating some carbs. And between that and another couple of rounds of steroids this year, my weight is back up over 200 which is messing with all my psych stuff. But, when I see my doc in a couple of weeks, I'm confident that we'll deal with my medical issues, not fat-shaming. I know that I'm fortunate. I hate reading these stories of other people's experiences. I hate knowing that I was part of a dysfunctional system and participated in it.
Thank you for doing better and for making others aware.
First of all, I’m honored you read my stuff and that you take the time to comment!! And thank you for sharing your experiences. It will make someone else who’s reading it feel so much less alone. And reading what you wrote made me realize that we are all temporarily able bodied and all the other privileges we enjoy are almost always temporary. I just hope the culture is such that being human with each other is the norm no matter where we are in our life’s journey. But I guess that’s why we are here. To make the changes. 🥹
My personal stories for anti-fat bias in medical spaces can go on and on, but three are pretty poignant:
My mother spent 30 years asking for doctor's to address debilitating joint pain throughout her body. The response was always to lose weight. Finally, at age 60, she was diagnosed with psoriatic arthritis and other autoimmune conditions that were the main culprits behind her pain. She suffered for years because no one would look further than her obesity.
I went to a doctor a few years ago with issues of extreme fatigue like I had never felt in my life and difficult losing weight/weight gain no matter what I tried. I was scolded into a sleep study for sleep apnea that cost me 900 dollars out of pocket, even though I was sure I was not having any issues sleeping. The test concluded I had no apnea. This year, under a new doctor, I finally got bloodwork for my thyroid, including an antibody test. I have Hashimoto's and hypothyroidism, which is pretty unsurprising when you look at my family history. I'm glad I didn't have to wait 30 years like my mother.
Finally, my husband went to a clinic for an infection on his finger caused by a deep puncture wound from a cat we fostered. He was told he was obese and needed to lose weight, which did not relate at all to the abcess on his finger.
Thank you for writing this piece and doing the work you do! It is so important that we try to shift doctors and other healthcare providers away from fixating on weight as the only issue when it comes to treating fat people. My heart aches for all the people like my mom who have had their problems grossly overlooked. We know better and we can do better. <3 Great piece!
I still remember my first regular gynecologist appointment after having had a baby some months before. The provider was confused as she looked at me and then looked at my chart. Apparently someone else in the practice had deemed me “morbidly obese.” First of all, to the extent that that’s a technical diagnosis, I never met it. Second, I had been PREGNANT at the time. WTF. I don’t go there anymore.
We can be "against" a disease, but we don't want to be against people with that disease. Instead of labeling someone as obese, we need to reframe our concepts and see them as a person who has obesity. In other words, we need to see people as people, not as their disease. Which makes me wonder if referring to a person who sees a doctor as a "patient" might be doing them a disservice?
Possibly of interest -- I'm doing a public online talk on Saturday night about fat. https://rntq.substack.com/p/fat
It is so easy for thin people to be judgemental when looking at folks carrying excess weight. Thanks for taking this topic on.
I have an awesome and accepting PCP who treated my obesity is something other than a moral failure, And it is sad to me how many people don't have that access. Thanks for writing this.