Anti-Fatness Is Bad Medicine
You heard me.👏
Disclaimer 1: some parts of the content in this article come from my July OpEd for MedPage Today.
Disclaimer 2: the word “fat” is used as a neutral adjective here, as it is the preferred term by Size Acceptance activists. When the words “overweight” and “obese” are used, they are in a medical context to demonstrate their stigmatizing tendencies.
Disclaimer 3: when humor is used in this piece, the intention is solidarity and resilience.💟
Raise your hand if you’ve ever been told by a medical professional to “just lose weight” and all your health problems will go away.✋
Raise your hand if your doctor’s visit has ever turned into a finger-wagging body-shaming experience.✋🏻
Raise your hand if you already get these shaming sessions regularly from the larger society (no pun intended) and you don’t need the person in the white coat doing the same. ✋🏼
Raise your hand if you’ve been denied a discussion about your health until you’ve lost X amount of (arbitrary) weight. ✋🏽
Raise your hand if you’ve ever starved yourself as a result.✋🏾
Raise your hand if your health problems got worse after you starved yourself.✋🏾
Raise your hand if you’ve been patted on the back by your doctor for successfully starving yourself and feeling even sicker (physically or mentally).✋
Raise your hand if you’ve started to avoid going to the doctor’s because no one seems to be able to look beyond fatness. ✋🏻
Raise your hand if all this stress has made you fatter. ✋🏼
Raise your hand if medical anti-fatness has caused you harm. ✋🏽
Did I get everyone?
And if you haven’t raised your hand yet (perhaps you have thin privilege), you might after this:
Raise your hand if you’ve been on the giving end of weight stigma (receiving and giving are not mutually exclusive in this case) and you are ready to change your ways.✋🏾
My hand is up.✋
Fat People Deserve To Be Sick?
That’s the prevailing assumption in medicine.
To demonstrate this point, yesterday I asked people on X if they’ve been told to “just go lose weight” by their doctors.
600 people voted, and an overwhelming 90% said they had.
The comments showed the large variety of medical conditions for which “just go lose weight” has been touted as the magic cure!
So far, the answers have gone from swimmer’s ear to ovarian tumor; from psoriatic arthritis to strep throat; from a broken toe to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); from cardiac arrythrmia to inherited connective tissue disorders…🤯🤕
I must say, at first, I was enraged but also amused by the ridiculousness of these cases.
But as the list grows, the joke is becoming less and less funny…
…and more and more gaslight-y.
Disclaimer 4: All #AskThePatient polls are used for educational purposes in various forms (self-educating, lectures for students, residents, colleagues, and medical and cultural critical writings). Thank you for helping the medical community learn. Or should I say: thank you for helping us unlearn.💟
“So, what? Doctors are people. And some people can be assholes,” some say.
It’s not that simple.
Though anti-fatness is equally as prevalent in the general population as among healthcare professionals, doctors aren't merely another component of the general population (in this sense).
But let me first point out how disturbing it is that healthcare professionals embody the same level of explicit anti-fat attitude as the general population. Don’t we expect us to do better?
I say this with utmost humility: as a doctor, my actions can have far worse consequences for those who seek my care.
Medical Anti-Fatness Is Insidious and Harmful
No one puts up a sign at their door that says: We Treat Fat People Poorly!
(…although an “anti-fatness trigger warning” would be appreciated by many.😤)
Instead, doctors simply show less respect and make less effort to build a rapport with fat patients.
And…
Fat patients are less likely to be offered quick access to healthcare, effective treatment, and emotional support.
Fat mothers are less likely to receive support for breastfeeding from healthcare professionals.
Insensitive weight-based comments in the healthcare setting make women less likely to go through with gynecological cancer screening.
Anticipated weight stigma prevents patients from seeking care.
Weight-based discrimination may actually cause cholesterol and glucose problems and inflammation.
Even for people who do come in hoping to discuss weight loss, those who experience weight stigma from their doctors are less likely to succeed in losing weight than those who don't feel judged.
So…it begs the question:
If medical anti-fatness prevents people from getting cancer screening and prenatal care, and fat patients have higher cancer rates and worse obstetric outcomes…
Is “obesity” the risk factor, or is medical anti-fatness? 🤯🤯
Sure! Lemme just go lose weight. Brb.🏃🏾♀️
I've worked extensively with women suffering from hidradenitis suppurativa (HS💟, purple heart used because it’s the official color picked by HS advocates and a condition near and dear to my heart), a chronic, recurrent skin condition that causes painful sores, often in private areas. “Obesity” has been identified as a comorbidity.
As a result, like many who shared on X, nearly everyone living with HS💟 tells me that "the doctor told me to ‘just go lose weight,’” often, without even looking at the skin.
First of all, sustained long-term weight loss is nearly impossible.
Telling fat people to “just go lose weight” is like telling people who live in poverty to “just go get rich",” — both demands are oblivious to the privileges it takes to get from point A to point B.
And…
There is no strong evidence that weight loss consistently leads to clinical improvement in HS💟. On the contrary, rapid weight loss after bariatric surgery may lead to worsening symptoms in up to 69% of patients!
“I had the most painful HS💟 lesion after I became so upset by my doctor’s refusal to treat me until I lost xxx lbs!” A patient told me recently with tears in her eyes.
When “just go lose weight” becomes the “treatment,” what we are really prescribing is medical anti-fatness.
Let’s See Past Fat
There was a joke during my training that "XXX was so fat we had to use the elephant MRI in the zoo to scan them."
Once during a night shift in the hospital, I accompanied my fat patient to the CT scanner. We needed to scan his toe to make sure he didn’t have a bone infection.
“When was the last time he was even able to look down and see his toes? Right?” The technician said loudly to me with a stupid grin, implying that my patient couldn’t see past his fat belly.
To my horror, we stood just a few feet from the scanner. Not behind a closed door. NOT whispering.
The audacity.
Ladies and gentlemen and everybody in between, I let the technician hear it, too.
“I don’t find it funny.” I jumped away from him to distance myself. (No one wants to associate with assholes.) “Plus, my patient is fat. But he’s not deaf! You need to lower your voice.”
I’ve since marinated in my anger toward that incident a lot and thought of many “smarter” ways to answer him. 🤣
Here is one: “Fat jokes have no place in medicine. And the failure to accommodate larger bodies in healthcare is not funny.”
Here is another: “Fat people avoid coming to see us in healthcare. And YOU, sir, are part of the problem!”
And lastly: “I don’t know if my patient could look past his belly, but people like YOU clearly can’t look past your fatphobia!”
What would you have said? 🤣
Let’s be serious: What Do We Do?
First, medicine, as a science and a service, must include people of all sizes.
Currently, people living with “obesity” are not required to be included in U.S. clinical trials. Drug dosing in larger bodies, therefore, becomes an unknown territory. In cases such as infections and cancer, this can be a killer.
We’ve all heard stories of how a “super-morbidly-unholy-disorientatingly-obese patient” (I am making this term up to protest against it) died from clots in the lungs (pulmonary embolism) in the ER because no one knew how to dose clot-breaking medications at their weight range.
Shame on us.
But there are many clinical settings where the weight of the patient is not important.
When a patient comes in for an atypical mole, is it really necessary to know their exact weight?
How about a sore throat? An ear infection? A pap smear? Most things?
And why can’t we ask patients for their permission before weighing them?
You can’t think of any reason?
Me, neither.🤷🏽
Additionally, all healthcare environments should adapt facilities, equipment, and policies that are large-size appropriate.
No one should have to go to the darn zoo for a scan. 😤 No one should be worried about not fitting into the armed chair in the waiting room.
People come in many sizes, and so should blood pressure cuffs, patient gowns, speculums (longer NOT wider!), scales, and toilet seats!
Second, health should be addressed at every size in a non-judgmental manner.
Health At Every Size teaches that healthcare is a human right for people of all sizes and the refusal to provide care until arbitrary weight loss (or weight gain) criteria are met violates the patient's bodily autonomy.
Mic drop.
Additionally, after obtaining permission to discuss weight, the language used matters. It should be person-centered, collaborative, non-judgmental, non-blaming, respectful, evidence-based, and without assumptions.
Lastly, training to break the anti-fatness vicious cycle must start early in medical education.
In a 2010 randomized control trial, for the same exact symptom, medical students were more likely to recommend “lifestyle changes” and less likely to prescribe symptom-relieving medications for fat patients.
By residency, an alarming level of anti-fat biases exists across all specialties.
Through this lens, perhaps it’s not so surprising that full-fledged doctors would, for the same condition, tell fat patients to “just lose weight” but prescribe thin people medications.
Either medical education cultivates anti-fatness or it does a terrible job correcting it.
Or both.
"I know you’ve been told otherwise. But I really need you to listen to me: your weight did NOT cause your HS💟."
When I meet a new patient living with HS💟, I slow down to emphasize this point.
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.
Weight stigma creates so much trauma outside of our exam rooms. We must break the cycle in the one place where people expect care, compassion, and safety.
Because every body has a rightful place in medicine.
And every body deserves to heal.
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!
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.