The Fat Patient
who carried the cost of bias
Welcome to Ask The Patient, a doctor’s love letter to patients everywhere. Together, we’re reclaiming the stories that make medicine human. If it speaks to you, share, like, or subscribe.
Raise your hand if a medical professional has ever told you to “just lose weight” as if it were a universal cure.
Raise your hand if a doctor’s visit has morphed into a body-shaming lecture you didn’t consent to.
Raise your hand if the world already treats your body as a problem and you didn’t need the person in the white coat doing the same.
Raise your hand if you’ve been denied a real conversation about your health until you lost an arbitrary amount of weight.
Raise your hand if you’ve starved yourself because a doctor made thinness sound like salvation.
Raise your hand if your health worsened afterward.
Raise your hand if you were congratulated for starving yourself and left the clinic feeling sicker, lonelier, or more ashamed.
Raise your hand if you’ve started avoiding medical care entirely because no one seems to look past your weight to see you.
Raise your hand if all this stress made your body change in ways you were then punished for.
Raise your hand if medical anti-fatness has harmed you.
Did I get everyone?
And if your hand is still down, perhaps because you live in a thin body, there is one more: Raise your hand if you have ever been on the giving end of weight stigma, and you are ready to unlearn it.
My hand is up.
No One Deserves To Be Sick
That is the unspoken assumption that underlies anti-fatness in medicine:
fatness equals fault, and fault equals forfeited care.
I ran a poll yesterday on X asking whether people had been told to “just lose weight” by their doctors. Six hundred people responded. 90% said yes. But the diagnoses they shared stunned me.
“Just lose weight” was offered as the cure for:
— swimmer’s ear
— a broken toe
— strep throat
— cardiac arrhythmia
— ovarian tumors
— connective tissue disorders
— psoriatic arthritis
— ME/CFS
… the list goes on and on.
At first, I was half-laughing at the absurdity. But as the replies kept coming, the laughter dissolved. And what remained was anger. Because what people were describing was not bad advice.
It was gaslighting wrapped in a prescription pad.
Some say: Well, doctors are people. And some people have biases. It’s not that simple. Though explicit anti-fat attitude is equally as prevalent in the general population as among healthcare professionals — a very disturbing fact in itself — doctors aren't simply another component of the general population.
As physicians, our biases can have far worse consequences for those who seek our care. They shape diagnoses, dictate treatments, and determines who receive care and who are left abandoned.
Medical Anti-Fatness Is a Health Hazard
Anti-fatness in medicine does not announce itself with slurs or signs on the door. It wraps around a patient quietly…
In shorter appointments, less eye contact, less rapport-building effort, fewer treatment options, and less emotional support.
Research shows:
Fat patients receive less access, less support, and less timely care.
Weight stigma reduces cancer screening rates, particularly gynecologic cancers.
Anticipated stigma makes patients avoid care entirely.
Weight-based discrimination can worsen cholesterol, glucose regulation, and inflammation.
Even people actively seeking weight loss succeed less when they feel judged by their clinicians.
So then we must ask: When assumptions replace investigation, patient-blaming becomes the assessment, and fat patients have worse health outcomes, is the risk factor actually their weight, or the way medicine treats them?
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“Just Lose Weight” Is Not a Treatment Plan
I care for many people with hidradenitis suppurativa (HS), a devastating inflammatory condition that causes painful sores, often in private areas and disproportionally affect women of color. “Obesity” has been identified as a comorbidity.
Nearly every patient tells me the same story: “My doctor told me to just lose weight.” Often without examining the skin or without understanding HS at all.
First of all, sustained long-term weight loss is nearly impossible —something decades of research support. Telling someone to “just lose weight” is like saying: “Just climb out of poverty.” “Just stop being depressed.” “Just grow taller.”
And worse, there is no strong evidence that weight loss consistently improves HS. On the contrary, rapid weight loss after bariatric surgery can worsen symptoms in up to 69% of patients.
“My worst flare happened after my doctor refused to treat me until I lost weight.” 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.
The Day I Stopped Laughing Along
There was an “inside joke” during my training that a fat patient was so large they needed to be scanned at a zoo using an animal MRI. I knew it was cruel. But cruelty in medicine often wears the mask of “humor,” and new doctors learn quickly what silence buys.
Then one night, I accompanied a fat patient for a CT scan. We needed to image his toe for possible infection. The technician smirked loudly, theatrically: “When was the last time he could even see his toes? Right?”
We were three feet away. Three feet. My patient could hear every word.
“I don’t find it funny.” I pulled away from him, made sure we were no longer standing as a united front.
I’ve replayed that moment so many times that I have come up with many sharper comebacks. But what I really wanted to say was:
“Fat shaming has no place in medicine. And the failure to accommodate larger bodies is not a punchline.”
What Do We Do?
1. Include people of all sizes.
Medicine, as a science and a service, must include people of all sizes. Clinical trials in the U.S. currently do not require participation of people with larger bodies. So for infections, cancer, and countless other conditions, doctors are often guessing at dosing. People have died because of those guesses.
2. Stop weighing patients reflexively.
Unless weight is medically necessary, which it usually isn’t, ask permission before weighing. Consent and respect might not be part of the vital signs, but they are vital to care.
3. Build a healthcare environment sized for real people.
Chairs, gowns, cuffs, scales, speculums… if the equipment doesn’t fit the patient, then the problem is the equipment. No one should have to go to the zoo for a scan. No one should be worried about not fitting into the armed chair in the waiting room.
4. Practice Health at Every Size.
A patient’s weight is information, not a diagnosis. Meaningful care is still possible without conditional promises of thinness. 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.
5. Train clinicians to do better.
Medical education breeds anti-fatness early. One study showed medical students offered fewer medications and more “lifestyle advice” to fat patients for the same symptoms. By residency, bias is fully grown. By practice, it is normalized. We can break that cycle. But only if we name it.
"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. Almost every time, they cry.
Weight stigma is its own disease. 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.
Ask the Patient
Each week, I end with a question for reflection. Perhaps through sharing, we can help someone else feel a little less alone.🩵
Has weight stigma, subtle or overt, ever shaped the care you received or the care you avoided? How did it change your relationship with medicine?
I’d love to hear from you.
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.