How to Mitigate Anti-Fat Bias in Healthcare

This article contains descriptions of fatphobia in a medical setting, as well as discussion of eating disorders. 

The widespread adverse effects of anti-fat bias in healthcare have been well documented. While implicit biases around race, skin color and sexuality have, at worst, remained stable, implicit anti-fat bias actually increased by 40% between 2004 and 2010. And, fat-shaming has been shown to make people sicker over time. ​​Mitigating anti-fat bias in healthcare can help fat people, and people in all bodies, get the proper care and treatment for the health issues they may experience.

There are many different ways to talk about fat.

As a physician at the Gaudiani Clinic, which provides outpatient medical care to people with eating disorders and disordered eating, Dr. Sarah-Ashley Robbins, MD, uses the Health At Every Size® (HAES®) approach in her work. The HAES® model centers treating patients’ medical conditions without focusing on intentional weight loss. For Dr. Robbins, using language like “obese,” “overweight” and “BMI” medicalizes fat. Instead, she often opts for non-stigmatizing clinical terms like “patient in a larger body” or “patient in a smaller body.” 

But some within the fat community are pushing to reclaim the word “fat” as a neutral descriptor like “tall” or “brunette,” even coining their own vocabulary to describe the size of larger bodies, including terms like superfat, small fat, mid fat and infinifat. Others opt for person-first language like “person with fat,” and some try to remove the word “fat” from their vocabulary entirely, which fat activist and author Aubrey Gordon worries could have the adverse effect of removing an opportunity for fat people to share their own experiences. 

What can people do to talk about the topic without offending others? Rather than assuming how her patients may want to discuss fat, Dr. Robbins asks what language would make them most comfortable. A simple discussion can go a long way toward setting boundaries. 

For the purposes of this article, the terms “person in a larger/smaller body” and “fat” will be used, as these are considered to be value-neutral descriptors. 

As reported by the New York Times, fat was associated with privilege in Europe from roughly 1500 to 1900, which could be seen in the art and fashion of the time. In the late 1800s, however, a change began, which Sabrina Strings, PhD, described in her book Fearing the Black Body: The Racial Origins of Fat Phobia. 

“One of the things that the colonists believed was that Black people were inherently more sensuous, that [Black] people love sex and they love food, and so the idea was that Black people had more venereal diseases, and that Black people were inherently obese, because they lack self-control. And of course, self-control and rationality, after the Enlightenment, were characteristics that were deemed integral to Whiteness.”

Colonial anti-fatness gave rise to a toxic diet culture which can now be found in once fat-positive cultures. And diet culture has helped fuel the intentional weight loss market in the United States that has grown to 72.6 billion dollars as of 2021. Christy Harrison, anti-diet dietitian, names some aspects of diet culture.

Healthism: described by political economist Robert Crawford as a belief system wherein the pursuit of health is everyone’s moral duty. If you get sick, it’s your fault.

Thin ideal: imbues thin people with pretty privilege and thin privilege and puts them on the winning side of desirability politics.

Nutritionism: described by food politics professor Gyorgy Scrinis as an ideology that categorizes food as good or bad depending on its nutritional content. “Eating bad food” is a moral failure stemming from character defects.

Anti-fat bias manifests itself in many ways in healthcare. Doctors have been shown to have shorter appointments with fat patients and to develop less of an emotional rapport with fat patients. Fat discrimination can also prompt physicians to engage less, sit further away from, use less physical language with, and share less information about the health of patients with larger bodies (PDF, 5.5MB). 

The result can be dire for people in larger bodies. Weight discrimination itself is linked to increased risk of mortality. The effects of sizeism have even been seen in children as young as 3, who have been documented to express negative self-image due to weight stigma and to talk about dieting. 

“I can’t tell you how many of my patients had their eating disorders start when they were very young due to a negative experience at the doctor’s office where they were told their weight was too high or they were too big,” Dr. Robbins recalls. 

Eating disorders are also often misdiagnosed in fat people, with the severity of the situation compounded for racial and ethnic minorities who are more likely to have their eating disorders misdiagnosed by a healthcare professional.

Dr. Robbins notes that, in general, fat patients are often misdiagnosed because doctors are preoccupied with treating a patient’s weight rather than their symptoms. A healthcare professional may misattribute a fat patient’s condition to their weight and, as a result, not order specific tests. This leads to conditions being undiagnosed and untreated. Dr. Robbins cites osteoporosis as one example of a condition that remains unidentified among patients in larger bodies because doctors simply assume pain associated with osteoporosis is actually caused by the fat patient’s weight. Patients in larger bodies may also be told to lose weight without even being told their diagnosis. 

Eliminating sizeism will take a lot of work, both internally and externally. Even people who specialize in intentional weight loss can have weight bias, so everyone should consider taking an implicit fat bias test multiple times on different days and averaging the results. 

How to Mitigate Fat Stigma in Medical Practices

Dr. Joy Cox, PhD, is a researcher, fat activist and author of Fat Girls in Black Bodies: Creating Communities of Our Own. While institutional changes to healthcare may command focus, Dr. Cox highlights the importance of “Small things that allow people to feel welcome, seen, and heard from the time they walk into the facility until the time that they leave.” Dr. Cox provides some recommendations.

Incorporating body diversity and size diversity in representation throughout the medical practice, and not just in content about size discrimination or intentional weight loss. 

Advocating for patients who are denied care by other medical professionals or insurance companies because of their weight. 

Providing seating in the examination room, equipment and gowns that accommodate people of all sizes.

Arranging furniture in a way that makes the area accessible to all patients and clients.

There’s a growing medical consensus that the body mass index (BMI) is an inaccurate determinant of body fat mass. The BMI is in everything from medical texts to insurance company diagnostic recommendations, says Dr. Cox, so it may take some time to eliminate the BMI entirely. Until then, healthcare professionals can reconsider using the BMI or recommending intentional weight loss interventions to every patient.

“When your goal is to manipulate someone’s weight rather than truly address the underlying medical health issues that they’re presenting, then you’re just harming the patient,” explains Dr. Robbins. Weight loss does not guarantee improved health status, and people often yo-yo diet, which entails losing weight and gaining it back again. Studies show it can be detrimental to health. Dr Robbins also points out that being regularly told to lose weight can be harmful, too. 

“A lot of the patients that seek Health At Every Size® primary care are literally recovering from medical trauma,” Dr. Robbins says. Stress has been linked as a contributing and exasperating factor for conditions such as type 2 diabetes, heart disease and many other conditions, adds Dr. Robbins—the very conditions that patients in larger bodies are warned will be caused by their body weight. 

Healthcare professionals who take the HAES® approach are able to treat the patient and not the number associated with their weight, Dr. Robbins says. Metabolically healthy obesity is well documented, and it’s possible to target diseases that people have without focusing on intentional weight loss. For these reasons, Dr. Robbins never recommends intentional weight loss interventions. 

Similarly, Dr. Robbins never recommends bariatric surgeries. While such procedures can lead to weight regain or insufficient weight loss, bariatric surgeries can also lead to weight loss in the short term, just like other forms of intentional weight loss. When vitals a year after the procedure are compared to vitals prior to the procedure, there may even be improvement, Dr. Robbins says, but when the scope of evaluation is widened to include more than just weight loss, gastric surgery can end up being negative in many other ways.

Not only has implicit sizeism been documented among medical students, but, as of 2020, many American medical schools admit that they fail to train their students to treat fat patients. 

Dr. Robbins points out that many doctors in training are from high socio-economic statuses, which can make them more inclined to believe that a patient’s health and weight are rooted purely in the life choices of the patient. Without an awareness of the systemic forces that contribute to the health of patients, it becomes harder for doctors to effectively treat patients. 

“You need to meet the patient where they’re at and not just talk about how they need to eat more fruits and vegetables,” explains Dr. Robbins. 

To weed out anti-fatness in medical education, students, professors, textbook publishers and others may need to step outside of the culture of anti-fat bias in which all people exist and take an intersectional approach.

“Given the idea that it’s normal to dislike fatness, that fatness as a whole is already bad, nobody’s looking outside that bias,” Dr. Cox says. Dr. Cox provides the following suggestions.

• Medical school professors can provide supplemental reading materials to mitigate the effect of weight stigma in the curriculum.

• Given that the CDC retracted its foundational research on the “obesity epidemic” due to statistical and methodological errors, schools should rethink teaching about the “obesity epidemic.” When it is taught, it can be taught with caveats that acknowledge the “obesity paradox.”

• Schools can lift BMI restrictions for donating bodies to medical research. Restrictions can prevent students from learning how to care for fat bodies. Additionally, students who handle larger bodies in gross anatomy labs have been documented to display anti-fat attitudes, which should be challenged whenever and wherever such sentiments are expressed.

• Schools and instructors can actively dismantle sizeism by confronting white supremacy in the classroom. White supremacy has come to define what constitutes acceptable health practice, which creates harmful narratives about people from different cultures, who have different movement, eating and cooking practices.

• Medical schools should include community engaged service-learning into the curriculum. Better understanding of the lived experiences of the patients who they treat can help correct medical students’ misperceptions about what contributes to illness.

 

How to Advocate For Yourself in a Clinical Setting

Until a model like Health at Every Size® receives widespread adoption, getting medical care for patients in larger bodies will likely remain challenging and potentially traumatizing. Dr. Cox offers some advice.

• Patients have the right to not be weighed. Even if they are pressured, patients can refuse.

• Patients should come prepared and conduct their own research because healthcare professionals may dismiss or minimize concerns based on body weight.

• Providers can be notified in advance not to broach the topic of intentional weight loss or to avoid any discussion of weight. This can also be done after the visit.

• Online groups that are made by and for the fat community can provide support, guidance and recommendations to make it easier to get healthcare.

• Patients shouldn’t feel compelled to follow anti-fat advice.

• Patients should consider bringing a friend or family member for support.

There’s a lot of content created by the fat community across many different mediums that provides further guidance on how to navigate and eliminate fat discrimination.

This article is for informational purposes only. Individuals should contact a licensed healthcare provider for any healthcare concerns or needs.