If you’ve ever gone to the doctor’s office for strep throat only to be lectured about your weight, received a referral to a commercial weight-loss program rather than to physical therapy for your knee pain, or been told your incapacitating abdominal pain is because you’re “obese,” when it turns out you have a grapefruit-sized tumor, then you’ve encountered weight-centric health care.
Both public health and the medical system subscribe to a weight-centric health paradigm that puts body weight at the center of notions about health. This focus on weight has been embedded in medicine for decades, but it’s been baked into society for much longer. In “Fearing the Black Body: The Racial Origins of Fat Phobia,” sociologist Sabrina Strings writes “ … the current anti-fat bias in the United States and in much of the West was not born in the medical field. Racial scientific literature since at least the eighteenth century has claimed that fatness was ‘savage’ and ‘black.’”
What does this mean for patients with fat bodies? (I’m using “fat” as a neutral descriptor, like “short” or “tall.”) It means they are more likely to experience harm at the hands of the health care system. As Marquisele Mercedes, a doctoral student at Brown University School of Public Health, writes in her article, “No Health, No Care: The Big Fat Loophole in the Hippocratic Oath,” in the online magazine Pipe Wrench, “For over 60 years, doctors and researchers have likely harmed and killed millions of fat people through their insistence on social and scientific mandates for thinness and that ob*sity is a disease requiring intervention, despite the existence of evidence that says this is wrong.”
Research is clear that anti-fat bias is common among doctors and other health care providers. So what contributes to the perpetuation of weight-centrism in health care, and the health inequities that come with it? It’s multifactorial, said Lisa Erlanger, a family physician and clinical professor of family medicine at the University of Washington School of Medicine.
“I deeply believe that most physicians truly intend to provide care that will help their patients — and we are people too,” Erlanger said. “We’re immersed in the diet culture that pervades every corner of society. But we are also a group of privileged people by and large.” She said physicians are more likely to be white and come from a higher socioeconomic background — and they are also likely to be taller, more conventionally attractive, and be in at least relatively smaller bodies. Their lived experience is not applicable to patients who have very different bodies and backgrounds.
As far as what is taught in medical school, Erlanger points to the multibillion-dollar (and growing) diet / weight cycling / medical obesity industry. (Why “weight cycling”? Because most people who lose weight gain it back and repeat the cycle … repeatedly.) “We know it was members of that industry who drove the definition of ‘obesity’ as a disease and are now marketing and profiting off the treatments for that disease,” she said. “As a medical community, we’ve accepted much poorer evidence for weight-loss surgery and weight-loss drugs than we would for anything else. The reason we accept that is partly because we have been slowly conditioned to accept more and more outrageous ‘science’ from this industry and because we’re predisposed to believe it because of the diet culture we live in.”
Speaker, researcher and writer Ragen Chastain (her Substack newsletter “Weight and Healthcare” is a must-read) said the diet industry’s successful conflation of “health” with “weight” and “health care” with “weight loss” has become codified in medical school curriculum. “The weight-centric paradigm and the inequities it creates have led to a health care system that is myopically focused on making fat people thin,” Chastain said. “This means that not only do they fail to support our health, but they often harm it.” She said this is despite research showing that weight-neutral health care strategies — supporting patients’ health at their current weight — provide greater benefit with less risk than pursuing weight loss.
“There are lots of ways that being smaller makes life easier, but that’s because of our fatphobic medical and cultural society, not because being smaller makes life healthier and better,” Erlanger said, although the idea that smaller is better is reinforced because starvation — consuming fewer calories than is needed to sustain weight and body functions — initiates a cascade of changes, including lowering blood pressure and blood sugar and increasing the stress hormone cortisol, which has feel-good numbing effects. “It’s not sustainable to deprive a body of the calories it needs, so those benefits are not sustainable.”
Worse, anti-fat bias in medicine contributes to poorer health. “It’s larger-bodied people delaying or avoiding preventive care and follow-up care. It’s people ending activities that might improve their wellness — such as movement, better sleep, dietary changes — because they don’t result in promised weight loss. It’s misdiagnoses in fat people and in smaller people because we associate size with health,” Erlanger said. This drives further health inequities, she said, then those inequities are blamed on the larger-bodied people instead of on the weight stigma-based care. It’s a vicious cycle.
“We know how short medical visits are, and we know if we’re centering weight loss, we must be making trade-offs in how we spend the time,” Erlanger said. “Do we believe that the other things we would do are so unimportant? We’re keeping larger-bodied people from all that other evidence-based care.” Plus, she said it’s demoralizing talking to people about weight loss when it can’t be achieved in a safe and sustainable way. “We’re banging our heads against the wall, and we’re taught to blame the patients. That’s not why we went into medicine. We went into medicine to offer treatments that work, and a weight-centric system can never offer that.”
Next week: How doctors can move toward becoming “weight inclusive,” and how patients can advocate for themselves.