Shame and stigma have never been an effective way to help a person become healthier. But when it comes to the topic of weight, this approach still persists within the health care system.

People with larger bodies, also known as “fat people” by some activists, are often viewed as having poor lifestyle choices and a lack of willpower.

The oversimplified story goes like this: an “overweight” patient eats too much and exercises too little.

How did we create this mythology?

We have held onto this narrative despite a growing body of evidence that shows there are many other factors that contribute to weight gain, including (but not limited to) sleep, stress, hormones, and medications.

Beyond the misconceptions surrounding weight gain, there’s also a growing body of evidence that BMI (body mass index) is an incorrect signal of health.

Both patients with larger body sizes and patients with smaller body sizes can be healthy or at risk for heart disease, diabetes, and other health problems.

‍50% of U.S. adults who have been labeled “overweight” are actually healthy, based on measurements of blood pressure, triglyceride and cholesterol levels, and glucose levels. In another study, an additional 20 million people who fall into the “obese” category were also shown to be healthy.

We have held onto our collective fatphobia despite every indication that it’s wrong.

When higher weight does not always equal being unhealthy and being thin does not always equal being healthy, clinicians can adopt weight-inclusive care.

Weight-inclusive care is seeing beyond the physical size of a body to better care for all patients with higher accuracy and respect.

So how should you, as a health care professional, ever take into account a patient’s weight as part of a bigger picture of their health?

Beyond prioritizing metabolic indicators as more correct signs of health, weight-inclusive care requires understanding each patient’s individual context and a willingness to move beyond stereotypes.

‍How anti-fat bias informs clinical interactions.

Anti-fat bias—the prejudice, stereotypes, and discrimination associated with weight—is prevalent throughout the entire health care system, from the institutional level all the way down to the interpersonal level.

When it comes to weight, anti-fat bias is front and center in medical literature as well as in popular culture.

The notion that a person with a larger body is in danger of serious health complications if they don’t lose weight is not a fact. It’s actually much more complicated.

Dr. Shayla Toombs-Withers, who works at Thirty Madison, a Violet partner and major brand delivering solutions for chronic conditions on a single platform, noted, "it's important for those in health care to approach patients from a perspective of health, prevention, and improvement of chronic disease; not placing the primary focus just on the number on the scale. The majority of individuals don't choose to be overweight. Weight gain and the science of obesity have taught us that this chronic condition is far more complex than a condition of ‘lack of willpower.’ So we should treat this condition as such."

In order to see beyond bias, let’s first break down how anti-fat bias informs clinical interactions.

• Negative attitudes. Unlike most health conditions, weight is often viewed as a moral issue—it’s the result of a patient’s laziness or non-compliance. For a person in a bigger body, these attitudes are prevalent at every touchpoint in the health care system, from the check-in desk to in-patient care. It’s unsurprising that many people in larger bodies chose to delay preventive screenings or forgo seeking care for fear of stigma and bias.
• ‍Equating weight with health. Clinicians can get stuck on weight, and struggle with giving weight-neutral advice to patients for conditions like diabetes, joint pain, and high cholesterol, even though these conditions can affect people of all sizes. Using weight as a proxy for health perpetuates the stereotype that there are problems that only affect “obese” people, which can cause thin people to skip important screenings.
• ‍Oversimplifying. Losing weight is not a straightforward process. To effectively and compassionately address a patient’s weight requires more than suggesting “a change in diet.” Guidelines outline the need for a multidisciplinary approach that includes a psychologist, specialist nurse, dietitian, and exercise physiologist, which is much more complex than simply suggesting a change of diet.
• ‍Missing the other issues. Clinicians already get very little time with their patients in a primary care setting, so when a person seeks care for an issue unrelated to their weight (e.g. an ear infection), patients may find that the initial reason they came into the doctor’s office is being ignored in favor of discussing the health risks of obesity.

In more dire cases, clinicians’ unwillingness to see past a patient’s weight has led to delayed or missed diagnoses. In a devastating example, Ellen Maude Bennett sought medical care for years, but was repeatedly told to lose weight, and by the time her real health issue came to light, she was given only days to live.

‍The effects of stigma.

‍Discrimination is a major barrier for many people seeking health care, and studies have shown time and again that experiencing shame and stigma negatively impacts a person’s mental and physical health.

• Chronic stress. While the relationship of weight to a person’s health varies by individual, the chronic stress of experiencing anti-fat bias actually causes its own health issues. An analysis from the National Epidemiologic Survey on Alcohol and Related Conditions found a correlation between experiencing weight stigma and an increase of heart disease, stomach ulcers, diabetes, and high cholesterol.
• Higher cortisol levels. Living with discrimination raises a person’s stress responses and cortisol levels, which are tied to negative health outcomes and can actually contribute to weight gain.
• Mental health. Shame and stigma are directly related to depression, anxiety, and suicidal ideation, and they often correlate with self-medicating behaviors like substance use and smoking. Weight stigma in particular can lead to disordered eating, including atypical anorexia, as well as eating behaviors and attitudes about food that would qualify as problematic for a person with a smaller body.

Redefining “healthy.” Moving from weight-centric to weight-inclusive care.

A weight-inclusive approach means providing the same care to a patient who has a higher weight and to a patient with a lower weight. It’s a trauma-informed model that focuses on making healthy lifestyle changes rather than having the sole objective of losing weight.

• Healthy behaviors are important at any size. As Virginia Sole-Smith writes, “Fitness matters more than fatness.” Whether or not a person is active has a greater influence on their health than their size. A 2020 analysis of Americans 30 to 64 showed that physical activity had a bigger impact on a person’s 10-year heart disease risk than whether or not they had a “normal BMI.” However, because exercise is so often correlated with weight loss, if a person does not “get skinny” through routine physical activity, it may be viewed as a failure, when in fact it’s greatly improving their health.
• Mental health benefits of weight-inclusivity. Taking a patient-centered approach and focusing on positive changes instead of “BMI” can make a huge difference to a person’s emotional health and well-being. Working together to identify realistic interventions and protective factors is a much more encouraging way to engage patients than focusing on risks. More importantly, helping patients stick to healthy behaviors that can be sustained long-term builds better self-esteem and confidence.

"For years, using a weight-normative lens in medicine has proven not only to be inaccurate and harmful to individual patients, but it also has widened the health equity divide. This is especially true for folks from BIPOC and LGBTQIA+ communities who have been the target of medical trauma for far too long. A weight-inclusive approach should be a part of any clinician's toolbox whether they are seeking to holistically partner with an individual patient on their health journey or working towards health equity on a larger scale," explained Dr. Lillian Holloway, a clinician who works at Arise, a Violet partner and virtual care platform for all people healing from eating disorders.

Challenging anti-fat bias in clinical settings.

Now that we’ve explored the impacts of anti-fat bias on patients, let's go over some ways that clinicians can move past stereotypes and take a weight-inclusive approach.

• Take a cue from the body positive movement. Helping patients cultivate self-acceptance and self-compassion will help increase health-promoting behaviors. Body positivity actually has a number of health benefits and makes a person more likely to sustain a healthier lifestyle.
• Make mindful language choices. The words we use can be stigmatizing, so ask your patients how they prefer to describe their weight, and make a note about it in their chart. One study showed that patients preferred the term “excess weight” over “obese,” but this will of course vary from person to person. The term “fat” should only be used if a patient chooses to identify this way—some Size Acceptance activists prefer this term, while others may find it hurtful. The important thing to remember is that language should not judge or pathologize a person’s body, so when in doubt, ask what terms a patient prefers. Important reminder: Do not comment, compliment, or ridicule when a patient loses weight or gains weight unless medical attention is necessary. In this instance, use neutral, inclusive language. Otherwise, these conversations can be triggering for any patient, especially people with body dysmorphia, eating disorders, and other challenges.
• ‍Look at the bigger picture. It’s important to understand each patient’s context and the uncontrollable biological, genetic, and environmental factors that may affect them. It’s especially important to consider each patient’s social determinants of health. For example, never assume that a patient has easy access to healthy foods and safe spaces to exercise. This is especially important for patients from culturally diverse communities which are disproportionately impacted by environmental factors that contribute to obesity.
• ‍When addressing weight, use the 5 As. This framework for counseling was developed by Obesity Canada to better support patients in improving their health.
  
  1. Ask permission to discuss weight.
  2. Assess risks and root causes of weight.
  3. Advise on health risks and the available treatment options.
  4. Agree on realistic outcomes and health goals.
  5. Assist in identifying resources and addressing barriers.

‍Practicing body positivity in the health care space.

‍Challenging anti-fat bias and taking a weight-inclusive approach to care means creating a dialogue with your patient and empowering them—not shaming them—and working towards healthy outcomes, together and inclusive of whatever shape or size is healthy for your patient.

Addressing bias is a key part of creating a more equitable health care system. To learn more about Violet and our cultural competence upskilling program, request a demo today.