Weight bias can contribute to incorrect diagnoses, eating disorders, and feelings of shame in people of size.
Amena Azeez was 13 years old when she slipped on a diving board in Mumbai, India, landing flat on her back.
Although the pain was severe enough to result in temporary loss of movement, it wasn’t until two years later that she began experiencing continuous discomfort in her back.
Doctors were confident that her back pain was a symptom of her larger size.
“You are fat and that is putting pressure on your back, they’d say. Lose weight and your back will be fine,” she recalled doctors telling her.
“I joined the gym and did aerobics and hard-core cardio. I was so obsessed with losing weight, I used to do 500 crunches every alternate day… I was always on some diet or another, so I was perpetually starved or binge eating,” Azeez said.
For the next 10 years, Azeez continued pushing her body to its limits. But the more she worked out, the more her back seemed to hurt.
Still, doctors kept dishing out the same advice: lose weight.
The pain continued to worsen for Azeez, despite all efforts toward weight loss.
It was when she became almost immobile that an orthopedic doctor referred her to a spine specialist, who conducted the necessary MRI she’d needed for the better part of a decade.
The MRI showed that she’d injured her lower back to a very large extent, most likely during that original fall, Azeez explained. The injury had been deteriorating the muscles in her spine since it first occurred.
Her weight, on the other hand, had been wholly irrelevant.
Much like Azeez’s experience in India, fat bias within the medical community can be observed around the world, often at life-threatening costs.
Only a few years ago, Canadian model Elly Mayday was infamously told that her back pain was a result of her weight, too.
But Mayday felt like something deeper was going on. It was her skepticism of the initial diagnosis that led her to pursue better care — and to the discovery of ovarian cancer.
Stories such as Azeez and Mayday’s aren’t few and far between, but rather a normal aspect of existence for people of size.
The general public, in most Western cultures, is conditioned to condemn overweight individuals.
As Lilia Graue, MD, LMFT, explained to Healthline, the list of repercussions for such biases is a long one.
Doctors often “fail to provide adequate and timely diagnosis and treatment due to all kinds of assumptions, [which] affects patients along the full weight spectrum,” she said.
According to Graue, common occurrences include “missing a diagnosis of a metabolic illness because of an assumption that thin individuals are healthy [or] failing to diagnose and/or treat a condition that did require care because all of the attention was directed to someone’s higher weight.”
“When the focus is on weight, there are [also] high rates of what we call attrition, noncompliance, or resistance, all due to disregard of the patient’s concerns and needs,” Graue added.
By body shaming, doctors further risk harming patients’ sense of self-efficacy, which then adversely affects all health-related behaviors, well-being, and quality of life.
When people living in larger bodies have traumatic healthcare experiences, they sometimes avoid seeking healthcare and develop otherwise preventable complications.
Overweight patients learn quickly that “doctors repeatedly advise weight loss for [them] while recommending CAT scans, blood work, or physical therapy for other, average-weight patients” with the same symptoms, Graue said, so they start to think: “Why even bother trying?”
This all amounts to inequity and injustice in the delivery of care to larger people, she explained.
This is all assuming that we can get care in the first place, of course. Insurance providers often have BMI cut-off points when accepting patients into their plans, regardless of an individual’s actual health status.
Some medical centers do, too. Many of the newest, fanciest, most comfortable birthing centers near me in the United Kingdom are off-limits due to my weight alone.
People in larger bodies who have eating disorders don’t receive the diagnosis or treatment they need, since they don’t fit the classic idea that someone with an eating disorder has a thin frame.
Further, doctors often contribute to the development of disordered eating, according to Graue.
For people in larger bodies, doctors often prescribe behaviors they’d consider disordered eating in thin patients.
I was 13 when a gynecologist in New Jersey started recommending weight loss.
After months of heavy, consistent periods, the doctor gave me a diagnosis of polycystic ovarian syndrome (PCOS).
My PCOS, I was told, would result in thick body hair growth, further weight gain, and potentially lead to diabetes by the time I was 20.
Unless I shed about 70 pounds from my 170-pound, 5-foot-6-inch frame, of course.
My doctor didn’t know it at the time, but I was already in the early days of disordered eating and crash dieting.
Soon enough, I was restricting myself to 400 to 500 calories a day, and working off three times as many calories on the treadmill in my mother’s bedroom before anyone got home to see me doing it.
With every pound I lost came more praise from family, friends, and both my gynecologist and family physician.
“Keep up the good work,” my doctors would say at the end of each visit, upon seeing a lower number on the scale. “And don’t worry about feeling dizzy. It’s just a sign of your progress.”
In a solitary school year, I lost 40 pounds. I see photos from that time and can’t believe how sick I looked. How fragile and pale.
Yet even after I began fainting regularly at the slightest physical exertion, even after I developed anemia, even after my core body temperature dropped to dangerous levels, even after I could barely keep water down, my doctor’s words persisted: “You’re doing great.”
Because I was fat when I first began dieting — and because I didn’t present as emaciated even after I was in the throes of anorexia — every sign of my eating disorder was overlooked.
Speaking strictly from a weight loss perspective, fat shaming by medical personnel doesn’t actually tend to motivate clinically “overweight” people to drop any pounds.
One study by University College London examined nearly 3,000 British adults, finding that “weight discrimination does not encourage weight loss… it may even exacerbate weight gain. Stress responses to discrimination can increase appetite, particularly for unhealthy, energy-dense food.”
Fat shaming by doctors also jeopardizes patients’ mental health.
Joan Chrisler, PhD, a professor of psychology at Connecticut College, presented to the American Psychological Association her recent research that “implicit attitudes might be experienced by patients as microaggressions — for example, a provider’s apparent reluctance to touch a fat patient, or a head-shake, wince, or ‘tsk’ while noting the patient’s weight in the chart. Microaggressions are stressful over time and can contribute to the felt experience of stigmatization.”