Weight bias can contribute to incorrect diagnoses, eating disorders, and feelings of shame in people of size.
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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.”
Stylist Kat Eves of Los Angeles, California, couldn’t receive treatment for her lupus after moving to a new city in 2017. “My doctor refused to give me the prescription for the same drugs I have taken for over a decade that had been prescribed by multiple doctors until I dieted first,” she told Healthline.
“The result of this was that I continued to live in both pain and shame in the following months and became increasingly depressed.”
She was eventually able to switch doctors, finding someone who would prescribe the life-saving prescription she’d be on for 15 years.
“Not surprisingly, the drugs worked and everything, including my quality of life, improved,” Eves noted.
Then there’s designer Shawna Farmer of Portland, Oregon.
When her vision began to deteriorate, she was told it must be due to high blood pressure or diabetes — even after receiving negative test results for both conditions.
“A new doctor immediately said I had pseudotumor cerebri, because it’s most common amongst younger overweight females,” Farmer recounted to Healthline. “The only way to actually diagnose that is with a spinal tap that they never gave me.”
Despite never receiving the spinal tap, she was put on diuretics that cost “hundreds of dollars a month [and] made my fingers and toes go numb randomly and made all carbonated drinks taste rancid,” she remembered.
“Only to go to an amazing doctor eight months later to find out I actually had keratoconus, which has been fixed now by surgery.”
Farmer’s weight was ultimately irrelevant to her condition. Still, her weight was what led to a costly and incorrect diagnosis.
The psychological strains of the stigmatization evident in all of these anecdotes can be acutely debilitating, creating a chain effect onto the rest of the body.
As Chrisler explained in her presentation, “Disrespectful treatment and medical fat shaming, in an attempt to motivate people to change their behavior, is stressful and can cause patients to delay health care seeking or avoid interacting with providers.”
Graue told Healthline that these pervasive biases within the medical community are a result of ingrained misinformation within educational and cultural structures.
“As doctors, we have been indoctrinated in a system in which weight bias is rampant,” she explained.
“We have been fed greatly biased and faulty research with the conviction that ‘science’ is true and neutral,” she pointed out.
“So, we have a heavy dose of biased, weight-centric science that does not make room for the social determinants of health, and a broader system’s perspective that allows for an intersectional lens or a view informed by social justice and trauma,” Graue said.
Graue believes in approaching the treatment of people of size as one would any other patient.
Still, there are times when weight must be addressed, particularly “when the patient brings up a concern related to their weight.”
At this point, medical practitioners have “a wonderful opportunity to dispel myths around equating weight with health, share some of the science that proves that focusing on weight is harmful, and shift the conversation, depending on the setting, to healing the relationship with food and body, and/or focusing on health and well-being-enhancing behaviors, always attuned to the patient’s needs and requests.”
Before jumping into an automatic conversation about weight, Graue adds that doctors “can ask permission and consent to discuss what [a patient’s] experience of living in a larger body has been like, and whether they are engaging in harmful behaviors (i.e. dieting or other risk behaviors).”
“We [doctors] can also explore how we can help patients who are struggling in a fat-phobic world, for instance, by promoting and helping them find weight-inclusive spaces for physical activity,” Graue said.
In order to discuss weight in a way that feels neutral and unthreatening, Graue also suggests that practitioners create environments that are tangibly equipped to accommodate all patients.
“This means not only learning and practicing from a weight-inclusive approach, such as Health at Every Size, but also making sure that the office space, furniture, etc., is welcoming to people of all weights and sizes,” she suggested.
Linda Bacon, a health professional, researcher, and author of “Health at Every Size: The Surprising Truth About Your Weight,” thinks the medical community is ready for this shift — despite a history that suggests otherwise.
When she discusses her work and findings — all of which suggest the mental and physical advantages of detaching perceptions of health from weight — she’s regularly greeted by support rather than condemnation.
“When I speak on these topics to the medical community, the greater response is tremendous relief,” she told Healthline.
“I think I put words to the niggling discomfort that most practitioners feel, and they are relieved to know that there is an alternative way to more successfully reach their goals of improved health and well-being for their patients. They are also relieved to consider that they can partner with — rather than be adversarial with — their patients,” Bacon added.
In the meantime, we patients of size must also seize opportunities to advocate for ourselves.
If a practitioner automatically advises weight loss, with no regard for symptoms or thorough examinations, one of my go-to responses is to ask them how they’d handle the situation if dealing with a thin patient.
Would their diagnosis be the same? Would they prescribe weight loss rather than blood work, physical therapy, X-rays, or medication?
This might not help with the dehumanizing feeling of sitting in a room with a fat-phobic doctor, of course.
It will, however, hopefully lead to a discussion.
In the words of writer, editor, and sex educator Melissa A. Fabello for Self.com, another option — if you’re dreading a potentially triggering lecture on numbers or your BMI — is to request that you not be weighed at all.
Fabello, who’s open about her history of disordered eating, never gets weighed at the doctor anymore. And, as she notes in her piece, we don’t have to, either.
If can be a tough conversation to have with a provider. Handing your doctor a letter expressing your wishes to not be weighed and to focus on your health without discussing weight is an alternative.
Before visiting a new practice, we people of size can also call the office and ask whether they operate under principles of Health at Every Size.
If they don’t know what that means, we can ask whether it would be possible to approach care and treatment in a weight-neutral way. Can we avoid a discussion about size or numbers, because that’s not what we need to talk to a doctor about?
In the end, people in larger bodies must demand that we be treated like any patient with a BMI within the “normal range” might be.
We have a right to fair healthcare — even if it has been denied to us for far too long.