5 Ways Weight Stigma Harms Fat People's Health

There are a lot of articles and studies that try to compare health conditions and outcomes for fat people with those of thinner people, claiming that if fat people have a higher condition incidence or worse outcomes then it’s clear that fat bodies the issue. They are all, to a one, complete bunk. That’s because you can’t blame body size for health outcomes if access to healthcare is wildly unequal for those in larger bodies.

Here are five ways that weight stigma harms fat people’s health, with more harm being done to those in fatter bodies and those who deal with multiple marginalizations including racism, ableism, transphobia et. al.

Lack of Equipment/Accommodation

Often healthcare facilities fail to have even the most basic equipment to work with fat people. Everything from a lack of accessible seating in the waiting room, to a lack of properly sized blood pressure cuffs, gowns, knee braces, crutches, etc. And many diagnostic technologies don’t work for fat people including MRIs and CT scans, ultrasound and more. These are major discrepancies in care that can lead to misdiagnoses and missed diagnoses.

Take blood pressure for example. Blood pressure cuffs have specific tolerances (it’s not just about whether or not the velcro will fasten.) An adult large typically fits an arm with a circumference of 13.8 – 17.3 inches. If the arm is larger than that, the cuff may still go around, but it will give a reading that is too high. Often even if we know our arm measurements and push back, the person taking our BP will try to push ahead, I once had a nurse say to me “let’s just try this.” Um, no. This isn’t broccoli, it’s a piece of health information, we’re not going to “just try” to do what is clearly wrong.

This alone calls into question the number of fat people who are diagnosed with high blood pressure, and that doesn’t even take into account “white coat hypertension” which is raised blood pressure that is due to the completely valid fear of mistreatment from fatphobic healthcare workers.

And that’s just one example. I’ve heard of one woman who went to the ER with a knee injury. The doctor was visibly disgusted by her, refused to touch her, refused any diagnostics or treatment and told her that she should go home and make an appointment with her primary care physician. In the meantime, she was told, she absolutely shouldn’t put any weight on the leg and doing so could result in permanent damage. That’s when they explained that they didn’t have a knee brace that fit her, or crutches that were rated for her weight. Some volunteer firemen who happened to be there used quick drying plaster to create a mold to the back of her knee and affixed it by wrapping an ace bandage around it. It fell off as soon as she sat up and put her legs over the side of the bed (which was too small for her.) They had a wheelchair to take her to the front door but from there she was on her own to somehow get home and up the flight of stairs that were waiting for her, only using one leg. A thin person likely would have been able to get diagnosed and treated but even if they didn’t they would at least be sent home with crutches and a proper knee brace.

This is unconscionable, unforgivable and unjustifiable. They knew fat people existed when they created these diagnostic tools, when they ordered the gowns, and the blood pressure cuffs, the braces etc. The choice to allow fat people to suffer is blatant discrimination for which fat people’s bodies then get blamed.

Research

Issues with research fall into two categories: poor research and a lack of research.

Let’s start with poor research. Much of the so-called research around weight and health that gets published in peer reviewed journals would get a freshman failed in their research methods class. Because of rampant weight stigma, these studies are allowed to commit basic research fallacies with no pushback from the journals in which they are published. Lucy Aphramor wrote an excellent journal article outlining many of these issues. Her conclusion was:

“Dietetic literature on weight management fails to meet the standards of evidence based medicine. Research in the field is characterised by speculative claims that fail to accurately represent the available data. There is a corresponding lack of debate on the ethical implications of continuing to promote ineffective treatment regimes and little research into alternative non-weight centred approaches. An alternative health at every size approach is recommended.”

The second issue is lack of research. More often than not, fat people are left completely out of research for interventions or pharmaceuticals (unless those interventions and drugs are trying to manipulate our body size). We’re seeing this now with the COVID vaccine. Experts are pointing out that it’s long been known that flu vaccines don’t work as well for fat people. (It should be noted that they also don’t work as well for older folks, but they developed a “super shot” vaccine to mitigate that issue, while deciding that it was fine that fat people be more at risk.)

Now the race to develop a COVID vaccine is on and despite already being clear about this issue, trials are still leaving out fat people. Major news outlets are reporting on it but they are not, as they should be, outraged at the prospect that fat people may be left unprotected even with a vaccine. They are upset that fat people’s lack of protection puts thin people at risk, and they are blaming fat people for creating the problem… by existing.

Lack of Training

The vast majority of training that healthcare professionals receive about working with fat patients is about how to medicalize and pathologize fat bodies. Medical schools are literally teaching weight stigma to students and many don’t even have fat cadavers, meaning that students are not learning about fat bodies like they could and should.

This myopic focus on making fat patients thin instead of helping fat patients be healthy leads to a pervasive attitude that fat people don’t deserve the kind of competent, evidence-based care that thin people get unless and until they become thin themselves. This despite there not being a single study where more than a tiny fraction of people succeed at significant long-term weight loss, but a number of studies which demonstrate that (understanding that health, by any definition, is not an obligation, barometer of worthiness, or entirely within our control) behaviors are a far better predictor of future health than is body size. (Bacon and Aphramor have provided us with an incredibly thoroughly cited literature review explaining this.)

Practitioner Bias

Often practitioners are so laser focused on weight loss that they utterly fail to give fat patients ethical, evidence-based care. Many times this shows up as stereotyping — practitioners making assumptions and recommendations based completely on their stereotypes. (I once had a doctor “challenge” me to start walking 10 minutes a day. I was in the middle of training for a marathon at the time and had done an 18 miler the night before.) If they do ask questions, they often simply refuse to believe the answers if those answers don’t align with their their stereotypes and bigotry.

It can also be seen in doctors blaming almost anything on body size — I had a friend who was moving and she lifted a heavy box and had sudden, debilitating back pain and leg pain. She went to the doctor and, without ever touching her, he told her that it was because of her weight and that she should diet and exercise. This is someone who had been hauling boxes around the day before and today couldn’t stand up straight and could barely move because of the pain. She had to go to another doctor to get treatment for her herniated disc. My friend dealt with a lot of pain but others, like Ellen Maud Bennett, have paid for doctor’s fatphobia with their lives.

Treating Fat People’s Lives As Inherently Less Valuable/More Risk-able

Let’s say a thin person presents with high blood sugar and gets diagnosed with Type 2 diabetes. They will typically be prescribed evidence-based interventions to help control their blood sugar. However a fat person with the exact same symptoms may be prescribed weight loss surgery, which mutilates a health organ in order to create what would be considered a disease state in a thin person, in order to force behaviors that mimic an eating disorder. This surgery often has terrible outcomes including horrific lifelong side effects and, for some, death.

Thin people are not asked to risk their lives and quality of life just to control their blood sugar but fat people often are, and can be labeled “non-compliant” if they ask for the same intervention that a thin person would get. Fat people are often encouraged to have this surgery as an alternative to taking a single pill. The brilliant Deb Burgard has pointed out that fat patients are rarely asked “would you like to have this dangerous surgery that could kill you, or would you prefer to take two pills instead of one?”

This is also an incredibly profitable surgery that is aggressively marketed, with testimonials from people who are happy, but not a word from those who have horrific lifelong side effects and would do anything to take the surgery back, or from the friends and family of those who just wanted to be around to see their kids grow up (which was incredibly likely to happen statistically without the surgery), but instead died on the table. Often fat people, with or without a health issue, are prescribed dangerous diet drugs with very little proven benefit. It’s a clear sign that the medical community views fat people as less valuable and more risk-able than thin people, there’s actually an entire Board-Certified Specialty that is completely based on the idea that it’s absolutely worth risking fat people’s lives for the slightest chance that they might get even a little bit thinner.

Not to mention that the vast majority of weight loss attempts result in weight regain, with many gaining back more than they lost. After which their healthcare provider will likely… prescribe another diet. Which will have the same abysmal chance of success. This results in weight cycling (sometimes called yo-yo dieting) which has been independently correlated with health issues, which will most likely be blamed on the fat person’s body rather than the dieting.

Patient Disengagement

Let’s bring it all together, shall we? We have a situation in which even if a fat person can jump through all the hoops to be able to go to the doctor (they can afford it, get time off work, get childcare if necessary and get transportation there etc.,) they may not be able to sit down in the waiting room, or get their correct blood pressure taken. When they finally see the doctor they know, typically from experience, that the doctor is likely to ignore their actual health issues and just prescribe weight loss. And even if they find a doctor who is willing to treat their health issue, they may not have access to the necessary diagnostic tools (for which they will likely be blamed) and even if they can get the diagnostics, the treatment was probably not tested on people their size and so may be completely ineffective. And at every stage of this process they are highly likely to interact with healthcare providers operating from a place of deep weight bigotry. So it’s no surprise that fat patients often disengage from their own healthcare and/or wait until things are truly terrible before seeking medical care, and then they get blamed for that as well.

So the next time you see an article talking about the health impacts of fat people, or the cost of healthcare for fat people, understand that they are actually measuring the health impacts and costs of medical weight stigma.