Fat Phobia in Health Care
Why a Health at Every Size Approach Should be the Standard of Care.
Unfortunately fat phobia is notorious in health care. This makes larger individuals less likely to seek or receive quality health care (Alberga et al., 2019).
Weight stigma effects job prospects, relationships, increases likelihood of depression (and suicide) and eating disorders, often shames people out of physical activity and ultimately causes increased weight gain (Alberga et al., 2019)
Health practitioners commonly over-estimate the control an individual has over their weight and project ideas of laziness onto them (Alberga et al., 2019). All health issues are commonly attributed to weight in larger individuals which can result in fatal mistakes including the case of Ellen Maud Bennet who passed from cancer due to a biased health care team (this is just one example of thousands) (Phelan et al., 2014; The Conversation, 2022). In Australia, no laws exist around this form of discrimination. It is currently one of the only socially acceptable forms of discrimination.
What does weight stigma look like in a healthcare setting?
Blaming all health symptoms on weight
Blaming the individual for their weight
Assigning moral meaning to weight
Assigning traits in association with weight e.g. laziness
Assuming higher risk of certain conditions without testing or asking questions around risk factors
Making assumption about diet or lifestyle based on their appearance. This is not only incorrect but can be dangerous – larger individuals can also suffer from eating disorders including atypical anorexia.
Accusing individuals of lying about their food intake
Not screening for eating disorders including anorexia in larger people
Not having equipment which will suit a larger person e.g. scales which only hold a certain weight, blood pressure cuffs which are not wide enough, smaller chairs with arm rests, imaging machines such as MRIs which only hold a certain size/weight.
Yes, our body size can effect health outcomes, but it is one factor amongst many which contributes to disease. It is also important to note that long-term weight loss is unsuccessful in clinical trials to date (Mann et al., 2007). An analysis of 14 studies found that an average of 41% had regained more weight than they had lost by the 4th year follow up. One study observed that over a 5 year period 80% of participants gained back more weight than they had lost (Mann et al., 2007). These studies have many methodological issues which likely increase these percentages further. A very high drop out rate is reported over the 4-5 year follow up, hypothesised to be due to participants fear of fat phobic rhetoric or shame around regaining the weight over this period (Mann et al., 2007). Many participants also report participating in other diets during this follow up period (from 20 to 60%) which further confounds the results. One study found participants had lost another 11.8kg on average from diets during the follow up period, making the average weight regain reported even more stark (Mann et al., 2007).
Focusing on weight as a central health marker can result in chronic cycles of weight loss and gain which are known to dysregulate hunger and hormone signals. A significant factor in the link between poorer health outcomes with higher body weight is attributable to weight stigma and chronic dieting (Mann et al., 2007). Large observational studies suggest that weight cycling increases all cause mortality, is associated with increased risk of diabetes, stroke, heart attack, elevated LDL cholesterol, suppressed immune function and elevated blood pressure (Mann et al., 2007).
Fat phobia is a toxic exposure. It permeates throughout society so is it a surprise that a result of this toxic exposure is poorer health outcomes for those experiencing the brunt of the exposure (i.e. fat people) ??
Ongoing stress caused by weight stigma negatively effects health by increasing stress hormones, altering gastrointestinal function (an altered microbiome even) and increasing insulin resistance.
A 2016 study found that experiences of weight stigma were associated with increased incidence of diabetes, elevated cholesterol, stomach ulcers and heart disease (even after controlling for BMI, level of physical activity and socioeconomic status!!). (note: BMI is an inherently flawed tool which should only be used at a population level not to assess an individual) (Cohen & Shikora, 2020). Experiences of weight stigma are also linked to harmful health behaviours including poor sleep, disordered eating, and alcohol use regardless of body weight (Lee et al., 2021). Research finds that ones perception of size alone significantly influences health outcomes. Across the BMI range, a perception of oneself as being “overweight” is associated with increased inflammatory markers (e.g. CRP) alongside elevated blood pressure, blood glucose, HbA1c and triglycerides.
Encouraging a positive body image & satisfaction at every size instead of focusing on weight reduces incidence of eating disorders, depression and further weight gain (Rubino et al., 2020).
Weight stigma is a threat to physical, mental and emotional health (Tomiyama et al., 2018)
We have significant evidence that physical activity/fitness is a better predictor of health outcomes versus body size. For example, a 2014 meta-analysis found that mortality rates were dependent on levels of physical activity versus BMI. Sedentary individuals had a doubled mortality risk regardless of BMI. Whilst higher BMI participants who were fit had a mortality risk equal to “normal weight” physically active participants (Barry et al., 2014). One study observing over 22, 000 participants found that physical activity levels were a greater predictor of their 10 year cardiovascular disease risk versus weight (Zhang et al., 2020). The Rotterdam study similarly found that over 15 years, physically active individuals with a higher BMI did not have an elevated cardiovascular disease risk (Koolhaas et al., 2017).
Respected medical institutions & popular media discuss larger bodies in dehumanising ways and report that being fat “increases risk for severe, debilitating and deadly diseases” (Harvard, 2022).
How can we talk about the fact that larger bodies are at higher risk of chronic disease without acknowledging that the way we speak about larger bodies increases risk of chronic disease?
One survey involving 3 008 individuals found that over 2/3rds of those considered “obese” considered it a serious, even deadly, health conditions (more so than diabetes, hypertension and cardiovascular disease) (Rubino et al., 2020). Considering the placebo effect alongside the effects of stress on health behaviours and physiology (e.g. increases in insulin resistance, stomach ulcers), this feels incredibly unethical.
Let’s change our focus away from body weight, and towards health behaviours. This means developing stress reduction techniques, educating around adding more nutrition to meals, improving sleep, finding joyful movement, finding more community and addressing individual underlying health conditions.
My clinic strictly practices with a health at every size mentality. This involves:
Not focusing on weight
Not weighing or measuring clients
Not prescribing weight loss. Instead I focus on the health condition/s or symptoms effecting the individual with the aim of relieving the symptom/condition by modifying nutrition & lifestyle alongside targeted supplementation. If symptoms reduce and body weight changes that is fine, if symptoms reduce and body weight does not change that is also fine - weight is simply not the focus, health is (these things are not synonymous!). In some cases weight loss can be harmful, for example weight loss in elderly people increases their risk of osteoporosis (Jiang & Villareal, 2019). In some cases, clients may be seeking weight loss to reduce stress on painful joints due to conditions like osteo arthritis. In these situations supporting slow weight loss might be indicated. However, this would not involve fad/restrictive dieting but a holistic approach looking at the overall health of the individual e.g. improving sleep, reducing stress, supporting thyroid function, restoring the gut microbiome.
Never putting clients on overly restrictive diets. Adding nutrition to meals (e.g. with colourful plant foods!) versus just taking food away. As a practitioner focusing on gastrointestinal complaints it is often necessary to replace certain foods in the diet to alleviate gut symptoms. But, there are ways to do this while expanding instead of restricting the diet. Significant dietary restriction typically results in disordered eating patterns, particularly binge eating.
Ensuring my clinic space is welcoming to people of all sizes e.g. having sturdy comfortable chairs without arm rests & not permitting fat phobic language.
Why do I use a health at every size approach?
The research (and patient feedback) tells us it is the best way to practice. A weight-centric approach to health contributes to the experience of discrimination and bias which larger people face on a daily basis. As mentioned above, encouraging a positive body image at all sizes improves health outcomes including reducing depression, eating disorders and future weight gain.
Weight stigma effects everyone. A health at every size approach also acknowledges the important fact that those sitting in the “healthy BMI range” may struggle with conditions typically linked with a higher body weight such as insulin resistance. This is well illustrated by a study involving 10, 000 type 2 diabetics, which noted that 63% of participants had a body weight considered within the “ideal” weight range. Those within this weight range had higher fasting glucose, post-prandial blood glucose and HbA1c versus the higher weight participants (George et al., 2015).
If you would like a judgement free experience with a qualified health care practitioner which focuses on your quality of life/specific symptoms not your weight make an appointment today. Or if you experience stress around food and would like to begin a freeing journey into intuitive eating let me know! (Intuitive eating may not work for everyone! Your health is unique and there are many ways to improve our relationship with food).
Sam 😊
If you enjoyed this brief introduction to fat phobia and the bias within healthcare/research let me know and keep an eye out for more in-depth analyses of diet culture and the physiology of fat cells.
References:
Alberga, A. S., Edache, I. Y., Forhan, M., & Russel-Mayhew, S. (2019). Weight bias and health care
utilization: a scoping review. Prim Health Care Res Dev, 2019(20). https://doi.org/10.1017/S1463423619000227
Barry, V. W., Baruth, M., Beets, M. W., Durstine, L., Liu, J., & Blair. S. N. (2014). Fitness vs
fatness on all-cause mortality: a meta-analysis. Progress in Cardiovascular Diseases, 56(4). https://doi.org/10.1016/j.pcad.2013.09.002
Cohen, R., & Shikora, S. (2020). Fight weight bias and obesity stigma: a call for action. Obesity
Surgery, 30.
George, A. M., Jacob, A. G., & Fogelfeld, L. (2015). Lean diabetes mellitus: An emerging entity in the era of obesity. World Journal of Diabetes, 6(4), 613. https://doi.org/10.4239/WJD.V6.I4.613
Harvard School of Public Health. (2022). Obesity Prevention Source.
https://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/health-effects/
Jiang, B. C., & Villareal, D. T. (2019). Weight Loss-Induced Reduction of Bone Mineral Density in Older
Adults with Obesity. J Nutr Gerontol Geriatr, 38(1), 100-114. https://doi.org/10.1080/21551197.2018.1564721
Koolhaas, C. M., Dhana, K., Schoufour, J. D., Ikram, M. A., Kavousi, M., & Franco, O. H. (2017). Impact
of physical activity on the association of overweight and obesity with cardiovascular disease: the Rotterdam study. Eur J Prey Cardio, 24(9), 934-941. https://doi.org/10.1177/2047487317693952
Lee, K. M., Hunger, J. M., & Tomiyama, A. J. (2021). Weight stigma and health behaviours: evidence
from the Eating in America Study. International Journal of Obesity, 45.
Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare's
search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220–233. https://doi.org/10.1037/0003-066X.62.3.220
Phelan, S. M., Burgess, D. J., Zeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & can Ryn, M. (2014).
Obesity treatment/outcomes impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 2015(15), 319-326. https://doi.org/10.1111/obr.12266
Rubino, F., Puhl, R. M., Cummings, D. E., Eckel, R. H… & Dixon, J. B. (2020). Joint international
consensus statement for ending stigma of obesity. Nat Med, 26(4), 485-497. https://doi.org/10.1038/s41591-020-0803-x
The Conversation. (2022). https://theconversation.com/how-weight-bias-is-harming-us-all-107352
Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018).
How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16(123).
Zhang, X., Cash, R. E., Bower, J. K., Focht, B. C., & Paskett, E. D. (2020). Physical activity and risk of
cardiovascular disease by weight status among U.S adults. PLoS One, 15(5). https://doi.org/10.1371/journal.pone.0232893