When we talk about weight stigma, we’re talking about physical characteristics associated with fatness that essentially indicate a lower social value or worth. In modern times, fat is synonymous with being less attractive. And in a society where beauty is currency, the weight loss industry is big business. Until recently, this was particularly true of women whose value depended on whether or not they could attract a mate, settle down and have a family.
But times have moved on. Women can vote now. We can have careers, live independently and enjoy the kind of sexual freedom that we have never experienced before. Our value is less tied up in our looks, or at least it is seen to be this way. The weight loss industry can no longer rely on beauty to sell their product. So in the last 30 years or so, they have shifted their focus.
Nowadays they’re selling health. In fact, I believe that health has become the new currency that defines our value and worth. Or I should say, the appearance of health. Because health is far more complex than whether or not you can run up the stairs without getting short of breath.
Why I won’t shut up about weight stigma
People love to try and bait me into arguing with them whether you can be fat and healthy. Better yet, whether a fat person can ever be more healthy than a thin person. And that’s a very loaded debate for several reasons. Firstly, the evidence is biased (see later). Secondly, there is a high degree of cognitive dissonance that I have to overcome which is mentally and emotionally exhausting for me and puts me at a disadvantage. Thirdly, it deflects from the real point I am trying to make here (and I’m guessing that a lot of the time that is kind of the point).
I’m not here to argue whether it is possible to be fat and healthy. That evidence already exists and there are a number of books that have been written about it. I am here to talk about how weight stigma is contributing to poor health outcomes in people who inhabit bigger bodies. I am here to tell you that weight stigma is making fat people fatter and that intentional weight loss is NOT the solution.
Unsurprisingly, I’m making a lot of enemies along the way.
The dangers of stigma
It is fairly well established that any stigmatized trait can increase a person’s sense of low self worth and poor self esteem. This can lead to symptoms of depression, anxiety and low mood. It is also a risk factor for poorer quality of life in general. I think we can all agree that any form of stigma is bad and we should all strive to avoid it in every area of life.
Society has taken steps to address racial stigma, disability stigma etc. We are nowhere near done, but we have started trying to reduce stigma and prevent discrimination throughout healthcare, the workforce, education and the criminal justice system. But weight stigma is yet to be recognised as an issue that we need to address. There is no legal protection for people who experience size bias in the workplace. Teachers are not taking steps to reduce weight stigma in schools. Social workers are harassing families in which one of more of the children are ob*se. And healthcare practitioners are perpetuating weight stigma on an unprecedented scale. From where I am standing, it seems to be getting worse and worse.
There was a fantastic paper written by Sean Phelan and his team that was published back in 2015 in Ob*sity Reviews. It was entitled “Impact of weight bias and stigma on quality of care and outcomes for patients with ob*sity”. I have read it from start to finish on a number of occasions, because it draws on studies that are scattered across a number of different disciplines. If you are interested in the evidence, I would suggest you read this article as a good starting point. It is a narrative review that looks at all the peer-reviewed papers on stigma, bias, discrimination, prejudice and medical care. They quote 109 studies in their paper and manage to condense it down to six A4 pages which are available to download for free.
Weight stigma is a serious issue
Ob*se individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight. The prevalence of weight discrimination in the United States has increased by 66% over the past decade [between 1999 and 2009], and is comparable to rates of racial discrimination, especially among women. Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that ov*rweight and ob*se persons are lazy, unmotivated, lacking in self-discipline, less competent, non-compliant, and sloppy. These stereotypes are prevalent and are rarely challenged in Western society, leaving ov*rweight and ob*se persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma.The Stigma of Ob*sity: A Review and Update (R Puhl, 2009)
Let’s take a moment to reflect on this quote from a paper by another fantastic researcher Rebecca Puhl. For the longest time I used to believe that I was being discriminated against because of my body. Now I know that this is true. And whilst it makes me angry, it is also a bit of a relief. The experts have studied this and agree with what I always suspected but could never prove. When people look at me they see someone who is lazy, unmotivated, lacking in self discipline, less competent, non-compliant, and sloppy.
How weight bias changed the course of my life
Ouch. That hurts. It hurts because it is not true. And it is not true because I have made sure of it. I spent the last 20 years trying to prove myself by working hard, challenging myself to be more self-disciplined and forcing myself to remain motivated and to achieve more than my peers. I’m a perfectionist. I’m an over-achiever. I refuse to accept failure. Why? Because people assume that I am worth less. And that makes me feel like I am worthless.
So right now I am juggling three kids, a career in medicine, a home, a mortgage… During the last year of this pandemic I’ve increased my hours at work, home schooled my daughter, adopted a puppy and “launched my brand” (whatever that means). And it’s exhausting. I’m exhausted. But what choice do I have? This is all I have ever known.
What choice do I have?
People often say “I don’t know how you do it”. And I think to myself, what choice do I have? If I don’t you’ll think less of me. And that terrifies me. I know I shouldn’t care what people think of me. And on the surface, I’ve developed a thick skin and am fairly indifferent to the hate and the trolling that I have experienced over the last couple of months. But at the same time, I’ve been rejected because of my weight by the people who were supposed to love me the most. Of course I’m afraid that this is going to happen again.
And it’s stressful. It’s really stressful. I feel like I am constantly having to prove myself. But I don’t want to be this way. I want to be free to fail and embrace the stereotypes of lazy, lacking in self discipline and sloppy. As my incredible sister often points out, what’s wrong with being lazy? Lazy people aren’t the ones responsible for all the terrible things going on in the world. Lazy people don’t cause wars or abuse children. Lack of self-discipline doesn’t actually harm anyone.
I’m trying not to care
I want to not care. I went to therapy for years so that I could learn not to care. But I’m not there yet. I am better than I used to be, but I still have a long way to go. More recently, I find myself wondering why I have to change? Shouldn’t the rest of the world be trying to do better? Why should I, the stigmatized person, spend a lifetime trying to overcome that stigma to the point that I am damaging my own health? Why should I be the one that has to spend years in therapy trying to unlearn those habits in order to undo all the effects that chronic stress has placed on my mind and body?
The world continues to operate in a way that makes anti-fat bias perfectly acceptable and indeed part of the norm. And we fat folk are resigned to a lifetime of trying to prove ourselves to the employers who don’t want to hire us, or the colleagues who don’t take us seriously, or the online trolls who thinks it’s perfectly OK to call a doctor with 20+ years medical experience an “obese moronic bitch”.
How weight stigma impacts the medical profession
There are a number of studies that demonstrate anti-fat bias among health professionals. One study that looks at ob*sity researchers and health professionals that attended an ob*sity conference in 2013, showed that both explicit and implicit levels of bias were present across the board. I’m struggling to get my head around this. These health professionals are supposed to be helping fat folk, and instead they are judging them. These researchers are writing the papers that the rest of the world gets their information from. If they can’t overcome their bias, how can we expect the rest of the world to?
In another study of 4732 medical students, 74% exhibited implicit weight bias and 67% explicit weight bias. Listen to this. “Explicit attitudes were more negative toward ob*se people than toward racial minorities, gays, lesbians, and poor people.” And here’s the real kicker folks. Both “implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race.” People get very angry with me when I point to thin white men as some of the worst offenders when it comes to weight stigma, but the evidence backs me up here.
What is explicit bias?
With explicit bias, people are aware of their prejudices and attitudes toward certain groups. In their study of medical students, Sean Phelan and the team separated these into dislike, blame and fear. They used the following anti-fat statements to assess explicit bias.
- I really don’t like fat people much
- I have a hard time taking fat people seriously
- Fat people make me feel somewhat uncomfortable
- Fat people tend to be fat pretty much through their own fault
- Some people are fat because they have no will power
- I feel disgusted with myself when I gain weight
- I worry about becoming fat
39% of medical students strongly agreed with the statements, 19% moderately agreed, and 9% slightly agreed. Less than 35% of medical students did not show any form of anti-fat bias, and only 5% showed pro-fat bias. That’s the reality of how future doctors feel about fat folk. In the US, over a third of their future patients will be ob*se but only a third of future doctors will treat them without explicit bias. This will impact the way they speak to their patients and their treatment decisions. And that is simply not OK.
What about implicit bias?
Implicit bias is different. Implicit bias are unconscious attitudes and stereotypes that people are usually unaware of. They can be assessed using an Implicit Association Test, such as the one that Harvard University created. I strongly recommend you have a go at an IAT. I’m sad to say that I personally have a moderate amount of anti-fat bias. It could be worse, but it should be better.
The reality is that I grew up hating myself and my body. I have all sorts of negative associations with fatness and they aren’t going to magically disappear overnight. The problem is that this implicit bias that most of us are unaware of can affect our non-verbal communication. That look of disgust or disinterest on your doctor’s face? You’re not necessarily imagining that. And just like explicit bias, implicit bias also clouds our judgement and treatment decisions.
In his narrative review of weight stigma in healthcare, Sean Phelan states:
The goal of primary care is to improve patients’ health, longevity and quality of life through the provision ofImpact of weight bias and stigma on quality of care and outcomes for patients with ob*sity (Phelan et al, 2015)
patient-centred care. To do so, healthcare providers must identify modifiable behaviours that increase disease risk, and help patients change them.
He goes on to suggest that in order to this, we need to adopt the ethos of patient-centred care. But anti-fat bias is going to influence this. Studies show that doctors are less likely to have conversations about health behaviour with patients whom they believe are less compliant. So if a doctor thinks their patients is less likely to adhere to treatment or self-care recommendations or they think they’re lazy, undisciplined and weak-willed, then they are less likely to bother. Seems pretty obvious, right?
Doctors treat fat folk differently
Doctors also have less respect for their fat patient and tend to allocate less of their time to them compared to their straight-sized patients. And finally, and in my opinion most importantly, Phelan demonstrates that “physicians may over-attribute symptoms and problems to obesity, and fail to refer [them] for diagnostic testing or to consider treatment options beyond advising the patient to lose weight”. Does that sound familiar to anyone?
Apparently in one study involving medical students, virtual patients with shortness of breath were more likely to receive lifestyle change recommendations if they were obese (54% vs. 13%), and more likely to receive medication to manage symptoms if they were normal weight (23% vs. 5%) (Persky et al, 2010). I keep getting this question over and over again whenever people interview me about weight stigma in the medical profession.
Why does my doctor blame everything on my size and tell me to lose weight instead of investigating or treating my symptoms? The answer is complicated but it all boils down to one thing. Bias.
Why I think weight stigma should be the next hot topic within General Practice
Good medical practice describes what it means to be a good doctor. It says that as a good doctor you will:
– make the care of your patient your first concern
– be competent and keep your professional knowledge and skills up to date
– take prompt action if you think patient safety is being compromised
– establish and maintain good partnerships with your patients and colleagues
– maintain trust in you and the profession by being open, honest and acting with integrity.Good Medical Practice, GMC
I’ve studied the guidelines for best practice in great detail. As a GP appraiser, I need to know them inside out. Whenever I appraise a GP, I create a summary that covers the main points highlighted above. Which is why I am going to spend the rest of my time using them to enforce my argument that we cannot waste any more time talking about this. The time to act is now. Ready?
If you want to make the care of your patient your first concern…
…then you need to practice patient-centred medicine. In order to that doctors need to be able to communicate with their patients effectively and not allow their anit-fat bias to cloud their diagnostic and treatment decisions
If you want to be competent and keep your professional knowledge and skills up to date…
…then you have to make sure you need to address your confirmation bias. Doctors believe many things about how fat impacts a person’s health. Anything that does not fit into that narrative is labelled a paradox. In order to really understand health, doctors need to acknowledge their bias and strive to overcome it.
If you want to take prompt action if you think patient safety is being compromised…
…then you need to take immediate action to end weight bias within the medical profession. Diagnoses are being missed. I am aware of a number of patients who presented to their doctors with unexplained weight loss only to be told that this was a good thing. It turns out they had cancer. Whilst this is an extreme example, it is happening across the globe and it is absolutely unacceptable. Patient safety is compromised when doctors fail to take their symptoms seriously. This needs to end.
If you want to establish and maintain good partnerships with your patients and colleagues…
…then you have to stop being such a fatphobic a***hole. Enough said.
If you want to maintain trust in you and the profession by being open, honest and acting with integrity…
then you have to practice fairly and without discrimination. Weight stigma is not just wrong, it is harmful. Doctors need to hold ourselves to the very highest of standards when it comes
That’s it folks. This is why I keep going on and on about weight stigma. This is why people will never get me to shut up. Got anything to add? Why not write something in the comments below. And don’t forget to subscribe to my email list if you want to be reminded every time I bring out a new blog post.