Medical Moralism
The Lose Weight or Die Narrative in Heart Health
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Content Warning: This post contains discussion of weight stigma, medical bias, and challenging experiences with healthcare professionals that may be triggering for some readers.
Medical moralism has transformed heart health from a medical issue into a moral judgment. You know what I’m talking about – the ominous warning delivered across medical exam tables: lose weight or face dire consequences. I call this the “lose weight or die narrative”, and it’s time we examined how medical moralism drives this harmful framework.
Many of you will immediately recognize this scenario. You visit your doctor, and they give you the distinct impression that if you don’t lose weight, you’re going to die. But of what? A heart attack? Stroke? Cancer? It remains frustratingly vague, yet the sense of urgency is crystal clear – do something now, or pay for it later.
Medical Moralism: When Health Becomes a Moral Issue
Medical moralism is the framework that positions health as a moral obligation and illness as a moral failure. Instead of viewing health and illness through a neutral lens, we choose to believe that:
- Health is an obligation – a debt you owe to society
- Illness is a moral failing – you’ve done something wrong
- Prevention is your individual responsibility
- Reluctance to adhere to medical advice is a character flaw
This form of medical moralism shows up everywhere in healthcare, but it’s particularly evident in how we discuss heart health. While preventing heart disease is without a doubt a sensible healthcare goal (it’s the leading cause of death around the world) problems arise when medical advice becomes wrapped in moral judgment rather than evidence.
How Medical Moralism Creates Harmful Language
Consider the terminology we use: “good” cholesterol versus “bad” cholesterol. Explaining high-density and low-density lipoproteins isn’t an easy task, so it’s natural to want to simplify these terms for everyone to understand. But these moralistic labels extend beyond cholesterol to patients themselves. Healthcare professionals regularly categorize patients as “good” or “bad,” “compliant” or “non-compliant.”
The term “non-compliant” is particularly troubling. It effectively means: if you listen to me and do what I say, then you’re good. If you don’t, you’re non-compliant and therefore bad. This positions healthcare professionals as judge and jury, rather than partners in care.
The unspoken message becomes: "I've decided what you should do, and if you don't do it, you're to blame. Whatever happens to you is your fault."
Metabolic Markers as Moral Measuring Sticks
Through medical moralism, blood pressure, cholesterol, and HbA1c have become moral measuring sticks. These numbers increasingly define people’s sense of self-worth. Many can quote their numbers as readily as their phone number – these metrics have become part of our core identity.
This moralization leads to oversimplification. Complex health conditions get reduced to simple formulas that maintain moral judgments. We’re told that if we eat certain foods, exercise a specific amount, and get enough sleep, our blood pressure will normalize, our blood sugar will stabilize, and our cholesterol will improve.
But it’s not that simple. These conditions are far more complex, influenced by genetics, socioeconomic factors, early life experiences, and numerous other variables beyond individual control. Yet to maintain the good/bad narrative, we’ve oversimplified everything.
When we obsess over these numbers through a moral lens, we tend to either overtreat or miss something important. Evidence suggests we are overtreating type 2 diabetes, desperately trying to force blood sugar into “normal” ranges when evidence suggests this approach may cause more harm than good. At the same time, we miss important clues in the “good” patient because we assume their cardiovascular health is optimum when it isn’t.
The Financial Incentives Behind Medical Moralism
There are powerful financial motives behind prescribing both weight loss and other preventative measures. Consider who profits:
- Pharmaceutical companies make billions from preventative medications like blood pressure drugs, statins, and increasingly, weight loss medications
- The weight loss industry has shifted its marketing from cosmetic appeals to health-based messaging – “lose weight for your health” sells better than “lose weight to look good”
- Healthcare systems have created entire specialties around preventative medicine, from lipidologists to specialized clinics
The influence of these financial incentives extends into research funding, medical education, and clinical guidelines. When the same entities profiting from preventative medicine fund the research and develop the guidelines recommending these interventions, we face significant conflicts of interest.
What Really Impacts Cardiovascular Health?
While we fixate on individual metrics and behaviors, robust evidence shows that social determinants of health have far greater impact on cardiovascular outcomes:
- Access to healthcare
- Economic stability
- Systemic racism and discrimination
- Safe neighborhoods
- Access to education
- Food deserts and food apartheid
Since the 1960s Whitehall Studies, we’ve known that income significantly predicts cardiovascular health. The research consistently shows that social determinants outweigh individual factors like diet and exercise. Yet by focusing on individual responsibility, medical moralism conveniently ignores these social determinants. After all, if health is solely an individual responsibility, we don’t need to address societal inequities.
Childhood Environment and Heart Health
A fascinating 2023 study titled “Evidence for the association between adverse childhood family environment, child abuse and caregiver warmth and cardiovascular health across the lifespan” followed a cohort for over 20 years examining how childhood environments affect adult cardiovascular health.
The findings were striking:
- Higher childhood adversity was linked to poorer cardiovascular health, with each unit increase in adversity reducing the odds of ideal cardiovascular health by 4%
- Childhood abuse was associated with 13% lower likelihood of achieving ideal cardiovascular health
- Caregiver warmth increased the likelihood of ideal cardiovascular health by 12%
- The association between childhood adversity and poor cardiovascular health persisted in those with higher adult income, but was not significant in lower income groups
This last point is particularly revealing: childhood adversity affects cardiovascular health in middle and higher-income groups, but in lower-income groups. This demonstrates that economic disadvantage itself is so impactful that childhood factors become statistically insignificant by comparison.
These childhood factors are far more influential than diet or exercise interventions, yet receive far less attention in preventative healthcare.
Remember This When Medical Moralism Makes You Worry
The next time you’re stressing about your blood pressure or cardiovascular risk, remember that much of what affects these outcomes occurred long before you had any control. You didn’t choose your childhood circumstances, economic status, or early life experiences. These factors influence your health in ways that transcend individual behavior.
This isn’t meant to foster hopelessness, but to challenge the moral framework through which we view health outcomes. Your cardiovascular risk isn’t a moral judgment or personal failing – it’s the complex interplay of numerous factors, most of which are outside your control.
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