Why It Matters
“Whatever ailment you walk in with, the problem is your weight. You can have your arm cut off by a buzzsaw and they want you to lose weight.”
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The Risks of Fatphobia to Health and Equity

By Rachel Hock | Wednesday, June 28, 2023
The Risks of Fatphobia to Health and Equity Photo by i yunmai | Unsplash

In June 2023, the American Medical Association (AMA) adopted a new policy to clarify the use of the body mass index (BMI) in medicine. The new policy notes that BMI is “significantly correlated with the amount of fat mass in the general population but loses predictability when applied on the individual level.” The policy also acknowledges both the BMI’s “historical harm [and] use for racist exclusion” and its shortcomings because “BMI is based primarily on data collected from previous generations of non-Hispanic white populations.” The subcommittee report adds that, “The current BMI classification system is also misleading regarding the effects of body fat mass on mortality rates.” The AMA now suggests using BMI in conjunction with other measures and urges physicians to understand the benefits and limitations of using BMI to determine the best care for their patients.

While the new AMA policy is a step in the right direction, there is more work health care needs to do, especially when it comes to dealing with our own biases, assumptions, and actions that can lead to harm. The following experiences shared by real people help show why.

Real People, Real Risk of Harm

Leah (she/her, not her real name) started seeing doctors at age 16 to try to diagnose her chronic joint pain and fatigue. She was told to diet and exercise. She was told she would feel better if she lost weight. Her weight fluctuated dramatically. When she was heavier, she resisted going to the doctor for fear of her symptoms not being taken seriously due to her size and her gender. It was not until she was 24 years old that a pediatric rheumatologist diagnosed her with Ehlers-Danlos Syndrome.

In 2019, Joey (they/them) went to a cardiologist for chest pain, fainting, heart palpitations, and shortness of breath. The cardiologist told them to exercise and lose weight. Joey laughed at the doctor because they were doing high-intensity cardio workouts four times a week at the time. They eventually saw an electrophysiologist who found premature ventricular contractions (PVCs), a type of irregular heartbeat, on Joey’s EKGs. They needed a cardiac ablation, a common surgery to cauterize part of the heart. If they had listened to the cardiologist, Joey may have been at elevated risk for a heart attack in 10 or 20 years.

In 2007, it became clear that Gail (she/her) needed a hysterectomy to address her menstrual problems. Providers denied this necessary procedure because of her weight. She later testified before a committee at the Massachusetts State House to have the words “weight” and “height” added to the list of reasons it is illegal to discriminate against someone. The bill has not yet passed, and Michigan is currently the only state in the US in which it is illegal to discriminate against people for their weight.

Weight Discrimination as an Equity Issue

The framework in the Institute for Healthcare Improvement (IHI) white paper, Achieving Health Equity: A Guide for Health Care Organizations, includes guidance to decrease institutional racism by reducing implicit bias within organizational policies, structures, and norms, and in patient care. The white paper goes on to say, “Implicit bias is not limited to race; implicit bias can exist for characteristics such as gender, age, sexual orientation, gender identity, disability status, and physical appearance such as height or weight.”

Boston Medical Center defines fatphobia as “the implicit and explicit bias of overweight individuals that is rooted in a sense of blame and presumed moral failing.” As shown in the stories above (and countless others), fat patients systematically and systemically do not receive equitable care. “Whatever ailment you walk in with, the problem is your weight,” Gail said. “You can have your arm cut off by a buzzsaw and they want you to lose weight.”

The people interviewed for this article, and fat liberation activists, expressed a preference for using the term “fat” to describe themselves. Although the word has negative connotations because of our fatphobic culture, it is a value-neutral descriptor, like “tall” or “blonde.” Weight is not an indicator of health so health should be decoupled from weight. Since patients will have their own preferences for terminology, consider using the terms an individual prefers whenever possible.

The term “obese” is often tied to an individual’s BMI, the calculation used to measure body size. Aside from the fact that BMI does not account for body composition, the BMI scale is demonstrably racist in its roots and its usage.

The intersection of fatphobia and racism has a long and influential history. In Hannah Carlan’s book review of Fearing the Black Body: The Racial Origins of Fat Phobia by Sabrina Strings, Carlan writes, “The most current manifestation of institutionalized fatphobia around ‘obesity’ as a public health crisis is deeply reliant on the same ideologies that European race scientists drew on to construct fat as indicative of the laziness of body, mind, and spirit.”

What Patients Would Find Helpful

As Leah lamented, “I wish that MDs knew that saying, ‘change your diet and exercise’ is very unhelpful” since they rarely offer specific guidance and make these recommendations sound deceptively easy to follow. She added, “I wish the questions [clinicians asked were] more functional based. ‘Do you feel like you can lift the things you need to lift? Do you have the endurance to do the things you want to do? Do you have a relationship with food that feels sustainable?’”

Joey pointed out that greater awareness of fatphobia needs to be at all levels of the patient experience. “You have to teach this at the medical assistant level because those are the first people who interact with a patient,” they explained. “It doesn’t matter how good a doctor or nurse practitioner is, if you get someone [else] introducing that stigma, [the patient is] not going to go back.”

Accessible facilities would also help to counter systemic fatphobia. Wheelchairs, doorways, chairs, and exam tables are often too narrow for fat people. Gail lamented, “I’ve gone for mammograms, and they have no johnnys to fit me, so I’ve had to sit there naked. It may be health, but it’s not care.”

Rachel Hock is an Institute for Healthcare Improvement Senior Executive Assistant.

You may also be interested in:

No-Nonsense Advice for Health Equity Leaders

The New National Patient Safety Goal: What Does It Mean for Equity?

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