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Weight Stigma in Medicine

Updated: Jul 12, 2021

I’ve had a few comments and questions following my last post. The recurring one seems to be about people who need to lose weight for medical reasons. I am rambling about things as I learn myself so please don't be under any illusion that I have all the answers to questions - I'm probably asking the same questions myself. But given that this is all a learning process, I have done some more reading around this particular question and am here to present you with my findings. N.B. I am no doctor. I am not remotely qualified in any way to tell someone that they need to lose weight for medical reasons. Unless you are a doctor, neither are you. And even if you are a doctor, understand the consequences of your instructions before you issue them to a patient.

Let's dive straight in. Weight stigma is the term for stereotyping or discriminating people on the basis of body size (aka. fat-shaming or fatphobia). A study in 1957 asked 10-11yr olds to rate 6 images of different children in order of which child they liked best. The images were of a 'normal' child, an 'obese child', three children with various physical disabilities and one with a facial disfigurement. The 'obese' child ranked last consistently [source]. We are taught from a very young age that fat = bad, ugly, unhealthy, unlikeable. However, cultural and societal factors caused this idea to proliferate, not medical. The history of body shape and weight is really interesting (I'm slightly biased with my history degree roots) and I had written a whole paragraph on it but then I decided it was quite dry so you can breathe a sigh of relief that you're not being given a history lecture. BUT I will say (tantalisingly) that during the Victorian era, larger bodies became associated with 'savagery' i.e. the racist term given to black people, in the classification of bodies and hierarchies of races, and also women (to prove their inferiority to men). Social Darwinism is just delightful isn't it?!

Though it's easy to forget (just as it's hard to believe that teachers could possible have a life outside school), doctors are humans and therefore not immune to cultural and societal pressures. There are countless horror stories about people being misdiagnosed, body-shamed or made to feel absolutely terrible by doctors because of their weight. Doctors also frequently ignore eating disorders in patients that don't fit the classic stereotype of anorexia (i.e. emaciated, white teenage girls) which has devastating consequences for the individuals that are not given appropriate medical care for what is: a. serious. mental. health. condition. But in fact, only 6% of people with a medical diagnosis of an eating disorder are actually 'underweight'. Studies have shown that 'many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making.' [source]. The fact that nutrition and lifestyle is barely given a mention in the 6 years of a medical degree probably doesn't help [source].

What does this mean in reality? Essentially that people with serious medical conditions including cancer, congenital heart defects, arthritis, joint problems caused by injury or alignment issues etc. etc. are dismissed and sent home without any advice other than to 'lose weight'. Ellen Maud Bennett's cancer was diagnosed days before she died because doctors had spent years misdiagnosing her symptoms as simply a consequence of being too fat [source]. It means that when Linda Gerhardt started getting violently ill after eating, aged just 16, her family doctor snapped that maybe it was “just bulimia, but,” she said, “at least you’re losing weight.” Seven months later, when Linda was yellow and too weak to go to school, an emergency ultrasound revealed gallstones and she had to have her gallbladder removed [source]. Knee pain and joint problems which a thin person would have taken seriously are dismissed in larger people because of the assumption that the problem has arisen from their weight. Correlation between weight and certain health problems does not equate causation.

But given that statistically dieting doesn't work (and doctors do know this), it seems that people within the medical profession are actually driving the 'obesity epidemic' as opposed to tackling it. By dismissing patients and treating them with less compassion, doctors and nurses impose stigma which has direct consequences too. Patients who experience stereotype threats or stigma often experience significant measurable stress. If stress levels are high for an extended period of time, it can lead to several long-term physiological health effects, including heart disease, stroke, depression and anxiety disorder. You might notice that these diseases disproportionately affect 'obese' individuals. It is SO important to understand that the effect of stress pathways provide an alternative explanation for a proportion of the association between obesity and chronic disease [source].

And is having fat on your body actually unhealthy? Studies have found that anywhere from 1/3 to 3/4 of people classified as 'obese' show no signs of high blood pressure, insulin resistance or high cholesterol. Meanwhile, about 1/4 of non-'overweight' people are 'lean unhealthy or "skinny-fat". A 2016 study found that unfit skinny people were twice as likely to get diabetes as fit fat people. People dedicate their lives to this kind of research and I've been reading bits and pieces in my spare time over the last month or so. Please don't think I'm pretending to know it all, or have the arrogance to assert that my opinion is fact. It's not, it is just an opinion, but I definitely feel as though it's a fundamental issue that we need to get to the bottom of before more people suffer. In fact, in the process of researching for this blog post I came across this article. I found it really helpful so I encourage you to read it:

Hopefully what you've read thus far might have got you to reconsider your immediate concern for people who need to lose weight for medical reasons. Firstly (and this is an arrogant statement), it's impossible to assess someone's health by their weight alone. Secondly, correlation doesn't equal causation. Just because someone is 'overweight', doesn't mean they are automatically unhealthy. And blimey, the evidence that stress (caused by weight stigma) causes a lot of health problems rather than weight itself has made me question a lot of the long-standing assumptions I had about weight and health.

It is vital that we continue having conversations to educate one another, listen to people's stories and experiences, and start challenging the preconceptions and societal stereotypes that we are surrounded by, Our 'obesity epidemic' is categorically going to get worse by fat-shaming people. Bullying tactics do not work. They increase stress and pressure which, as I have just learnt, can cause long term health problems. In order to stop people from getting to the stage where they aren't able to do the things they want to do due to their weight, we need to overhaul the way we understand weight and diet and lifestyle completely. Instead of children as young as 3 years old being worried about their weight, we need to help children focus on fun movement and exercise, try a large variety of food, hear positive language directed about all bodies and see role models of all shapes and sizes.

And next time you look at someone who is 'overweight' or 'obese' and immediately make judgements about how unhealthy and unhappy they must be, maybe just don't.



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