Note to Doctor is Masterclass in Pushing Back Against Diet Culture

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After the all of the strife of the Lancet “clinical ob*sity” opinion piece deep dive today I’m excited to bring you a resource to help push back against diet culture/weightloss industry influence in healthcare.

Regular readers may remember that last year I wrote a two-part series about a Prescribe Fit. Prescribe Fit is a company that sells weight loss programs to patients through their orthopedist or other healthcare provider. I first heard about it from a patient who was referred by their orthopedist to what they thought was physical therapy after knee injury but turned out to be this weight-loss program. At the time I looked into the company that the scientific basis (or lack thereof) behind Prescribe Fit.

I was recently contacted by Emily Gilbert, Assistant Professor and Information Services & Liaison Librarian at the University of Illinois Chicago (UIC) who told me she had been ‘“prescribed” the program by her podiatrist.

She shared the letter that she wrote to her doctor with me and I asked if I could publish it here because it is a beautiful example of how to push back against this (including the use of academic privilege.) I also think that, even though some parts are specific to Emily, much of the letter can be helpful to others who are writing similar letters.

So, with immense gratitude to Emily for her stellar work here and for allowing me to share it, here is her letter, complete with references! (If you’re looking for background info on Prescribe Fit, you can find that here.)

Dear Dr. [Redacted],

I am writing in response to the email and automated voicemail I received from you about my “prescription” to Prescribe FIT, as well as the emails and now two calls I have received from the company. When I first saw the “Access Your Prescription” button, I assumed it had something to do with the medication you prescribed me on my first visit. However, I quickly realized that it was a weight-loss program through an orthopedic lens. The email said it can help with surgery preparation/recovery or pain, neither of which I have needed your care for.

As we have chatted about in our appointments, I am a professor in the library at UIC. I probably haven’t mentioned that my academic research focuses on anti-fatness within libraries, and I also work with UIC medical students on how they can best serve fat patients. (Like most other fat studies researchers and fat activists, I use the term “fat” as a neutral descriptor, and I reject “obesity” as a term rooted in anti-Black racism that has been used to other and pathologize fat people.)

While the Prescribe FIT email doesn’t explicitly mention weight loss, I am very familiar with the attempted semantic softening of the weight loss industry. I inferred that while the program may provide orthopedic benefits to people in specific situations, this is ultimately a weight loss program. Notably, the provider area of Prescribe FIT’s marketing website lists weight loss as the first potential outcome for patients.

The email I received also mentioned joint pain and mobility issues. I do not have either of those; I came to see you due to an issue with my toenail. Given the absence of those factors, I can only assume that I was recommended for this program due to my body size. I find this highly inappropriate for several reasons:

1. What assessments did you perform on my health behaviors to determine that a behavioral intervention is appropriate? I don’t ever remember you asking me about my diet and exercise, so it seems that you determined my candidacy for this program based on assumptions.

2. What screenings did you do for eating disorder history to determine the likelihood of triggering a relapse through the many, many times I have been contacted about this program? I do not recall you ever asking me about any ED history.

3. Is this a weight loss program as I have inferred? If so, do you think I should gain weight? Because that is the most common long-term outcome of behavioral weight-loss interventions.^1–3

4. The mention of a Bluetooth-enabled scale in the email I received made it clear that this is a Remote Patient Monitoring effort, which is an absurdly invasive suggestion for a patient who does not need frequent weight checks, such as one with cardiogenic edema. Frequent weight checks are also very triggering for people in ED recovery⁴, which, again, I was never asked about. Furthermore, I am aware that programs like Prescribe FIT provide compensation to doctors whose patients use the RPM a certain number of days per month. It concerns me that this financial incentive is given priority over the risks your patients incur by the bombardment of contact from this company asking us to start frequently weighing ourselves.

Anti-fat bias is pervasive throughout society, and it is imperative that healthcare providers take the time to learn more about this bias and how it impacts their patients. This is not an intellectual exercise—societal contributions to the oppression and exclusion of fat bodies have distinct and tangible harms. We are hired at a lower rate than our “normal-weight” peers with the same qualifications⁵, and when we are hired, our wages are lower.⁶ We are less likely to be believed in courtrooms, either as jurors or as defendants.⁷ When we experience sexual violence, we are less likely to be believed by the police.⁸ Existing with a visible body difference associated with unworthiness is very stressful, and our mental health suffers for it.^9,10 And finally, it may well be the anti-fatness that causes poor health outcomes rather than the makeup of our bodies.^11,12 There are many barriers between fat people and health care, including how providers view their fat patients. As we are often perceived as lazy, unintelligent, and physically revolting, providers may choose to spend less time with us, which can lead to less preventive care and fewer diagnostic tests.^13,14

Though Prescribe FIT may be beneficial for a subset of your patients, I am disappointed that you would put myself and other patients without those specific needs in harm’s way by promoting a weight loss program with RPM. I made a pledge to myself in 2022 to find doctors who would listen to and respect me regardless of my body size, and I specifically addressed my feelings about intentional weight loss with my GP and OBGYN. I never thought this would come up in a podiatric setting, or I would have discussed it with you, too.

Finally, these poor outcomes are much worse for fat people with additional marginalized identities. I have the privilege of my education and research background and capacity to speak up to you about this, but how many other patients of yours don’t? How many others will suffer from this and never tell you about it?

I encourage you to unpack this bias against fat patients and to engage with readings on weight-neutral practices (see Appendix A). I have also included a list of books which will inform your understanding of the fat experience (see Appendix B).

It is clear to me that we cannot have a productive and therapeutic doctor-patient relationship moving forward, so I will be moving on to another practice. I urge you to consider the concerns I have brought forward to avoid further patient harm.

References

1. Tomiyama AJ, Ahlstrom B, Mann T. Long-term Effects of Dieting: Is Weight Loss Related to Health? Soc Personal Psychol Compass. 2013;7(12):861-877. doi:10.1111/spc3.12076

2. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220

3. Aphramor L. Validity of claims made in weight management research: a narrative review of dietetic articles. Nutr J. 2010;9(1):30. doi:10.1186/1475-2891-9-30

4. Froreich FV, Ratcliffe SE, Vartanian LR. Blind versus open weighing from an eating disorder patient perspective. J Eat Disord. 2020;8(1):39. doi:10.1186/s40337-020-00316-1

5. Roehling MV, Roehling PV, Pichler S. The relationship between body weight and perceived weight-related employment discrimination: The role of sex and race. J Vocat Behav. 2007;71(2):300-318. doi:10.1016/j.jvb.2007.04.008

6. Baum CL, Ford WF. The wage effects of obesity: a longitudinal study. Health Econ. 2004;13(9):885-899. doi:10.1002/hec.881

7. Beety VE. Criminality and Corpulence: Weight Bias in the Courtroom. Seattle J Soc Justice. 2013;11(2):523-553.

8. Yamawaki N, Riley C, Cook M. The effects of obesity myths on perceptions of sexual assault victims and perpetrators’ credibility. J Interpers Violence. 2015;33(4). https://journals.sagepub.com/doi/full/10.1177/0886260515613343

9. Hatzenbuehler ML, Keyes KM, Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obes Silver Spring Md. 2009;17(11):2033-2039. doi:10.1038/oby.2009.131

10. Brochu PM. Weight stigma as a risk factor for suicidality. Int J Obes 2005. 2020;44(10):1979-1980. doi:10.1038/s41366-020-0632-5

11. Muennig P. The body politic: the relationship between stigma and obesity-associated disease. BMC Public Health. 2008;8:128. doi:10.1186/1471-2458-8-128

12. Sutin AR, Stephan Y, Terracciano A. Weight Discrimination and Risk of Mortality. Psychol Sci. 2015;26(11):1803-1811. doi:10.1177/0956797615601103

13. Lee JA, Pausé CJ. Stigma in Practice: Barriers to Health for Fat Women. Front Psychol. 2016;7:2063. doi:10.3389/fpsyg.2016.02063

14. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obes Silver Spring Md. 2009;17(5):941-964. doi:10.1038/oby.2008.636

Appendix A: Literature on weight-neutral practices

Bacon L, Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal. 2011;10(1):9. doi:10.1186/1475-2891-10-9

Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105(6):929-936. doi:10.1016/j.jada.2005.03.011

Gaesser GA, Angadi SS. Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks. iScience. 2021;24(10):102995. doi:10.1016/j.isci.2021.102995

Matheson EM, King DE, Everett CJ. Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. The Journal of the American Board of Family Medicine. 2012;25(1):9-15. doi:10.3122/jabfm.2012.01.110164

McEntee ML, Philip SR, Phelan SM. Dismantling weight stigma in eating disorder treatment: Next steps for the field. Front Psychiatry. 2023;14:1157594. doi:10.3389/fpsyt.2023.1157594

Muennig P, Jia H, Lee R, Lubetkin E. I think therefore I am: perceived ideal weight as a determinant of health. Am J Public Health. 2008;98(3):501-506. doi:10.2105/AJPH.2007.114769

Tylka TL, Annunziato RA, Burgard D, et al. The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity. 2014;2014. doi:10.1155/2014/983495

Wei M. Relationship Between Low Cardiorespiratory Fitness and Mortality in Normal-Weight, Overweight, and Obese Men. JAMA. 1999;282(16):1547. doi:10.1001/jama.282.16.1547

Appendix B: Further reading

Harrison DL. Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness. North Atlantic Books; 2021.

Strings S. Fearing the Black Body: The Racial Origins of Fat Phobia. New York University Press; 2019.

Gordon A. “You Just Need to Lose Weight”: And 19 Other Myths About Fat People. Beacon Press; 2023.

Gordon A. What We Don’t Talk About When We Talk About Fat. Beacon Press; 2020.

Cooper C. Fat Activism: A Radical Social Movement. Second edition. HammerO Press; 2021.

Boero N. Killer Fat: Media, Medicine, and Morals in the American “Obesity Epidemic.” Rutgers University Press; 2012.

Pausé C, Wykes J, Murray S, eds. Queering Fat Embodiment. Ashgate; 2014.

Oliver JE, ed. Fat Politics: The Real Story Behind America’s Obesity Epidemic. Oxford University Press; 2006.

Rothblum ED, Solovay S, eds. The Fat Studies Reader. New York University Press; 2009.

Thank you again Emily for a spectacular letter!

For those looking for research in addition to Emily’s incredible list, I have a list here that may be helpful.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.