Questions for Healthcare Practitioners to Ask Themselves about Weight Bias

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!

Research and lived experience tell us that a large number of healthcare practitioners harbor bias against fat* patients. Unfortunately sometimes this bias is explicit - these practitioners are aware of (and, in some cases seem quite proud of) their stereotypes of, and biases against, their fat patients. They feel that they are justified and they wield them like a weapon against these patients. This is a life and death issue that compromises the healthcare of many fat patients. It is not, however, what today’s piece is about.

Today I want to talk about implicit weight bias. This is weight bias that exists under the surface, without awareness, and thus unexamined. Below you’ll find some questions that you can ask yourself to see if you might be operating from weight bias. This is not an exhaustive list, but a place to start.

If you uncover bias, understand that’s not a galloping shock - we live in a world (and healthcare training tends to be) rife with fatphobia. So while you may feel some (warranted) guilt or shame (you are not alone, I’ve also been there,) the most important thing is to do the work to learn and do better. I’ve put some resources for doing that work at the end of the piece. Note that while there is a Harvard Implicit Association Test for Weight, I have not included it here because it utilizes terms that medicalize and stigmatize fat people.

Some questions:

Do I tell higher-weight patients to “eat less and exercise more,” without having any information about how much they eat or exercise?

Fat patients eating and movement behavior is as wide-ranging as that of thin patients. Fat patients can also be dealing with all the same disordered eating behaviors and eating disorders as thin patients. So, telling fat patients to restrict food and increase movement (including and especially if you don’t know anything about their current eating and exercise habits or possible disordered eating/eating disorder status) is a dangerous practice. Beyond that, it’s important to understand that, regardless of a fat person’s eating or exercise habits, intentional weight loss (including “eat less exercise more”) has failed for the vast majority of people for decades, and is not an ethical, evidence-based intervention for anything, so simply ending the practice of recommending weight loss will decrease the harm you are doing while you take the time you need to address the weight bias that has driven this practice.

Do I recommend that fat patients start a movement program?

I once had a doctor tell me that I should start walking ten minutes a day…the day after I had completed an 18-mile training walk for an upcoming marathon. Movement is not an obligation or a barometer of worthiness (completing a marathon and watching a Netflix marathon are morally equivalent activities), and there are people for whom it is not an appropriate recommendation at all. That said, if you make an assumption that your fat patients are not already participating in movement, then you are practicing stereotypes instead of medicine. This mistake is compounded when you make a recommendation to “just walk.”

Do I believe that fat people shouldn’t be “stigmatized” but that fatness should be eradicated?

If you think that fat people shouldn’t be made to feel badly because they are fat, but are still invested in ideas like the pathologizing fat bodies (with concepts like “ob*sity” and “overw*ight”) or the “obesity epidemic” or “eradicating ob*sity” then you are still operating from weight bias. “I don’t want to stigmatize you, but I do think the world would be better if nobody who looked like you existed” is not an anti-stigma stance. This would be true even if intentional weight loss didn’t fail for the vast majority of people (which it does.)

Do I prescribe weight loss to fat patients, but prescribe other interventions to thin patients with the same symptoms/diagnoses?

When practitioners prescribe diets to fat patients in an attempt to treat health issues for which they would prescribe different interventions to thin patients, not only are they prescribing an intervention that fails the vast majority of the time, but they are delaying care for their fat patients (while giving thin patients immediate care) allowing health issues to progress indefinitely during the weight loss attempt. This can also drive disengagement when the patient doesn’t come back because the weight loss has been (predictably) unsuccessful and/or because they are aware that their healthcare has just been compromised by weight stigma and they don’t want to go through that again.

Do I stretch the truth when fat patients decline weigh-in?

If you are telling fat patients that they have to weigh in, that routine weigh-ins are medically necessary, or that their insurance requires them when they don’t, you are not being honest with them about their rights of informed consent and informed refusal and the reality that routine weigh-ins are almost never necessary. This type of weight stigma can drive patient mistrust and disengagement. For some patients, for example those with or recovering from eating disorders, it can bullying them into participating in a practice that harms them.

If a diagnostic tool or piece of medical equipment isn’t big enough to accommodate a fat patient, do I get frustrated with/blame the patient?

This often sounds like “You’re too big for [this equipment]” rather than “I’m so sorry that [this equipment] doesn’t accommodate you.” Weight stigma dupes us into blaming fat patients for existing, rather than directing our anger at a system that leaves healthcare providers without equitable tools to care for their higher-weight patients. If you find yourself blaming fat patients for a lack of accommodation, reframe this to realize that their healthcare is being compromised by weight stigma. If you aren’t able to solve the problem immediately, at least make it clear that they aren’t at fault, that this shouldn’t be happening, and that you are on their side. Here is a resource for what to do if you find that you can’t accommodate a fat patient.

Do I talk about (but not to) fat patients in front of them?

A situation that happens to fat patients (often when they are faced with a lack of accommodation) is that HCPs talk about them as if they weren’t there. For example, fat pregnant people have reported HCPs complaining to each other that the patient might become incapacitated during labor, and then talking about how they would handle their bodies, all as if the patient wasn’t sitting right there. This treatment is stigmatizing and dehumanizing. Either talk with fat patients, or don’t speak in front of them (and take care not to use the fact that they aren’t there to perpetuate weight stigma.)

Do I make anti-fat comments and jokes with my colleagues (or anyone else)?

I have had healthcare practitioners suggest that fat jokes and complaining about fat patients existing constitute the kind of “gallows humor” that HCPs need to get through the day. In truth, gallows humor is to help HCPs deal with the tragedy and death they experience, not an excuse to engage in and spread bigotry and stigma against patients who regularly receive a lower quality of care because of that bigotry and stigma. Often a good place to start dismantling our weight stigma is with our own mouths, and refusing to participate in anti-fat comments and jokes is a great example of that.

Do I recommend treatments for fat patients because of the impact those treatments might have on their weight, rather than the impact the treatments might have on their symptoms?

While a full discussion of the side effects of any treatment is always warranted, if you aren’t discussing all of the options with your patients because you don’t want to offer options that might increase their weight, or if you are only telling them about medications that might cause (at least short-term) weight loss, then you are treating your patients from a place of weight bias. It’s far better to offer a shared decision-making process where you give your patient all of the options and the facts about each option than to try to manipulate the patient into taking medication because of the impact it might have on their weight.

Do I recommend interventions that risk patients’ lives and quality of life?

This one may be controversial, but if you believe that it’s worth risking a fat patient’s life and quality of life to be thinner, I consider that a form of weight bias. When a doctor tries to convince me to try dangerous diet drugs or to have weight loss surgery, it is an immediate sign to me that this is someone I can’t trust because they are fully willing to kill me in an attempt to make me thin.

Resources for moving forward:

First and foremost, follow, learn from, and support people who are doing this work, especially those with lived experience in fat bodies, especially those who are multiply marginalized. Beware of anyone whose work still utilizes stigmatizing terms like “ob*se” or “overw*ight”, or who is pushing a weight loss message (especially for profit.) The diet industry is getting more sneaky about co-opting these messages so we have to be vigilant. Here is a quick guide to tell the difference between true anti-stigma work and diet industry propaganda.

Read and/or listen to 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, Marquisele Mercedes has an excellent Patreon as well as this powerful piece about weight stigma in healthcare. Monica Kriete wrote an incredible piece about weight-stigma in public health, both of those are part of The Fat Issue of Pipe Wrench Magazine which I highly recommend. Other folks to follow include Shelby Gordon, FatDoctorUK, Unsolicited: Fatties Talk Back, as well as the five co-hosts individually - @fatmarquisele, @dashaunlh, @chairbreaker, @blackqueeriroh, and @jordallenhall. You can find resources, research, and diagnosis-specific weight-neutral care guides at HAESHealthSheets.com. Here is a guide to creating a size-inclusive office

Finally, I frequently give talks to healthcare practitioners about research-based best practices for caring for higher-weight patients. Feel free to email me (ragen at sizedforsuccess dot com) if you would like more information about that.

Again, this is a very partial list meant to get you started (feel free to add others in the comments)

Did you find this post helpful? You can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter (and the work that goes into it!) and get special benefits! Click the Subscribe button below for details:

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.