The Harm of Weight-Based Healthcare Inequalities

Happy 2024! I am ready for another year of writing about the intersections of weight science, weight stigma, and healthcare and I’m glad you are here reading! This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!

I received the following question from reader Lisa:

I notice that when you write about things that can hurt larger people’s health you usually mention weight cycling, weight stigma, and healthcare inequalities. I’ve read your posts for the first two – is there a post that describes the third one?

Thanks for asking Lisa, I’ve been meaning to write this and you’ve given me the perfect gentle push! For the record the piece for the harm of weight cycling is here and the one on the harm of weight stigma is here.

The idea of healthcare inequalities is difficult to quantify because it’s such a vast category. In terms of a definition, the one I’m going to use here is any way in which higher-weight people’s healthcare experiences differ from those of thin people to the detriment of higher-weight people.

It’s always important to remember that when we discuss these inequalities we are clear that they don’t impact everyone equally, as people’s weight becomes higher their experience of inequality typically increases as well and, utilizing Kimberlé Crenshaw’s framework of intersectionality, those who have multiple marginalized identities will also face greater inequality in their individual marginalizations and at the intersections of them.

Finally, I want to point out that thin people can face healthcare disparities as well based on things like marginalized identities and socioeconomic status. The comparisons I’m drawing here are about the typical experience of thin people and are not meant to indicate that thin people never face issues in accessing healthcare, just that as a group thin people are not systematically marginalized within the healthcare system because of their size.

I also want to be clear that this is not an exhaustive list and I welcome you to add other examples in the comment section. I’m going to divide these up into groups to help give this conversation some structure.

Practitioner Bias

This includes a lot of different things. Before I get into it, I want to point out that providers aren’t necessarily bad actors who just hate fat people (though, sadly, some absolutely are.) Many are simply a product of a healthcare system (including healthcare education) that is deeply rooted in weight stigma. Regardless of how they got to this place, these practitioners are responsible for the harm that they do.

Some practitioners are operating out of implicit bias, which is to say that the bias is subconscious. Others are operating from explicit bias, they are fully aware of their negative beliefs and stereotypes about higher-weight people and they are working with higher-weight patients based on those beliefs and feelings. This can lead to a lot of negative impacts. Some examples:

There is the classic (and far too prevalent) example of a practitioner who offers ethical, evidence-based treatments to thin patients for health issues, but sends higher-weight patients with the same symptoms/diagnoses/complaints away with a diet.

There’s the “Occam’s razor” mistake. Occam’s Razor states “plurality should not be posited without necessity.”  Said another way, when choosing between theories, the simplest one is usually correct. This gets applied to the care of higher-weight patients when providers don’t address individual health issues/symptoms/diagnoses/complaints for fat patients because they assume weight loss will solve them all (and/or they want to see what weight loss solves before attempting the ethical, evidence-based treatments that thin people would typically get for the same issues/symptoms/diagnoses/complaints.)

Some practitioners assume that fat patients are lying if what they are telling the provider doesn’t match up with the provider’s stereotypes of people their size. These practitioners base decisions and recommendations on their stereotypes rather than what the patient is telling them.

There are practitioners who, consciously or subconsciously, are reluctant to touch fat patients or manipulate their bodies which can impact everything from examinations to post-operative care.

There are practitioners who think it’s worth risking fat people’s lives and quality of life in attempts to make them thin. Some of these practitioners take this further by deciding that they know better than fat people and so try to manipulate/trick/bully fat people into weight loss interventions (including dangerous drugs and surgeries) by almost any means necessary including intentionally failing to give a thorough informed consent conversation – blowing patients off with phrases like “all drugs have side effects” or “it’s nothing to worry about” rather than being honest about the risks and/or making threats about the patient’s health and life expectancy that are not supported by evidence.

These inequalities can lead to many harms. First of all, we know from a century of data that weight loss almost never works and typically results in weight cycling which is independently linked to a number of harms. It can also delay care – when a thin person gets an intervention at their first appointment but a fat person with the same symptoms/diagnosis gets sent away with a recommendation to lose weight the higher-weight patient’s actual care is delayed.

The “Occam’s Razor” mistake creates similar problems. It must be remembered that Occam (actually, it seems, Ockham but that’s a whole other thing) was a philosopher, not a physician. Deciding to treat something as complex as the human body by going for the simplest strategy is problematic on its face, even before we add the ways that weight stigma impacts providers' beliefs around and treatment of higher-weight patients.

And there is another layer of harm here. As we’ll see over and over, the harm from healthcare inequalities is intensified when the results of the harm are blamed on fat bodies. For example, higher-weight patients follow practitioners' advice to attempt weight loss. They lose weight short term and gain it back long term (which is exactly what all the research we have says will happen.) Their doctors tell them to try again, they weight cycle again. This happens repeatedly across their entire lives. Eventually these patient are diagnosed with cardiovascular disease (CVD). The fact that CVD is strongly linked to weight cycling is completely ignored and research (often created by/for the weight loss industry) blames “ob*sity” for the CVD and uses these higher rates of CVD to lobby for greater insurance coverage of weight loss treatments and the cycle of harm continues unabated.

Structural Inequalities

This occurs when the things that higher-weight patients need in order to access healthcare don’t accommodate them. This can be because the things don’t exist or because the healthcare facility that the patient is visiting doesn’t have them.

Again, there are too many examples here to name. One very common example is chairs. Having sturdy armless chairs in the waiting room, treatment rooms, and anywhere a patient may need to sit is the absolute least a facility can do and it’s deeply disturbing how many facilities don’t even get this right.

Then there are the absolute basics of care – when the practice doesn’t have (or can’t find) properly sized/accommodating blood pressure cuffs, proper length vaccine needles, gowns, scales (for medically necessary weigh-ins like those to dose medications or check for edema from a heart condition). These are all things that thin patients can typically expect to be available.

Durable medical equipment is another area where structural inequalities can compromise care – crutches, braces, walkers, wheelchairs, prosthetics.  Even when these things are available, they are often exponentially more expensive even when they don’t have to be custom made.

Then there are more specialized tools like operating tables and surgical instruments. Often the only place these instruments can be reliably found is in centers that focus on weight loss surgeries, meaning that higher-weight patients are excluded from the kind of surgical care that is routine for thinner patients.

Next is imaging -   MRI and CT scanners that have high-weight rated tables and large enough bore sizes, ultrasounds that can appropriately view through adipose tissue, x-ray tables and spaces that are accommodating and more. Harm is added here when energy from those in the healthcare system is wasted on complaining that higher-weight people exist or justifying the lack of care, rather than focusing on solutions and working from the basis that healthcare should fit bodies, bodies shouldn’t have to be changed to fit healthcare.

As an example of this, let’s look at the ways that a single MRI appointment can create healthcare inequalities. A patient is referred for an MRI of their knee with contrast. First, the patient goes to the facility to which their doctor referred them but is turned away because the MRI is too small. They call the referring doctor, who isn’t aware of any other option and tells them to call around. After hours of research they find an MRI with a 550 pound weight limit and a bore size that will accommodate them, but unlike the first facility this one has a backlog so they’ll have to wait three more weeks. When they arrive for their appointment the MRI tech is using a Gadolinium-based contrast agent (GBCA). The dosage table the tech has stops at 300 pounds and the patient says that they weigh more than that. So the tech decides to use a GBCA calculator, using the formula of the recommended dose (mmol/kg) multiplied by weight (kg) and divided by concentration (mmol/mL). Except the scale in the MRI facility has a limit of 400 pounds which is less than this patient weighs. The tech explains the risk of incorrect dosage and tells the patient that they can either cancel the MRI or give the tech their best guess of their weight. The patient offers their best guess. The patient is given a gown to change into, but it’s way too small. The patient is told that they don’t have gowns that are any bigger. The patient offers to wear their own clothes, explaining that they have worn 100% cotton clothes for exactly this reason. They are told that it’s against policy and that the tech will have to ask their boss. The boss is off today so the patient can be rescheduled in 3 weeks and the tech says he will “try to remember” to ask his boss about the patient wearing their own clothes but suggests that the patient keep calling to try to verify and also that the patient find a scale that works for them so that they can give the tech an accurate weight. The patient comes back in three weeks with an accurate weight and having confirmed that they can wear their own clothes. They lay down on the MRI table and the tech tries to put the knee in the dedicated knee coil that allows the MRI to view the knee structure. It is too small for the patient’s leg. The patient is told that there is no way to get an MRI of their knee.

This is just one scan for one patient, and this is based on a true story. The failure of the healthcare system to accommodate higher-weight patients has the potential for a massive amount of harm, most of which goes uncaptured or, worse, is blamed on “ob*sity.”

Research Bias

This also happens in multiple ways. It can include higher-weight people being left out of research. For example, it is well known that clearance rates of some anesthesia drugs can vary based on the amount of adipose-tissue a patient has, but higher-weight patients have traditionally been excluded from the trials for anesthesia medications so there isn’t good data on this.

Here harm is also increased when naming the inequality is seen as sufficient remedy. I recently spoke at the combined conference for the Washington State Society of Anesthesiologists and British Columbia Anesthesiologists' Society (which was an absolute delight! I gave a keynote and then had the honor of being on a panel with Dr. Lisa Erlanger and Dr. Sandi Pitfield.) In preparation for this, I read hundreds of pages of anesthesia research. What I repeatedly found were decades of studies that started by saying that higher-weight patients’ exclusion from drug trials created serious knowledge gaps, but then just moved on. Admitting that there is a problem is the first step, it must be followed by taking steps to solve the problem. The solution is not to cobble together what exists and keep creating guidelines based on shoddy research.

Part of this issue is researcher bias, limitations of time and money, and perceptions that it’s not worth studying fat people or that it’s reasonable for fat people to be excluded from research (often under the guise that it’s acceptable to make fat patients become thin before they can access ethical, evidence-based medicine.)

Another issue is the massive amount of money that is earmarked only to study the prevention and/or eradication of fatness instead of researching how to actually support the health of fat people.

It Seems Like A Lot…

This happens when we actually do know what fat patients need, for example, in terms of dosage. But they are still under-medicated because the amount that higher-weight people need “seems like a lot” to those who are dosing the drugs and who are used to the dosage for thinner patients.

When someone’s education is focused on thin patients (including viewing thin patients as “normal” and higher-weight patients as “different/abnormal/extra” and the treatment protocols for thin patients are the focus, then those practitioners can balk at what higher-weight patients actually need.

Risk predicated on size

This happens when patients who are higher-weight are given treatments that are more dangerous based on their size alone. In an example I wrote about more in depth here, thin patients with type 2 diabetes are not referred to weight loss surgeries that create a permanent disease state in their digestive systems, carry extensive risk, and have very little long-term term data. Patients with so-called “class 1 ob*sity” have the surgery offered if they can’t reach their glycemic management goals. Those with so-called “class 2 ob*sity” have the surgery “recommended” if they can’t reach their glycemic management goals. Patients with so-called “class 3 ob*sity” have the surgery “recommended” regardless of their glycemic management. Even if someone believes that these surgeries meet the requirements of ethical, evidence-based medicine, the reality is that they are risky and suggesting that someone with well-controlled type 2 diabetes have a dangerous surgery simply because of their size is another dangerous healthcare inequality.

BMI-Based Denials of Care

I’ve written about these, and options to fight them, quite a bit (this is a good place to start). This occurs when a fat patient is denied healthcare (often a surgical procedure) unless or until they change their height-weight ratio. These denials are often “justified” using rationale that comes from blaming fat bodies for the negative outcomes of weight stigma, weight cycling, and other healthcare inequalities (for example, as I wrote about above, higher rates of post-op complications) and they amount to holding healthcare hostage for a weight loss ransom (and a ransom that most people will not be able to pay.) While all of the denied procedures are important, in some cases (like some organ transplants,) the procedures that are denied are truly life or death.

Saving Money Through Healthcare Inequalities

A common attempted “justification” for the healthcare inequalities that fat people face is the idea that fat people shouldn’t get the resources they need if they happen to need more resources than the average thin person. When added to a general focus on profit (especially in the US healthcare system) this leads to staff-to-patient ratios that make it impossible to correctly care for fat patients (for example, having adequate staff to safely turn patients to prevent bed sores or help them ambulate to improve post-surgery outcomes.) It can also mean not having the supplies that these patients need in order to have the best outcomes. Some examples are InterDry to prevent/treat skin fold infections or Hoyer lifts so that they can use a commode and avoid bedpans and chuck changes (both of which are made more difficult and dangerous for the patient and more likely to create negative outcomes when staff-to-patient ratios don’t allow for adequate care, even if the practitioners aren’t coming from a place of weight bias.)

All of this, in turn, can create practitioner bias when they blame higher-weight patients rather than the healthcare system that is leaving both patients and practitioners without what they need.   

When healthcare facilities are allowed to decide that they don’t want to spend the money to give higher-weight people the care they need, or they are not adequately funded to do so, then higher-weight patients suffer. Here again the negative impacts of this are often simply blamed on “ob*sity.” For example, research on post-operative complication rates will often suggest that “ob*sity” causes higher complication rates without exploring the ways that these size-based healthcare inequalities may actually be at the root of any elevated rate of complications.

This is not an exhaustive list of healthcare inequalities that higher-weight people face (please feel free to add other examples in the comments.) I’ll also say that this is made much worse because these harms are not adequately measured or remedied and the harms from them get attributed to “ob*sity” rather than the inequalities that higher-weight people face.

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:

Liked the piece? Share the piece!

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.