Weight Loss Is Not a Substitute for Healthcare: Part 1- The Basics

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Substituting weight loss for health and/or healthcare accommodation is a primary source of harm enacted on higher-weight people by the healthcare industry. I’ve had a bunch of requests asking me to write about it from a number of perspectives, so I decided to do a series to offer a comprehensive perspective .

This is complicated and there is a lot to discuss so I’m breaking it up into five parts. I want to make help define the problems and draw them into sharp relief both to help readers recognize it and avoid blaming themselves for the failures of healthcare, and so this can be used as a resource to send to people who aren’t getting it. Then, in the final installment of the series, I’ll talk about what can be done. Before I dig into this, I want to say that I’m thrilled you are reading this whether you stumbled onto it or are a free or paid subscriber. Today I also want to offer some extra gratitude to my paid subscribers - a series like this takes a lot of time to create and your support makes this kind of deep dive possible.

Part 1 - The Basics

Part 2 - Denial of Care

Part 3 - Delay of Care

Part 4 - Case Study

Part 5 - What Can Be Done?

The problem that underlies all of this is the idea that healthcare providers/facilities/insurance can/should be able to pick and choose whether they want to accommodate higher-weight people. So much of the healthcare that we receive - tools, techniques, best practices - has been created using research that excluded higher-weight people. There are massive gaps in both healthcare’s knowledge about, and accommodation of, higher-weight bodies. A common justification for this is that higher-weight people can lose weight, and so if they become thin, then they will have access to ethical, evidence-based care and so there is no need to provide ethical, evidence-based care to higher-weight patients.

The idea that higher-weight people can reach whatever weight healthcare wants them to in order to access care is questionable at best (and we’ll discuss that later,) but even if they could, the idea that people do or do not deserve care based on their body size is still horrifying and is still at the root of suffering and even death for higher-weight people.

This has been going on for a long-time - from holding healthcare hostage for a weight loss ransom, to recommending weight loss surgeries for type 2 diabetes in higher-weight patients (when thin patients with the same diagnosis and labs are not asked to take the major risks and life changes of those surgeries), to tools and equipment that aren’t properly rated for higher-weight patients, and more. That said, with the advent of the new generation of GLP-1 weight loss drugs (and their relentless marketing as “miracle” weight loss drugs), I’ve been seeing and hearing about this even more, with providers, facilities, and insurance companies treating these drugs as a substitute for providing proper care to higher-weight people.

I want to be clear that I take a firm view of bodily autonomy in general as well as specific to this situation, I would never shame or blame a patient who attempted to lose weight in order to access healthcare or for whatever their reasons or sincerely held beliefs about weight loss might be. I also take a firm view of what constitutes the ethical, evidence-based practice of healthcare, including informed consent, and that’s where we run into an issue with this substitution of weight loss for healthcare.

One clear and obvious example is BMI-based denials of care. This happens when a patient is told that they cannot have a procedure they need or want (for example joint surgeries, spinal surgeries, or gender affirming care) unless or until they reach a certain BMI or percentage of weight loss.

Rather than creating healthcare for the patients who exist, the suggestion is that higher-weight patients don’t deserve care unless and until they become thinner patients. This also quickly becomes a matter of privilege and resources - a patient’s access to care can determine their fate - some patients can get a procedure and/or accommodation at a BMI at which another patient will be denied. Those with better insurance, the resources and ability to travel etc. have a better chance of accessing care.

The other issue is with accommodation. This occurs when higher-weight patients don’t have access to the same things that thinner patients have. This includes everything from a chair they can sit in, imaging equipment, a bed in the emergency room or hospital, a table in the cath lab, an overbed and/or hoyer lift and/or appropriate staffing ratio to help providers move patients in ways that keep both safe, and more. Higher-weight patients can face a healthcare system that was not built for them. This can also be life or death. I was advocating for a patient meeting with a cardiologist at a very highly-regarded cardiology center. The cardiologist told that patient that if she did have a heart attack, the table in the cath lab was not appropriately weight-rated for the patient and there would be “nothing to do” but medically manage and “watch.” (The facility has since acquired tables rated for higher weight.)

For those who can’t access appropriate, accommodating care, the recommendation is often to lose weight. And I’m using the term “recommendation” loosely here because at this point the patient's healthcare is being held hostage for a weight loss ransom. We have to start and keep asking questions about the ethics of this, the potential coercion (and the ramifications for patients and providers when, for example, a surgeons is being begged by a patient to give them a weight loss surgery that the surgeon knows the patient doesn’t want to have. We have to ask questions about an attitude that the provider/facility/insurance will not treat the patient who exists and needs treatment, and will only treat a hypothetical patient that they believe/hope this patient might possibly become (after enduring difficult and sometimes risky interventions). And if the patient will not subject themselves to the risks of (trying) to become that (thinner) patient, healthcare will allow the patient to suffer and even die and blame the patient.

Certainly the paternalistic and coercive nature of this is a huge issue here, but even if someone believes that weight loss is an appropriate substitute for care or accommodation, there would be some questions they would need to answer around both the denial and delay of care.

In Part 2, we’ll look at denial of care more deeply.

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*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.