on nutrition
If you’ve ever been to a doctor’s office for strep throat just to be lectured about your weight, been referred to a commercial weight-loss program instead of physical therapy for your knee pain, or been told that your disabling abdominal pain is due to being “obese”, when it turns out you have a tumor the size of a grapefruit, then you have found yourself with weight-focused health care.
Both public health and the medical establishment subscribe to a weight-centric health paradigm that puts body weight at the center of notions of health. This focus on weight has been embedded in medicine for decades, but it has been embedded in society for much longer. In “Fearing the Black Body: The Racial Origins of Fat Phobia,” sociologist Sabrina Strings writes “…the current anti-fat bias in the United States and much of the West was not born in the medical field. The scientific racial literature since at least the 18th century has claimed that fatness was ‘wild’ and ‘black.’
What does this mean for patients with fatty bodies? (I’m using “fat” as a neutral descriptor, like “short” or “tall”). It means they are more likely to be harmed at the hands of the health care system. As Marquisele Mercedes, a doctoral student at the Brown University School of Public Health, writes in her article: “Without health, without care: the great legal loophole in the Hippocratic Oath”, in the online magazine Pipe Wrench, “For more than 60 years, doctors and researchers have probably harmed and killed millions of fat people through their insistence on the social and scientific mandates for thinness and that ob* sity is a disease that requires intervention, despite the existence of evidence that says this is wrong.
Research is clear that anti-fat bias is common among doctors and other health care providers. So what contributes to the perpetuation of weight-centrism in health care and the health inequities that come with it? It’s multifactorial, said Lisa Erlanger, a family physician and clinical professor of family medicine at the University of Washington School of Medicine.
“I deeply believe that most physicians really do intend to provide care that helps their patients, and we are people, too,” Erlanger said. “We are immersed in the diet culture that permeates every corner of society. But we are also a group of privileged people in general.” She said the doctors are more likely to be white and come from a higher socioeconomic background, and they are also likely to be taller, more conventionally attractive, and have at least relatively smaller bodies. His lived experience is not applicable to patients who have very different bodies and backgrounds.
As for what is taught in medical school, Erlanger points to the multi-billion dollar (and growing) diet/weight cycling/medical obesity industry. (Why “weight cycles”? Because most people who lose weight gain it back and repeat the cycle…repeatedly.) of treatments for that disease,” he said. “As a medical community, we have accepted much poorer evidence for weight-loss surgery and weight-loss drugs than for anything else. The reason we accept that is in part because we have been slowly conditioned to accept more and more outrageous ‘science’ from this industry and because we are predisposed to believe it because of the dietary culture we live in.”
Speaker, researcher and writer Ragen Chastain (his newsletter Substack “Weight and Health” is a must read) said the industry’s successful combination of “health” with “weight” and “health care” with “weight loss” diets has been codified into the college curriculum. medicine. “The weight-centric paradigm and the inequalities it creates have led to a health care system that is myopically focused on making fat people lose weight,” Chastain said. “This means that not only do they not support our health, but they often harm it.” She said this is despite research showing that weight-neutral health care strategies (supporting patients’ health at their current weight) provide greater benefit with less risk than pursuing weight loss. .
“Being smaller makes life easier in many ways, but that’s because of our fat-phobic cultural and medical society, not because being smaller makes life healthier and better,” Erlanger said, though the The idea that smaller is better is reinforced because hunger: Consuming fewer calories than necessary to maintain weight and bodily functions initiates a cascade of changes, including lowering blood pressure and blood sugar and increasing of the stress hormone cortisol, which has feel-good numbing effects. “It’s not sustainable to deprive a body of the calories it needs, so those benefits are not sustainable.”
Worse yet, the anti-fat bias in medicine contributes to poorer health. “They are people with larger bodies who delay or avoid preventive care and follow-up care. They are the people who end activities that could improve their well-being, such as movement, better sleep, dietary changes, because they do not result in the promised weight loss. They are misdiagnoses in fat people and in smaller people because we associate size with health,” Erlanger said. This creates more health inequities, he said, and then those inequities are attributed to larger-bodied people rather than weight-stigma-based care. It is a vicious circle.
“We know how short doctor visits are, and we know that if we’re focused on weight loss, we have to make compromises in how we spend our time,” Erlanger said. “Do we think that the other things we would do are so unimportant? We’re keeping people with bigger bodies from getting all that other evidence-based care.” Additionally, he said it’s demoralizing to talk to people about losing weight when it can’t be achieved in a safe and sustainable way. “We bang our heads against the wall and are taught to blame the patients. That is not why we are in medicine. We are in medicine to deliver treatments that work, and a weight-centric system can never deliver that.”
Next week: how doctors can move forward to be “weight inclusive” and how patients can advocate for themselves.
