By Jamie M. Marchetti, MS, RDN, LD
March 14, 2019
Beth was obese. She had been bigger her whole life, so this was not news as she reached her late-twenties. Beth ( her name has been changed to protect her privacy) was getting married and ready to start a family, so she went to her obstetrician/gynecologist to have her intrauterine device (IUD) removed and to discuss the implications of her polycystic ovarian syndrome (PCOS) on fertility. The doctor scoffed and stated, “I don’t know how we’re going to get it out. At your size, I’m not even sure how they managed to get the IUD into you.” Further, it was discovered that Beth had grapefruit-sized cysts on both ovaries, and the doctor told her that neither he nor any doctor would do surgery to remove the cysts given her body size. Beth was desperate, so through her hurt and anger, she chose a crash diet to follow, which resulted in acute renal failure within weeks. Heartbroken and at the end of her rope, Beth found herself crying in a dietitian’s office, convinced that the well-balanced diet she was already eating must be harming her since doctors insisted she must not be nourishing herself properly if she wasn’t losing weight. Beth explained that she was content with her body, but that she was tired of seeking medical care and being treated poorly because of her size.
Beth’s case is not unique, nor is it fabricated. Larger-bodied patients face weight stigma and discrimination consistently in health care, regardless of their actual health status.1 These patients tell stories of going to the doctor for sinus infection symptoms and being sent away with instructions to lose weight, or being told that rather than a balanced, heart-healthy diet, they must lose weight “or die.” The narrative underlying all of this is that thin bodies are “good” and healthy, and fat bodies are “bad” and unhealthy; that anyone in a fat body needs to be trying to make their body smaller; and that making it uncomfortable to exist in the world in a fat body is motivation to lose weight and be smaller. This is called weight stigma.
Weight stigma shows up in so many ways throughout our society that it’s nearly impossible to detect until it is called out. Size discrimination is ubiquitous to the point of being normalized. Some of these might sound familiar:1,2
- Being teased by peers because of your body size/shape
- Having close family or friends show or state embarrassment about your body size/shape
- People having low expectations because of your body size/shape
- Being excluded, ignored, avoided, attacked, or stared at because of body size/shape
- Being treated poorly by coworkers or not getting jobs/promotions because of body size/shape
- Pressures to lose weight/be thin
- Compliments about weight loss
- Comments from doctors about weight
- Confronting barriers and obstacles in the physical world, such as public seating being too small
Despite insistence that the “obesity epidemic” causes adverse health outcomes, recent research has illuminated the fact that weight stigma alone is more harmful to health than the weight itself.3,4,5 This happens in several ways. First, patients like Beth end up avoiding health care because they are tired of being told that the bodies they live in every day are “wrong.”6 The stress of weight stigma puts people at higher risk of anxiety and depression, eating disorders, low self-esteem, and increased body dissatisfaction.5,6,7 Further, although many thin-bodied people believe that various forms of weight stigma will prompt fat-bodied people to make behavior changes, weight stigma actually leads to lower rates of physical activity and, ironically, heightens the risk of obesity.8 If people do make unsustainable behavior changes, such as restrictive dieting and excessive exercising, and lose weight, they will almost certainly regain the weight they lost. They are then at additional health risk, as weight cycling—the repeated losing and regaining of weight—may actually explain excess heart risk seen in higher-BMI patients, and it also increases risk of chronic inflammation, osteoporosis, and subsequent fractures, gallstone attacks, and loss of muscle tissue.2,9
What do we, in health care, do about this? We implement and practice size inclusivity. Size inclusivity is accommodating bodies of all sizes and treating all patients as complete individuals. This better serves patients by helping to ensure correct diagnoses by avoiding assumptions that thin patients are healthy and fat patients are unhealthy; helping to reduce patient anxiety about seeking health care and receiving adequate care in a timely manner; and reduced risk of disordered eating and lowered stress responses to weight stigma. There are lots of ways to increase size inclusivity in health care:
- Create an environment that is welcoming and comfortable.
- Have wide chairs available in all seating areas, including some sturdy seats without arms
- Ensure that walkways are adequately wide
- Provide wide wheelchairs for patients with limited ambulation abilities
- Have equipment such as scales and blood pressure cuffs that accommodate larger bodies
- Use language that is accepting and inclusive.10
- Avoid terms such as “overweight,” “obese,” and “morbidly obese”—instead use phrases such as “larger body” and “body/weight changes” that are more neutral
- Remain neutral in discussion of body size/shape, even if the patient speaks negatively of themselves
- Ask the patient’s permission before discussing body size/shape rather than assuming the patient sees these as problematic
- Ask neutrally about food and exercise habits, and take care to trust the patient, rather than making assumptions about food and exercise, or that the patient is being untruthful
- Implement Health At Every Size ® principles throughout the office or practice.11
- Respect celebrates diversity of human bodies and all varying attributes therein, including age, sex, race, gender, size, ability, and others
- Critical awareness questions scientific and cultural assumptions, and tunes into the patient’s body’s knowledge and lived experiences
- Compassionate self-care invites body movement in a pleasurable manner and nourishing the body with foods that support health, enjoyment, response to body cues like hunger and fullness, and respect for an individual’s priorities about which foods they are able to access
While many people have trepidations around creating inclusiveness for larger bodies, the perception that barring larger bodies from public spaces encourages people to make their bodies smaller is a myth. What is more beneficial to supporting overall health for all body sizes is creating an environment in which all bodies are welcome and accepted, and treated as complete humans versus simply a problem to be solved. Begin promoting size-inclusivity by implementing the methods discussed here on an individual and practice-wide basis.
Earn CME credits in: Lifestyle Medicine: Nutrition and the Metabolic Syndrome
- Puhl RM, Brownell KD. Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults. Obesity. 2006;14(10):1802-1815.
- 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. [PDF] J Obes. 2014;2014:983495.
- Vadiveloo M, Mattei J. Perceived Weight Discrimination and 10-Year Risk of Allostatic Load Among US Adults. Ann Behav Med. 2017;51(1):94-104.
- Himmelstein MS, Incollingo Belsky AC, Tomiyama AJ. The Weight of Stigma: Cortisol Reactivity to Manipulated Weight Stigma. Obesity. 2015;23(2):368-374.
- Wu Y-K, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018;74(5):1030-1042.
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of Weight Bias and Stigma on Quality of Care and Outcomes for Patients with Obesity. Obes Rev. 2015;16(4):319-326.
- Jackson SE, Steptoe A. Association between perceived weight discrimination and physical activity: a population-based study among English middle-aged and older adults. BMJ Open. 2017;7(3):e014592.
- Puhl RM, Heuer CA. Obesity Stigma: Important Considerations for Public Health. Am J Public Health. 2010; 100(6): 1019-1028.
- Bacon L, Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J. 2011;10(1):9.
- University of Calgary. Inclusive Language Guide. 2017. https://www.ucalgary.ca/odepd/files/odepd/inclusive-language-guide-june-13-2017.pdf.
- ASDAH: HAES® Principles. https://www.sizediversityandhealth.org/content.asp?id=152.
Jamie M. Marchetti, MS, RDN, LD, is a Health At Every Size ® dietitian. She is also a freelance writer and a MA Mental Health Counseling candidate who plans to combine her skill sets to provide nutrition and body acceptance therapy through her private practice, Wonderfully Well.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.