The ideal future is one in which healthcare equality exists. Health equity involves fair opportunities for everyone, regardless of demographics, to achieve optimal health and wellness. As the goal of healthcare is to help the public stay healthy, one would assume health equity would be attainable. However, insidious biases still pervade the healthcare system which makes this philosophy unachievable.
The CDC describes health equity as the advancement of healthcare for those who have historically faced and currently face stereotyping and injustices. These injustices are described as avoidable, and the system strives to close gaps in healthcare accessibility for these marginalized groups.
The CDC found that obesity affected 41.9% of adults from 2017 to 2020. This means that the majority of the U.S. population is categorized as overweight or obese by the CDC — and this majority may be on the receiving end of anti-fat bias because of the way weight is unduly associated with unhealthiness.
Understanding anti-fatness
Anti-fatness is defined as the implicit or explicit bias against people who are deemed overweight. It is rooted in Western culture’s stigmatization of being fat, often with the blame for “moral failing” being placed on the person who is overweight.
Whether it is a conscious or unconscious bias, anti-fatness is a societal viewpoint that is deeply ingrained into media and daily life. The anti-fat bias oppresses most of the U.S. population and extends to the healthcare system.
About calling it “fatphobia”
“Fatphobia” is another term for anti-fatness that’s popularly used in the public discourse on the topic. However, there are conceptual failures around calling anti-fatness “fatphobia.” Fat activists don’t use “fatphobia” to describe the categorically egregious treatment of people who are overweight. While it is a layman’s term that most can understand, it erases the true meaning of being anti-fat by associating this discrimination with fear.
The suffix “-phobia” leads people to interpret fatphobia as an irrational fear of fat. This can mean many things, but it does not cover the actual motivation behind most discriminatory acts toward this group of people.
Stereotypes and stigma surrounding fatness
Instead, “anti-fatness” and “anti-fat bias” encompass the marginalizing, oppressive behaviors that happen as a result of stereotypical beliefs about being fat. Weight stigma can include:
- Lack of willpower;
- Laziness;
- Diminished morals;
- Poor hygiene;
- Low intelligence levels;
- Unattractiveness.
These beliefs find their beginnings and perpetuation in a whole array of areas. Media like TV shows and movies depict overweight characters as lazy or the butt of the joke.
Anti-fatness can even be seen in educational settings — students with obesity are less likely to obtain higher education and more likely to be targeted negatively by their peers and teachers. Workplaces have been known to put overweight employees in non-customer-facing roles and are less likely to advance them up the ranks.
Finally, anti-fatness is perpetuated in healthcare — with providers behaving inappropriately toward overweight patients and prioritizing their “normal-” and underweight counterparts.
Fat and health: Misconceptions
One of the most common misconceptions about people who are fat is that they are also unhealthy. This is not always the case. Of course, fatness can coexist with unhealthiness. However, each factor, alone, is not inherently indicative of the other. To achieve health equity, health providers, patients, and the general public need to understand that health and weight aren’t always connected.
Although being overweight or obese may increase your risk of developing certain diseases, there are often extraneous caveats patients and healthcare providers should be aware of.
Eating habits
Anti-fat biases lead people to assume that overweight people must have poor eating habits in comparison to their counterparts with smaller figures. However, the ways in which people eat don’t always match outward appearances. For example, someone with a smaller body type may eat high-calorie, fatty foods without affecting their outward appearance, but they may develop an “invisible illness” such as high cholesterol or diabetes.
On the other hand, people who are overweight may eat healthy, balanced meals but experience weight fluctuations due to medications or underlying diseases like thyroid problems.
Cardiometabolic health
It’s typically assumed that excess weight puts strain on a person’s heart and metabolic processes, presumably leading to a whole host of cardiometabolic disorders.
Cardiometabolic diseases can include issues like heart attacks, strokes, diabetes, and fatty liver disease. The results of a thorough study analysis of 177,792 participants uncovered that body fat — but not body weight — was positively correlated with a higher risk of cardiometabolic disease.
Therefore, someone with a lower weight and body mass index (BMI) may not appear stereotypically fat, but they could be at higher risk of developing these diseases than someone with a higher weight and BMI.
BMI: A deeply flawed measurement
The CDC touts BMI as a “reliable indicator of body fatness for most people.” However, BMI is still hotly contested in regard to its accuracy. In its simplest form, BMI can be calculated by dividing a person’s weight by the square of their height. Modern interpretations also take age and sex into consideration.
Developed in the 1800s by Adolphe Quetelet, BMI has a controversial history. It was created based on data drawn exclusively from Western European men and has not been accurately updated to reflect differences in race, ethnic groups, gender, sex, or age. The American Medical Association (AMA) has released a clarification of BMI’s use as of 2023 that acknowledges these shortcomings, but its indoctrination into the healthcare system is far-reaching and has already caused widespread issues related to anti-fatness.
Further, the creator explicitly stated that it cannot and should not be used to indicate the level of fatness in an individual. However, that’s exactly what the CDC says it is a reliable indicator of. Instead, it is used in almost every clinical setting up until today, regardless of its lack of evidence to support its long-term benefits for health outcomes related to morbidity.
In reality, BMI use has perpetuated weight-related discrimination. The measurement fails to account for the relative proportion of bone, muscle, and fat in the body. This means that a person with a higher weight will always have a higher BMI, regardless of whether or not they have excess fat in their body. Some studies have even provided evidence that low muscle mass is a better indicator of health risks.
In turn, using BMI as a measure of fatness and relative health status miscategorizes many people, which may affect their overall treatment at healthcare facilities.
Bariatric surgeries
Healthcare providers shouldn’t treat patients by solely looking at their BMI and outward appearance. Instead, each patient should be treated equally, catering to their conditions and actual health status. Instead, different interventions are suggested for patients to lose weight. Bariatric surgery is one such intervention.
There are several types of bariatric surgeries, including gastric sleeve, gastric bypass, gastric banding, and biliopancreatic diversion with a duodenal switch. Broadly speaking, they all serve the same purpose: to reduce the effective size of the stomach to help facilitate weight loss. This action may also indirectly improve a variety of comorbid health conditions such as:
- Heart disease;
- Sleep apnea;
- High blood pressure;
- High blood sugar;
- High cholesterol;
- Non-alcohol-related fatty liver disease;
- Type 2 diabetes;
- Asthma;
- Urinary incontinence;
- Kidney disease.
The procedures themselves are minimally invasive and carry a low risk if done by a qualified bariatric surgeon. However, they can fail to produce the desired results or even cause complications. Comorbid conditions may not be adequately addressed, particularly if bariatric surgery is suggested for weight loss alone.
Post-procedure complications
Some risks of undergoing bariatric surgery include:
- Acid reflux;
- Anesthesia-related issues;
- Esophagus dilation;
- Inability to tolerate certain foods;
- Infection;
- Internal bleeding;
- Nausea and vomiting;
- Organ injury;
- Stomach obstruction;
- Weight gain or failure to lose weight.
Patients are not guaranteed to lose weight after bariatric surgery. It can also lead to long-term issues like:
- Blood clots;
- Bowel obstruction;
- Dumping syndrome;
- Hernias;
- Gallstones;
- Low blood sugar;
- Malnutrition;
- Ulcers;
- Vitamin deficiency.
This isn’t an all-inclusive list, and it is recommended for patients to ingrain healthy habits before and after the surgery in their routine to minimize risks and help them achieve their desired results.
Examples of anti-fat bias in healthcare
Historically, research has shown a clear anti-fat bias in healthcare providers. Patients have reported being told to lose weight at every doctor appointment — even if their concerns have nothing to do with their weight. This leads to overweight patients being less likely to engage with providers for fear of mistreatment and judgment.
Medical education perpetuates the weight stigma by providing minimal instruction on obesity and touting unhelpful mantras like “calories in, calories out.” This limited view fails to acknowledge the complexities of obesity and boils it down to the stereotypes that are harmful to the treatment of the majority of Americans — and few medical students are aware of their biases against fatness.
Discrimination in care
A scoping study analysis on anti-fat bias in providers revealed that between the years 2000 and 2017, the following themes occurred:
- Ambivalence;
- Assumptions about weight gain;
- Attribution of all health issues to excess weight;
- Avoidance or delay of treatment;
- Barriers to healthcare utilization;
- Contemptuous, patronizing, and disrespectful treatment;
- The expectation of differential healthcare treatment;
- Increased “doctor shopping”;
- Lack of training;
- Low trust levels;
- Poor communication.
The negative treatment of fat patients by healthcare providers is correlated with their decreased ability and eagerness to seek further care.
Impacts of anti-fat bias on higher-weight patients
Heavier patients feel burdened by the pervasive anti-fat bias in healthcare — and rightfully so. The impacts on patients’ mental and physical wellness often have the potential to be quite detrimental.
Mental health
Perceived weight discrimination affects mental health, correlating significantly with higher rates of psychiatric disorders and overuse of substances. A bombardment of anti-fatness, especially in healthcare, can lead to internalized weight stigma. Feeling like society views you negatively due to your weight can lead to a whole host of psychological issues, such as:
- Anxiety;
- Depression;
- Disordered eating;
- Distorted body image;
- Low self-esteem;
- Reluctancy to access medical care.
It’s a vicious cycle in which the patient feels discriminated against, they internalize that judgment against their weight, and they slip into unhealthy habits that affect their mental health and ability to stay healthy.
Physiological effects
Even if a person who is overweight is also perfectly healthy to start with, healthcare can do them a disservice. Weight stigma stops heavier patients from being able to access proper care in one way or another, and this ultimately can result in:
- Increased blood pressure;
- Increased cortisol levels;
- Inflammation;
- Fat deposition.
Mental health issues can cause physical health issues, and vice versa. Further, disordered eating, aging, imbalanced sex hormones, and total body fat contribute to body fat distribution that leads to a greater risk of chronic disease and obesity-related comorbidities. In essence, obesity alone does not indicate a higher risk of physical issues, but anti-fatness in healthcare contributes to advancing the actual indicators of poor health.
Health at every size: Foundations for a new paradigm
Anti-fatness has infected the healthcare system for a long time and continues to seep into patient care and the psyche of patients and the public. Luckily, strides are being made to improve healthcare for heavier individuals. For example, the Association for Size Diversity and Health (ASDH) has put forth a program called Health at Every Size (HAES). It perpetuates the idea that health falls along a continuum. It is not black and white. It is ever-changing and not dependent on size at any given time.
The holistic approach of HAES includes the following principles:
- Weight inclusivity;
- Health enhancement;
- Eating for well-being;
- Respectful care;
- Life-enhancing movement.
This framework can be used by healthcare professionals and patients alike to bring forth a new and necessary perspective.
Core tenets
To push back against anti-fatness, patients are taking matters into their own hands through HAES ideology. HAES advocates stand up for themselves in their communities and spread the word that:
- Human bodies come in all shapes and sizes.
- Health extends beyond the physical — focus on boosting mental wellness.
- Eating and exercise aren’t solely about weight management.
- Your body knows what it needs — trust it.
Of course, healthcare officials and educators have their own responsibilities when it comes to HAES — mainly by changing how medical students are taught about weight-related topics. Providers should focus on opening their points of view and becoming aware of these biases, first and foremost. It may be challenging at first to find a provider who can overcome these deep-seated biases around weight. It may never happen. You have to be your own advocate to reap the benefits.
Health benefits
A HAES framework is the inherent belief that your health is your priority. This means advocating for yourself in and out of doctor’s offices. With these actions among others mentioned earlier, you can enjoy the following health benefits:
- Healthier relationships with food and exercise;
- Positive social and emotional health impacts;
- More respectful, purpose-driven medical care.
The more people that adopt this framework, the more change will occur — especially among perceptions of fatness.
Improving healthcare for higher-weight individuals
Healthcare institutions and paradigms must recognize that there is much room for improvement when caring for higher-weight patients. A peer-reviewed discussion on policy in the AMA Journal of Ethics outlines five ways in which healthcare can improve for fat people. In summary, these include:
- Acknowledging the diversity in weight amongst the human race.
- Recognizing fat people as a community that has faced systemic oppression.
- Representing fat people in leadership and decision-making positions.
- Providing inclusive healthcare equipment and spaces that can accommodate all sizes and weights.
- Avoiding recommendation of weight-loss surgeries without cause beyond societal pressures.
Recognizing the importance of compassionate and inclusive care should be the first step. Healthcare professionals can at times lack the social and interpersonal skills necessary to provide adequate care. This is something that needs to be addressed in addition to the overall recognition of anti-fat biases. Further, it must be acknowledged that, while correlated, weight is not the only cause of most illnesses and patients should be examined more closely to determine effective treatment plans.
Promoting body positivity and health equity
Although holistic health for all seems like the obvious choice, body-positive groups and movements need to lobby for this change. Start by incorporating ideas from these groups into your daily habits, like intuitive eating and moving your body for wellness instead of aesthetics. With patience and resilience, the healthcare system can improve to be inclusive of all shapes, sizes, and weights. For the health of the public, it must.