A major component that is missing from this conversation is racism. I have never had a black doctor and my experience and treatment by doctors as a black woman has been horrific. I have completely normal test results by all measurements except one - I am fat. But at every physical, or when I break a bone or have a rash or just want to check on something, every doctor has to go on and on about my weight. Moreover, you would be shocked at the things doctors say to black women.
When I was pregnant, I had to switch ob/gyn because my first one was downright abusive to me. I gained a total of 15 pounds my entire pregnantcy and this doctor would not stop talking about my weight. She almost ruined what was a completely average, normal uncomplicated pregnancy with her comments. Not to mention her assumptions about my birth control and my lifestyle, that were extremely racist. I'm a lawyer, happily married and it was my first child, but she assumed I was, well you know what she thought.
My point is that the BMI is racist. Fatphobia is racist. We have seen different, negative outcomes for black women with similar conditions as white women due to medical racism. We need doctors to learn more about how their racial bias is affecting their practice of medicine with BOTH black women and fat people.
Thank you for exploring this issue, I'm not at all intending this to be a cudgel or gotcha, I just think race is an important part of this conversation.
Doctors think they are being "scientific" when it really is fat phobia. For several years I lived with a horrible flare of ulcerative colitis. 3 years of undiagnosed and untreated disease, massive blood loss, loss of bowel control, constant diarrhea. But I was fat, so despite my textbook symptoms they were all ignored, no need for diagnostic tests, they decided I couldn't have UC or CD because I was fat. I was 175 at the time. After months of hospitalization, IV prednisone, and a total colectomy my joint pain was blamed on my obesity. That SAME obesity that saved my life during my final UC flare. I'd lost 30 pounds in a month. Ignoring the prednisone use it took months to get a diagnosis of Avascular Necrosis in many joints - all from the IV steroids, the excruciating pain had NOTHING to do with my body size. I was 160 and looked hollowed out. My CKD was blamed on type two diabetes, which was blamed on obesity. Even though I had NO protein in my urine. It took 3 years of testing for me to convince the many doctors that my CKD was from long-term dehydration from 30 years of living with a high output ileostomy. At 224 I was deemed too fat to live and denied a spot on the kidney transplant list until I lost weight. I'm down to 170, and finally got on the list, but I'm still obese and 2 of the 3 transplant programs in my state still won't accept me. The irony is that an underweight person would have no trouble getting listed. Even though they are MUCH less likely to survive dialysis and transplant. Study after study shows people who are overweight and at the low end of obese survive longer with CKD and have better outcomes from both dialysis and transplant. There is NO science showing obese folks would waste a kidney. It's based on bigotry, not science. Especially at my weight. I'm treated the same way someone who is 2000 pounds. Once I got CKD I found an endocrinologist. He was the FIRST Dr. to blame my genetics, my insulin resistance, my metabolism for my T2D. Obesity didn't give me T2D. T2D, especially after starting insulin, made me obese. He openly told me that as a post menopaused, insulin dependent person I would have to get off the insulin and eat less than 800 calories a day to lose weight. He also openly admitted that exercise will not lead to weight loss. I still go to the YMCA 5 nights a week for several hours, but that is more about showing compliance, than actually impacting my weight. The transplant folks demand compliance to stay on the list. Study after study shows obesity doesn't cause T2D. T2D causes obesity. Yet very rarely do Dr. follow the science. They follow the culture. I HATE urgent care. They blame absolutely everything on my weight. Small bowel blockage - must be because you are fat and you must have overeaten. Not because of the 6 abdominal surgeries and multiple adhesions and strictures. I got 2 cavities, must be caused by eating candy all day. HA! 61 years of being fat = 61 years of crappy medical treatment.
Thank you so much for this! As a dietitian I always say that when we get our degrees in the health field, we get degrees in diet culture and fatphobia. We have to do the work to undo this.
Doctors and nurses (and other medical personnel) tend to have big egos about their jobs and need to be able to distance themselves from the pain of their patients. The latter while necessary and understandable can make some people cold and reinforce bias especially because they aren’t tapping into compassion or empathy. Add onto this a society, especially in the U.S. that makes these jobs both God-like but also randomly in need of defense. So we have a culture that isn’t particularly scientifically literate and thinks doctors are paid too much because other people are paid too little, and nurses are often coded as “subpar” doctors, well, who wouldn’t have a chip on their shoulder! But the problem is that fat people, particularly fat Black people have to deal with this most and most egregiously. Because of all this we don’t have a true service model around healthcare. We have multiple layers of medical, financial and institutional (like insurance companies and hospital policy) that gatekeep access often based on stereotypes and stigma.
Thanks for a great post. Have really been enjoying your writing. I found you via Burnt Toast, and as a family nurse practitioner that does primary care, feel so deeply so much of what you write. Happy to be following your journey and knowing there are other likeminded providers out there.
So happy to be in community with you, Rachel! If you're interested, please consider joining https://weightinclusivemedicine.org/ -- we have a WhatsApp group and it's really nice to be in touch with like-minded clinicians.
Such a great, thought provoking article. I also wonder how - or if - the medicalization of obesity comes into play. There is an irony here. Medicalization is generally thought to reduce stigmatization by reducing individual blame/responsibility. Clearly this isn’t the case for obesity or having a BMI of a certain level. Why?
I think the reasons you pose make a lot of sense; I also wonder if the age-old recommendation “eat les move more” confounds the stigma reduction elements. If we individualize medical responsibility can we ever escape the snare of stigma?
Also, if physicians are taught that obesity is an illness with myriad related health conditions, do they believe they are acting beneficently by “counseling” patients? And if so, how can/should medical educators counteract those beliefs in ways that can create space for practitioners to provide care that is supportive and meaningful to patients?
More questions than answers here. Thanks for getting/keeping the conversation going!
Great questions. I really do think most doctors genuinely believe they acting beneficently. But there's such a disconnect between that sense doctors have of "I'm doing the right thing" and patients experiences of that counseling.
However, we need more rigorous definitions of maleficence than simply "patients don't like it." (Although that might be a reasonable definition? Is it doing harm to do something patients self-report as harmful?)
That's where the inefficacy of weight counseling comes in -- not only do patients generally perceive it as harmful, there's really no evidence that it achieves desired outcomes, like reducing your risk of a heart attack or losing a limb due to diabetes. That seems like a pretty clear example of harm: patients report that it's harmful, and it doesn't lead to the desired beneficent outcomes.
This was a great read. When I started using the word "fat" to describe myself, it was a way of taking back my power at the word that had been used to hurt me over and over. I have a friend who worked very hard to lose weight in a healthy way and is a power lifter and she doesn't like that term at all, but she understands it. And I know it's because it makes her look at herself in a fat body, which only exists in her mind.
I would love to find more fat friendly providers. I'm 51 and between PCOS and early menopause, my body is mess, but not in a bad way. After all, I have perfect numbers and they love me for that. *sigh*
A major component that is missing from this conversation is racism. I have never had a black doctor and my experience and treatment by doctors as a black woman has been horrific. I have completely normal test results by all measurements except one - I am fat. But at every physical, or when I break a bone or have a rash or just want to check on something, every doctor has to go on and on about my weight. Moreover, you would be shocked at the things doctors say to black women.
When I was pregnant, I had to switch ob/gyn because my first one was downright abusive to me. I gained a total of 15 pounds my entire pregnantcy and this doctor would not stop talking about my weight. She almost ruined what was a completely average, normal uncomplicated pregnancy with her comments. Not to mention her assumptions about my birth control and my lifestyle, that were extremely racist. I'm a lawyer, happily married and it was my first child, but she assumed I was, well you know what she thought.
My point is that the BMI is racist. Fatphobia is racist. We have seen different, negative outcomes for black women with similar conditions as white women due to medical racism. We need doctors to learn more about how their racial bias is affecting their practice of medicine with BOTH black women and fat people.
Thank you for exploring this issue, I'm not at all intending this to be a cudgel or gotcha, I just think race is an important part of this conversation.
💯 thank you so much for sharing your experiences. We need to do better.
Doctors think they are being "scientific" when it really is fat phobia. For several years I lived with a horrible flare of ulcerative colitis. 3 years of undiagnosed and untreated disease, massive blood loss, loss of bowel control, constant diarrhea. But I was fat, so despite my textbook symptoms they were all ignored, no need for diagnostic tests, they decided I couldn't have UC or CD because I was fat. I was 175 at the time. After months of hospitalization, IV prednisone, and a total colectomy my joint pain was blamed on my obesity. That SAME obesity that saved my life during my final UC flare. I'd lost 30 pounds in a month. Ignoring the prednisone use it took months to get a diagnosis of Avascular Necrosis in many joints - all from the IV steroids, the excruciating pain had NOTHING to do with my body size. I was 160 and looked hollowed out. My CKD was blamed on type two diabetes, which was blamed on obesity. Even though I had NO protein in my urine. It took 3 years of testing for me to convince the many doctors that my CKD was from long-term dehydration from 30 years of living with a high output ileostomy. At 224 I was deemed too fat to live and denied a spot on the kidney transplant list until I lost weight. I'm down to 170, and finally got on the list, but I'm still obese and 2 of the 3 transplant programs in my state still won't accept me. The irony is that an underweight person would have no trouble getting listed. Even though they are MUCH less likely to survive dialysis and transplant. Study after study shows people who are overweight and at the low end of obese survive longer with CKD and have better outcomes from both dialysis and transplant. There is NO science showing obese folks would waste a kidney. It's based on bigotry, not science. Especially at my weight. I'm treated the same way someone who is 2000 pounds. Once I got CKD I found an endocrinologist. He was the FIRST Dr. to blame my genetics, my insulin resistance, my metabolism for my T2D. Obesity didn't give me T2D. T2D, especially after starting insulin, made me obese. He openly told me that as a post menopaused, insulin dependent person I would have to get off the insulin and eat less than 800 calories a day to lose weight. He also openly admitted that exercise will not lead to weight loss. I still go to the YMCA 5 nights a week for several hours, but that is more about showing compliance, than actually impacting my weight. The transplant folks demand compliance to stay on the list. Study after study shows obesity doesn't cause T2D. T2D causes obesity. Yet very rarely do Dr. follow the science. They follow the culture. I HATE urgent care. They blame absolutely everything on my weight. Small bowel blockage - must be because you are fat and you must have overeaten. Not because of the 6 abdominal surgeries and multiple adhesions and strictures. I got 2 cavities, must be caused by eating candy all day. HA! 61 years of being fat = 61 years of crappy medical treatment.
no one should have to go through all that. It's an indictment against the medical system.
Thank you so much for this! As a dietitian I always say that when we get our degrees in the health field, we get degrees in diet culture and fatphobia. We have to do the work to undo this.
Absolutely! I just subscribed to your newsletter -- so happy to be in community with you 😍
Doctors and nurses (and other medical personnel) tend to have big egos about their jobs and need to be able to distance themselves from the pain of their patients. The latter while necessary and understandable can make some people cold and reinforce bias especially because they aren’t tapping into compassion or empathy. Add onto this a society, especially in the U.S. that makes these jobs both God-like but also randomly in need of defense. So we have a culture that isn’t particularly scientifically literate and thinks doctors are paid too much because other people are paid too little, and nurses are often coded as “subpar” doctors, well, who wouldn’t have a chip on their shoulder! But the problem is that fat people, particularly fat Black people have to deal with this most and most egregiously. Because of all this we don’t have a true service model around healthcare. We have multiple layers of medical, financial and institutional (like insurance companies and hospital policy) that gatekeep access often based on stereotypes and stigma.
Thanks for a great post. Have really been enjoying your writing. I found you via Burnt Toast, and as a family nurse practitioner that does primary care, feel so deeply so much of what you write. Happy to be following your journey and knowing there are other likeminded providers out there.
So happy to be in community with you, Rachel! If you're interested, please consider joining https://weightinclusivemedicine.org/ -- we have a WhatsApp group and it's really nice to be in touch with like-minded clinicians.
Such a great, thought provoking article. I also wonder how - or if - the medicalization of obesity comes into play. There is an irony here. Medicalization is generally thought to reduce stigmatization by reducing individual blame/responsibility. Clearly this isn’t the case for obesity or having a BMI of a certain level. Why?
I think the reasons you pose make a lot of sense; I also wonder if the age-old recommendation “eat les move more” confounds the stigma reduction elements. If we individualize medical responsibility can we ever escape the snare of stigma?
Also, if physicians are taught that obesity is an illness with myriad related health conditions, do they believe they are acting beneficently by “counseling” patients? And if so, how can/should medical educators counteract those beliefs in ways that can create space for practitioners to provide care that is supportive and meaningful to patients?
More questions than answers here. Thanks for getting/keeping the conversation going!
Great questions. I really do think most doctors genuinely believe they acting beneficently. But there's such a disconnect between that sense doctors have of "I'm doing the right thing" and patients experiences of that counseling.
However, we need more rigorous definitions of maleficence than simply "patients don't like it." (Although that might be a reasonable definition? Is it doing harm to do something patients self-report as harmful?)
That's where the inefficacy of weight counseling comes in -- not only do patients generally perceive it as harmful, there's really no evidence that it achieves desired outcomes, like reducing your risk of a heart attack or losing a limb due to diabetes. That seems like a pretty clear example of harm: patients report that it's harmful, and it doesn't lead to the desired beneficent outcomes.
So much more to discuss!
Great article, thought provoking.
Thank you!
This was a great read. When I started using the word "fat" to describe myself, it was a way of taking back my power at the word that had been used to hurt me over and over. I have a friend who worked very hard to lose weight in a healthy way and is a power lifter and she doesn't like that term at all, but she understands it. And I know it's because it makes her look at herself in a fat body, which only exists in her mind.
I would love to find more fat friendly providers. I'm 51 and between PCOS and early menopause, my body is mess, but not in a bad way. After all, I have perfect numbers and they love me for that. *sigh*