Weight stigma, also known as weight bias, is the discrimination, stereotyping, and social exclusion based on a person’s weight. Fat people experience prejudice, verbal harassment, and poor treatment within a multitude of settings. Weight stigma shows up in school, at work, in public spaces, at home and in health care. Weight stigma impacts fat people everywhere they go and this discrimination based on body size leads to poorer physical and mental health outcomes.
Note: While the term “fat” has historically been used as a slur, there is a movement to reclaim the term as a neutral, and even positive, descriptor. I recently read some criticism of the phrase “larger body” (which I have used in the past) and so am using the term “fat” in this post as a neutral descriptor of body size.
Stereotyping fat people and making assumptions about health based on body size is common in health care. There are many factors that impact health and focusing on weight as an indicator of health does more harm than good.
A weight-centric approach to health is steeped in weight stigma which is a recipe for disordered eating, chronic stress, poor body image, and weight cycling.
Where Does Weight Stigma Come From?
There are a few theories about the origins of weight stigma:
Weight as an indicator of health
Our culture moralizes the pursuit of health, passing judgment when someone doesn’t fit our definition of health or doesn’t devote a lot of time or money toward their health. We incorrectly assume that fat bodies are unhealthy bodies solely because of their size.
There is a common and misinformed belief that someone’s size is within their control. Many people believe it is someone’s responsibility, and even a moral imperative, to lose weight if they are fat.
In her book The Beauty Myth: How Images of Beauty Are Used Against Women, Naomi Wolf examines the history of American beauty ideals, which teach women that thin is beautiful. This constant focus on size and pursuit of weight loss hinders women’s ability to compete with men economically and politically.
In her book Fearing the Black Body: The Racial Origins of Fat Phobia, Sabrina Strings, PhD, demonstrates how fatness has been racialized starting more than 200 years ago and has been used as an instrument of prejudice.
How Weight Stigma Shows Up in Health Care
Envision going to a health care appointment as a fat person. You walk into the waiting room and you don’t see any chairs that can comfortably or even safely hold you. You see anti-fat literature promoting weight loss. When you’re called for your appointment, you’re first led to a scale to get weighed. When you get into the exam room, and the nurse goes to take your blood pressure, the cuff is too small for your arm and the nurse has to dig around for a few minutes to find one that fits. Finally the doctor enters the room and the first thing they mention is your body mass index and that you “really need to lose some weight.”
Both the health care setting and health care providers contribute to weight stigma. Research shows that there is a significant divide between how providers treat thin individuals versus fat individuals:
- Providers often make assumptions about a patient’s lifestyle behaviors based on their body size
- Providers bring up a fat patient’s weight even when the appointment has nothing to do with body size
- When providers encounter fat patients, communication is often less patient-centered and more time is spent lecturing versus listening
- Providers spend less time with fat patients
- Providers tend to assume that fat patients are lazy
- Fat patients are less likely to be referred for diagnostic testing which delays diagnoses which then contributes to worsening health
Consequences of Weight Stigma in Health Care
When we judge a person based on their body size, we break trust as providers. Research has found that when patients experience weight stigma in health care, they are more likely to avoid or delay medical care and are less likely to adhere to recommendations from the provider.
Weight stigma also tends to discourage folks from engaging in health-promoting behaviors. Contrary to what some may believe, shame is not a motivator for self-care and healthy lifestyle behaviors.
Experiencing weight stigma is extremely stressful and starts a cascade of events. Elevated stress hormones can lead to chronic inflammation which can lead to chronic disease. People who experience weight stigma have a greater risk of death. The reality is the higher health risks we see in fat people are not necessarily a reflection of their weight. They are a reflection of the weight stigma they experience.
People who experience weight stigma are also more likely to suffer from a mood, anxiety, or eating disorder.
The “O” Words are Stigmatizing
There is no evidence that self-perceived weight status leads to sustained weight loss. In other words, simply telling people they are *verweight or *bese doesn’t do anything positive (but it does contribute to weight stigma). Even if weight loss was the goal, telling people how *verweight they are doesn’t actually help them lose weight.
Fat people already know they’re fat. Perceiving oneself as *verweight, no matter their actual weight, leads to negative health outcomes (including unhealthy weight control behaviors and disordered eating). When providers assign these labels, it creates a heightened awareness that leads to stress, poor body image, and shame.
And, when providers automatically see fatness as sickness (which is the case when *besity is a medical diagnosis), they ultimately treat fat patients worse, perpetuating weight stigma and harming fat peoples’ health.
Please read this important piece on medical fatphobia from fat stigma scholar Marquisele Mercedes.
What Really Impacts Health
Contrary to popular belief and oversimplified research, there is little evidence to suggest that higher weight itself causes poor health. When research takes weight stigma and lifestyle behaviors into account, the link between higher weight and worsening health tends to disappear or become much weaker.
One study found that engaging in healthy lifestyle habits (specifically: eating 5 or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking) was associated with significantly decreased mortality no matter someone’s body mass index. The adoption of each additional healthy habit decreased all-cause mortality between 29% and 85%.
The takeaway: Behaviors impact health much more than weight. People of all body sizes can improve health without seeking weight loss.
That being said, what determines health extends far beyond our individual behaviors. Health is largely impacted by a combination of factors including social, physical, and economic determinants. These factors are largely out of an individual’s control and include:
- Availability of affordable and safe housing
- Access to affordable health care
- Access to nourishing food
- Environmental quality (air, water, soil)
- Exposure to crime and violence
- Living conditions
- Racism and discrimination
- Working environment
- Access to academic and economic opportunities
How Health Care Providers Can Combat Weight Stigma
If you’re a health care provider, there are some key ways you can combat weight stigma at work. And if you’re not a health care provider, consider asking your clinicians about these items and advocating for more size-inclusive care (especially if you’re thin – use that privilege for good!).
- Listen to fat patients and treat them with respect
- Do not jump to conclusions about a patient’s health just because they are fat
- Provide comfortable, safe seating for fat people
- Purchase equipment and gowns that can fit all body sizes
- Learn about Health At Every Size® (HAES) and how to provide equitable care to fat folks (research indicates a HAES approach improves both physical and mental health)
- Create a mission statement conveying that all body sizes are welcomed and valued
- Provide weight-inclusive literature and use photos of diverse bodies
- Reduce frequency of weighing and ask for consent before weighing
- Focus on the reason for the visit, rather than the patient’s weight
- Focus on behaviors related to the problem (remember: weight is not a behavior)
- Ask for consent before discussing weight or offering advice
- Provide referrals to behavioral health professionals and registered dietitians
Nervous about approaching your doctor about this? That’s understandable. Check out these helpful resources from Ragen Chastain for talking to your health care providers and advocating for weight-inclusive care.