I recently stumbled across a blog called First, do no harm. It’s an unassuming website that you could easily dismiss. But scrolling through the pages, it describes the harrowing discrimination that overweight and obese individuals face when visiting their health professionals. One writer described how a colleague was praised for losing a large amount of weight. It turns out the cause of her weight loss was actually a deadly form of cancer. Another woman describes how after being in a car accident and admitted to the emergency room, a doctor said that her abdominal swelling was just because she was obese. She nearly died as a result.
The more I searched, the more I realised this issue wasn’t isolated to a handful of anonymous individuals. Thousands of people at home around the world have shared their stories online. Health professionals have admitted their wrongdoings, speaking out online about their struggles to overcome weight-related bias in their practice. Scientific journal articles have been published looking at the issue of weight bias and stigma by health professionals. With the enormity of the issue and the recent spike of obesity rates, it bares the question: why aren’t we talking more about weight bias and stigma in healthcare?
Before we delve into the issue, it is important to define the terms ‘weight bias’ and ‘weight stigma’.
The Canadian Obesity Network explains that weight bias and weight stigma are two very different things. Their website states that weight bias is “the negative stereotyping of individuals living with obesity”. Whereas weight stigma, or weight-based discrimination, is “the unfair treatment that people with obesity face”.
Fiona Sutherland, a dietitian and Co-Founder of Body Positive Australia, explained that sometimes the two terms are used interchangeably even though they have very different meanings. “We use the terms interchangeably, and they are not really interchangeable” said Ms Sutherland. “Bias is when you hold ideas which are leaning towards prescribing meaning to certain things” said Ms Sutherland. “Stigma is the way in which bias is enacted in practice”.
An audio clip from an interview with Fiona Sutherland (Source: Rachel Ben-David)
In other words, weight bias is the thoughts that an individual has to a person living in a bigger body. Weight stigma is when you act on those thoughts, often in a hurtful and harmful way.
Weight bias and stigma most commonly affect those who don’t fit the stereotypical perception of ‘health’. Usually, it’s those who are living in bigger bodies, who most health professionals would describe as ‘overweight’ or ‘obese’. Vulnerable individuals, such as those from minority groups and those of a lower socioeconomic status are more likely to be affected.
Why does weight stigma exist?
We live in a world where smaller, thinner, lighter bodies are perceived to be better (whether that is true is a whole other can of worms). This is not only from a health perspective, but through television, magazines and social media. We live in a culture where people in bigger bodies are openly criticised and condemned because of the way that they look.
Weight bias is a socially acceptable prejudice.
“Weight stigma outside the healthcare setting is everywhere” said Sutherland. “But it’s everywhere inside the profession too”.
Fiona Willer, a PhD candidate, author and educator at the Queensland University of Technology, agrees that weight stigmatisation is an issue for both society and health professionals. “It’s a cultural problem that has overflowed into health” says Ms Willer.
And that’s where the problem lies. If health professional are holding bias and stigmatising patients living in larger bodies, then their treatment might be compromised.
Unfortunately, this is a regular occurrence.
Everyone that I interviewed for this article has a horror story about their experience with weight stigma.
In her practice at Body Positive Australia, Ms Sutherland specialises in eating behaviour. She often sees patients who have experienced weight-based discrimination. Sutherland sighs, “I could literally give you a hundred examples”. She proceeds to tell me the story of how one of her clients avoided having a pap smear for eight years because her doctor made her feel so ashamed of her body. Another one of her patients went to see their GP for a rash on their arm and left with a weight loss diet. “The rash was from gardening”, Sutherland explained.
Sarah Davidson, a mother of three from Melbourne, was told by her GP that she “just needed to have a bit of self restraint” in her bid to lose weight. Thankfully, Sarah ditched that GP and found someone who looked beyond her weight. As it turns out, it was her thyroid causing the weight gain.
Then there is Izzy Lomax-Sawyers, a blogger and medical student from Dunedin, New Zealand. She went to see a GP for anxiety and received a lecture about her weight.
“I stopped seeing one GP who told me I was going to die in ten years if I didn’t lose weight… I went to see him for anxiety” said Lomax-Sawyers. Not only that, but when she sought treatment from another GP at the same practice, she was sent a news article on on how it’s not possible to be fat and fit. “It was an interesting choice that she [the GP] made”, laughs Lomax-Sawyers, “and now with a reasonable amount of clinical experience, I really struggle to [see how it could be justified]”.
Health professionals who enact weight stigma are putting their patients at risk. These people are receiving a lower quality of healthcare than they deserve, and those health professionals are not meeting their duty of care. It can be fatal.
Willer highlighted that there are severe consequences for people that are stigmatised by their health professionals. “We know that people in bigger bodies aren’t as engaged in preventative healthcare, like going to get their screenings and so forth” said Willer, “which is even sadder because people in larger bodies, statistically, are at a high risk of things. But, the way that we are treating them drives them away from having those things picked up early enough to get proper treatment”.
“Then of course they delay treatment, and finally present again when things are really bad… And then it’s too late”.
“We are going to treat you so that you don’t come and see us, delay diagnosis so your illness is further along than it had to be be, then we’re not going to treat you effectively and we are going to blame your death on your weight. It’s incredibly bad” – Fiona Willer
Sutherland agrees, “Bias often stops us asking the right questions, and we often jump to conclusions and make incorrect assumptions about people, their lifestyle and history. People feel like they can’t access good health care because every time they go to a doctor or specialist they are told about their weight”.
We need to change, and we need to change now.
Obesity is on the rise, and showing no signs of slowing. Our health professionals need to recognise that weight bias and stigma are serious issues. Our doctors, dentists and dietitians need to know that by discriminating against these people, they are putting their health at risk.
So what can we do to stop weight stigma?
Willer, an outspoken supporter of the Healthy At Every Size (HAES) movement, believes that we need to stop focusing on weight and start focusing on health.
“To really reduce weight bias we need to truly accept that people come in all shapes and sizes, and acceptance truly means that we’re no longer trying to change that” said Willer. “Weight bias can’t be diminished in our culture until we accept people the way they are”.
Lomax-Sawyers agrees, noting that change needs to come from governments and policy makers.
“At the public policy level, some of these assumptions need to be changed” said Lomax-Sawyers. “At a population level, how we communicate health promotion messages, when it comes to weight bias, actually needs to be challenged quite seriously”.
So why aren’t we talking more about weight bias and stigma in healthcare?
Well, the truth is that we are. There are websites like First, do no harm filled with story after story. There are Facebook pages and Twitter treads with comment after comment describing horrible experiences. There are professionals like Fiona Willer and Fiona Sutherland speaking out against the status quo. And brave individuals like Izzy Lomax-Sawyers and Sarah Davidson sharing their own experiences.
The real problem with weight bias and stigma is that we aren’t listening.
Erica Manser: A real life example of the dangers of weight stigma
On a sunny Autumn day, I packed up the car and drove down to Geelong, one hour South-West of Melbourne. I was meeting Erica Manser, a local nurse and nutrition student who had reached out to me on social media to share her weight stigma story.
“I’m in red and black” texted Erica about ten minutes before we were scheduled to meet. “You can’t miss me”.
Erica is a born and bred Geelong local. Just like her clothes, Erica’s colourful character shines through the busy cafe. She has a warm personality and an air of familiarity to her. It feels like I am catching up with an old friend.
As we chatted over coffee, Erica told me about her weight loss story; how she had struggled over the years with her weight and how she was stigmatised by friends, colleagues and health professionals. Eventually Erica chose to have bariatric surgery, undertaking a gastric sleeve operation in 2015. She was a confident speaker, and even in the noisy cafe I could hear her over the whirring of the coffee machine and the chatter of other customers.
Unlike most people affected by weight stigma, Erica has seen both sides of the story. She has experienced the discrimination from her own doctors and seen first-hand how health professionals in her workplace enact bias and stigmatise patients. Even as a registered nurse, Erica has been treated differently because of her weight.
“I’m treated differently by the doctors now that I’m thin” said Erica. “I’m not sure how to describe it. Is it a look on their face? Is it how they respond to me? It’s definitely different”.
But, it’s not only the doctors who discriminate. We know from research that nurses, dietitians, physiotherapists, occupational therapists and many other health professionals have been found to hold biased views towards larger patients. Erica sees this first-hand at her work.
“I have a colleague”, sighed Erica, “She’s very thin and has always been thin. One day she made a specific comment about a patient she saw, and she said ‘how could you allow yourself to get so big”. Erica tried to explain to her colleague that most people don’t want to be obese. You can tell this is a conversation that she has thought about having many times before.
Unfortunately, these experiences don’t even begin to scratch the surface of the horrible treatment that Erica herself has received over the years. Like many others I have spoken to, Erica can’t even recall the first time that she was stigmatised by a health professional. She begins to tell me how, time after time, doctors focused on her weight, even if there were other underlying problems. She recounted that at one point “I didn’t feel safe [going to the doctor]”.
But, when it came to talking about about one particular experience with weight stigma, Erica’s demeanour changed. She sat back in her chair, crossing her arms and lowering her voice. “I don’t think ill get emotional” she said quietly. You could tell that sharing this experience brought back negative memories. And so it should.
During one of her pregnancies, Erica had a doctor who was so focused on her weight, that she believes he failed to provide her with proper medical care. She described how the doctor was encouraged her to stay physically active despite the fact that she should have been on bed rest due to medical complications.
An audio clip from an interview with Erica (Source: Rachel Ben-David)
“He was more concerned about my weight and movement” said Erica. “I understand that there was a risk of DVT [deep vein thrombosis]. But now, as a nurse, I know that we’ve got prophylaxis for that”.
Under the instructions of her doctor to keep moving, Erica went into early labour at 23 weeks and two days. Sadly, she lost the baby.
“That was probably one of the most dark recollections of being treated differently” said Erica.
Erica’s life has changed a lot since these experiences. She has found an “amazing GP”, who doesn’t discriminate against her. She is still working as a nurse but is also studying nutrition. “I want to help people” said Erica. She wants to give people living in bigger bodies better support than she received. You can tell that she is going to change people’s lives for the better.
When looking back on her experiences with weight stigma, it is clear that her past experiences still have an effect on her. “It’s probably had long-term effects” says Erica. “It’s sometimes still a mental battle to see [a doctor]because of how I was treated”.
We need to work with our health professionals to stop this acceptable prejudice.
If Erica’s experiences don’t show why we need to stop weight-based discrimination, then I don’t know what will.