Weight stigma is inextricable from larger problems of structural inequality and unequal access to healthcare. De-pathologising higher-weight bodies is essential for combating stigma and creating a more evidence-based, weight neutral paradigm.
Weight stigma and weight bias can harm patients and healthcare providers. Photo: Ragen Chastain
Within our healthcare system, weight stigma (and weight bias) harm patients and providers and, in cases like that of Ellen Maude Bennette, can be fatal. Fully eradicating weight stigma must be a healthcare and public health priority.
Types of weight stigma
In implicit weight bias, negative beliefs, assumptions, and stereotypes are subconscious. For example, a provider asks thin patients how much they exercise, but reflexively tells higher-weight patients to start exercising, subconsciously assuming they don’t. In explicit bias, the provider is aware of their negative beliefs and acts on them purposefully. Internalised bias occurs when higher-weight people absorb others’ negative beliefs about their own bodies, which can cause them to feel unworthy of care. Finally, structural stigma occurs when things that higher-weight people need—sturdy armless chairs, properly-sized blood pressure cuffs, research, best practices, durable medical equipment, imaging equipment etc.—are not accessible.
“The idea that higher weight is a disease to be cured by weight loss was and is primarily architected by the weight loss industry, which has grown into a multi-billion dollar business.”
These biases are deeply harmful, and they come from a place that is often not only unexamined, but also exacerbated by the weight loss industry: The pathologising of higher weight is, in and of itself, weight stigma. Consider the terms that are used: “overweight” clearly views higher-weight as wrong. The word “obese” comes from a Latin root that means “to eat oneself fat,” far more stereotype than science. The idea that higher weight is a disease to be cured by weight loss was and is primarily architected by the weight loss industry, which has grown into a multi-billion dollar business.
Still deeper, as scholars including Dr Sabrina Strings and Da’Shaun Harrison have explained, weight stigma, including the pathologising of higher-weight bodies, is rooted in, and inextricable from, racism and anti-Blackness. In just one example, the equation for the body mass index (BMI) was drawn from the work of Belgian statistician Adolphe Quetelet, who sought the proportions of “the average man” but only included white men in his sample.
Impacts of weight stigma
Pathologising higher-weight bodies, in turn, leads to weight cycling (the most common outcome of weight loss attempts) and weight stigma, which have both been correlated with health issues that get blamed on being higher weight.
Weight stigma has been linked to psychological and physical health implications including increased blood pressure, blood sugar, and cortisol levels, reduced healthcare engagement, reduced trust of healthcare providers, depression, anxiety, substance abuse, suicidal tendency, more advanced and poorly controlled chronic disease, low health-related quality of life, and an increased mortality risk of nearly 60%.
“Health issues that are labeled ‘weight-related’ may actually be weight stigma (and weight cycling) related.”
Despite this, research that seeks to correlate higher weight with health issues fails to control for these confounding variables. Thus, health issues that are labeled “weight-related” may actually be weight stigma (and weight cycling) related. Meanwhile, the weight loss industry is trying to cast itself and those on its payroll into the role of weight stigma experts. This has been followed by their best attempts to replace true anti-stigma messaging with the weight loss industry friendly notion that we should be against the blatant mistreatment of higher-weight people, but we should still insist that their existence is an epidemic and that they should be eradicated from the earth. As someone who is both higher-weight and queer, I find this eerily familiar.
The New England Journal of Medicine recently published an article called “A Legacy of Cruelty to Sexual and Gender Minority Groups” that traces the pathologisation of LGBTQIA+ identities, including attempts to “remove or destroy” their desires. The article acknowledges that “given this history, it should not be surprising that LGBTQ+ communities face health disparities and outsized ill effects related to every major disease.” Not surprising indeed.
Yet the pathologising of higher-weight bodies increases, creating a vicious cycle wherein the healthcare system creates weight stigma, weight cycling, and healthcare inequalities, then blames the negative impacts of those on higher-weight bodies, then uses those negative impacts as the justification to create more weight stigma, weight cycling, and healthcare inequalities. Higher-weight people are harmed as the weight-loss industry brags to their shareholders about record profits.
Moving forward
By de-pathologising higher-weight bodies we can pull weight stigma out by its racist roots, giving way to an evidence-based, weight-neutral paradigm that shifts the focus from manipulating the body size of higher-weight people to supporting their health directly based on individual priorities. This requires doing the research to create tools, techniques, and best practices specifically for higher-weight bodies. Of course there is much more work to do to dismantle racism, ableism, homophobia, transphobia and other oppressions, but de-pathologising higher-weight bodies is a critical step to creating a healthcare system, and a world, where all people of all sizes can truly thrive.
The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.
Ragen Chastain holds an MEd and is a Board-Certified Patient Advocate (BCPA). She is a distinguished speaker, writer, researcher, and health and fitness professional. Her extensive experience includes providing research and teaching services to hospitals, leading companies like Amazon and Google, and esteemed universities such as Dartmouth and Yale. Ragen is the author of Fat: The Owner's Manual and editor of the anthology The Politics of Size. Discover more about her work at www.WeightAndHealthcare.com.
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