We Have Questions: Fatphobia in Health Care
By: Sam Kokoska
Tags: Health, Culture, Body, Weight, Social Justice

By Becca Allen and Sam Kokoska

Image drawn by Sam Kokoska

We are medical students, here to name our observations and critiques of how weight and body size are presented in health care. We recognize that our sentiments may be shared by individuals across the United States, in and outside of health care. We are not here to claim these thoughts as novel. We are here to question and disrupt fatphobia in health care, in solidarity with liberatory movements.

In a recent lecture, a professor stressed the importance of creating a “supportive office environment,” by avoiding terminology such as “morbidly obese” and “obese.” In this same lecture, patients were repeatedly classified as “obese” or not, a distinction continuously made over the course of the year. If it is harmful to use “obese” when speaking with patients, why are we using this term in medical spaces?

Consider how fatphobia causes harm, not only through the words we choose, but also in how much time we spend with patients, the treatments we offer, and the creation of a distrustful medical system. Health care workers have the power to prescribe and encourage treatment options. We are taught that weight loss is a treatment goal for various health concerns, if the patient is categorized as “overweight” or “obese.” It’s as easy and simple as that: weight loss. But how does this look in practice?

The societal tendency is to turn to prescriptive diets. Medical institutions maintain a similar response, as shown by our single nutrition lecture entitled, “Nutrition in the Treatment of Obesity.” Yet, as a professor pointed out, the vast majority of diets fail to result in sustained weight loss. Additionally, dieting for weight loss can harm mental and physical health through weight cycling, disordered eating, and altered relationships with food and one’s body. Despite these truths, weight loss persists as the diet treatment goal for many, especially in health care settings. Why has thinness become an absolute and complete health equivalent?

The elevation of thinness in health care has informed and been reified by sociopolitical constructs of the “ideal” body: constructs rooted in slavery, racism, and misogynoir. The Body Mass Index (BMI), a tool that only accounts for weight and height (not body composition), was constructed with groundings in white supremacy and eugenics, with no intention for its now ubiquitous use as a proxy for health. When used as a health “indicator,” who does the BMI presume represents health? What is missed when weight becomes the primary proxy for health?

One professor emphasized the “success” of weight loss surgeries in leading to sustained weight loss and altered gut hormones. However, there was no acknowledgment of any other consequences and what the accompanying psychological process can feel like. Individuals who get weight reduction surgery are more likely to self-harm or attempt suicide. Why is mental health being excluded from the conversation?

The narratives centered by health care education do not exist in a vacuum; they are shaped by the same capitalistic forces that exist within society. The weight loss surgery industry was valued at 1.35 billion dollars in 2018. The U.S. diet and weight loss and U.S. food industries are valued at 72 billion and 1.7 trillion dollars, respectively. Relationships with food and one’s body are inevitably influenced by the forces of capitalism, most of which we are unaware. How do we contextualize education and training in the society in which we live?

We live and breathe in an unjust world: a world in which fatphobia is only one of many forms of oppression that humans have described experiencing. Oppression operates through power structures, elevating some groups over others. Individuals elevated to positions of power have shaped institutional education and narratives of what is considered “normal” and “healthy.” It follows that these definitions lead to the marginalization and exclusion of oppressed groups. How can we shift these definitions?

A cultural shift requires an understanding that “health” is not a single outcome that everyone can or should be seeking. We must recognize that definitions of health: vary between individuals, vary throughout an individual’s life, and are informed by identities, cultures, relationships, and experiences. Additionally, mental and physical health care, desired nutrition and food intake, and exercise and movement — factors which may be incorporated into an individual’s definition of health — are not equally accessible to all. A single definition of health, especially one dependent on size, is inaccessible and discriminatory. How do we create health care spaces that inspire trust and belonging for patients of all sizes?

We challenge health care workers and trainees to consider and create spaces to discuss: your assumptions about who can or cannot pursue “health,” your answers to the below questions, and how your practices disrupt or reify fatphobia.