Weight Discrimination in the American Healthcare System

Written by Erin Walden
Edited by Jinshi Zheng

     Weight discrimination has long been prevalent in America, affecting how we view bodies, attractiveness, and self-worth. Recent studies have shown that unlike other forms of discrimination, weight discrimination in America has increased by over 66% in the past decade.[1] Often, weight-based discrimination is researched in the context of hiring and wage disparities. Studies have shown that there is an increasingly severe penalty across wage distribution for women. Women affected by obesity tend to earn 6% less than women whose bodies are deemed “normal."[2]

     But more than affecting financial stability, widespread weight discrimination affects mental and physical health. One of the many problems with weight stigma is that individuals tend to internalize anti-fat beliefs, making them less likely to advocate for themselves and to be comfortable accessing healthcare. Hospitals and doctor’s offices are places where the body is put on full display and where body size is an indicator of health.

Stigma is not a beneficial public health tool for reducing obesity

     This is the root cause of healthcare avoidance—the way we define “health.” People, including medical professionals, draw judgments about health based on appearance. The BMI (body mass index) chart is a common way to measure health, drawing sharp lines between weight classes  using one’s sex assigned at birth, height, and weight. This is not a personalized approach to health because it does not take into account muscle/bone mass or body composition. In fact, it was developed 200 years ago as an easy way to for the government to gauge the obesity of the general population.[3] It was never meant to determine an individual’s level of health.

     There are many factors that influence weight, and to generate a conclusive healthy/unhealthy diagnosis using the appearance of weight is deceptive. In fact, weight has been shown to be a less important measurement than blood pressure, resting heart rate, heart rate recovery, and cholesterol [4]. The problem is that these are not visible factors. Bianca Santaromita-Villa, a Dietitian from Ontario notes that, “someone in a larger body could be consuming the exact same thing as someone in a smaller body, doing the same exercises, and they are still going to live in that larger body.”[5] Many people believe that encouraging weight loss is beneficial, but in reality, “[fat] stigma is not a beneficial public health tool for reducing obesity or improving health. Rather, stigmatization of obese individuals pose serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts.” [6]

​     Some studies have looked at the impact of weight stigma in healthcare. Researchers found that fat cis women are less likely to receive cervical cancer, breast cancer, and colorectal cancer screenings than non-fat cis women are. Fat women with breast and cervical cancers are more likely to die from these cancers than non-fat women with the same conditions.[7] In this study, “fat” refers to those with a BMI over 30 (obese on the BMI chart). In another study, 68% of almost 500 fat women reported a delay in seeking care because of their weight and 85% reported weight was a barrier to receiving appropriate healthcare.[8]

     Many doctors themselves harbor anti-fat attitudes, resulting in doctors choosing to spend less time with fat patients. This results in fewer preventive and diagnostic tests for fat patients because doctors report that these tests are “more challenging with fat bodies.”[6] In addition to personal biases, inadequate equipment and lack of education may cause healthcare providers to be less interested and able to tend to fat patients. Almost 10% of obese and morbidly obese women reported that a family planning clinic they had visited was not prepared to provide care for heavier women. Around 25% of obese women reported at least one item in the clinic was not adequate for their size.[9] These items included gowns, exam tables, and blood pressure cuffs that were too small.

...they couldn't believe that someone so fat was metabolically healthy.

     Though there have been efforts to change how fat people are treated in healthcare, many barriers exist to bettering the system. One woman, Cat Pausé, discussed how difficult it was to start her medical residency because of her weight. After three rounds of completing immigration checks, she was deemed to not meet the acceptable standard of health based on her BMI.

     It was so incredibly frustrating; to undergo additional testing because they couldn't believe that someone so fat was metabolically healthy. A few weeks later, I received the decision from Immigration that I was denied residency because I did not meet the medical standard required. Based solely on my BMI. All of my medical tests had been good. Nothing raised any flags, or fell outside of normal parameters. But my BMI was over 30, so nothing else apparently mattered. And the belief that because of my BMI, I would end up costing up to $25,000 in medical care costs during my time in New Zealand.[6]

    Fat people that understand what it is like to live in their bodies and are well-equipped to provide for others that have similar experiences are being prevented from becoming doctors due to the outdated BMI system.

     The focus on BMI as a be-all and end-all of health is called the “Weight Normative Approach.” [10] The Weight Inclusive Approach, however, challenges the belief that a particular BMI reflects health status and suggests that wellness can be fostered independent of weight. It is an approach that celebrates the natural diversity of bodies and seeks to eradicate stigmatization within healthcare.In line with the Weight Inclusive Approach, many doctors and hospitals are starting to adopt the Health at Every Size (HAES) guidelines. These guidelines, developed by Dr. Linda Bacon, outline that weight inclusivity, health enhancement, respectful care, eating for well-being, and life-enhancing movement can be the foundations for creating change in communities, including the healthcare community. The Association for Size Diversity and Health (ASDAH) is a professional organization that supports the HAES principles; it aims to promote health, well-being and respect for all bodies. 

     Doctors are moving away from using weight, BMI, and calorie intake as determinants of health. These numerical measurements may be quick and easy to take, but do not offer a personalized or inclusive model of healthcare. If the healthcare community wants to change, they must work to decenter the element of weight from the concept of health. Changing conceptions of health starts with educating ourselves on the negative impacts of our current system and working within our communities to create and uplift a system that works for all people.

[1] “Weight Discrimination: A Socially Acceptable Injustice.” Obesity Action Coalition, https://www.obesityaction.org/community/article-library/weight-discrimination-a-socially-acceptable-injustice/. Accessed 1 Oct. 2019.
[2] “Weight Bias: Does It Affect Men and Women Differently?” Obesity Action Coalition, https://www.obesityaction.org/community/article-library/weight-bias-does-it-affect-men-and-women-differently/. Accessed 1 Oct. 2019.
[3]  “Top 10 Reasons Why The BMI Is Bogus.” NPR.Org, https://www.npr.org/templates/story/story.php?storyId=106268439. Accessed 1 Oct. 2019.
[4]  Roberts, Caroline. “These Health Stats Are More Important than Your Weight.” CNET, 6 September 2019, https://www.cnet.com/news/6-health-stats-that-are-more-important-than-your-weight/.
[5]  “Health Professionals Attempting to Fight Weight Stigma.” The Concordian, 27 Aug. 2019, http://theconcordian.com/2019/08/fighting-weight-stigma/.
[6] Lee, Jennifer A., and Cat J. Pausé. “Stigma in Practice: Barriers to Health for Fat Women.” Frontiers in Psychology, vol. 7, Dec. 2016. PubMed Central, doi:10.3389/fpsyg.2016.02063.
[7] Ibid.
[8]  “Facts on Size Discrimination.” NAAFA, https://www.naafaonline.com/dev2/assets/documents/naafa_FactSheet_v17_screen.pdf. Accessed 1 Oct 2019
[9] Ingraham, Natalie, et al. “Prior Family Planning Experiences of Obese Women Seeking Abortion Care.” Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, vol. 24, no. 1, Feb. 2014, pp. e125-130. PubMed, doi:10.1016/j.whi.2013.10.008.
[10]  Tracy L. Tylka, Rachel A. Annunziato, Deb Burgard, et al., “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss,” Journal of Obesity, vol. 2014, Article ID 983495, 18 pages, 2014. https://doi.org/10.1155/2014/983495z