When Arielle Schultz started med school last fall, she immediately found anti-fat bias baked into her lessons. She wasn’t surprised. “I’ve definitely had the experience of going to the doctor’s office and being told to lose weight,” Schultz, a member of Medical Students for Size Inclusivity, tells SELF.
Weight discrimination runs rampant in the US health care system: In multiple studies, doctors, nurses, and medical students have reported negative beliefs about fat folks, including the assumptions that they are less likely to follow treatment plans and are more “unpleasant” and “sloppy” compared to thinner patients; some providers have even said they’d prefer not to care for fat people.
Unfortunately, these appalling, unacceptable attitudes have become very normalized: Thanks to 20-plus years of “obesity epidemic” moral panic, many providers approach their care with the misconception that thin equals healthy and weight loss automatically improves a person’s well-being. When medical schools take a weight-centric approach as a catchall, physicians are often left to their own devices to discover what decades of research have shown: Intentional weight loss doesn’t necessarily make people healthier and usually doesn’t last anyway.
Though there has been some incremental progress—such as the American Medical Association finally calling out the BMI as an “imperfect” and biased measure of health last month, along with advocates like Schultz organizing with like-minded weight-neutral providers—that doesn’t mean that the majority of doctors practice from an unbiased perspective. If you’re on the hunt for a doctor who isn’t laser-focused on your body size, it’s probably going to take some effort. Of course, it’s completely unfair that this work is falling on your shoulders, but until the medical community takes bigger steps toward size-inclusivity, self-advocacy might be your only option.
Here, experts explain the basis for weight-inclusive health care—and how to get it for yourself.
What weight-inclusive health care looks like in practice
Different doctors use different labels to describe this approach—weight-inclusive, weight-neutral, and Health at Every Size (HAES) are common. But the goal is the same: divorcing health from weight. “I don’t assume that large people are fully nourished and don’t have eating disorders, and I don’t assume that small people don’t have classically weight-correlated illnesses or that they haven’t experienced weight bias,” Lisa Erlanger, MD, a physician who practices and teaches family medicine at the University of Washington, tells SELF.
Yes, a handful of health issues—such as joint pain, diabetes, and sleep apnea—have been linked with higher BMIs (again, an unreliable measure of health, at best). But weight-inclusive medicine emphasizes that correlation doesn’t imply causation. “The evidence that higher body weight is the cause of illness is very poor quality,” Dr. Erlanger explains.
Even for conditions that might be connected to BMI, weight-neutral medical providers do not turn to prescribed fat loss. “Deliberate weight loss does not work long-term,” Jennifer L. Guadiani, MD, founder and medical director of Denver’s Gaudiani Clinic, tells SELF. “Our bodies evolved to resist it and to react to inadequate calories by preserving body weight and making it rise higher to protect us from the next famine.” Not only are diets an ineffective way to lose weight for most people, but they’ve actually been shown to cause weight gain in the long term. When someone believes that regain is their fault, they may try to shrink their body again. This second (or third or fourth) attempt will likely also fail, Dr. Guadiani says, in a harmful pattern known as “weight cycling.”
“Weight cycling is metabolically and psychologically devastating,” Dr. Erlanger says, adding that it’s been shown to “increase levels of cardiovascular disease, diabetes and insulin resistance, and mortality.” It can also hurt your mental health, she adds, underscoring the emotional toll of losing weight out of desperation to adhere to social norms—which can be driven by your doctor’s recommendations—only to feel even worse about yourself when the pounds come back on.
Fat people especially may notice immediate differences in their care under a weight-inclusive provider. However, folks of any size can benefit from seeing a doctor who is conscious about removing anti-fat bias from their practice. Weight-neutral care can be particularly helpful for those who’ve dealt with disordered eating and poor body image, Dr. Guadiani says.
That’s not to say your weight is never your doctor’s business. Dr. Guadiani also notes a few scenarios in which she believes tracking weight is a necessary part of a person’s care, but cautions that there needs to be a clear reason. “The benefit of getting someone’s weight has to be higher than the potential distress of checking that weight,” she says. And every physician SELF spoke with for this story identified at least one such example. These include:
- Tracking a child’s growth to ensure healthy development
- Ensuring that someone is gaining enough weight during pregnancy
- Prescribing medications with weight-based dosing
- Monitoring nutritional adequacy and weight restoration as someone recovers from an eating disorder that caused weight loss
- Monitoring certain weight-associated conditions, such as congestive heart failure or thyroid disorders. In this case, changes in weight may necessitate further testing or medication adjustment
It’s also worth noting that unexplained weight fluctuations—in either direction, regardless of a person’s starting weight or current weight—can point to serious health problems. (For example, sudden weight loss can be a sign or symptom of any number of issues, including type 1 diabetes and depression.) In those cases, a person’s weight may be useful information and a cause to order tests and dig deeper.
These conversations might be difficult, especially if you’ve experienced medical weight bias in the past. But finding a provider you trust can go a long way toward easing some of that anxiety.
So how do I find a weight-inclusive doctor?
You can start by looking into specialized directories, Ragen Chastain, a fat activist and certified patient advocate, tells SELF. For example, Chastain co-authors HAES Health Sheets, a site where you can find a list of resources that include several such databases. A quick google of “fat-friendly doctors” also yields sites such as Fat Friendly Healthcare Providers and Bare, a searchable directory of providers across the country.
If you can’t find one that fits your needs or takes your insurance, there are some strategies to help you determine whether a potential doctor is going to be hyper-focused on your weight:
“Word-of-mouth recommendations for physicians who are more open-minded when it comes to weight can be very helpful,” Lesley Williams, MD, an Arizona-based family medicine physician tells SELF. Ask friends, family members, or colleagues if they know of anyone great who takes a patient-centered approach, she advises. Suggestions from people you trust—and who share your values—go a long way when it comes to finding a well-matched provider.
If references from your social circle don’t get you very far or you don’t feel comfortable asking for them, reviews from strangers can be helpful too. For online word-of-mouth recs, Chastain suggests reading reviews via ZocDoc or Google. (Fat-positive Facebook groups and subreddits can also be great resources for firsthand accounts.) At best, this can lead you to a phenomenal weight-inclusive physician, she says; at the very least, you may be able to spot some red flags.
Most fat people Chastain works with have had the experience of going in for an ailment unrelated to body size—like an injured shoulder—and being prescribed a restrictive diet. Reading that kind of story in a review might save you from the same fate.
Chastain recommends contacting a practice or office in advance, which you can do anonymously. “Call ahead and say, ‘I’m looking for a provider who will focus on weight-neutral interventions, who won’t recommend weight loss, and who won’t talk about my weight. Is there someone in this practice who can do that?’” she says. If the answer is yes and you book the appointment, she adds that you can ask a receptionist or nurse to put these requests in your chart so your doctor can review them ahead of time.
When you meet the doctor in person, keep the questions coming. Dr. Williams suggests asking, “Would you feel comfortable caring for me if weight was not a central theme?” Dr. Erlanger’s go-to question: “What are your beliefs about weight and health, and how do you approach that in your practice?” The answers to these types of queries can give you an idea of what to expect down the line. If a provider espouses the use of restrictive diets and weight-loss medications to improve health, you probably assume that thinness will always be a goal under their care.
You can also ask: “What are my options if I prefer not to be weighed?” A doctor or physician’s assistant may tell you that they are required to weigh you, but you don’t have to agree. “Even if the weight is required by policy, it is not legally required,” Dr. Erlanger says. “And it’s not required for you to get insurance coverage.” If you and your doctor agree that tracking your weight is medically necessary, Dr. Erlanger says you can wait until the end of your appointment to step on the scale. This “keeps the focus of the visit from being on weight and also keeps the anxiety around weight from overshadowing the visit,” she says. And even then, you can ask the nurse or physician’s assistant not to tell you the number.
If you can’t find an explicitly weight-inclusive, weight-neutral, or HAES provider, Dr. Gaudiani suggests trying to seek out someone who is at least collaborative and willing to listen to your concerns without judgment. “When you’re calling for a new physician, you can ask the receptionist, ‘Between you and me, which of the doctors in this practice do the patients just love?’” she suggests. “If the doctor is beloved, that’s a good sign that they have a sense of curiosity and compassion.”
Online reviews and website language can also be helpful indicators of a doctor’s style and general vibe. Chastain says to avoid obesity specialists and physicians whose profiles mention “weight management,” for example, which indicates they may pathologize weight. In short, temperament can make all the difference. A particularly empathetic provider may give you more say in guiding your treatment plan, which could give you space to advocate for a weight-neutral approach.
Whether you get lucky with a compassionate, weight-neutral physician or you’re stuck with a less open-minded doc, it may behoove you to bring someone along to your appointment if the practice allows plus-ones in the exam room. “An advocate can be helpful, especially if the physician doesn’t get it right away,” Dr. Erlanger says. “I know for myself, it gets harder and harder to stand up for myself as the visit goes on.” This supporter can be a trusted friend or family member, and they might help in a number of ways.
If you tend to get flustered at appointments, you could ask them to help keep you on track by making sure you mention a particular symptom you have or test you want done, she suggests. If you know you probably won’t speak up if the doctor mentions weight or suggests dieting, Chastain says you might have your buddy help redirect the conversation (she suggests asking her magic question: “What would you do for a thin person who has this issue?”). Or even if you don’t want them to speak at all, having someone at your side who can witness your appointment, take notes, and debrief with you afterward can still help you feel much more comfortable.
Dr. Erlanger, Dr. Gaudiani, and Dr. Williams all found their way to weight-inclusive health care after or outside of medical school. But there’s potential for a major ripple effect when future doctors like Schultz and the rest of the Medical Students for Size Inclusivity advocate to rewrite the narrative in educational settings.
“Something that’s made me feel very optimistic is just how many med students care about this and are passionate about it,” Schultz says. “That gives me a lot of hope that once we’re all graduated and we’re the attending physicians 10 years down the line, we’ll start to see even more progress.”
Related:
