A Doctor for all Sizes
My coworker was having worsening headaches, nausea, dizziness and vision changes, but she wouldn’t go see her doctor. Instead she would come to me, then a family medicine resident in training at the clinic where we worked, to ask about her symptoms.
“I don’t say this very often,” I told her, “But you need to be checked for a brain tumor. You have to go see your doctor.”
“No!” She practically shouted. “She’s going to weigh me.”
My coworker was more willing to risk a brain tumor than face being shamed for her weight at the doctor’s office. She had been told so many times to lose weight no matter why she came in, that she felt there was no point. From the moment she got on that scale, she knew how the rest of the visit would go. She could shame herself about her weight all on her own without her doctor’s help.
I did eventually coax my coworker into going, and luckily her brain was fine and her symptoms improved. But I see this fear of the doctor’s scale all the time. ALL. THE. TIME. It leads people to ignore important symptoms, and it leads them to delay preventive care such as cancer screenings. There is a lot of evidence that people in larger bodies, especially women, are more likely to delay medical care. Unsurprisingly, folks who delay care are more likely to be sick, sometimes beyond the point of treatment, when they do get seen.
And we pretty much blame the patient, right? They’re neglecting their health, they’re noncompliant. But it’s not like people are imagining the hostility and discrimination. There is also plenty of evidence that health care professionals see fat patients differently, and sometimes treat them differently. Yet contrary to popular opinion, weight shaming does not make people thinner. In fact it may actually make people fatter.
What if we took another approach, and made medical care inclusive for patients of all sizes? After all, over 40% of Milwaukee residents fall into the so-called “obese” category. If I’m not showing up for these patients, what am I even doing here?
As a doctor I find it challenging to choose the best wording to explain that I’m not planning to be a monster. I don’t mind being called a Fat Friendly doctor, but that makes some patients nervous (and it sounds dorky). Outside of work I hang out in social justice spaces where the term “fat” has been reclaimed in the context of Fat Acceptance or Body Positivity, but most of my patients still experience the word as an insult. In the medical world we typically use disease language with technical definitions like “overweight,” “obese,” or the term I hate the very most—“morbidly obese.” Given the stigma associated with these terms, many well-intentioned medical professionals use euphemisms like “bigger guy,” or “fluffy,” which makes me want to drink scotch at my desk (for the record, I resist the urge). For today’s purposes I’m going to say what I mean, which is “fat.”
A size-inclusive approach to medicine recognizes that all patients have the right to pursue their best health regardless of what they weigh, and regardless of whether they want their weight to change. Most fat patients come to me wanting to lose weight, and I will typically start by encouraging them to see their weight as part of a bigger picture of their health. When we talk preventive health, I don’t need to know what you weigh to know we are going to be making plans for exercise, nutrition, restorative sleep, and mental health. Only when those things are really solid am I going to consider focusing on that scale. Even if you wind up on a medication or getting surgery—guess what dude, you still need to be on top of nutrition and exercise. Weight is an outcome, and outcomes aren’t always in our control, but our behaviors are.
I also welcome patients who want to take a weight-neutral approach to their health. This will often be someone with a history of disordered eating, or who has a long history of weight cycling that they feel has damaged their mental or physical health. But you don’t need a reason. In fact I’m going to go ahead and quote this position statement from the World Obesity Federation: “Given that current narratives equating weight and body size with health contribute to weight stigma, health promotion strategies should focus on health outcomes instead of weight. A shift is needed away from a focus on weight, weight loss, and a predetermined notion of ‘healthy weight’ (based on BMI) towards a holistic focus on health and wellbeing for an individual, regardless of their weight or size.” These guys are not fringe fat activists, trust me.
And guess what a weight-neutral preventive health plan is going to be? Did you say exercise, nutrition, restorative sleep, and mental health? Good job, you were paying attention! We really need to uncouple healthy behaviors, especially nutrition and exercise, from weight loss. Everybody needs to eat nourishing food. Everybody needs to move their body to feel good (ME/CFS folks, you’re excused from this sentence, but the rest of you are not). I’ve moved away from using the words Health at Every Size (HAES) recently because it is a copyrighted term whose ownership has been contested in recent years, and I intentionally avoided going to law school so I wouldn’t have to deal with issues like that. But it does nicely capture the idea that the pursuit of health happens in the body you have today.
Size inclusivity sometimes means giving fat patients care that may be different from a thin person with an otherwise identical health history. Quite literally, one size does not fit all. That can mean choosing different medications or dosing them differently. That can mean screening more aggressively for diseases that are more common in fat people. That can mean asking if you want to be weighed when you come in (here’s a video I made about when it is or isn’t important to get weighed at the doctor’s office). That can mean designing the physical space of the clinic to accommodate large bodies—if your doctor’s chair doesn’t fit your butt, the visit’s already off to a bad start.
Right about now someone is frantically mashing his keyboard to say “Don’t you know fat people are unhealthy?” Calm down, Brad, I went to medical school. And public health school. I’m very well aware of the associations between fatness and risk of disease. And I want everyone to appreciate the full complexity of how those risks come about. Some diseases can be directly caused by someone’s fatness. Obstructive Sleep Apnea, which I studied for my PhD work, is a good example of this. We are going to hold this idea in our minds at the same time as the idea that stigma and discrimination can make fat people sick too. What we’re not going to do is miss diagnoses by blaming all of fat people’s health problems on their size. And we’re not going to withhold treatment that we would offer to thin patients by making weight loss the sole recommendation for every fat patient’s problem.
By the way, size inclusivity also extends to people with very lean bodies. Though the health care system is less directly at fault here, plenty of people still experience criticism and hostility for being seen as excessively thin. In a culture that loves to police bodies, you truly cannot win. And I’ve seen lean patients with obvious symptoms of diseases like diabetes, sleep apnea, and binge eating disorder that were missed by doctors who assumed thin meant healthy. That lazy thinking is a disservice to thin people too.
I didn’t invent any of this. There’s an enormous body of scholarship, criticism, and activist writing on fat justice issues in and out of health care available for those who want to learn more. I’m going to be lazy and link you to Aubrey Gordon’s reading list because I have no reason to believe I’d do it better.
The bottom line is that all bodies deserve respect. Body respect starts with you. Maybe you’re not in a place to love your body today, but you can show it respect. You can feed it, exercise it, water it, rest it. And then you can go see your doctor.
If you’d think joining Presence Primary Care might be right for you, schedule a free Discovery Call with Dr. Mirer to learn more about the practice.
