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OP ED: How anti-fat bias in health care endangers lives

The Conversation by Patty Thille 09 May 2019

When Ellen Maud Bennett died a year ago, her obituary published in the local newspaper gained national media attention in Canada, though she wasn’t a celebrity.

Bennett’s obituary revealed she died from cancer days after finally being diagnosed — after years of seeking help.

Her diagnosis came so late, beyond the point where treatments were possible, because the 64-year-old woman was repeatedly told her health problems were caused by her weight — or more specifically, by the amount of fat on her body.

She died because of bad assumptions that caused poor quality care. And she used her own obituary to share her dying wish:

“Ellen’s dying wish was that women of size make her death matter by advocating strongly for their health and not accepting that fat is the only relevant health issue.”

How to know if this might be happening to you? When do you need to advocate for yourself? I studied the phenomenon of anti-fat stigma in Canadian primary care clinics for my PhD. Knowing how it happens might help.

Fatness as a sign of inferiority

Bodily fatness is a stigmatized body characteristic in Canada and other wealthy countries.

Within any given culture, some characteristics or histories are assumed to reflect a character flaw. The characteristic is treated as a sign of inferiority. The result is loss of social status and widespread societal discrimination.

With bodily fatness, the assumed character flaws are laziness, ignorance or weak willpower.

In a comprehensive review published 10 years ago, there was strong evidence of fatness-related discrimination in employment, while other sectors were less researched. Studies carried out since that time confirm the pattern — including within health care.

‘Just eat more salads’

Poor quality clinical care due to anti-fat stigma occurs when doctors or nurses assume the stereotype holds true.

One common way this happens: a clinician simply tells you to “lose weight,” as Bennett heard many times when seeking help. That’s like telling patients to “lose blood sugar.” Telling people to produce an outcome is not good quality clinical care.

This is especially awful when weight is not related to the topic at hand — an ear infection, for example. Sometimes, clinicians do this as “opportunistic counselling.” It’s done assuming the benefits outweigh harms — except we know that doing this for weight reduces trust in health-care providers. And reduced trust can lead to avoidance, for obvious reasons — needs aren’t met.

Unfortunately, some clinicians give very simplistic weight loss advice, such as “eat more salads,” without any assessment of what the patient already knows, does, has tried or can afford and fit into their lives.

Simplistic advice is patronizing at best; it assumes patients are ignorant, as per the stereotype. This approach vastly underestimates the knowledge of a patient, gained in part through repeated past attempts to change body composition. One Canadian study found that half of those classified as overweight, and 71 per cent of those categorized as obese, had attempted to reduce their body weight in the last year.

Simplistic messages — “lose weight” or “exercise more” — assume thinness is easy and simply involves some lifestyle tweaks.

When such advice is given without assessment of health concerns — for instance, headaches — anti-fat biases can endanger lives.

Bias trumps science, sometimes

Clinicians should, at minimum, recommend actions that have a chance at producing an outcome. Lifestyle changes only produce modest effects for most, yet many clinicians assume much bigger impacts.

Obesity Canada, an organization that uses evidence-based action to better prevent and manage obesity, reminds health-care providers that the typical body weight reduction from sustained lifestyle changes is five per cent of body weight. Dramatic life changes, such as those of participants on the TV show The Biggest Loser, can slow the body’s resting metabolic rate, triggering weight regain.

Science also tells us that factors beyond lifestyle are influencing population shifts around body weight and fatness.

But these scientific findings are still not routinely integrated into health-care professionals’ understandings of weight. As a result, many still emphasize poor willpower as the core problem.

You shouldn’t have to advocate for yourself to get adequate health care. You should be able to trust your health-care professionals.

How to advocate for yourself

There are many people working to ensure access to good quality health care. But tackling discrimination is complex.

You can help. When clinicians make one of these common mistakes or in some other way block you being diagnosed or treated, you are on good grounds to challenge them. Say something like: “What would you do if someone with a thin body had this problem?” Then encourage them to treat you in the same way.

Send them this or other articles. Write your story and give it to them. Find a Health-At-Every-Size® practitioner, and check for local resources (such as the Good Fat Care website in Winnipeg).

After receiving poor quality care, register a complaint with the provider’s professional licensing body. They may not investigate your individual complaint but do track trends. Patient advocates are also available in some hospitals to help you get the care you need.

News stories come and go. But the issues Ellen Maud Bennett raised in her obituary should not disappear from our consciousness so quickly. You deserve good care, just as she did.

This article is written in memory of Ellen Maud Bennett, with the permission of her sister.

Patty Thille is Assistant Professor in Physical Therapy at the University of Manitoba.