Is Fat Phobia in Medicine Harming Doctors and Patients?

Weight bias is pervasive in healthcare. Doctors and other medical professionals blame body weight for a myriad of health conditions—we use inflammatory language and metaphors of battle as we "fight the obesity crisis," and prescribe weight loss to cure all manner of ailments. In doing so, we imply weight is solely one’s personal responsibility and cast shame and judgement on those in larger bodies who are "burdening the healthcare system" with disease.

We are all casualties in the "war on obesity." As doctors, we are unintentionally harming ourselves and our patients by perpetuating the disordered societal belief that weight is something we can, and should, control and a useful marker of health.

In a world in which thinness is synonymous with both success and health, it is all too easy for doctors to channel the drive for achievement onto our bodies.

“That very same sense of ‘I want to do what’s right, I want to do and be my best, I want to show up and really make the most of this’ then gets set into a culture that is diet obsessed and fat-phobic. And it is easy to channel those same successful traits into food and body, and to start thinking 'Well, if I’ve worked so hard on all these other things, why wouldn’t I also work hard on this one thing that society tells me is the most important of all?' To have a young, thin, able, light-skinned body.” —Jennifer Gaudiani, M.D., eating disorder expert and physician

There is an incredible amount of internalized size bias in all of us. We unconsciously absorb messages from society, from our families, from the media, and from our medical training, and secretly believe that thinness means a person is desirable or successful—and that thinness equals health. We end up trying to change how we look and how we come across to the outside world in order to make up for a perceived defect within ourselves.

As Dr Gaudiani tells her patients, this is not a body image problem—it’s an exposure-to-society problem. And combatting it is not simply about individual change or fixing our sense of self, but about recognizing the toxic nature of the society and professional culture into which we have settled.

These beliefs not only negatively impact those who do not conform to a societal ideal and contribute to an inappropriately weight-centric healthcare model, but can ultimately drive people to unhealthy dieting behaviours and eating disorders. As doctors, we recommend these behaviours to our patients in the misguided belief that we are encouraging them to take responsibility for improving their health. Unless we are aware of this, we cannot actively combat it.

Acknowledging and addressing my own internalised weight bias has been an uncomfortable but integral part of my recovery from anorexia. In taking a hard, honest look at my attitudes to weight and the connotations I misattributed to both ends of the spectrum, I have come to understand that my anorexic identity was closely aligned with my professional identity—both in terms of behaviour and physical appearance. It was all intertwined into a distorted view of what you’re supposed to embody as a doctor. Recognising my biases has been an essential step in challenging my own pathological beliefs, but in doing so I have also become acutely aware of how pervasive weight stigma is throughout the medical profession—and how damaging this can be for both doctors and the patients for whom we are trying to care.

Whether we like it or not, there is a certain type of person who is considered by the appearance of their physique—before a word exits their mouth—to be a successful, self-controlled, "proper" person. Being white, able-bodied, and thin confers a degree of privilege. And, in a profession and a world in which we are all scrabbling to prove our worth, the idea of voluntarily giving up a hard-earned ticket to privilege is a bitter pill to swallow. Even if, as in eating disorder recovery, we know this pill is pivotal to restoring our health.

Evidence suggests that doctors have negative opinions of "obese" patients (Phelan, 2013; Schwartz, 2003; Teachmann 2001; Budd, 2009), holding stereotypes that they are lazy, undisciplined, unmotivated, unhealthy, and weak-willed (Puhl, 2009; Foster 2003; Harvey, 2001; Puhl, 2001; Heble, 2001), and respecting them less than patients with a "normal" BMI (Heble, 2001; Huizinga, 2009). People with larger bodies are the most common target of derogatory medical student humour (Wear, 2006) indicating that explicit negative attitudes towards weight are acceptable in a way that gender, racial, and other prejudices are not. Although this is uncomfortable to discuss, it is important to acknowledge and address—both to ensure high-quality and equitable care for patients and to reduce the negative impact when healthcare professionals turn these biases upon themselves.

The flip side of anti-fat bias is over-valuation of thinness. A study of female medical students indicated a high prevalence of body image dissatisfaction—although 79 percent had a normal BMI (mean 22.2), 67 percent expressed a desire to lose weight (Bosi, 2016). A UK Facebook group for female doctors practicing intermittent fasting has 2,400 members, and the group’s pseudo-scientific eulogies of the benefits of extended periods of self-starvation have to be seen to be believed. These are sensible, successful, well-educated professional women—women who, in my view, could be channelling their energies into changing the world—encouraging one another to endure long periods without food under the guise of health. This isn’t unique to women—there is an equivalent group for men (but I have no idea what goes on behind their closed doors).

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Weight bias in the medical profession is congruous with the anorexic over-valuation of thinness and fear of weight gain. Over-identification of positive attributes with the thin ideal and misattribution of undesirable characteristics to those in larger bodies reflect the cognitive distortions that characterise eating disorder psychopathology.

Happiness is an ice cream sundae

Source: Andreas Photiou, used with permission

I found it very difficult to untangle my aberrant anorexic core beliefs from opinions widely held both in general society and throughout the field of medicine. My pathological fat phobia was mirrored in attitudes exhibited by my colleagues. The values I assigned to thinness and negative associations of fatness are espoused throughout healthcare, where the pressure to embody "health" implies that one should look a certain way. When I was ill, I wanted my body to be a physical manifestation of the thin attributes of self-discipline, competence, health, and strength of character—the idea of appearing fat, lazy, undisciplined, and weak-willed felt abhorrent and incongruous with my professional identity. In this respect, the concept of weight gain not only went against every fibre of my own being, but also seemed to contradict the ethos of my professional culture.

Of course, I know this is bullsh*t. I have friends and colleagues of all shapes and sizes, and some of the best doctors I have worked with have larger bodies. I can see that my larger friends and colleagues are beautiful and healthy and wouldn’t dream of recommending they lose weight. I certainly would not assume that doing so would make them better people, or that if they were thinner they would perform better at work. As with most distorted thoughts, my ridiculous standards only made sense when applied to me.

Although I recognise my anorexic beliefs were extreme and have worked hard to challenge them, this isn’t just an eating disorder thing, and it isn’t just a doctor thing. Weight bias is internalised throughout society and probably affects every one of us to a greater or lesser degree. It can be very difficult to take a step back when disordered societal and professional cultural beliefs align with our own—it all feels very egosyntonic and it is easy to wonder if there is even any point. But there is—and we must challenge both. For ourselves, and for our patients.

As doctors, the aberrant beliefs we hold about weight and what it represents reach the very core of our professional identities and are reflected in the culture in which we work. Eating disorders are not about looking good in our scrubs or worrying our stethoscopes make us look fat. This isn’t about wanting to look pretty—it’s about the representation of the physical embodiment of an internalised professional identity, a societal ideal projecting an image of success, competence, self-control, and health. It’s about saying “if I can manage my weight and look a certain way, I can manage everything else.”

The second article in this two part series will explore how healthcare professionals perpetuate these problems by passing our misguided beliefs that thinness is synonymous with health on to our patients. It’s time to break the cycle.

I would like to thank Dr Jennifer Gaudiani, M.D., for her insightful contributions to this article.