Scrap the BMI and stop focusing on weight loss

Why the government has finally taken a stand against weight stigma in healthcare

By guest contributor Dr Natasha Larmie

“We have been hugely saddened to hear of the number of people who have faced appearance and weight-based discrimination when accessing NHS services. The use of BMI inspires weight stigma, contributes to eating disorders, and disrupts people’s body image and mental health. Public Health England should stop using BMI as a measure of individual health, and instead focus on a ‘Health at Every Size’ approach.”

That was one of the take home messages from the Women and Equalities Committee’s report on body image that was published by the House of Commons last week. I read it over breakfast, and almost spilled my cup of tea! Reflecting on it now, I find myself overjoyed and deeply saddened at the same time. Overjoyed because someone is finally agreeing with those who recognise the damage that weight stigma causes and want to make healthcare weight inclusive. Saddened because I know deep down that this report is unlikely to make much of an impact on either individual practice or national policies for the foreseeable future.

And we need change to come now, because people are dying as we speak. Cancers are being missed. Treatment is being delayed. When a patient experiences weight-based discrimination at the hands of their health professional, they lose their ability to trust and communicate, they are less likely to comply with advice, and they are more likely to avoid seeking medical attention in the future. This is extremely dangerous and is leading to poorer health outcomes for people who inhabit bigger bodies. It also explains why so many medical conditions are associated with ob*sity.

Not only are health professionals allowing our own prejudices to cloud our judgement and discriminating against our patients by ignoring their symptoms and dismissing them with the advice to just ‘eat less and move more’, but we are shaming and stigmatising them to the point that they fear coming to see us.

Just look at the swine flu pandemic. In 2016, a systematic review showed that there was a definite link between swine flu deaths and ob*sity. However, there was also a link between ob*sity and delayed treatment, and once you factored in the treatment delay, the link between ob*sity and swine flu disappeared. Think about that for a moment. Fat people died in higher numbers because they didn’t get the right treatment in time.

Whilst it is impossible to compare the swine flu with COVID because the evidence simply doesn’t exist yet (it took seven years for the swine flu data to be analysed), you’ve still got to wonder why. Why was there a delay in treatment in the first place? Why did thin people receive better treatment from a deadly virus than their fatter counterparts?

I’ve been a doctor since 2003, and I’ve been a fat person for even longer than that. I don’t mean to cause offense by using the f-word and am using it in a completely neutral non-judgemental way. There’s no need to rush to my defence and remind me that I am beautiful and shouldn’t think of myself that way. I am beautiful. I’m healthy too, and I already know this. The difference between me and most people is that I believe that it is possible to be fat, healthy and beautiful too. Fat isn’t a bad word unless you want it to be.

I spend a lot of my time trying to educate my colleagues about the way in which weight stigma impacts healthcare. When we talk about ‘stigma’ we mean a physical characteristic - in this case fatness - that marks the bearer as having lower social value. The reality is that the majority of healthcare professionals believe this to be true whether they realise it or not.

In a study of 4732 first year medical students, Sean Phelan and his team found that most of them showed evidence of explicit and/or implicit bias. The study showed that before they had even begun their illustrious medical care, the future doctors of tomorrow disliked fat people, blamed them for their weight gain, and feared becoming fat themselves. And that’s before they started learning the current weight normative approach to medicine and had further anti-fat bias drummed into them by their educators and supervisors.

What is even more interesting is that the study showed that implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. It was also noticeably higher in people whose parents had a degree and grew up with a higher socioeconomic status. People get very angry with me when I point to thin white privileged men as some of the worst offenders when it comes to weight stigma, but the evidence backs me up here.

That being said, weight stigma doesn’t start and end in the doctor’s office. It begins in schools, where children as young as four are being taught that some foods are “good” and others are “bad”. Teachers are just as biased as healthcare professionals, because we have all grown up in the same society where thinness equates to health and moral superiority.

I believe that thinness has become a form of currency that buys you happiness, acceptance and influence.

Being thin equals cheaper insurance, more likes and follows on social media, and better job prospects. Over the last forty years, the narrative surrounding health and its relation to weight has become almost like a religion to some.

Since the birth of the weight loss industry, whose estimated annual profit is around $72 million, thinness has become synonymous with health. Which is ironic, because a hundred years ago, being thin was associated with poorer health outcomes. Why? Because a hundred years ago, we were most likely to die of malnutrition or infectious diseases like Tuberculosis and Cholera. Back then, health insurance companies offered lower premiums to fat folk.

But as time went by, fashions changed and people started to associate fatness with greed and laziness. The Christian church had a big role to play in this, as did a hefty dose of racism. In her book “Fearing the Black Body: the Racial Origins of Fat Phobia”, Sabrina Strings explains this in great detail. Fatphobia is rooted in racism and religious doctrine. Over the past century or so, fat folk have become the enemy.

Unsurprisingly, research scientists and healthcare professionals allowed their conscious and unconscious bias to bleed into their medical research and began looking for proof that fat was bad for your health. The technical term is confirmation bias. By the turn of the 21st Century, we had convinced ourselves that fat was as unhealthy as it gets. And any evidence that suggested otherwise was branded a “paradox”. Yet there is no question that it is possible to be healthy at every size, and there is a lot of evidence to support this. I am glad to see that the powers that be are finally beginning to acknowledge it.

The term ‘ob*sity’ comes from the latin word obesus which essentially translates as “to eat too much so as to become fat”. And that is the prevailing theory, is it not? Supposedly, fat people are fat because they eat too much and don’t do enough exercise. But medical research tells us otherwise. Weight gain is caused by a number of factors including genetics, early childhood experiences, hormones, stress, pre-existing medical conditions, medications and environmental factors including income and education. Most importantly, the single biggest predictor for weight gain is intentional weight loss.

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Health behaviours such as adequate nutrition, exercise, good sleep and stress management all have a role to play, but weight is not a behaviour. It is not something that you have much control over. That is not to say that weight loss is impossible. Most peo