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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 people find themselves shedding a few pounds when they try out a new diet or join a slimming club.

But the evidence is clear that up to 95% of people who lose weight will gain it back within five years. In fact, the current data suggests that up to two thirds of people will end up heavier than they were when they started. The weight loss industry depends on this to turn a profit. It is what keeps us coming back year after year after year. If weight loss was a permanent solution, then why do people have to keep trying?

We are all living in a world where toxic diet culture is having a very negative impact on our own body image and self-worth. You just have to read the Women and Equality Commission’s report. But in addition to that, people who inhabit bigger bodies are experiencing discrimination throughout our lives.

We are paid less, are less likely to be hired at interview, less likely to be promoted, and less likely to receive a bonus. We are more likely to receive a harsher sentence in a trial and less likely to get married. Teachers discriminate against fat pupils. Employers discriminate against fat employees. And doctors discriminate against fat patients.

Not only is our current government refusing to do anything about this, but they are actually making things worse. “The Government’s latest Ob*sity Strategy is at best ineffective and at worst perpetuating unhealthy behaviours,” is how the commission put it. Numerous studies make it clear that anti-ob*sity strategies are promoting disordered eating, poorer mental health and weight gain.

Talking about diets and weight loss, weight shaming or teasing, and placing children on a diet are all known to have detrimental effects on their mental health. Not only does it increase the risk of eating disorders, but it is also a risk factor for childhood ob*sity.

And yet a recent case has come to light involving West Sussex County Council, whose social service department spent 10 years forcing two children to attend weight watchers and report on their exercise patterns on a regular basis. And when they failed to lose weight, a judge removed them from a safe and loving home and placed them into foster care. In my opinion, this is simply unacceptable, which is why I have started a petition and am trying to help put things right.

Two months ago, I went on This Morning to debate the benefits of fat representation in schoolbooks with a self-styled weight loss guru who essentially accused me of ‘glorifying obesity’. I stated that I believed that you could be healthy at any size and that we had to stop encouraging people to lose weight. Instead we should be focussing on improving health behaviours and stop placing the blame and responsibility on the individual. I argued that society had a responsibility to address inequalities in our environment that make it harder for some to maintain their health than others.

At least I tried to say that. It is pretty hard to get your point across in under ten minutes when someone keeps interrupting and talking over you! What I did manage to get out was that I was willing to stake my medical career on this belief. And in a way, I have. I cannot tell you how many people have reported me to the GMC for stating that health professionals are prejudiced, that weight stigma is endangering patients and that weight loss is definitely not the answer.

This is never going to be a popular message. Not only does it go against everything that we have been taught for the past 40 years, but there are a number of multimillion dollar organisations that depend on the weight loss narrative in order to survive. Add to this the religious-like quality of healthism and we are facing an uphill battle all the way.

Dr Lucy Aphramor says that healthism assumes that “personal health is derived from correct body/mind management practices” and “is the property and responsibility of the individual”. They go on to say:

“It sees the pursuit of being healthy in this way as a moral obligation, ranked above everything else, like world peace or being kind. It ignores the impact of poverty, oppression, war, violence, luck, historical atrocities, abuse and the environment from traffic, pollution to clean water and nuclear contamination and so on. It protects the status quo, leads to victim blaming and privilege, increases health inequities and fosters internalized oppression. Healthism judges people’s human worth on the basis of their health, and often also on their degree of commitment to healthist beliefs and behaviours.”

As a doctor with over twenty years of medical experience, I can assure you that health is not simply a case of ‘mind over matter’ and ‘lifestyle cures all’. Neither is health a personal or moral obligation. We are all entitled to be valued and respected, irrespective of our health status. It is time we stop judging a person by the size of their body, and ensure that those who do are held to account.

About the author:

Dr Natasha Larmie is a GP with over 20 years of medical experience. She is a card-carrying, flag-waving member of the body acceptance movement and is advocating to put an end to weight stigma in healthcare. Since May last year, she has been blogging under the name the Fat Doctor and has appeared in a number of articles, interviews and podcasts as well as a guest speaker and honorary university lecturer. She is known for her infamous appearance on This Morning which earned her a reputation for being both a “deluded moron” and “brave campaigner”, depending on who you ask. She is due to launch her podcast at the end of this month, and you can find her on her website and all on all the usual social media channels.

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