I grew up believing I was overweight. I do not know if I first decided this in my pediatrician’s office when they explained to me that I was in the 98% percentile for weight. Or when I saw pictures of me standing next to my small friends. Either way, I knew I was big and I knew that was bad.
My little brain came up with all sorts of schemes and plans to lose weight. My adorable puppy journals from elementary school contain exercise routines and diet plans. As I got older, I started counting calories, refusing cake at parties, and eating meal replacement bars for lunch. Still, I was bigger than my friends.
When I went to college, I finally had complete control over what I ate and how much I exercised. I adopted a restrictive diet and began overexercising in order to be “healthy.” Maintaining these behaviors slowly took over my life and evolved into an eating disorder.
With the guidance of counselors, I have worked hard to heal my relationship with my body. I have adopted a new way of thinking about my weight influenced by intuitive eating and, the “health at every size” (HAES) movement. Through this healing process, I began to question the relationship between health, healthcare, and weight.
My struggle with weight and health is not unique. The majority of the population is “overweight” or “obese”, and the belief persists that a lower weight is ideal. Not only is thinness seen as more attractive but losing weight seems to be a requirement to be healthy. Even my “normal weight” peers frequently discuss their attempts to lose weight. The fear of fat is that deeply ingrained.
I believe we do not need to fear fat but can instead view it as a neutral descriptor with no moral value. My personal experiences have shown me that focusing on weight might lead to worse overall health- not better. Size diversity is natural and forcing everyone to be the same size may only cause problems.
Society has been waging a war on obesity, but I believe there is a better way. I would like to introduce the idea of weight-neutral healthcare.
Weight-neutral healthcare does not focus on a person’s weight. Instead, diverse sizes are accepted as normal and natural. This shift would allow people to move past fatphobic practices and pursue health no matter their size.
This idea may seem radical however, ample research supports this change. (See references at the end for a few of the best studies providing evidence.)
Research shows that being overweight does not make a person unhealthy. Anywhere between one-third and three-quarters of the people who have been classified as obese by the BMI are, in fact, metabolically healthy.
While being overweight may not negatively impact health, weight stigma does cause real harm.
People with larger bodies often avoid doctors due to the incessant recommendation to lose weight. The fear of poor treatment and weight stigma can lead to delayed medical treatment and worse outcomes.
When fat people do seek care, their concerns may be ignored and treatment withheld because weight loss is considered necessary and beneficial.
Studies show there are multiple negative physiological side effects related directly to the stress of weight stigma -not weight- including increased blood pressure, type II diabetes, and metabolic syndrome. Our society’s negative attitudes toward fat might be causing the disorders the “war on obesity” was supposed to help.
Further, sustainable weight loss may not be possible.
Weight loss may seem simple- move more and eat less. But this idea is not supported by research. Individuals who diet can initially lose weight; however, one-third to two-thirds of the weight is regained within one year, and almost all is regained within five years. While weight loss may only be temporary, studies do show long-term negative consequences of restrictive diets including dangerous weight cycling and eating disorders.
A person’s weight is determined by a complex network of factors including genetics, environment, and stress. Individuals have much less control over their weight than what is usually assumed. Lifestyle factors such as diet and exercise have a very small impact on someone’s overall size- especially over the long term.
Of course, I am not saying that nutrition and exercise are unimportant. Everyone knows that moving more and eating a balanced diet can improve quality of life and potentially prevent some diseases.
However, these lifestyle changes may or may not alter a person’s weight.
Personally, my body feels healthy when I am more active, practicing intuitive eating, and effectively managing stress. When I have time to exercise regularly, I might notice some minor weight loss, but typically my size does not change. For me to lose enough weight to have a normal BMI, I would need to jump back into the restrictive diets and overexercising that led to my eating disorder.
I acknowledge that not all large individuals are healthy. As a nurse, I have interacted with many patients whose weight does negatively impact their health. However, this does not mean weight bias is justified. I see people dismissed and even demeaned because of their size.
Healthcare tends to see being overweight as a personal failing that can and should be fixed. Fat people are often viewed as unhealthy and non-compliant. This negative attitude is made worse when healthcare workers assume weight loss is necessary and possible. However, I hope the evidence presented above shows why we need to challenge this misbelief.
If a medication did not produce lasting positive effects and caused harm, medical professionals would not promote and/or prescribe it. So, why does weight loss continue to be encouraged?
A person who is concerned about their health has many options of health-promoting interventions that can be recommended that have nothing to do with a person’s size. Physical therapy to improve movement, counseling to reduce stress, and medications to treat a variety of symptoms can improve an individual’s quality of life- just to name a few.
(There are also many systemic changes that would allow for better health like making sure everyone has access to adequate resources and enabling individuals to have a better work-life balance. This is where the biggest impact on health can be made, however, these changes will require collective action. So, while systemic changes have great potential, most likely they won’t happen anytime soon.)
By implementing some of these interventions, a person’s body and mind may begin to feel better. As an individual’s health improves their weight may or may not change- and that is ok! Health and weight are not the same thing.
My hope is that healthcare professionals can stop viewing someone’s weight as something that can and needs to be changed. Rather I encourage viewing someone’s size as a part of who they are and to stop focusing on weight loss.
Weight-neutral health care can offer hope.
Hope for all the kids growing up believing there is something wrong with their bodies.
Hope for all the people stuck in harmful patterns of weight cycling and disordered eating who believe they need to lose weight to be healthy.
And, most importantly, hope- and respect- for all the fat people who have been bullied by the healthcare system insisting they engage in weight loss behaviors that are known to cause damage and that are ineffective in producing any lasting positive change.
The relationship between health, healthcare, and weight is messy and nuanced. I want to believe healthcare can be a positive force. However, first, we need to challenge healthcare’s fatphobic beliefs and practices. Weight-neutral healthcare offers a first step toward a more compassionate version of healthcare.
Thanks for reading.
1. Bacon, L., Aphramor, L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J 10, 9 (2011). https://doi.org/10.1186/1475-2891-10-9
2. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol. 2007 Apr;62(3):220-33. doi: 10.1037/0003-066X.62.3.220. PMID: 17469900.
3. O’Hara L, Taylor J. What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight-Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift. SAGE Open. April 2018. doi:10.1177/2158244018772888