Sometimes, when you see a repeated injustice, you get cynical or resigned and roll your eyes. And sometimes, you get teed off. I’m guessing you can guess which one I’m more predisposed to.
Sam shared this twitter story (here and here) from Jen Curran, who had elevated protein levels in her urine during her pregnancy, and she was told to “lose 40 pounds” and come back. Weeks, and a second opinion, later, she learned that she had blood cancer. Her regular doctor ignored what she was saying, and focused on her size instead (as she was pregnant, no less). This is not news.
And it pisses me off.
How is this STILL happening to larger bodied people? How is it that doctors are looking at our sizes, our weights, and our BMIs as if they are useful pieces of data unto themselves?! Do fatter people get cancer? Broken vertebrae? Appendicitis?
We are far past critical mass here–it is long past time for doctors to take a long hard look at their biases. Because make no mistake, that is exactly what this is. In their core, many doctors believe that fatness is of bigger importance to their patients’ health than almost any other factor. The proof of this supremacy is in their persistent focus on weight, above the narratives provided to them by the patients. Every fat person has a story about how their needs and concerns were ignored as their doctor asked them about trying to lose weight.
And this bias is causing life and death decisions to be made, and fatter people are dying.
As an example, people with more body fat are more likely to die after a cancer diagnosis. Is this because of something intrinsic about body fat, or is it because fat people go longer before they reach a diagnosis? Are doctors more reticent to be aggressive with treatments because they are distracted by the “elephant” in the room, possibly assuming that the fat person doesn’t do their part to take care of themselves? Obviously, doctors are not listening to their fat patients as openly–does that mean they miss critical complications until they are too difficult to treat? How much of the “fat is bad for you when you have cancer” conversation is colored by these unconfronted fat biases?
When I was a fat teenager, I dreaded going to the doctor. No conversation at the doctor did not also include a conversation about my weight. I had nearly disabling low back pain from carrying a heavy book bag for years, including on the couple miles walk home from school each day. Did they offer me exercises to strengthen my core muscles? No. I needed to lose weight.
Depression? Have you tried to lose weight?
Irritable bowel syndrome? What have you done to try to lose weight?
Broken bones in your hand after punching a kid in the hallway for calling you a “freak?” Well, you get the idea. I’m pretty sure my weight came up in that conversation, too.
And, I’m sorry to say it doesn’t get a ton better when you go from being a medically fat person to a merely, nearly fat person.
I changed doctors last year after a frustrating conversation along these lines. I am no longer medically “overweight,” but I am just barely so. Over about six years, I changed from a BMI of about 32 to about 24, just under the “normal” threshold. I have also reduced my health risk factors in innumerable ways–I eat more produce, less processed food, and less added sugar and salt. I do some kind of intentional exercise most days of the week. I don’t smoke or drink alcohol. I have been working hard on managing stress (still a work in progress), and I try to get enough quality sleep. I see a therapist regularly to help me manage my depression and trauma.
And when I went in to get a referral for a physical therapist, what did he say? “Your BMI is ok, it’s in the normal zone, but just barely. You might want to do some work to bring that down.” This had NOTHING to do with my current medical concerns. In fact, the opposite. As I have increased my activity levels over the years, underlying imbalances I’ve lived with for nearly two decades have become problematic. It may not have mattered that my muscles and nerves were out of whack when I wasn’t pushing them. But the more physically fit I’ve become, the more I’ve become aware of how my surgical history has permanently impacted how my body works. I was there to see him so I could continue to be physically active, something I’m sure he would recommend as a part of “fixing” my BMI to a lower end of “normal.”
I challenged him on this and reminded him that I was a weightlifter. That maybe some of the “extra” weight I was carrying might be muscle. He said most people overestimate how much that is a factor. I don’t disagree with him, but I kinda wanted him to lie down on the floor, so I could prove I could deadlift him up off of it.
But of course, my BMI in that moment, or any, wasn’t really relevant. BMI is a poor tool for estimating body fat. And body fat is a poor tool for estimating health. What we’re really seeing time and again, people like Jen and me, and so many others, is the biases of our doctors, who see fat and can’t see anything else.
Fat bias is a habit, and habits are hard to break. Doctors who are serious about improving the health of their patients need to begin the hard work of challenging their own assumptions in these moments. To stop themselves before they bring up their patient’s size and ask themselves, “If this patient were smaller and came to me with these concerns, what would I suggest to them?” Fat people know they’re fat. Most of them have tried, and failed repeatedly, to be less fat. Ask them what they are doing to take care of themselves. Ask them what they are hoping to get from the appointment. Ask them what they think is going on. And for goodness sake, treat them like people, not just bodies.
Marjorie Hundtoft is a middle school science and health teacher. She can be found picking up heavy things and putting them back down again in Portland, Oregon.