Weighty manners

One morning in prenatal clinic I was catching up with a patient early in her second trimester. The patient’s morning sickness had abated and she was excited about her pregnancy. We went over her medications—just a prenatal vitamin and a baby aspirin. She asked why the doctor had prescribed the aspirin and I explained that her doctor had started the medication because she had multiple moderate risk factors for preeclampsia, including obesity. The low-dose aspirin would significantly reduce the risk of preeclampsia, preterm birth and fetal growth restriction. She looked at me hurt, confused and a little angry before blurting out, “Are you calling me fat?”

In that moment, seeing the concern and hurt on her face, I felt terrible. Pregnancy is a time when the human body does amazing and spectacular things. Pregnancy is also a time where the body changes significantly, in ways that can clash with the strict American interpretation of an Acceptable Female Body. The last thing I wanted to do was make this woman feel self conscious about her body, or feel shamed by her healthcare providers. The evidence shows that the patient’s elevated weight could put her, and her baby, at risk, and our intervention could help protect them both. However this information was delivered within a charged societal context.

Rates of obesity are rising in the US. In 1990, less than 15 percent of American adults were obese, while today that figure stands at 36.5 percent. There are legitimate criticisms of the most common tool to assess obesity status—body mass index—but nevertheless the trend is obvious. While not all overweight or obese people are unhealthy, obesity increases risk for heart disease, diabetes, certain types of cancer and osteoarthritis.

Despite the rising prevalence of the disease, cultural biases against the overweight and obese persist. While evidence suggests that a complex mix of genetics, hormones and environmental cues all play a role in body weight, many still attribute obesity to a lack of discipline or laziness. These deeply held cultural beliefs translate into concrete ramifications. Obese children are more likely to experience bullying. Obese people are paid less than their peers of normal weight. Importantly, exposure to these biases does not spur people to lose weight, and may in fact predispose individuals to further weight gain.

Medical providers are not immune from these biases. Anecdotes abound about doctors, nurses or EMTs who behave cruelly or insensitively towards overweight patients. One survey found that 24 percent of nurses agreed or strongly agreed that caring for an obese patient repulsed them. Another study documented significant bias against obese patients among medical students. Patients may avoid care care if they do not trust their medical provider, leading to delayed diagnoses and treatment. Similarly the providers’ bias can lead to misdiagnoses, particularly if all problems are arbitrarily attributed to weight.

As a counterbalance to this overwhelming cultural negativity, I began reading works from writers who identify with the body positivity or fat acceptance movement. Generally these writers and activists support the perspective that bodies come many sizes, and that all bodies have equal value. They support an idea that health is achievable at all sizes, and question the linear connection between obesity and illness, thinness and health. They stridently assert that people have the right to exist in their body without discrimination, prejudice or commentary. They’re sick of the reductionist view of fat bodies as ill, inferior, and unattractive put forth by society and the medical establishment.

The works of the body positivity and fat acceptance writers are radical, challenging and a breath of fresh air compared to the general vitriol directed at larger bodies. However, I was struck by an underlying question—can a doctor be body positive, but still advocate for weight loss in medically appropriate settings? In many ways the experiences of the body positive writers was divergent from the patients I had seen in clinic. The writers were educated about demonstrated high levels of health literacy. Despite being overweight, many of them were highly active and none disclosed the harbingers of impending metabolic disease such as elevated blood sugar or abnormal lipids.

In clinic, on the other hand, I see many patients with limited nutritional education. One patient lost 30 pounds after cutting sweetened carbonated beverages from his diet. Before talking to a nutritionist, he just didn’t realize how bad the soda was. Other patients face significant environmental barriers to maintaining a healthy weight. Some patients live in food deserts, where access to fresh fruits, vegetables, meat and dairy are limited. For some patients, concerns about neighborhood safety precluded outdoor exercise, along with underfunded parks and recreation centers. Many of these patients would like to lose weight, not to bend to societal norms, but because they saw an uncle’s eyesight decline due to diabetes, or a neighbor struggle after a heart attack. Other patients see weight loss as a tool they can use to avoid taking expensive medications with disruptive side effects. When doctors talk about fighting the obesity epidemic, it’s an effort to mobilize resources to better serve this population.