The Lady Bears, fat activists, educators and artists JDP and Sookie Bardwell, continues their practical guide to creating a ‘a fat medical utopia’. The second part focuses on medical education and personal responsibility.
3) Evidence based medicine
Our bodies operate just like many others. We just have a coating of adipose tissue which our bodies are using to protect us. Please stop using the BMI as a system to measure our health, and to shame us into changing our bodies- doing so is more likely to negatively impact our health and well-being by contributing to the excess stress we’re already experiencing as a result of weight stigma and discrimination and encouraging disordered eating and dangerous weight cycling. The BMI scale is an ineffective and inaccurate measure of health. The originator of the scale, Lambert Adolphe Jacques Quetelet, was a mathematician, not a physician. He designed this measure to be used by governments to assess the way in which resources would be allocated to whole populations, not as an assessment tool to indicate the “level of fatness in an individual” (NPR 2009). It is not only scientifically nonsensical, but also doesn’t account for differences in the proportions of an individual’s bone, muscle, and fat and how these may be distributed differently on different bodies (NPR 2009; Vox, 2018). Simply assessing where our bodies fall on the BMI scale does not provide an accurate measure of our health. What it does do is to ensure we receive poor treatment from practitioners who remain focused on this outdated, inaccurate and ineffective model; and that we are shouldered with paying extra money to insurance companies for literally the same thing as everyone else.
Junk Science Isn’t Good Science.
Science is not value neutral and it’s important to remember that your personal biases, social stigma and the influence of the market on research funding can impact the “problems” that we identify and the hypotheses that we create in addressing them. The idea that all human bodies should conform to a narrowly defined “acceptable” weight range ignores the reality and beauty of the body diversity that exists. For a fun exploration of body diversity please idea please watch Poodle Science.
Obesity research is commonly funded by companies who are invested in selling weight loss (Charles, 2021; Harrison, 2019; Moodie, 2016; Thomas, 2005). The Diet Industry is a multi-billion-dollar enterprise which thrives on perpetuating the idea that our fat bodies are “the problem” so that it can market products to “solve” it (Charles, 2021; Harrison, 2019; Moodie, 2016; Thomas, 2005). The reality, however, is that long-term maintenance of weight loss is rare and incredibly difficult (Bacon & Aphramor, 2011; Hall & Kahan 2018). Approximately 80% of those who lose a substantial amount of body fat are unable to maintain this change for even the subsequent twelve months and are likely to regain more than half of the pounds they have shed within two years (Engber 2020). And, while intentional weight loss is unlikely to bring about a lasting change in body-size, it is highly likely to result in lasting adverse psychosocial impacts, including social difficulties and exclusion, low self-esteem, depression, disordered eating and other mental and emotional health concerns; and physiological consequences, including dysregulated metabolism and cardiovascular stress (Daee et. al., 2002; French & Jeffrey, 1994; Wadden et. al., 1996).
There’s pressure on practitioners to maintain the status-quo around how we understand fatness from peers being impacted by the same knowledge systems (Flegal, 2021). Use your critical thinking skills and check your sources. Who is providing you with the research indicating that long term weight loss is possible? What effects will that have on your patient’s mental health? How will it affect them to be on medication or following food restrictions which offer weight loss? Is this sustainable over the long term? Please start to question your source material. Question your biases. Why are you so willing to believe that weight loss in a sustainable way is even possible? How will that affect your patient on an ongoing basis?
4) Adequate training on fat bodies
If you feel that you can only offer healthcare to patients in smaller bodies, start to unpack that. Why do you feel this way? Do you feel like there are gaps in how you understand what fatness means for and in a body based on the information you’ve had access to? How can you access information to fill in these gaps or to correct misconceptions based on the aforementioned impact of the Diet Industry in weight research? Were there absences in the training you received that impact your confidence in providing care to fat patients? Use your position and power to advocate for pre and in-service training that considers body-size diversity and includes clear and evidence-based information about how to serve patients in larger bodies so you can offer equitable healthcare to everyone. We all deserve competent, affirming, respectful and effective (C.A.R.E.-ing) healthcare!
5) Removing personal biases – Access Education
Start by asking yourself how you know what you know about fat bodies, and how this knowledge is impacting the care you are able to provide. Take action to develop an understanding of what weight bias, stigma and discrimination look, sound and feel like (Obesity Canada info-graphic); how they show up in healthcare- including in your own attitudes and practices (Fruh et. al., 2016; Hebl & Xu, 2001; Miller et. al., 2013; Rubin 2019; Sabin et. al., 2012); how they impact the quality of the care you are able to provide to your patients; and the outcomes that this has for us (Cody Standford, 2019; Lee & Pausé, 2016; Phelan et. al., 2015; Sagi-Dain et. al, 2021). The National Association for Fat Acceptance (NAFFA) has some excellent resources, including “Guidelines for healthcare providers with fat clients”. If you’re looking for somewhere to start, check out the “NAAFA Healthcare Bill of Rights©” and make an effort to ensure that the care you’re offering to your patients is in alignment with the ten declarations around equitable treatment for people of all body sizes. If this feels difficult or impossible, ask yourself why?
Think critically about the language you are using when you talk about fat people and our bodies, and the individual and collective impact that language can have. Make space for us to share the language that feels most comfortable for us. The language of ob*sity is something that many of us experience as violent since it’s wrapped up in a system of Medicalized Fatphobia which de-facto pathologizes our bodies, and is rooted in the inaccurate BMI scale (ob*se and overweight- over what weight, exactly?) Further, the term “Morbid Ob*sity” emerged from bariatric medicine as part of a push toward stomach modification surgeries (American Obesity Treatment Association, n.d.). It didn’t exist prior to these (dangerous) surgeries. It’s now a term used widely in medical circles, and you need to drop it from your vocabulary immediately if it’s part of how you understand and talk about fat bodies.
Cultivate a thorough understanding of the connections between fatphobia and other forms of oppression. Fatphobia is rooted in and perpetuates anti-Black and anti-Indigenous racism (Strings, 2019), healthism and ableism (Finoh, 2020), and gender-based oppression including binarism, cissexism and misogyny. Critically consider how these oppressive systems impact your attitudes, speech and behaviours, and how you can actively work to unlearn them and address the harms they do to and through all of us with immediacy.
Become informed about toxic diet culture and its impacts and interrogate how it shows up in how you view yourself and others, what you say, and how you provide care. Consider the impact of Toxic Diet Culture in how you view and treat fat patients- remember the aforementioned impact of Diet Industry funding on the data available around the Ob*sity Epidemic and the health concerns we associate with having a larger body (Charles, 2021; Harrison, 2019; Moodie, 2016; Thomas, 2005).
Make an effort to learn about size-inclusive frameworks and practices including Health At Every Size (HAES) (Bacon, 2021; Bacon & Aphramor, 2011) and Intuitive Eating (Tribole & Resch, 2013; 2019). If you’re unfamiliar with what it means to engage in Body Liberation-centred (Baker, n.d.) approaches/practices, find opportunities to learn more so that you can provide more size-inclusive and equitable care to everyBody who comes into your practice. If you’re unfamiliar with the Association for Size Diversity and Health, start by checking out their website where you can find some excellent resources to help you get started.
If you don’t currently understand it as such, do whatever you need to do to recognize that Fat Acceptance is a Social Justice issue like any other (McPhail & Orsini, 2021). One way to start is by becoming informed about the many efforts that fat activists have made to support other fat folks around the health inequities that we experience. These include individual efforts like Ragan Chastain’s Doctor’s Office Survival Kit resources – which consists of simple info cards that patients can hand to their practitioners in order to assist them in self-advocacy and is part of her larger efforts to address and intervene in Medicalized Fatphobia; and collective efforts like the #NoBodyIsDisposable campaign which emerged in response to the Medical Fatphobia impacted fat folks’ access to care during the ongoing COVID-19 global health crisis.
Conclusion
We know that it can be difficult to completely reconfigure how you (have been taught to) think about fat people and our bodies but doing so is necessary in order to improve the quality of care that you’re able to offer to all of your patients. In all likelihood, you went into healthcare because you wanted to help people access health and well-being. Making sure that you’re able to practice in a size-inclusive, equitable way will ensure that you’re able to do so. We believe in you!
About the Authors
JDP (they/them) is a Fat activist, community organizer, peer counsellor and white settler on Treaty Six Territory in so called Canada. They have been educating doctors on their biases and fighting for better healthcare for the last 10 years. Ask them about how they convinced a third doctor to finally treat them for cancer via surgery instead of weight loss.
Sookie Bardwell (she/her/hers + they/them/theirs) is passionately committed to the work of helping people be better together. She is a white settler invested in the work of decolonization and racial justice. They are also a fat, queer, genderqueer femme living with invisible disability. Her work is informed by all of these ways in which she moves through the world. Sookie is a multimedia artist and co-editor of the Far Too Fat Zine. She is also an OCT certified teacher and Opt BC certified sex and relational health educator, who holds an MA in Gender Studies and Feminist Research from McMaster University where her research focused on self and community/collective care for support and social justice workers. They are also a founding member and the Director of Content Development and Learning Design with the Challenge Accepted Learning Collective. She has been involved in social change/justice work for almost twenty years as an educator, trainer, and facilitator on topics including LGBTQ+ equity and inclusion, Body Liberation, emotional and relational skills, and sexual health. She is honoured to do this work alongside her Challenge Accepted, Chub Love, and Body Buddies collaborators in a wide variety of spaces including through her relational coaching work, as part of student wellness and anti-violence programming on elementary, secondary and post-secondary school campuses, in workplaces in both corporate and not-for-profit settings, and in providing support to folks seeking healing from distressed and disordered eating. They believe that everyone deserves to be treated like a person (i.e. with basic respect and decency), and that we all deserve access to- and have the capacity to develop- the knowledge and skills needed to move through the world with compassion, kindness and a genuine curiosity in encountering difference.
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