# 7. Challenges to the Weight Centric Health Paradigm

#### **1. Fat Activism** 

 Let’s begin with a word about language. The terms “ob\*se” and “overw\*ight” were created and put into common usage predominantly by the weight loss industry, for the express purposes of pathologizing bodies based on shared size, rather than shared health metrics. They are considered by weight neutral advocates and fat activists to be harmful and stigmatizing. Terms like higher-weight, larger bodied, and person of size (terms that do not pathologize or medicalize fat bodies and that were not used as slurs) are often used as non-stigmatizing terms. “Fat” is a reclaiming term, with all of the complexities that come with reclaiming terms. While there are some people who might be described as fat who absolutely do not align with the label of “fat” (and that is a valid choice,) many fat people have chosen to reclaim the term as a way to reclaim its power. While nobody is obligated to choose to label themselves fat, it is critical that if people are using the term as a neutral/positive descriptor, that we not correct them or suggest that “fat” is a bad word since, even if someone doesn’t align with the term, claiming that there is something wrong with “fat” necessarily adds to weight stigma. In this module, when we use the term fat, we are always using its reclaimed form as a neutral/positive descriptor (like one might describe themselves as tall or brunette.)

 Fat activism, as in collective action talking about fat liberation and fighting against discrimination of fat people, in the United States has been documented from at least the 1960’s. We should note that this history coincides and intersects with US based liberation movements, rights movements, and international anti-colonial movements of the 1960’s and 70’s. The most cited activist moments from this time include a 1967 fat-in in Central Park in New York City, the beginning of the National Association to Aid Fat Americans (NAAFA) in 1969 which later became the National Association to Advance Fat Acceptance in the 1980’s, and the more radical Fat Underground collective which was explicitly rooted in feminism and gay liberation. These organizations were founded and steered by white people leading to what has been challenged as an inaccurate picture of the role that Black women played in fat activism during this time. One of the documented counter points to this white-washed history is the oft-cited[ article by welfare activist Johnnie Tillman](https://msmagazine.com/2021/03/25/welfare-is-a-womens-issue-ms-magazine-spring-1972/) in Ms. Magazine where she includes the dehumanization of fat, poor, women as part of her argument for why “welfare is a feminist issue”.

The range of fat activism in the US today is large. At one end of the spectrum is the modern “body positivity” movement. Body Positivity was originally created specifically for radical fat liberation, but over time and through influencer culture it has, in many ways, been co-opted by relatively thin, predominantly white women, many of whom still hold and espouse anti-fat views and who may or may not consider more systemic and interconnected reasons for fatphobia. On the other end of the spectrum are more radical, anti-capitalist, anti-racist, anti-imperial organizations such as Fat Rose.

##### **Intuitive eating** 

In the 1990’s, two nutritionists Evelyn Tribole and Elyse Resch introduced an anti-diet model called intuitive eating based on years of experience in working with people diagnosed with eating disorders. Their model takes diet culture as the problem and aims to instead work with people to build a relationship with food where they can learn to trust their body. It is important to state clearly that in their work, they are clear that there must not be food rules and that it is explicitly anti-diet in its foundational principles. We emphasize this because in recent years as this approach to eating and treating eating disorders has become more and more prevalent and accessible, some have tried to re-assimilate it into the same old weight-centric health paradigm and promoted it as a diet technique. It is a therapeutic intervention that has to do with taking care of root causes of not being able to be in touch with one’s own body because of trauma - individual, medical, and collective and other societally produced thinking about food and bodies that have people removed from their own relationships with their bodies.

Although intuitive eating along with other pushbacks from fat activism have increased general awareness of the dangers of diet culture, fad diets and the promotion of calorie (or carb) counting continue. The truth is that[ a 100 year history](https://weightandhealthcare.substack.com/p/who-says-dieting-fails-the-majority) of weight loss interventions has shown that the vast majority of people will lose weight short-term and regain it long-term. Still, restrictive diets - whether they seek to restrict calories, certain foods/food groups, times of eating, or all of the above continue to proliferate. In truth, the health of higher-weight people can be supported nutritionally in the same ways that the health of thin people is supported nutritionally - through access to the information and the food that people want to eat and without restrictive diets that focus on body size manipulation.

#### **2. Health Advocacy/Activism** 

##### **A. Overview**

For as long as the weight-centric paradigm has existed, health advocates and activists both inside and outside the healthcare system have been challenging it. The National Association to Advance Fat Acceptance (NAAFA), the oldest fat liberation organization on record maintains a [list of organizations](https://naafa.org/other-resources-1/#fatorgs).They have pointed out that since the beginning, intentional weight loss research has shown that the vast majority of people will lose weight short term and regain it long term, likely due to the physiological changes that intentional weight loss attempts create. Further, the resulting weight cycling (aka yo-yo dieting) is independently linked to health issues including increased inflammation, cardiovascular disease, and overall mortality. Health activists have pointed out that experiencing weight stigma is also linked to physical and psychological health issues including Type 2 Diabetes and hypertension. Finally, they have highlighted the fact that research (often funded by the weight loss industry) that seeks to blame being higher-weight for health issues fails to mention, let alone control for, these confounding variables and conditions that get called “weight-related” or “ob\*sity-related” may actually be weight-stigma-related health conditions and/or weight-cycling-related health conditions.

On the other hand, these advocates and activists continue to create and point to the body of research that shows that weight-neutral health - focusing on supporting health directly rather than on weight loss as a path to health - can provide the same or more health benefits with far fewer risks than weight loss attempts.

These health advocates have, and continue to, challenge the weight-centric paradigm and promote the weight-neutral paradigm through multiple channels including educating healthcare providers directly, educating higher-weight people directly, creating newsletters and websites to provide information, becoming medical advocates who support higher-weight people navigating weight stigma in the healthcare system, and forming organizations like the [Association for Size Diversity and Health](https://asdah.org/), [Medical Students for Size Inclusivity](https://sizeinclusivemedicine.org/), and the [Association for Weight and Size Inclusive Medicine](https://weightinclusivemedicine.org/), for support and advocacy.

##### **B. Advocating as a Higher-Weight Person** 

When one experiences weight stigma in the healthcare system, it is important to begin by reminding ourselves that even though this is becoming our problem, it is absolutely not our fault and it should not be happening. Below are some specific examples.

1. **Declining weigh-in:** Many higher-weight people choose to decline weigh-ins that are not medically necessary. This can be done for many reasons including avoiding something that can be an eating disorder trigger, and avoiding practitioner weight distraction. There are many options for this from just saying “no thank you” to saying “I’m exercising my right to informed refusal of a non-medically necessary weigh-in.” If there is a legitimate medical reason and you choose to move forward with a weight measurement, you can still request to turn around and not view the weight or be told the weight (remember to ask for it to not be added to your chart in this digital age).
2. **Declining weight-loss recommendations:** Patients have a right to healthcare that is based on their own values. For patients who are seeking weight-neutral care, that means declining weight-loss recommendations. This, again, can be accomplished in many ways. One short-cut is to ask the healthcare provider “what would you offer a thin person with this same health issue?” Another is to again say that “I’m exercising my right to informed refusal of weight loss interventions, please move on.”
3. **Asking for accommodation:** Because the healthcare system was built for thin bodies, higher-weight people can find themselves unaccommodated. That can be anything from a lack of sturdy armless chairs, and properly sized blood pressure cuffs, gowns and more to an MRI that fails to accommodate. Here it is critical to remember that you as the patient are NOT too big, the healthcare being offered to you is too small. Healthcare should fit the people who need it, people shouldn’t be asked to change themselves to fit into healthcare. You have the right to ask for accommodations and if the healthcare environment cannot accommodate you, that is not your fault. You may be able to escalate the request or find an alternative facility.

##### **C. Advocating for Higher-Weight People**

If you are someone who doesn’t live in a larger body, you can still help advocate for higher-weight people to have equity in their healthcare experiences. Below are some options

1. **Decline weigh-in:** You can help to normalize taking the focus off weight by declining weigh-ins that are not medically necessary. You may begin by saying something like, “no thank you” or ask “why do you need my weight?” depending on your comfort level. It is likely that you will be told that you can just turn around and not look at the number. One possible response to this is “Weight is a poor measure of health” or “Oh, I don’t do weight measurements because it is meaningless for health.” You may end up having a good conversation with a nurse or other healthcare worker who is simply tasked with taking weight and also knows it’s not a good measure of health but is told they have to do this as part of their job. If you want to go further advocating around this practice, you can talk to the doctors who own the practice about removing it as a default. If possible, you could join with other patients to push for this as a change. It has been removed from some doctors offices because of advocacy from patients and therapists and could be a small yet powerful act of local activism (see below for further steps you can take once you are having these conversations). This can help higher-weight people as well as people of all sizes who struggle with disordered eating and eating disorders, or who would prefer not to be weighed publicly. .
2. **Ask for inclusion:** Look around the healthcare provider’s office and notice if there is a lack of inclusion. If you look around the waiting room or the treatment room and you don’t see any armless chairs or loveseats, ask who to talk to about that. Discuss the need for chairs that work for people of all sizes.
3. **Accompany a higher-weight friend/family member:** While it’s very wrong, higher-weight people are often treated better when they are accompanied by someone else. You don’t have to have any specialized knowledge (or even talk,) just being there can be supportive of your loved one. You can chat with them beforehand to see what would make them feel the most supported. Do they want you to speak to them? To the provider? Do they want to arrange a signal (like tugging on their ear) to let you know that they want you to step in? Again, just being there can be incredibly helpful.

##### **D. Advocating within the Healthcare System**

If you work in the healthcare system, you can do a lot to create change. Start with the areas where you, personally, have privilege, power, and leverage to make change. Then form coalitions to create more privilege, power, and leverage.

1. **Advocate for inclusion:** Make observations about your space - what are the things that thin people can access that higher-weight people can’t? Are there sturdy, armless chairs everywhere that a patient might sit down? Are there gowns in the largest possible sizes? Are there properly-sized blood pressure cuffs (thigh or [troncoconical](https://weightandhealthcare.substack.com/p/the-need-for-troncoconical-blood)) at every station where vitals are taken? If your facility provides imaging, know the weight capacity and bore size (if applicable) of the equipment. Make this information public both on your website and to all patients when they book in. If you can’t accommodate a patient for any reason, apologize on behalf of the facility (even if it’s not your fault,) assure them that the equipment is the problem, not their bodies, know where to refer them to reduce the chance that they will disengage from care.
2. **Advocate for Education:** Ask for weight bias training <sup>9</sup> (and make sure it’s not coming from the weight loss industry or the “patient advocacy groups” they fund such as the Ob\*sity Action Coalition). Ask for education about the weight-neutral paradigm. That can include everything from conferences, to CMEs to office lunch-and-learns. Bring in experts to help you create the most size-inclusive space possible.
3. **Fight weight stigma:** Work to create an environment where fat-shaming, negative body talk, and diet culture including negative talk about certain foods are seen as unacceptable. They can create a hostile work environment for higher-weight healthcare workers and they create a dangerous environment for higher-weight patients. Interrupt this kind of talk. You can say something general like “I wish we could affirm bodies of all sizes,” or something specific like “that’s weight stigma, we don’t do that here.” Don’t let weight stigma go by unchallenged. If patients talk negatively about their own bodies, you can say something like “I hate how the world teaches people to hate their bodies, instead of helping everyone see that their bodies are valid, amazing, and worthy of love and care.”

<p class="callout info">9. Ragen Chastain, one of the authors, offers this type of training [https://www.sizedforsuccess.com/healthcare.html](https://www.sizedforsuccess.com/healthcare.html)   
So do Medical Students for Size inclusivity [https://sizeinclusivemedicine.org/](https://sizeinclusivemedicine.org/)</p>