Fundamentals: 5 Reasons We Need Weight-Inclusive Care

Just a quick note that I will be using the word ‘fat’ to describe body size instead of the medicalised and pathologising terms ‘ob*se’ or ‘overweight’, unless referring to research. Please also take care when clicking links as much of the research here frames body size as pathology and is inherently stigmatising.

Whether you’re seeing your GP or your dietitian, the care you get is likely rooted in assumptions, judgements, and inaccuracies about the relationship between weight and health, as well as the provider’s biases about what your weight says about you. Most healthcare professionals (HCPs), have been trained in, and practice from a weight-normative paradigm. 

The weight-normative paradigm (WNP) isn’t tightly defined. Instead it refers to policies and practices that prioritise weight-loss as the principal means of reducing disease risk, and in many cases, treating health conditions. The WNP is why you might go to see your doctor about a routine prescription or a sore wrist and walk out with a voucher for Slimming World. It's also why your concerns might get down-played or dismissed entirely, instead being told to ‘come back once you’ve lost weight’. It’s why you might get a lecture about bariatric surgery when you show up to A&E with a burst appendix. Or why you might delay going to see the doctor at all, because any notion of ‘care’ seems to dissipate beyond a BMI of 30.

The WNP rests on several assumptions:

1. That BMI can accurately predict how ‘healthy’ someone is
2. That fat bodies are inherently ‘unhealthy’ 
3. That weight loss is universally achievable and sustainable
4. That weight loss always results in better health outcomes
5. That fat people don’t know they’re fat and just need to be told (!!!!!!)

All of these assumptions were baked into my training as a nutritionist; I was told that fat folks were unreliable narrators of their own stories; that they were lying about what and how much they ate; that they didn’t exercise or do anything to ‘help themselves’; and even when my lecturers paid lip service to social determinants of health, body size was always framed as a failure of willpower and a simple physics equation. It wasn’t until I was a post-doc that I started learning about ideas like Health at Every Size and I began to interrogate the ways these assumptions are high in anti-fat bias, and low in evidence.

But evidence (or lack thereof) aside, I came to understand how deeply dehumanising the WNP is. This should, in and of itself, be enough to convince health care professionals that we need another approach. But so rarely do I see fat folks’ humanity convince my colleagues that we need to do better.

That said, there is a small and growing number of healthcare professionals challenging the status quo to help make sure that people across the weight spectrum get the care they need (some of you reading are already doing this work - I see you!). 

We’ll talk about an alternative to the WNP in a bit, but first let’s unpack the assumptions at the heart of the WNP.

1) The BMI is trash