The real dangers of an obesity diagnosis

Erika Grotto: The real dangers of obesity, today on HFMA’s Voices in Healthcare Finance podcast. 

Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, we’re talking about weight bias in healthcare and the devastating consequences it can have on patients. I’m thrilled to have Ragen Chastain, a speaker, writer, medical researcher and board-certified patient advocate on the podcast discussing how harmful a diagnosis of obesity can be, and it’s not necessarily for the reasons you might think. But first, let’s find out what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack. 

Nick Hut: Alright, everybody. We are discussing a blockbuster deal that took place within the last few weeks in which CVS Health acquired the primary care provider Oak Street Health for $10.6 billion. I’m happy to be corrected on this, but by my count, that’s the most money that any of these retail providers have shelled out for a healthcare company, and it’s actually the first such transaction to exceed the $10 billion. So with the usual caveat that the purchase has to pass regulatory inspection, it certainly has the potential to affect the industry landscape, particularly in the context of primary care and value-based payment. Shawn, when you heard about this deal, what was your reaction?

Shawn Stack: Well, Nick, if this goes through, I agree. This could be a landmark jump into value-based care. I mean, with CVS purchasing Oak Street Health and along with their previous acquisition of Signify Health, my calculations say they have about $20 billion to play with for value-based care and primary care and then of course home-based care initiatives. So that’s pretty exciting, right?

Hut: It is. The implications remain to be seen and as you alluded to, CVS Health has proposed spending—I think the precise figure is $18.6 billion between this and the purchase last fall of Signify Health. And of course, Signify has a sophisticated analytics platform that supports providers of various aspects, including the home health assessments—kind of their bread and butter—and ACO participation. So combine that with the fact that now they’ll have a foothold in primary care to go with their retail care outlets and obviously their pharmacy services, and they’re really becoming a factor in many segments of the healthcare ecosystem. So if they start drawing business away from traditional providers, especially among Medicare Advantage beneficiaries, what would be an effective strategic response? We’ve done a good amount of content over the last year on healthcare disruption, and I know you’ve been advocating for efforts to look to partner with some of these disruptors.

Stack: Yeah, Nick. I mean, with this purchase—Signify is in Chicago and in Detroit now, and I would assume that CVS is looking to expand that footprint. And then along with United Health Groups, Optum and LHC Group, which is primary and post-acute care, and then Walgreens Boots [Alliance], Village MD and CareCentrix, which is post-acute care, this starts to eat up a lot of the healthcare ecosystem like you were saying. So you know, a hospital in those areas where this expansion is going on, reaching out, getting referral relationships with these giants could be very beneficial, not only to the hospital to stay relevant in some of these markets and some of these services, but also to the patient because we still have concerns over continuum of care, fragmented care with all this disruption going on. So it’s really in the best interest of the patient and those new disruptors to lean on those very solid legacy providers that are hospitals and established primary care networks.

Hut: Yep. Because one area where none of these disruptors has really made an incursion to date is acute care hospital operations. I wonder if someone like CVS Health, through Signify, might launch an acute care at home program that gains traction. But that’s a very heavy lift, so certainly what you might think of as hospitals’ core services, probably in the foreseeable future won’t be at risk. But very intriguing to see how all of this plays out.

Stack: Yeah, I would agree, Nick, but I think that the thing that hospitals and legacy providers need to keep in mind here are, these are typically the cream of the crop services. This is not typically the Medicaid population or, maybe the Medicare Advantage population where they’re getting a premium over Medicare rates, but also commercial volumes that are going to a lot of these groups. So it definitely is worth beginning to think strategically over how you’re going to build relationships with these disruptors who are really jumping into that value-based care arena.

Hut: Gotcha. Yeah, so it’s the real moneymakers in terms of services that may be at risk right out of the box. Well, alright, hey, thanks Shawn. I think that does it for us, and we’ll talk to you all next time.

Grotto: In January, the American Academy of Pediatrics released new guidelines related to childhood obesity, including interventions starting as early as age 2 and recommending weight loss surgery for children as young as 13. But according to my guest today, the label of “overweight” or “obese” is problematic in and of itself, inviting discrimination and dangerous treatments. Ragen Chastain is a speaker, writer, medical researcher and board-certified patient advocate focusing on the intersection between weight science, weight stigma, health and healthcare practice. This is an interview that might leave you with some questions, particularly about the body mass index, or BMI, a measure based on height and weight used to diagnose overweight and obesity. It’s a standard measurement we’re all familiar with, ubiquitous in healthcare, but according to Chastain, the BMI is deeply flawed. I’ve included several links with additional reading in the show notes, and we mention a few in the interview. When it comes to higher weight patients, Chastain prefers a word that’s taboo in healthcare and society at large, so we started our conversation with a little discussion of vocabulary. 

So, before we get into my specific questions, I want to talk briefly about a word that we’re going to use that might make some people blanch a little bit, and that word is “fat.” Tell me about your relationship with that word.

Ragen Chastain: I love to talk about fat. So “fat” is my preferred descriptor for myself. For me, it’s a reclaiming term. It’s kind of a way I tell my bullies they can’t have my lunch money anymore. You can’t insult me by simply accurately describing my body. It’s also important that it’s not a term that medicalizes or pathologizes my body. So the words “overweight” and “obese” were literally made up for the purpose of pathologizing higher-weight bodies, and so overweight is just sort of an overtly stigmatizing term that says there’s a right weight and you’re over it. Obese actually comes from a Latin root that means to eat until fat, so tons more stereotype than science there. And then, now the diet industry has gone to this person-first model, of a person with obesity or a person with overweight. And first of all, fat phobia gives me enough problems without making me grammatically problematic as well. But beyond that, this is not about reducing stigma. This isn’t coming from weight-neutral health community. This isn’t coming from fat liberation community. This is coming from the diet industry. Their big goal is to have simply existing in a higher weight be considered a lifelong chronic health condition because then they can sell their products to us for the rest of our lives. And so this idea of person with obesity or person with overweight exists only to further medicalize and pathologize higher weight bodies and actually becomes more stigmatizing because it means that your fat body is so terrible that we have to find a semantic workaround to talk about it. Nobody’s saying, “oh, the person affected by thinness.” In my life, no one’s ever said, “Oh my gosh. Don’t call yourself brunette. You’re just a person with brown hair.” So we don’t do person-first language for things we don’t think are a problem. And I also want to point out, it’s coopted from disability community, where it is also quite controversial. And so I recommend people read authors from disability community know more about that. But it was sort of just coopted whole cloth from the disability community by the diet industry. I prefer “fat.” I also will use “higher weight” or “larger bodied.” Basically anything that accurately describes higher weight bodies that doesn’t pathologize them and wasn’t used as a schoolyard taunt. Not everybody aligns with fat who might be described that way, and that’s totally valid. So those terms like “higher weight,” “larger bodied,” “people of size”—those can be more neutral for folks.

Grotto: So what are we talking about, because I do want to kind of define that. In healthcare, “overweight” and “obese,” those are the terms that people are familiar with. They’re the terms people use. When you say “higher weight,” higher than what? “Larger bodied,” larger than what? What  makes a fat person a fat person? Is there a definition?

Chastain: So it’s difficult to pin it down, because there are sort of degrees, right? Some people who are fatter than other people, within fat community we often use terms like “small fat, mid fat, large fat and super fat” based on essentially issues of access and issues of structural stigma. So for example, a smaller fat is going to have more access to clothes. More doctors offices are going to have a gown that fits them. Same with mid fats. When people start to get to be large fats, which is like when you look at a size 26, 28, then there’s less access. More equipment won’t be rated for those people. And then when we get to “superfat” folks, who are folks who are typically size 30 to 32 and above, folks who are having the least access, there’s the least chance that when they walk into a restaurant they’ll have a seat that fits them., that in the waiting room, there will be an armless chair that works for them, that the MRI will fit for them. And so it’s a matter of degrees. The thing about the ideas of “overweight” and “obese” that are based on body mass index—which, like all of weight stigma, is rooted in and inextricable from racism and anti-blackness—the problem with that is that one, it’s been malleable over time, directly through the influence of the diet industry. So what’s considered normal weight has been shifted over time. In 1998, it was shifted so that over 20 million people became “overweight” literally overnight. So when we think about these terms, we think of them as very scientific, but they’re basically  just based on a ratio of weight and height that has been, again, malleable over time.

Grotto: Thank you for kind of framing that a little bit. It can’t be—especially, I think, for the purposes of this conversation—it can’t be just that fat is whatever you, the individual, think it is. It might not be exact, but—

Chastain: Yeah, it gets complicated, right. Within our culture, fat can be defined as different things. So for a ballerina, what they’re considering fat is going to be different than what the rest of the world considers fat. When we talk about this in a medical context, we’re talking about people for whom their healthcare is often focused on manipulating their body size rather than providing the same ethical, evidence-based treatments that a thinner person would get.

Grotto: Yeah.

Chastain: And then looking at structural stigma, how is this person’s access to the world different? We know that perceived weight stigma can do a tremendous amount of harm. So even if somebody thinks that they’re fat, their perception of their own fatness, their perception of the stigma that comes with that, can impact them. So weight stigma can harm people at all sizes, but it will always do the most  harm to those at the highest weight and those with multiple marginalized identities.

Grotto: You touched on the BMI being rooted in racism. I want you to tell me about that.

Chastain: Sure. So Quetelet was a statistician in the 1800s, and he was looking to figure out the proportions of his “ideal man.” In his own words, anything that deviated that would be deformed and monstrous. And so he took all of these measurements to find this ideal man, but he was pretty sure that the ideal man was a cisgender, European white dude because those are the only people he included in his sample. And so you’ve got this measurement that was created specifically for cis, white men that’s now being applied, you know, to people of all sizes. And then, in general, weight stigma itself is rooted in white supremacy and racism and anti-blackness. It’s not my scholarship, so I don’t want to like be the white person who’s whitesplaining racism, but cannot recommend enough reading Sabrina Strings’ Fearing the Black Body and Da’Shaun Harrison’s Belly of the Beast to really educate yourself about the ways that not only is weight stigma rooted in and inextricable from racism and anti-blackness but is disproportionately impacting those communities today.

Grotto: Good recommendations. I want to check those out. I was really thinking of the BMI when I wrote this question, but I’m sure there are others that you can talk about here. What are the practices and systems that the healthcare industry uses that not just don’t help but actively harm fat people and maybe more importantly, erode their trust in provider organizations?

Chastain: Yeah. So clinging to this weight loss paradigm after a century of data tells us that almost everyone who attempts weight loss will lose weight short term and gain it back, and then just telling them, “OK, but try again” over and over for essentially what will be the rest of their lives, we have to move away from that. And people are starting to learn that weight loss almost never results in long-term significant success, and so it makes them also question the rest of their provider’s recommendations. If this person is so wrong about this, what else are they not getting right? But also, it creates a situation where when finally, the healthcare system is starting to recognize, yes, calories in calories out is not all there is to body size, they’re only doing that in the service of more dangerous, more expensive recommendations. So fat activists and weight-neutral healthcare practitioners have been saying literally for decades if you look at the research, about 95% of people lost weight short term, gain it back long term. Up to 66% gain back more than they lost. So this is not an ethical, evidence-based intervention for anything. And finally, seeing people say yes, that’s true, but only in the service of selling things like weight loss drugs and surgeries that are far more dangerous and that risk fat people’s lives and quality of life. So that, to me, is the first piece. Failing to accommodate fat people, justifying that lack of accommodation by saying, well, they’d be accommodated if they were thin, and then blaming the negative outcomes of that lack of accommodation on fat people’s bodies is a cycle that has to end. Holding healthcare hostage for a weight loss ransom. This happens when are faced with BMI limits for healthcare that they need. So it could be a joint surgery. It could be a gender affirmation surgery. It could be, in some cases I’ve had people come to me for help—they’re a chronic pain patient and the doctor said, “I won’t refill your medication unless you weigh 10 pounds less next time you come in.” That’s not ethical. That’s not evidence based. That’s not patient-centered care. That’s holding someone’s healthcare hostage for a weight loss ransom. And the more that that practice happens, the less care that patient can access, and again, the negative impacts of that tend to get blamed on fat bodies rather than on the system. And then the last thing I’ll talk about—well, second to last I guess—is this idea of, whenever in the research we find that being higher weight is correlated with a higher incidence of a health issue, that’s where the science stops. And we say, OK, well obviously it’s because they’re higher weight and weight loss is the solution. And as somebody who’s a researcher, that’s just like a first day of research methods class mistake. If you have two things that are correlated, you’re not allowed to stop and just say one causes the other. You have to look at what else could impact this relationship. And we know that weight cycling, or yo-yo dieting, the most common outcome of weight loss attempts, weight stigma and healthcare inequalities are all correlated with the exact same things to which being higher weight is correlated. And so in research that blames body size for health conditions and health issues, it doesn’t even mention these other confounding variables, let alone control for them. And so that’s a huge problem. And then the final thing I’ll talk about is the weight loss industry is so utterly enmeshed in the medical industry in ways that have allowed it to really steer the ship when it comes to patient care for higher weight patients and standard of care for higher weight patients.

Grotto: There’s so much there that I want to untangle. There were a few things you said that I think are really noteworthy here. One is holding hostage care. You know, I mean, that is unconscionable.

Chastain: Often, people who are denied surgeries because of BMI limits—right, so they needed joint surgery, gender affirmation procedure, and they’re denied that—will then be referred to weight loss surgery, which is ridiculous, right? They’re like, oh, it’s too difficult to do anesthesia at your size, but somehow we can do anesthesia if you’re willing to let us mutilate your perfectly healthy digestive system to put it into a permanent disease state. Suddenly that becomes safe.

Grotto: Yeah.

Chastain: And so there again, it’s predicating risk on size rather than focusing on health. And beyond that, often the excuse is, oh, well, it’s more difficult to do this procedure for higher weight people or they require more resources or they don’t have the same outcomes that thin people do. And that’s not surprising given they’re entering a healthcare system that was created for thin bodies. From the research, the best practices, the pharmaceuticals, all of that—the tools, all created for thin bodies. And the idea that a fat patient won’t have the same outcome as a thin patient then they don’t deserve care at all is ridiculous and really dangerous. We know that for joint surgery for example, pain reduction is a worthy goal even if their pain reduction might not be the same as a thin patient. So that’s still a worthy goal, and if they need more resources, then they need more resources. The idea that only the patients who need the least resources should get healthcare becomes a pretty slippery slope pretty quickly in terms of then who doesn’t get to get care. So a lot of that is really just pure weight stigma and really people based in this idea that thinness is possible for people despite the evidence that it’s really not for the vast majority of people and that fatness is the reason for inequality or lack of care, then that inequality or lack of care is justified.

Grotto: Something else that you brought up is just equipment. And it can be something from a blood pressure cuff to, you mentioned MRI I think.

Chastain: We can hear the weight stigma in the way that this is often addressed. You’ll hear someone tell a patient, “You’re too big for the MRI.” Like, no, the MRI does not accommodate the patient. We don’t make people work for machines. We make machines work for people. And we’re seeing more of that, wider bore MRIs, more options for open MRIs and things like that, but there’s so many barriers to fat people getting care and that then cause them to present with a more advanced case. And then all of that gets blamed on their body size rather than on looking at the lack of care from beginning to end of that patient’s cycle.

Grotto: So we’re talking about some pretty serious systemic stuff. What can individuals do, and what can help turn the tide? You mentioned before we started recording that the audiences that you speak to are getting a little bit more receptive to some of these things you talk about. Can you talk about that a little bit?

Chastain: Absolutely. And folks on the finance side can be heroes here. So the first thing to do is to look at whatever power and privilege and leverage you have, what can you do? So essentially, look around and see, in what ways are fat patients not having the same experience as thin patients, and how can we solve that? So it might be, we don’t have gowns for our higher-weight patients, and we tell them two wear two—which, by the way, is ridiculous. I don’t know if you’ve ever told a patient this or thought about this, but go get two shirts that are too small, try to wear both of them to cover yourself—not actually a great idea. So we can get more gowns. If there’s a blood pressure cuff in every room that works for thin patients but there’s only one thigh cuff and everybody has to scramble around to try to find it, that’s a procurement issue. We need more thigh cuffs. We have to get more conical blood pressure cuffs for higher weight patients. So finding those inequalities and solving them and then finding like-minded people and getting together to work within your system to create bigger change.

Grotto: Say more about that.

Chastain: If you’re somebody who sees the value into a weight-neutral perspective where we’re really focusing on the health of people at all sizes rather than body size manipulation for people at higher weights, then finding like-minded people and working to see, how can we do that. How can we, you know, stop taking routine weigh ins when they’re not medically necessary and when they often do harm to higher-weight patients. How can we focus on patients’ health rather than patient size? And learning more, getting education, bringing in speakers and medical education and helping to convince other people and making that shift.

Grotto: You’ve mentioned weight neutral a couple of times. I want to ask you about that. Is that the right perspective? Do we want to be weight neutral, or do we want to simply not be stigmatizing weight?

Chastain: So I think being against weight stigma is a good first step. But that also is currently being coopted by the diet industry. So people have been doing anti weight stigma work for decades, and now we’re seeing the diet industry coopt that to say, we don’t want to stigmatize fat people, but we definitely want to eradicate all of them from the earth, prevent any more from existing and hopefully make billions of dollars doing it. That’s not actually an anti-stigma approach. So ending weight stigma is an important and worthy goal, but I think a move to weight-neutral care is what the research tells us is the best option to care for higher-weight patients. And actually, I think weight inclusive care would be best, but we’re a long way from being able to do that. So weight-neutral care simply says people of all sizes get these health issues, so we’re going to give people of all sizes the same ethical, evidence-based treatment, so that it’s not, a thin person comes in and gets a recommendation for medication or lifestyle changes or surgery and a fat person comes in with the same symptomology but gets a diet instead.

Grotto: OK.

Chastain: Or a recommendation for dangerous pills or surgery. So weight-neutral care says we care about people’s health in the body size they’re at rather than we care about body size manipulation for higher-weight people as the primary go-to.

Grotto: OK. That makes sense to me, and maybe weight inclusive is what I really meant to ask about. 

Chastain: It’s hard, because patients do want weight loss, and they don’t want weight loss out of nowhere. They’ve been told their whole lives that that’s the only way for them to be healthy, so that’s where a healthcare practitioner can come in and say, look, we’ve been working in a really failed paradigm for a long time, and your experience of losing weight and gaining it back and losing weight and gaining it back, that’s almost everybody’s experience. And that weight cycling can do harm. So what we want to do is stop that cycle of yo-yo dieting that you’ve been in and look at supporting your body and your health. And we can do that using the same interventions, the same health-supporting behaviors that we would recommend to a patient of a different body size. And this is the thing about using weight as a proxy for health. There are people of the exact same size with wildly different health statuses. There are people of very different sizes with the exact same health status. So by using weight as a proxy for health, what we do is a disservice to everybody because we’re not focusing on their health. The American Academy of Pediatrics just came out with guidelines for higher weight children, and they recommend intensive health and behavioral lifestyle treatment as young as two years old, and they say that they need to get better at categorizing kids who are younger than two so they can begin their interventions earlier. They recommend diet drugs to kids as young as 12, and they recommend weight loss surgeries, which literally take a healthy digestive system and put it into a permanent disease state, to kids as young as 13 years old. The guidelines came out on a Monday, and I was giving grand rounds of Childrens of Minnesota on Thursday, and so I had to become an expert in these guidelines really fast. And it was so horrifying. They say repeatedly that what they’re recommending will not lead to sustained, long-term, significant weight loss. So what these guidelines do is essentially repackage weight cycling as a successful intervention. And there’s even a little graph about it, right, that the treatment has to increase and decrease for what they’re calling the relapsing, remitting quality of quote unquote obesity, which is literally saying weight cycling for the rest of your life is what is normal. And they say we should start at two and then we should expect that treatment to last for their whole life.

Grotto: So we’ve covered a little bit, you know, kind of the provider’s role when it comes to patients and their weight, and focusing on the health indicators, the health outcomes rather than saying well, there’s a fat person in front of me so therefore you must be unhealthy. What do you think about the role of the health plans, the payers?

Chastain: Yeah, so there again, often health plans and coverage can become a barrier. They often will be the ones instituting a BMI limit or suggesting that weight loss should be attempted before another treatment is offered, so addressing those issues so there’s a focus on the health of the patient and their healthcare is not being, again, held hostage for a weight loss ransom. Driving in whatever way—again, it goes back to using power, privilege and leverage, and what way can they create an environment that focuses on health rather than body size manipulation and in what way can they decrease the barriers to higher weight people getting help and what way can they increase access for fat patients to tools and spaces that accommodate them.

Grotto: And what about the patient? What is the patient’s role when they are faced with these conversations, which I imagine happen if not every time they walk into a provider’s office, almost every time.

Chastain: Yeah. This is hard, and I teach hour and a half workshops on trying to access healthcare as a higher weight patient. My basic  principle is, sometimes you have to do what you have to do to get what you need. Sometimes it’s saying hey, can we talk about this research? Can we talk about—my understanding is that this intentional weight loss intervention you’re suggesting fails 95% of the time. Is that accurate? I would like something that’s a little more successful. And then sort of the key question that I find is, what do you do for thin patients with this issue. Because sometimes that can bypass the whole discussion. I’m an expert in weight science evidence. I talk about this professionally. And there are still doctors who feel like they don’t have things to learn from people who aren’t doctors. That can be tough. So as a patient, you’re in a power imbalance, and if you’re a patient with marginalized identities, you’re in even more of a power imbalance. So sometimes you can sort of cut through all of that and just say, you know, I’m willing to talk about a diet maybe, but can we talk about what would you do for a thin patient with the same symptomology, and can we try that? But it’s really difficult, and I always—whenever I do one of these workshops, I say, this workshop shouldn’t be necessary. It shouldn’t be happening. You shouldn’t have to develop techniques and study up for a doctor’s appointment, but this is the state of healthcare for higher-weight patients, and so I want people to have the tools to get the healthcare that they need or at least to try with the understanding that this isn’t our fault but it becomes our problem, and often we don’t have the power, the privilege or the leverage to solve it.

Grotto: This has been so informative. Ragen Chastain, thank you so much for joining me today.

Chastain: Thank you for having me. If I can offer one tiny, final little thought?

Grotto: Absolutely.

Chastain: So we all know the story of Galileo, right. He was put under house arrest and called a heretic for questioning the idea that the sun didn’t revolve around the earth. What interests me is that in his time, his contemporaries refused to look through his telescope. So it wasn’t that they looked through and say this telescope is poorly made or your math is off. They just wouldn’t look. And I find a lot of that attitude when it comes to looking at the current paradigm, looking at the weight loss versus weight neutral paradigm. So my ask is, if you felt angry or defensive or in disbelief around anything that I’ve said, I felt all of those feelings in the 20 years that I’ve been digging into this research. So that’s valid, and that is a time when you feel that they I offer you the invitation to explore and to look through the telescope and to dig further. And please feel free to reach out to me personally if I can help with that.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Additional writing and research are done by Nick Hut, Shawn Stack and the HFMA editorial staff. Sound editing is by Linda Chandler. Brad Dennison is the director of content. Our president and CEO is Joe Fifer. Did you know you can now show your HFMA with apparel and other items from the HFMA store? We’ve got hoodies, t-shirts, bags and more. You can check out the catalog at hfma.org. 

What an obesity designation really means for patients

The American Academy of Pediatrics in January released guidelines for evaluation and management of weight in children and adolescents. According to the guidelines, “the current and long-term health of 14.4 million children and adolescents is affected by obesity, making it one of the most common pediatric chronic diseases.” But according to medical researcher and patient advocate Ragen Chastain, the label of overweight or obesity can do much more harm to a patient than their body size.

Vocabulary

Chastain doesn’t use the terms “overweight” or “obese,” preferring instead to say: “higher weight,” “larger bodied,” or simply, “fat.” The former terms, which link to the body mass index, pathologizes bodies, she said.

There’s also been discussion in the diet industry and elsewhere of a person-first model, where a person who would previously been called “an obese person” now becomes “a person with obesity.” According to Chastain, that language doesn’t help and can sometimes hurt.

“In my life, no one’s ever said, ‘Don’t call yourself brunette. You’re just a person with brown hair,’” she said. “We don’t do person-first language for things we don’t think are a problem.”

Links to health

Although higher weights have been linked to health conditions such as hypertension and diabetes, weight loss has not been proven an effective intervention, Chastain said.

“People are starting to learn that weight loss almost never results in long-term significant success,” Chastain said. “About 95% of people lose weight short term, gain it back long term.”

What results is often more drastic measures such as weight loss drugs and surgeries, she said.

Weight loss also is held out as a prerequisite for other care, Chastain said. She’s spoken to patients whose physician refused to refill a medication or perform a procedure until the patient loses weight.

“That’s not ethical. That’s not evidence based. That’s holding someone’s healthcare hostage for a weight loss ransom,” she said. “And the more that practice happens, the less care that patient can access … the negative impacts of that tend to get blamed on fat bodies rather than on the system.”

The way forward

Chastain recommends moving toward weight-neutral healthcare, where people of all sizes receive the same ethical, evidence-based treatments. Barriers to care of larger-weight patients should be addressed proactively. For example, physician’s offices should be equipped with appropriately sized gowns, blood pressure cuffs and machinery that can accommodate a larger body, she said.

“Weight-neutral care simply says that people of all sizes get these health issues, so we’re going to give people of all sizes the same ethical, evidence-based treatment so that it’s not, a thin person comes in and gets a recommendation for medication or lifestyle changes or surgery, and a fat person comes in with the same symptomology but gets a diet instead,” she said. “Weight-neutral care says we care about people’s health in the body size thatthey’re at, rather than … body size manipulation for higher-weight people as the primary go-to.”

A weight-neutral model can be challenging even for patients, many of whom might have struggled throughout their lives to reach what they’ve been told is a healthy weight.

“Patients do want weight loss,” Chastain said. “That’s where a healthcare practitioner can come in and say, ‘Look, we’ve been working in a really failed paradigm for a long time, and your  experience of losing weight and gaining it back … is almost everybody’s experience.”

She also encourages patients to research interventions and ask questions about them when they see their healthcare practitioners.

“I want people to have the tools to get the healthcare that they need, or at least to try with the understanding that this isn’t our fault, but it becomes our problem,” she said.