Weight Bias and Healthism: An Integrative Health Perspective

Background: Anti-Fat Bias

Body size and weight, most often officially judged and represented using body mass index (BMI), have become a primary focus of medical attention and social discourse about health over the past half century. This focus has been justified by evidence that higher BMI is correlated with increased morbidity, particularly related to metabolic and cardiovascular parameters, and to all-cause mortality. ¹ The nuance and complexity of this relationship have been largely obscured, however, by simplistic weight-focused discourse. This complexity is illustrated by a study outlining 59 distinct types of obesity, ² and research evidence showing that BMI-adjusted waist circumference is a much more accurate measure of health risk than BMI. ³

Importantly, it has been suggested that weight stigma itself may explain some of the relationship between weight and adverse health outcomes given the effects of chronic stress of all kinds on health, and because one of the most commonly reported effects of weight stigma is avoiding health care. ^4,5

As public health focus on weight has increased, so has stigma against people with large bodies. ^6,7 People who are fat are the frequent targets of overt and covert prejudice, such as being subjected to critical comments from family, being passed over for employment opportunities, and, most saliently, receiving poorer quality health care. Examples of explicit fatphobia in mainstream popular culture abound, ⁸ including in purported health-promoting spaces. ⁹

Independent of BMI, individuals who have been the target of anti-fat bias experience higher rates of depression and anxiety, greater body image distress, lower self-esteem, higher rates of disordered eating and eating disorders, avoidance of physical activity, and poorer metabolic health, meaning that weight bias may ironically lead to weight gain. ^10,11 For individuals who have internalized weight stigma (i.e., self-directed anti-fat bias), the negative impact on health is even more pronounced. ¹²

Anti-fat bias assumes three things: (1) There exists an ideal weight range for all people and weight outside this range is unhealthy, (2) it is fat people's fault that they are fat, and (3) attaining weight loss is simple and should be prioritized in all cases. The first assumption underlies health care policies intended to address the “obesity epidemic” and is accepted as true by most, despite evidence that the relationship between BMI—and health is not as straightforward as often assumed, especially for nonwhite populations and at the lower end of the “overweight” spectrum. ^13,14

The second and third assumptions are based on an individualistic view of health that presupposes that weight is primarily or entirely controlled by behaviors. This view is not supported by scientific evidence, which overwhelmingly supports that body size and weight are determined by a combination of biological, environmental, and behavioral factors. Each of those factors is themselves complex. Biology includes genetics, medical conditions, medications, and stage of life (e.g., menopause). Environmental factors include food marketing and food science, urban planning (e.g., car-centric cities), poverty, farming and food industry policy, and public policies (e.g., decreased physical education in schools). ^15,16

Behavioral factors, which notably include personal choice, are but one factor in the multifactorial etiology of body weight and size. Furthermore, despite the popular belief that losing weight is easy, research suggests otherwise. Meaningful weight loss is difficult to attain and approximately only 20% of patients maintain long-term weight loss. ¹⁷ Those who maintain their weight loss are likely to prioritize adherence to strict dietary and physical activity guidelines. This type of behavioral maintenance implies the privilege to afford to prioritize a specific version of health.

A closely related issue is healthism, a term coined by Robert Crawford in 1980 to describe the elevation of the pursuit of physical health as the primary value that all people “should” hold. ¹⁸ Healthism equates behaviors considered health promoting with morality, dictates the prioritization of values, and promotes judgment and discrimination against individuals and groups who are perceived to not prioritize their health. ¹⁹ Examples of healthism include expecting individuals to prioritize weight loss despite how difficult it is, prioritizing concerns about medication side effects over desired therapeutic effects (e.g., antidepressant medications and weight gain), and prioritizing the nutritional value of food over its taste or cultural significance.

It is critical to apply an intersectional lens to views of weight, size, and health. Anti-fat bias shares historical roots with eugenicist ideals and antiblackness and is tied up in Western standards of beauty that elevate whiteness and thinness. ²⁰ Individuals who are fat and belong to other marginalized groups experience the cumulative harm of multiple forms of discrimination. Furthermore, privilege influences how one views weight and size. Individuals who come from wealthy environments or privileged groups are more likely to attribute a person's weight to personal or internal attributes such as lack of self-control, poor diet, and lack of exercise, and less likely to attribute excess weight to situational or environmental factors such as gender, ethnic or racial identity, socioeconomic status, genetics, and food availability. ^21,22

Medical providers are part of the broader culture and are not exempt from forming similar biases that impact patients' quality of care, accuracy of diagnoses, treatment recommendations, and health outcomes.

Indeed, medical providers are often cited as the second leading source of anti-fat bias and research has shown that health care providers display high levels of both implicit and explicit weight bias. ^23,24 People who experience weight stigma in medicine report less frequent interactions with and less trust in providers, and importantly, avoidance of health care seeking. ^23,25 A commonly reported experience is having presenting concerns minimized in favor of vague advice to “lose weight.” ²⁶ Even when individuals desire weight loss, the structure of traditional medicine does not provide the kind of help or support that would be needed.

The Role of Integrative Health

The field of integrative health has a particular imperative to assess and confront anti-fat bias for several reasons. On the one hand, integrative health spaces may be at particular risk of perpetuating weight bias due to focusing on lifestyle modifications for health promotion. There is some real—and perhaps even more perceived—overlap between the modalities and approaches championed in integrative health and the fitness and wellness industries ²⁷ (e.g., yoga and restricted diets) and some integrative modalities (e.g., hypnosis) are popularly equated with the pursuit of weight loss.

In addition, many of the approaches promoted in integrative health have cultural links to spiritual frameworks, which can certainly enrich their healing effects but may also perpetuate the conflation of health behaviors and morality. The use of value-laden terminology, such as “clean” eating and “natural” medicine, implies a superiority that denigrates other choices. Finally, the emphasis within integrative health on “practicing what you preach” may promote a cultural milieu that excludes individuals with larger bodies and polices the behavior of those who work in this field.

On the other hand, the greater emphasis on relationship-centered and whole person care in integrative health provides an opportunity for integrative health providers to address and potentially heal harm done to individuals who have faced weight-related stigma in society and other realms of health care. People who experience weight stigma urgently need spaces in health care where they can feel validated, supported, and listened to, and where their own concerns and health goals—which may not include weight loss—can be prioritized.

These needs are squarely in line with the principle of patient-centered care, which is defined by the Institute of Medicine as “respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.” ²⁸ Integrative health has been recognized as a paradigm that exemplifies patient-centered care through its emphasis on patient–provider relationships and a healing approach. ²⁹ At its best, integrative health provides a framework for viewing health and well-being that is truly holistic and does not dictate the prioritization of one facet of well-being over others.

Frameworks such as the VA Whole Health Initiative's Circle of Health ³⁰ and Vanderbilt's Wheel of Health ³¹ decenter the physical body and elevate consideration of social, spiritual, and emotional well-being, creating explicit space for individuals to conceptualize their health broadly. Strategies such as health coaching and tools such as the Healing Works Foundation's Personal Health Inventory ³² provide a mechanism for eliciting and prioritizing individuals' values and goals and explicitly discourage paternalistic and directive approaches to health promotion.

These approaches give providers and clinics concrete mechanisms for helping avoid default and reflexive focus on weight, and for signaling to patients that they have a key role in setting the agenda for their care. However, to provide truly person-centered care across the size spectrum, integrative health providers and clinics must first recognize weight stigma as a problem and then work to be actively inclusive and affirming of people with larger bodies.

A Call to Action for Integrative Health

The field of integrative health has been ahead of the curve in the broader health care environment in terms of recognizing the importance of self-work as a prerequisite to collective and institutional change. Considering how ubiquitous anti-fat bias is, it is imperative that all health care providers ask themselves hard questions about how they have internalized these biases and how they impact their work. At the same time, we must begin to consider sizeism as a key component of diversity, equity, and inclusion efforts and implement policies and practices that limit harm and prioritize emotional safety and well-being for individuals of all sizes, both for those who work in integrative health and those who access our services. Specific action steps and resources are listed in Table 1.