Recent national attention combined with a strong body of evidence has recognized the deleterious impact of equating weight with health. For example, James Corden on the Late Late Show responded to a fat-shaming monologue from Bill Maher, arguing that shaming a person for their size is counterproductive and harmful. However, the detrimental impact of focusing on one’s weight and thin-ness instead of a healthy lifestyle is not new information. Decades of research has found that the number on the scale does not represent how healthy we are, and that restrictive eating and chronic dieting lead to weight cycling and poor health outcomes. Despite this recent attention and well-known study findings, 40-50% of U.S. adults experience weight bias, with higher rates among cisgender women. In addition, people in larger bodies who are also members of underrepresented groups, such as Black, Indigenous, and/or persons of color, or transgender and nonbinary individuals, experience exponential forms of discrimination.
Weight bias is defined as the “social devaluation of people because of their body weight”. It is activated by situational cues (e.g., a person’s size) and may influence one’s perception, memory, and behavior and lead to unfair judgment and discrimination. While other forms of bias such as skin tone, race, and sexuality have diminished in the US over the last decade, weight bias has increased. Explicit weight bias and specifically fat shaming are still socially acceptable in U.S. culture because of a general perception that body weight is a matter of personal responsibility and willpower, despite evidence that physiological, environmental, and genetic factors play prominent roles.
Experiences of weight bias start the moment a person in a larger body walks into a clinic. What is the first task we ask them to do? Step on a scale. This assessment plus other environmental cues such as chairs, gowns, and blood pressure cuffs that are too small can reinforce an anti-fat message. People in larger bodies routinely experience implicit and explicit weight bias during clinical encounters and are often given unsolicited weight loss advice. In addition, clinician weight bias toward people in larger bodies often negatively impacts clinical decision-making, as well as time spent with them and non-verbal and verbal communication. For example, people in larger bodies may be more likely to be pathologized for sexual health alterations or denied fertility treatment until the scale reads a specific number. Experiencing weight bias in health care also contributes to the avoidance of health care utilization. People in larger bodies have higher rates of unintended pregnancies compared to their standard weight counterparts, often due to contraceptive nonuse or greater reliance on nonprescription options with higher failure rates. Furthermore, weight bias can lead to increased biological stress levels, inflammatory markers, and higher rates of depression, anxiety, low self-esteem, social isolation, and weight gain.
Much of what we are taught in midwifery training relies on a weight-normative approach, which assumes that a higher body weight is a primary disease indicator. We have been trained in an environment and lived in a culture in which thin bodies are considered healthier than larger bodies. The use of body mass index categories to define health is also limiting, as it assumes weight as a modifiable factor.
As clinicians, we can do better. We must shift the paradigm away from equating weight as a marker of health, and more importantly, carefully examine how we perceive and treat people of a larger size. Midwives can play an essential role in promoting healthy lifestyle behaviors. Using the Health at Every Size (HAES) framework, a weight inclusive approach to health and wellness has shown to improve health outcomes for all bodies. This approach includes accepting body shape and size diversity, using respectful language, and encouraging people to eat for well-being and participate in physical activities that bring joy. With an awareness of the intersectionality of size with other social categorizations, clinicians can shift from potentially harmful to person-centered practices that support weight inclusion and health-promoting behaviors.
We encourage everyone to learn more about these concepts, the impact of weight bias on health and health care delivery, and how using the HAES framework can promote body positivity at an upcoming panel presentation at the ACNM 66th Annual Meeting, held virtually May 23 – 25, 2021.
Heather Bradford, MSN, CNM, ARNP, FACNM, has been a midwife since 2002 providing full-scope midwifery at EvergreenHealth in Kirkland, WA. She began as full-time faculty at Georgetown University in 2017 and serves as the Assistant Program Director for the Nurse-Midwifery and Women’s Health Nurse Practitioner Programs in the School of Nursing and Health Studies. She has advocated for advanced registered nurse practitioners at both the state and federal legislative front. Under her leadership, nurse-midwives achieved equitable reimbursement under Medicare Part B services. She became a Fellow of the American College of Nurse-Midwives in 2011 and currently serves on the Fellows Board of Governors as Vice-Chair. She is currently pursuing a PhD in nursing science from Vanderbilt University. She is exploring why patients with an elevated body mass index are more likely to birth via cesarean section, with a focus on birth attendant explicit and implicit weight bias.