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  • BIOETHICS FORUM ESSAY

Health Care for Obesity and Eating Disorders: What Needs to Change

Published on: February 28, 2020
Published in: Children and Families, Hastings Bioethics Forum, Health and Health Care, Public Health

The theme of National Eating Disorder Awareness (NEDA) week (February 24 – March 1) , “Come as you are: Hindsight is 20-20,” is designed to encourage those recovering from eating disorders to reflect on their journeys towards body acceptance. It also affords doctors and other health professionals an opportunity to evaluate how well they are doing to help patients reach this goal.

This subject is personal for me. After struggling with childhood obesity, I developed anorexia nervosa when I entered adolescence. This trajectory is common, as a 2013 article published in Pediatrics points out. Some experts propose that a reason is that people with obesity and eating disorders have shared risk factors, including a history of dieting, weight-related teasing, and poor body image. Some symptoms overlap, such as binge eating, which occurs with bulimia nervosa. In hindsight, I recognize that the stigmatizing attitudes I felt as a child with obesity, from not only peers and the media, but also from health professionals, contributed to my development of an eating disorder. But I also see the following tension: how can the medical community address obesity—which affects 42% of American adults–without contributing to the societal weight stigma that can aggravate both obesity and eating disorders?

In my case, a pediatric consultation when I was nearly 10 years old made me feel shame about my excess weight. After first going to my small North Dakota town’s primary care provider, I was referred to a hospital in a larger city to diagnose and treat a gastrointestinal sickness. While I went in feeling hopeful of finding answers, I left feeling desperate and helpless. The doctor coldly pointed by my abnormal place on the growth chart, showing my mother and me that it put me well into the “obese” category. He did not take due care to learn about and understand how this history of obesity might have contributed to both my gastrointestinal illness and my self-perception. The doctor prescribed weight loss as the answer to my GI symptoms and other health issues. Failing to ask me about my history of failed weight loss attempts, he seemed to believe that the advice to just “try harder” was sufficient.

When I finally did find measurable success with weight loss in middle school, I struggled with my impulse to restrict food consumption. My thoughts would drift back to my humiliating interaction with the doctor, and I was gripped with intense fear of gaining excess weight. As a defense, I fell into the spiral of eating disorder behaviors I found myself powerless to confront.

Unfortunately, decades of research suggest that my problematic interaction with a health care professional was not an isolated event. Insensitivity and outright “anti-fat” bias by physicians have been well documented and may be growing. Even physicians who specialize in treating obesity are prone to endorsing such statements as “Fat people are worthless” and ascribing the terms of “lazy” and “weak-willed” to their patients. Patients may not hear these comments from their health care providers, but they report feeling stigmatized, as I felt with the pediatrician. These judgements from physicians, respected and trusted within society, are biting and can lead to avoidance of the health care altogether. They are tied to unsuccessful weight loss attempts. In fact, research suggests that the emotional distress caused by weight stigma can itself lead to overeating and obesity, and that it can be especially harmful to children in developing a healthy self-concept.

 It is clear that the status quo can’t continue. What steps can health professionals take to address the adverse effects of addressing obesity?

Perhaps most fundamentally, they must remember that obesity is a complex health phenomenon and that patients’ histories with eating are heterogenous and complicated by years of internalizing weight bias. Weight stigma in health care settings needs to be addressed outside of academic journals and should be adopted into the curriculums of medical and nursing schools. Instead of focusing discussions on weight and BMI, providers need to take the time to understand their patients as people. What are their life experiences with eating and weight? What does being healthy mean to them? Answers to questions like these can help health care providers design a care plan that promotes aspects of health that matter most for each individual patient, honoring their life experiences with eating and weight and being careful not to send messages that equate worth to a numerical value. What truly allowed me to advance in my recovery from an eating disorder and improve body acceptance was being free from the fear of once again facing weight stigma in the health care setting. This came about by an individualized, flexible approach to eating that was reinforced by the support of an interdisciplinary team.

Outside of the world of eating disorder treatment, these principles lend themselves well to primary care providers’ work with patients with excess weight. The Department of Health and Human Services recently initiated collaborative efforts among key stakeholders in eating disorder and obesity prevention, with a 2019 report that ventured so far as to conclude that “obesity prevention is largely dependent on the prevention of stigmatizing messages.” The groups involved also agreed that “size diversity” and “body acceptance” are valuable, effective phrases to use in successful, inclusive messaging for both the eating disorder community and the obesity community, expressing support for the work of existing initiatives like body positivity, Health At Every Size, and fat activism.

The NEDA week theme of “Come as You Are: Hindsight is 2020” provides an opportunity for individuals recovering from eating disorders to reflect on their experiences and for health professionals to consider how they can better help patients to recover from eating disorders. As someone who will be entering medical school next year, I encourage my classmates and the health community to join me in honestly evaluating how our professional position and the societal power it confers can either confront or perpetuate public health problems, including the overlapping issues of eating disorders and obesity. We must keep in mind that making life decisions for health should be motivated by the goal of overall well-being, not just a number on the scale. My history suggests that effective, ethical behavior change emerges from the stable foundation of self-acceptance, balance, and grace. It is my hope that body acceptance will characterize my future medical practice and be taken up by the health care community as a whole. In doing so, we can be power leaders for healing and flourishing, championing for a more accepting, kinder, and healthier world.

Bethany Brumbaugh is a research assistant at The Hastings Center.

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  1. Gwin Wheatley Davidson on

    Bethany, Thank you for your willingness to share your personal experience and tie it to the larger discussion of weight bias, fatphobia, and stigmatization experienced by People of Size within medical settings. What we must recognize is that physicians and other providers are not immune to cultural expectations regarding appearance. They, too, have spent a lifetime being indoctrinated with idea that “thin is good and fat is bad.” These same individuals also promulgate these ideas using flawed and biased scientific models that attempt to link BMI and other measures of size to health and longevity. It is a viscous and reinforcing circle of bias. Programs like HAES, Intuitive Eating, and fat positivity have begun to crack the circle, but so much more must be done. I look forward to seeing more from you as you progress in your career as a researcher and clinician.

    • Bethany Brumbaugh on

      Thank you so much for you sharing your thoughts, Gwin! I agree that the bias demonstrated in a healthcare setting is largely a product of the cultural value of thinness. Research suggests that the bias becomes not just an aspiration, but a felt expectation among medical students and healthcare professionals themselves. The associated distress must be astounding for those in the health community who fall short of very narrow views of “healthy,” yet feel they must be representatives of health to their patients.

      Awareness of how weight bias can show up in everyday conversation is also important, and I appreciate the your attention to using non-stigmatizing terms. I admit that I have a lot to learn in this area as well, as well as understanding the movements you described (i.e. HAES, Intuitive Eating, and fat positivity) and how they can be beneficial in combating weight bias’ negative impacts on health and well being. It is my hope that medical school and research will afford opportunities to better elucidate the myriad of genetic and physiological influences that contribute to health and wellbeing, not limited to “excess” weight. On the advocacy side, I always hope to be an advocate for the unheard or ignored voices of People of Size and those battling with eating disorders.

      I hope that this is just start of the conversation on the problem of weight bias in health care, and thank you for offering your valuable perspective! Let’s keep on talking. 🙂

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