On Nutrition

Last week, I wrote about why the health care system is weight-centric (putting body weight at the center of notions about health), and why that’s a problem. This week, I continue my conversation with Lisa Erlanger — a family physician and clinical professor of family medicine at the University of Washington School of Medicine — and writer, speaker and researcher Ragen Chastain about what weight-inclusive health care looks like, and how we might get there.

Erlanger said weight-inclusive health care provides fat patients (fat is used here as a neutral descriptor, like tall or short) the care that a person in a smaller body would be offered for the exact same condition, “because there are not conditions that occur only in people in larger bodies. We know how to treat any disease without prescribing weight loss.” It also addresses the physiological and psychological trauma people in fat bodies have experienced, often at the hands of physicians.

More people today understand that weight loss isn’t healthy or sustainable and that diet culture is oppressive and inextricably linked to other systems of oppression — and they want no part of it, Erlanger said. “I think those voices are growing, along with other voices demanding liberation and equity, and as those people become patients and medical students and dietitians and therapists, there’s a counterpressure on the weight-cycling [diet] and obesity-medicine industry,” she said. “Ultimately the industry will always have the financial power, but as we begin to show that the emperor has no clothes, that the research is flawed, that the resulting practice leads to health inequities and doesn’t lead to population health, I do think the culture can shift.”

Erlanger said she’s increasingly contacted by medical students and residents who are shocked by the weight stigma being perpetuated in their curriculum, and by doctors with patients who are demanding different care. “Physicians are looking for support,” she said. “It’s difficult to practice weight-inclusive care because there are few resources and a lot of institutional pushback. This is not the first time that medicine has been very, very wrong.”

So how can patients who don’t live in thin bodies advocate for themselves? “First, understand that while medical weight stigma may become your problem, it is not your fault,” Chastain said. “You deserve ethical, evidence-based health care. A prescription for weight loss — whether it’s a diet, drug or surgery — doesn’t qualify. When a health care practitioner is struggling to move on from a focus on weight or weight loss, it can be helpful to ask, “What would you suggest for a thin person with this health issue?”

Erlanger said that question has an additional benefit — it can wake your provider up from a weight-centric trance. “Sometimes providers contact me who are truly flummoxed about how to treat diabetes without weight loss,” she said. “My answer is essentially, ‘You know how to treat diabetes without weight loss.’ This is something they very much have in their tool kit.”

Chastain emphasizes that health, by whatever definition, is not an obligation, barometer of worthiness, or entirely within our control. “Fat people have the right to ethical, evidence-based health care regardless of why they are fat, if there are ‘health impacts’ related to being fat, or if they could become thinner.”

For more resources, visit HAESHealthSheets.com for diagnosis-specific, weight-neutral health care guides plus a resource and research bank, and check out Chastain’s Substack newsletter, “Weight and Healthcare.” Erlanger helps moderate the private “Health At Every Size (HAES) for Physicians” Facebook group for physicians (MD, DO, and equivalent) and students in these programs.