Seven-year-old Sibongile Sithole watches as her mother and their general practitioner are in deep conversation. The adults are talking about her, but not to her. She glances back and forth between them. Something is clearly wrong with her, she thinks — that’s the only way to explain the worry on her mother’s face.
“I remember that day so vividly,” Sithole says. “It’s the day I started thinking something was wrong with my body.”
According to their doctor, Sithole’s weight was causing her chest problems, which is why her mother brought her in for a check-up. “I developed a tight chest along with other flu symptoms at the time, and I had a persistent cough. The doctor told my mother it was because I was fat.”
Her mother, with good intentions, followed the doctor’s advice to watch what her daughter eats and make sure she eats “healthy food”.
This changed Sithole’s life forever. She was traumatised, and from then on, she started seeing her body — particularly the size of her body — as a problem that needs to be urgently attended to.
“I started becoming aware of the otherness of fatness. I started to think there’s something wrong with being fat, especially because I wouldn’t see a lot of fat people on TV or in magazines. That confirmed what the doctor was saying to be true.”
Once her bout of flu passed, Sithole says so did her tight chest. Now, 20 years later, a much heavier and older Sithole is yet to have the chest complications her doctor warned her mother she would have if she did not manage her weight. She says her doctor was negatively biased towards her because of her body size.
Anti-diet dietitian and author Christy Harrison defines weight bias as “consistent, systemic oppression against larger-bodied people, which makes it difficult or impossible to find clothes and spaces that fit, healthcare that’s effective and non-discriminatory, equal access to employment and other basic human rights that we all deserve”. Essentially, this is the discrimination against fat people for no other reasons except their weight. It’s almost expected for general society to stigmatise fat people, but it can be the difference between life and death when medical professionals do it.
Healthworkers peddle weight stigma
Tsholofelo Tau* went to her first dietician when she was 11 years old. She was an active child at school — she played on the first team for netball, football and swam. But her mother, a nurse, was concerned about her weight and took her to see a dietician.
“I’ve always been big, and that’s how the dietician concluded that the problem was with what I was eating. She didn’t even ask if I exercised,” Tau remembers. The dietician told her mother to cut out carbohydrates from Tau’s diet and make sure she exercises more.
“There weren’t enough hours in the day for me to exercise more. But I stuck to the diet as best I could; I only stopped when I fainted at practices and when I started developing chronic nose bleeds because I lacked basic nutrients from my now-restricted diet.”
Focus on weight loss misses more significant conditions
Tau is 21 years old now, and she has seen four different dietitians in the past 10 years. They all told her the same thing: she needs to lose weight; she must restrict what she eats. When she was 16, Tau discovered a lump in her breast, which required a surgical procedure called a lumpectomy.
“My doctor said I would recover smoothly,” Tau remembers. “But, after a while, my stitches didn’t close, and I became septic.” After investigating, doctors discovered that she was insulin resistant, which was causing her stitches not to heal.
“My surgeon told me that I spent almost a decade switching from one diet to another, when I just had a very poorly functioning metabolism from the start. I was hurt that I spent all that time being told by dieticians that I must be cheating or lying about what I eat because I wasn’t losing weight.”
Several studies have shown that fat people are less likely to access healthcare and, when they do, the care tends to be biased and less evidence-based. In 2013, US-based researchers surveyed close to 5 000 first-year medical students from 49 medical schools to measure, among many factors, the implicit and explicit weight bias the students may hold.
The researchers found that 74% of the students showed implicit weight bias, whereas 67% exhibited explicit weight bias — which was “more negative towards obese people than towards racial minorities, gays, lesbians and poor people”. These medical students, the study states, believe it’s acceptable to hold negative attitudes about obese patients.
Registered dietician Gayle Landau says the medical professional needs a complete overhaul when it comes to what or how healthworkers think about weight and body size. Landau is the only dietician in South Africa who is also certified in intuitive eating, an anti-diet approach to eating that focuses on people’s relationship and connecting them to their body’s natural cues for hunger and fullness. Landau is based in a medical facility and sometimes surgeons refer patients to her because they want them to lose weight before surgery.
“Medical professions are lacking in their nutrition education and understanding the importance of a patient’s mental health as well,” she says. “I know there’s research that says outcomes are better when patients lose weight before surgeries such as a hernia removal. But we shouldn’t place the burden on patients; we need to make surgery safer for all patients — regardless of their body size.”
The complication of ‘obesity’
Landau says she’s observed how weight stigma has increased during the Covid-19 pandemic, which has left some of her patients anxious, and their mental health compromised even more.
“When all the statistics came out in terms of who is most at risk, people just were hooked on to the part that people in bigger bodies are the ones who are the most vulnerable,” she says.
Some experts have questioned the inclusion of obesity as a factor that can give rise to Covid-19 complications. A recently published article in The Lancet criticised the United Kingdom’s choice to include obesity as a risk factor for Covid-19 and said there is no available data to show that people with a body mass index (BMI) higher than 40 have “adverse Covid-19”.
Harrison, like Landau, is part of a movement of health professionals who stand against weight stigma. They practise intuitive-eating and health-at-every-size approaches with their patients. The concept is simple: your body size does not determine your health status.
This is a well-established movement in the United States and UK, but South African health professionals are yet to adopt this inclusive approach to medicine. Landau says one of the barriers is access to the courses, which are often very expensive. “I know many people who are interested in the courses, but just cannot afford to enrol in them.” But there is a growing body of work that is extricating body size from health.
“The doctor told me that my weight gain is the reason I am sick,” Zandile Finxa says. A recovering eating-disorder patient, Finxa went to the doctor because she wasn’t feeling well and was told losing weight would help her — despite the doctor barely examining her or inquiring more about her history with eating disorders.
“I was blown away. I just couldn’t believe that it didn’t matter that I had an eating disorder before. I never went back to that doctor again.” But finding another doctor also didn’t help; she was told, again, that her weight was the issue and that she would feel better after losing weight.
Many medical doctors say they focus on a patient’s weight for their patient’s health and safety because bad outcomes and a higher body mass are related.
Although most health workers have been taught that a higher BMI causes “poor health outcomes”, Harrison argues that it’s simply not true.
“We have a host of issues associated with high BMIs. But correlation doesn’t prove causation, and there’s a significant body of research showing that weight stigma and weight cycling can explain most, if not all, of the associations we see between higher weights and poor health outcomes,” she wrote in the New York Times.
As Finxa, Tau and Sithole recover from the stigma they experienced from different health professionals, they all say they won’t be returning to a doctor’s office any time soon. Both Finxa and Sithole have not seen a doctor in two years and use over-the-counter medicine when they’re unwell. Meanwhile, Tau’s insulin resistance forced her to see her fourth dietician who also prescribed calorie-counting as part of her treatment course for her condition. Finxa says: “I will only go to a doctor once I find one who won’t make me hate myself. Until then, I’d rather not.”