Saturday, 18 January 2020

The High Cost of Fatphobia

Any calculation about the “cost” of fat people is actually a calculation of the cost of stigmatizing and oppressing fat people in every aspect of our lives.It has become quite a popular practice to calculate the “costs” of fat people. (As if it’s ok to decide that a group of people with shared physical characteristics should be eradicated to make things cheaper for everyone else.) There are many, many problems with the calculations, but I think it’s important to realize that in our society fat people live under intense, constant, stigma and oppression.  That means that any calculation about the “cost” of fat people is actually a calculation about the cost of that stigma and oppression. This came up in several conversations today so I thought I would repost this.

Let’s start with healthcare costs since that’s one of the most popular things for people to calculate.  Studies from Yale showed that over 50% of doctors find fat patients “awkward, ugly, weak-willed and unlikely to comply with treatment” and 28% of nurses said that they were “repulsed” by their obese patients.   Mary Huizinga of Johns Hopkins found that “The higher a patient’s body mass, the less respect doctors express for that patient.  And the less respect a doctor has for a patient the less time they spend with that patient and the less information he or she offers.”

This leads to increased healthcare costs in a number of ways:

Fat people are treated so poorly by health care professionals – given no respect, called liars, told that all of our problems are due to our fat, lectured extensively about our weight regardless of the reason for our visit – that some of us start avoiding the doctor.  This leads to us not getting early intervention and, for some, only going to the doctor when the situation is more advanced and therefore more expensive.

When we do brave the poor treatment, discrimination and bigotry and go to the doctor our actual complaints are often ignored and whether we have tendonitis, strep throat, or a broken toe we are told that the cure is to eat less and exercise more.  Thin people get all the same health issues as fat people but they get interventions that have been shown to effectively address their health problems. Fat people are given an intervention intended to change our body size, which not only hasn’t been proven to effectively address health issues, but hasn’t been shown to effectively change our body size.

Because of fat stigma we are denied evidence-based care which means that instead of taking part in interventions that address health issues, those issues continue unabated while we try to change our body size because our health care provider tells us that is miraculously curative.  So sometimes we don’t get evidence-based healthcare until our health issues are in the advanced stage (and therefore much more expensive) and sometimes we never get evidence based healthcare and we die trying to lose weight.  Then all of those costs are chalked up to our fatness rather than the fact that we aren’t able to access good, evidence-based medical care.

Because our society enjoys blaming people for their health, there is shame and stigma attached to health issues that can often be effectively treated – like Type 2 Diabetes.  That shame and stigma are especially bad for fat people since despite the fact that thin people get these diseases, and despite the fact that a thin person and a fat person can have the same eating and exercise habits but very different weights, we are told that these are brought on by being fat, and that our fat is our fault.  Because of this stigma and blame, fat people are often too ashamed to seek medical care and so we don’t get good early treatment, and delayed treatment means higher costs and worse health.

Nobody is obligated to prioritize health, it’s not a barometer of worthiness, nor is it completely in our control – there are many factors (including oppression and access) that can have a profound affect on health. Still, a mountain of evidence has shown that when it comes to personal choices, habits are a much better predictor of health than body size, and there’s not a single study where more than a tiny fraction of people are able to maintain significant weight loss long-term. Yet medical professionals ignore this evidence and instead tell us that if our healthy habits don’t make us thin then they aren’t making us healthy.  So fat people give up on healthy habits because they almost never make us thin.  So because stigma leads to misinformation, our health hazard ratios go up along with our purported “costs”.

Although eating disorders are dangerous and in some cases deadly, fat people who present with disordered eating are often encouraged to continue and even escalate the behaviors. The fat stigma that these professionals hold means that they mistakenly believe that becoming thin by any means necessary is better than being fat.  Then all the costs that ensue from the disordered eating are chalked up to body size.

The costs of weight loss attempts, especially those that are “medically supervised”  are often folded into people’s calculations of how much fat people “cost society”.  The problem is that these interventions should never have been recommended in the first place since they do not meet the requirements of evidence-based medicine.  The people supervising these programs do not have a shred of evidence that would lead them to believe that the intervention will succeed, but they keep prescribing it and taking money for it, and in the end the fat people who are victims of a scam also get blamed for the cost of the scam.

Even when we lose weight and gain it back, which studies show us is the most likely outcome, we are encouraged to diet again. This leads to weight cycling (also known as yo-yo dieting) which has been correlated to many of the same issues to which being fat has been correlated.  So again, bad medical advice can lead to health issues but they get charged to the accounts of the fat people who were poorly advised.

Now let’s look at the cost of societal discrimination, bigotry, oppression and stigma:

Movement is beneficial for everyone’s health, and though nobody is obligated to exercise, when fat people who are interested in it attempt to engage in physical activity we often find ourselves the subject of ridicule.  Being “moo’d” at in the gym, having people throw thing at us from cars, and being humiliated for wearing a swimsuit are all things that are reported by fat people as regular occurrences.  A lot of my “normal weight” friends complain about having trouble finding the time to exercise, imagine how much harder that is when carving out time to exercise also means carving out time to be ridiculed and humiliated.

The media giving fat people tons of negative messages about our bodies, and having those messages reinforced by everyone from our parents to our doctors to strangers at the gym is an effective way of convincing fat people to hate our bodies.  It also turns out that people don’t take good care of things that they hate, and health issues and costs ensue.

To be crystal clear, it doesn’t matter how much fat people coast – it is not ok to find a group of people you can identify by sight, calculate their cost on society, and then have a national campaign to eradicate them because you’ve decided things would be cheaper if they didn’t exist.

But since that’s what’s happening let’s understand that until we end stigma, oppression and bigotry against fat people it is impossible to calculate the costs (if any) of our body size separate from the cost of our stigmatization.

Thus, any attempt to calculate of the cost of being fat will, in fact, be a calculation of the cost of being stigmatized and oppressed for being fat. Therefore, if the current cost calculations about being fat indicate that it’s the “greatest threat to public health”, then the actual greatest threat to public health is fat stigma and oppression. This is actually good news since we have no idea how to make people thinner but we do know how to stop stigmatizing fat people and we could do it right now.

Of course when you point this out you are told that the cure for social stigma, oppression and bigotry against fat people is…wait for it…weight loss!  Yes, people actually suggest that the problem isn’t that we’re being bullied, the problem is that we aren’t giving the bully our lunch money.  In other words, if we do what our oppressors want us to do and lose weight, they promise they’ll stop oppressing us.  The cure for social stigma is not weight loss, it’s ending social stigma, and I, for one, will not have the cost of the bigotry, hate, stigma, and bullying that I deal with charged to my account.

For a list of the research used in this post, go here and scroll to the bottom.

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