Takeaway: When we can see the clients as whole people, it makes room for us to bring compassion to the impact of the multiple traumatic experiences they have likely had with other health-care providers.
Let’s talk about something the wellness industry loves to judge in ways overt and covert: body size. The wellness industry devalues fat people. Few of us have escaped Western culture’s essential devaluation of the lives of people who live in bigger bodies. We need to start noticing it, owning it, and then commit to changing it. It’s deeply harmful, and it prevents us from being the caring people we purport to be. It’s also Ethics 101, my friends.
In January of this year, the American Medical Association (AMA) adopted a new policy about how physicians should (and should not) use the Body Mass Index (BMI) as a measure of health.1 Under the newly adopted policy, the AMA has chosen to recognize long-understood issues with using BMI as an indicator of health due to its historic harm, its use for racial exclusion, and because BMI is based primarily on data collected from previous generations of White, European, male populations.
The policy notes that BMI is significantly correlated with the amount of fat mass in the general population but loses predictability when applied on the individual level. That means it’s not a good measure of individual health. In fact, BMI is derived from a simple math formula (the result of a person’s weight divided by the square of their height) created in the 1830s by a Belgian astronomer, mathematician, statistician, and sociologist whose goal was to establish a standard to measure “the perfect man.” In his book, A Treatise on Man and Development of His Faculties, he made his goal and his bias clear. “If the average man were completely determined, we might consider him as the type of perfection . . . and everything differing from his proportion or condition, would constitute deformity or disease . . . or monstrosity.”2
Woof. If that doesn’t sound like eugenics, I’m not sure what does. Personally, I’m cool to hop off that train at the next stop.
Start the Change
The first thing we can do in our efforts to end fat stigma as massage therapists is to get clear about our scope. We are not registered dietitians. We are not endocrinologists. We are not qualified to provide any information for, or assessment of, our clients related to their eating habits, diet, or the size of their bodies. We can also skip talking about exercise levels or regimens with our clients. So, if you’re doing that (and you don’t have additional training and credentials to do so), stop doing it. Now.
“There’s a perception that weight stigma might feel bad but [that] it’s tough love and it’s going to motivate people,” says Sarah Novak, PhD, an associate professor of psychology at Hofstra University. “But research shows that this isn’t true.” Shaming someone into “eating better” or “exercising more” leads to a decrease in health-seeking behaviors—and an increase in weight—over time.3
Research also shows some important things about how health-care professionals care for fat people. Physicians are less patient with and less willing to assist patients who live in bigger bodies. They also spend less time with these patients and order fewer preventive tests for them.4 Certainly, as massage therapists, we’re not in the position to order preventive tests for our clients, but we would be wise to wonder if we exhibit the same behavioral patterns so many doctors exhibit when it comes to clients who are deemed overweight.
Acknowledge Your Bias
In their succinct and well-researched paper, Ending the Stigma: Improving Care for Patients Who Are Overweight or Obese, Dr. Ann Blair Kennedy (a massage therapist) and colleagues make clear recommendations about how we, as clinicians, can begin to shift these negative attitudes.5 We must interrogate and acknowledge our own biases. They suggest we ask ourselves, “When I see patients who are overweight, do I automatically assume they are inactive, have a poor diet, are uneducated, or are lazy?” Our ability to be with the truth that many of us do make these assumptions is the beginning of behavior change. We don’t have to say these things out loud for them to impact the care we provide. Noticing and then interrupting these thoughts is essential.
Moving through our biases is also key to another aspect of care that is so valuable for people who have experienced weight stigma their whole lives. When we can see the clients as whole people, it makes room for us to bring compassion to the impact of the multiple traumatic experiences they have likely had with other health-care providers. It’s tough to bring a trauma-informed lens to our work when some part of us believes that trauma was deserved. Our judgment can hinder our ability to bring the kind of healing presence and listening that can help a person who has likely been traumatized by previous health-care encounters feel seen and valued.
Kennedy writes, “Compassionate care of patients who are overweight or obese includes acknowledging the whole person, identifying your own biases, practicing patient-centered communication, creating a welcoming environment, and pursuing lifelong learning.” This last piece is not to be missed. We don’t learn a few things about how to be welcoming to people in larger bodies and then decide we’ve arrived. We need to commit to a lifelong investment in learning about ourselves, our biases, and what it means to create belonging.
Accommodating Your Clients
While there is plenty of work to be done inside each of us, there are also practical things you can do now to shift your practice away from one of “average body” privilege.
• Have furniture in your waiting and treatment rooms that is comfortable for patients in larger bodies.
• Use appropriately sized equipment, including sheets that are large enough to comfortably cover larger bodies.
• Choose reading materials that feature a variety of (rather than idealized) bodies and healthy lifestyles.
Want to better understand if you have bias related to weight? Take the Implicit Association Test (it’s free!) at https://implicit.harvard.edu/implicit/takeatest.html.
Check out Healwell’s online course (1 CE) called “What Are We Going to Do About the Weight? Weight Stigma in Health Care” at https://online.healwell.org/courses/weight-stigma.Notes
1. AMA, “AMA Adopts New Policy Clarifying Role of BMI as a Measure in Medicine,” June 14, 2023, www.ama-assn.org/press-center/press-releases/ama-adopts-new-policy-clarifying-role-bmi-measure-medicine.
2. Adele Jackson-Gibson, Good Housekeeping, “The Racist and Problematic History of the Body Mass Index,” February 23, 2021, www.goodhousekeeping.com/health/diet-nutrition/a35047103/bmi-racist-history.
3. Zara Abrams, “The Burden of Weight Stigma,” Monitor on Psychology 53, No. 2 (March 2022): 52, www.apa.org/monitor/2022/03/news-weight-stigma.
4. Sharon M. Fruh et al., “Obesity Stigma and Bias,” The Journal for Nurse Practitioners 12, no. 7 (July-August 2016): 425–32, https://pubmed.ncbi.nlm.nih.gov/28408862.
5. Ann Blair Kennedy et al., “Ending the Stigma: Improving Care for Patients Who Are Overweight or Obese,” Family Practice Management 29, no. 2 (2022): 21–5, https://pubmed.ncbi.nlm.nih.gov/35290004.
Cal Cates is an educator, writer, and speaker on topics ranging from massage therapy in the hospital setting to end-of-life care and massage therapy policy and regulation. A founding director of the Society for Oncology Massage from 2007–2014 and current executive director and founder of Healwell, Cates works within and beyond the massage therapy community to elevate the level of practice and integration of massage overall and in health care specifically. Cates also is the co-creator of the podcasts Massage Therapy Without Borders and Interdisciplinary.