"When I was 20, I needed to see a gynaecologist," Michelle tells me. "I ended up going to five, three of whom told me that all of my symptoms were due to my weight."
"It was summer, and because it was hot, they said being fat was making the problem worse. Having been overweight for a while, I was insistent that it was not. Finally, the fifth doctor discovered what the actual issue was."
Now a qualified NLP (neuro-linguistic programming) coach with her own company, Mindset for Life, through which she promotes body positivity and confidence in her clients, Michelle says that when you’re overweight, "often when you walk into a doctor’s office they won't look beyond your fat" – and she's not the only one who feels this way.
Body positive Instagrammer Cheyenne, also known as the Goofy Ginger, has been subject to this kind of scrutiny on numerous occasions. "Initially the visit seems normal. They’ll take my vitals, blood pressure, and weight," she details. "But instead of asking me why I'm coming in, they will ask, 'So, are you here to get treatment for diabetes?' 'Are you here to ask about gastric?' 'Have you checked your BMI recently?'"
"I dread stepping on the scale, not because I can’t handle it, but because I know they'll look at me like I'm a disgrace. Immediately I feel ashamed, and I regret even going in."
Individual experiences of routine medical care can differ vastly, it seems, depending whether you’re in your accepted weight range or whether you have a BMI of 25 or above, and are officially an "overweight" person. Many say that things worsen when you hit a BMI of 30 – or become by NHS guidelines, "obese".
In 2010, research from Yale found that almost 70% of overweight and obese women delayed seeking healthcare because of their weight, and 83% said their size was a barrier to getting the treatment they needed. Many felt "disrespected" by their doctors and embarrassed by the frequent unsolicited advice they received about losing weight.
Similarly, a 2012 study highlighted that professionals, including doctors, nurses, dieticians and nutritionists, demonstrated significant levels of "fat phobia", with only 1.4% of participants showing "positive or neutral attitudes" towards those with a high body mass index. Other surveys conducted with medical students have revealed that obese patients are often perceived as "lazy" and "non-compliant with treatment".
Notably, women say that they experience far higher levels of weight bias than men, even when they’re carrying fewer excess pounds, and it’s this bias that has the potential to be dangerous – either because they become so self-conscious that they stop seeking medical help altogether or, as Michelle recalls, the symptoms they do report are overlooked because of their size.
Body positivity doesn’t just address weight, or those who are overweight, but it is a term often used in part to celebrate bodies that don’t fit conventional size norms. "It’s not okay to make assumptions about people by their appearance, gender, or any other superficial aspect. Body positivity for me is celebrating my own body and respecting others," Cheyenne explains.
But while the hashtag may boast almost 2,500,000 posts on Instagram, that doesn’t mean that medical professionals will recognise it, or indeed, advocate everything that it represents.
"Don't forget it is now 'normal' to be overweight or obese – well over 50% of the population are," she says. "That means it is becoming more and more accepted and people are, quite rightly, fighting back against stigma or 'body-shaming'. I completely support this – but at the same time, we shouldn't be accepting 'fat' as the new normal."
Although she agrees that overweight patients certainly shouldn't face shame or discrimination, Sally generally wouldn't hesitate to mention a patient's weight to them – even if it wasn't related to the problem for which they'd booked an appointment.
"Denial doesn't help. Most of my patients may be upset to talk bluntly about their problems to start with but soon realise we are there to help, that we know they have been struggling for years, and they are glad to have that opportunity."
London-based GP Toni Hazell, on the other hand, won’t mention weight if it’s not related to the issue: "I don't have the time and it isn't appreciated and leads to complaints," she admits. "If I do bring it up, I'm quite sensitive in the way that I phrase it. I say things like 'losing weight is really difficult – if it wasn't, there wouldn't be a multimillion dollar slimming industry – you're not the only one'."
However, both doctors conclude that it’s unlikely you can be obese and healthy long-term.
"If you're overweight, it's better to be healthy with it," Sally says. "But there is no real truth in the belief that you can be fit and fat. Some studies have shown that distribution of fat is important but we are increasingly seeing that obesity is linked to many other issues like cancer and joint problems, so being overweight is highly likely to catch up with you."
"Overweight and healthy, probably," Toni ponders. "There is good evidence that lack of physical activity is a risk factor for cancer and it may well be that being overweight and active is better than being slim and unfit. But obese or morbidly obese, I don't think so."
An alternative message is presented by the organisation Health at Every Size, a group which "gives up on" the idea that there is an attainable "ideal weight or size", instead stating that "people in good health come in all shapes and sizes", and encouraging the adoption of healthy behaviours by people of all weights.
Linda Bacon, author of the book of the same name, points to various research from the last three decades which shows that bigger patients are less likely to obtain preventative health services like cancer screenings and pelvic exams, are more likely to cancel or delay appointments, and typically have physicians more likely to spend less time with them, leading to higher incidences of misdiagnosis and mistreatment.
She shares the story of her father, who was by her definition "fat", and had the same knee condition as she now does at a lower weight. She has been offered physical therapy, strengthening exercises and surgery. He was simply recommended diets, "over and over again".
"Carrying more weight may have aggravated my dad's joint problems; no doubt there are ways it's hard to be in a fatter body, although there are also ways it confers health advantage," she says. "But trying to lose that weight is no kind of solution. I can assure you, my father – almost all heavier people – they've tried already." (The HAES manifesto cites several further studies that show that dieting is a "strong predictor" of future weight gain.)
I’m reminded of Gemma, another blogger I spoke to, who has polycystic ovaries, and is constantly told that she must lose weight to manage the condition. While she acknowledges that this is recommended and can be helpful for people with PCOS, she says she has never been offered information outside of this one treatment option.
"I’ve given up going back because they always say the same thing," she discloses. "I am confident but after going to the doctor I just feel deflated, like there’s no one supporting me or willing to listen outside their 15-minute slot."
According to Linda, it’s an "unfortunate truth that larger people are likely going to need to set their own boundaries and advocate for themselves to get good treatment."
"My advice in training healthcare professionals in respectful care with larger people is to start by considering how they would treat someone in a thinner body," she suggests. "Appropriate exercise? Meds? Surgery? Then do what you can to support your patients in implementing your advice and handling the challenges posed by their particular body."
And as things stand now, is it possible for self-proclaimed body positive women to visit a doctor without experiencing any negativity – perceived or otherwise – towards their bodies?
"I've only ever met one body positive doctor – my cardiologist," says Cheyenne. "He has always listened to every symptom and struggle before making his assessment. He makes me feel heard, and it’s obvious he genuinely cares about the wellbeing of his patients."
"Everyone deserves the respect and understanding I've found in my doctor, and I hope by spreading body positivity we can make that happen."