What does it mean to be a Plus-Size Friendly Professional? What is Plus-Size Friendly Care?
In a nutshell, a Plus-Size Friendly Professional is someone who sees the person first and their size/weight/BMI later. Someone who asks questions and listens to the answers, instead of assuming they have the answers and delivering them unsolicited. Someone who looks to find the root cause of a problem, not presume excess weight is the reason for everything.
If you’re a plus-size friendly professional, it means you’re mindful that complications occur and risks are higher for bigger women, but you’re aware that they’re not much higher, most fat women do not experience complications, and we are not a statistic waiting to happen. You are thorough, observant, and attentive; quietly preparing for the worst, but expecting normality and reassuring us that that is most likely to be the case.
It’s easy to point out examples of bad practice, this 2023 review covers a lot of them. But how do we turn that around into good practice?
Big Birtha’s Tips For Aspiring Plus-Size Friendly Professionals
Top Tip #1: We are people, and this is the most important thing that will ever happen in our lives!!
This sounds obvious, but really it isn’t. My biggest complaint about my experience of hospital obstetrics is that I felt I was cattle being farmed; both ante and postnatally. It was dehumanising and disempowering to be treated as if I was no longer an individual, just a commodity; a statistic, a tick in a box, a number on a spreadsheet.
During my antenatal care, I felt herded through processes and protocols. This was especially clear when a midwife undertook a ‘manual handling risk assessment’ with me due to my BMI. In this assessment (where I’d just walked through a door and sat in a chair) she asked whether I could get myself in and out of a chair unaided. She’d just seen me do it!? But the question was typed on the page she was ploughing through, so despite being patently unnecessary and patronising, she read it out anyway.
It was clear in the maternity ward after I’d given birth that some of the staff were tired and weary of their job. But this wasn’t just ‘another day in the office’ for me! This was the most important thing I’d ever done in my life!
What to do/say instead:
I have a name, and so do my babies! “Mum” is the preferred term of use by HCPs too busy to take that extra second to look on the screen or folder in front of them. Take that second. Please. If my name is difficult to pronounce, by all means, ask me how to pronounce it repeatedly, but try. “Baby” is surely only acceptable if I’ve not yet decided upon a name! If I have, please use it!
There’s no need for embarrassment it’s the umpteenth time we’ve met and you still don’t remember our names! I don’t mind, I don’t expect you to remember everyone you see. I mind being called ‘mum’ because you can’t be bothered to check.
If there are forms to complete, please consider having a conversation exploring the topic as a way of getting necessary information. Prompt for specifics only where needed to ensure you’ve covered everything. For example; the manual handling assessment could have begun with “well, one of the questions on here is whether you can get in and out of a chair unaided, I can see that’s not an issue. Is there anything I need to know about access and movement?” and if that elicits a negative response, prompt further with “What about getting on and off a bed?” Far more conversational and likely to build rapport.
From my experience working in a different field, it’s equally effective, and actually quicker, to complete a form this way than reading questions out systematically! It only takes a little practice for this method to become very fluid and natural.
Please remember, for some of us, it may have taken a long time to get to the point where we’re sat in front of a midwife. There may have been a lot of false starts and disappointments along the way. We may be excited, we may be apprehensive, but this is a really really special time, not a funeral, and not detention!
Top Tip #2: Obesity is complicated.
We’re all individuals and our reasons for carrying extra weight are varied and personal. Or, to quote Harvard Medical School:
Obesity is a complex disease that cannot be minimized to the “calories in/calories out” mantra that has become commonplace. Factors that can contribute to weight might include biological issues such as genetics and hormonal changes that come with aging; developmental issues such as parental obesity; psychological issues including depression or history of trauma; or environmental factors, such as large portion sizes. And these are just a few of a myriad of possible contributors.
https://www.health.harvard.edu/blog/addressing-weight-bias-in-medicine-2019040316319
If it were so simple to lose weight and keep it off, Slimming World, Weight Watchers and all the others would have been out of business years ago! We’ve likely been struggling with our weight for a while.
Or perhaps we have come to accept that personally, when our weight is at its most ‘acceptable’ by the medical profession, it is actually when we are at our least healthy overall, particularly mentally. Our weight/BMI does not define us, and there is a lot more to health and fitness than a number on a scale.
HCPs may mean well when they fire off quick soundbites about ‘being careful what you eat in pregnancy; don’t gain too much weight, it’s bad for the baby’, ‘you’re at high risk, because of your weight’, but that’s not actually doing anything to help us here, and certainly isn’t going to motivate us, which is presumably the intention?
Any throwaway comments/observations come across as veiled (or not so veiled!) criticism. They’re just more likely to make us feel stressed, guilty, depressed even, and want to avoid you. It may even prompt us to comfort eat if that’s our coping mechanism for dealing with stress!
What to do/say instead:
“Are you interested in hearing about any of the support options available locally for maintaining a healthy weight during pregnancy/diet and nutrition during pregnancy/developing and maintaining fitness before the birth and beyond?”
There’s no point bringing up weight as a problem, unless you’re offering a solution!
If the answer is no, move on with a “that’s fine, just ask if you change your mind.” Perhaps add “if I ask again, please don’t be offended, I’ll have just forgotten I’ve already mentioned it”.
If there are options for groups with both people with a higher BMI and people of all sizes, explain this and ask if we have a preference. We’re not all the same; some will prefer the reassurance of being among people in a similar situation, others won’t like the feeling of being singled out to attend a ‘fat’ group and would prefer to be seen with everyone else.
If the group is only available to people with a high BMI, then phrase it as a positive, rather than a negative: “Luckily, you meet the criteria to join X, if you’re interested?”. This is called ‘positive re-framing’ and is a great rapport-building technique, used in all sorts of situations; from counselling to sales!
You can also use the ‘other people have said great things about/this was really useful/they found it helpful’ as a plus-size friendly way of recommending something without it coming across that you’re telling us what to do.
But remember, offering choice is the key – and crucially, respecting that choice!
Top Tip #3: Assumptions. Leave them at the door, please.
Only two assumptions are acceptable when you meet me.
- You can be pretty sure I’m aware I’m overweight, and
- I’ve probably already tried to do something about it, most likely many times.
Obesity stigma means that many people, HCPs included, have an internal narrative on the causes (and solutions to) obesity, and they’re usually chock full of assumptions, so here’s a whistlestop debunk of the most common:
- Not everyone who’s fat eats junk food or eats excessively
- I may be fat, but that doesn’t mean I don’t exercise
- Just because I’m fat doesn’t mean I want to lose weight
- Being fat doesn’t mean I’m lazy, or stupid
- Just because I’m fat doesn’t mean I don’t understand nutrition
- Being fat doesn’t mean I have an eating disorder, comfort eat, or ‘have an unhealthy attitude to food’
- Being fat doesn’t mean I don’t have an eating disorder that I’m managing
- I may be fat, but that doesn’t mean I’m unhappy, or feel unattractive
- The presenting problem (if there is one) may have nothing to do with my size!
- Just because I’m fat doesn’t mean my pregnancy will be problematic
- Fat doesn’t automatically mean someone is unhealthy; being thin isn’t necessarily healthy either!
Statements like “You need to get more exercise” when the HCP hasn’t established how much exercise I’m doing, or “cut out the biscuits and crisps” when we haven’t discussed my food intake or preferences, are presumptuous, patronising, and sadly oh so common.
Without asking, you’ve no idea whether I’ve lost several stones before getting pregnant! There’s nothing more soul destroying for someone who has lost a lot of weight, but is still overweight, to find they still receive flack from HCPs they’re meeting for the first time!
What to do/say instead:
Ask about our diet and weight history instead of making assumptions. Ask us what we’d like to do instead of telling us what you think we need to do. Treat us as individuals, with brains!
Being at a stable higher weight instead of yo-yo dieting is a more healthy choice for a lot of people, especially for those of us who have realised that dieting and good mental health do not go well together! Respect our lived experience.
Be aware of your own issues and prejudices: if you’re a naturally slim person, be conscious that you really have no idea what it’s like to be fat, or why I’m fat, any more than I have any idea why you like bonsai trees, chinchillas, or axe throwing (just a guess)!
Prejudice is not the exclusive preserve of the thin, however! Bigger people (and formerly big people) can be just as judgemental and make just as many assumptions about other big people. If you lost weight, it doesn’t mean I can; just because you want to lose weight, it doesn’t mean I do; if you like to comfort eat a packet of biscuits in the bath after a hard day, that doesn’t mean it resonates with me. Your body issues are yours, mine are mine.
We are here for your guidance and support while we grow and birth our babies. You can do that best by asking questions and listening to our replies, and removing your thoughts, feelings, and assumptions from the equation as best as possible..
Top Tip #4: Get suitable equipment!
Hopefully all health professionals know this, but if you use the wrong size blood pressure cuff on an arm which is too big for it, you actually get inaccurate readings. It’s really important to use the correct cuff. https://www.ncbi.nlm.nih.gov/pubmed/6123760
All equipment needs to be fit for purpose. What is the weight limit for your hoist in the pool room? Is it enough? What about the chairs in the waiting room – are at least some of them comfortable for a larger person to sit in (I’m thinking armless chairs here). If you provide gowns, are they big enough to ensure modesty?
Top Tip #5: Be Careful with Statistics!
While it is true that obesity comes with higher rates of certain complications in pregnancy, it certainly does not mean that any of those complications are a foregone conclusion.
It has become very commonplace for “Obesity = multiple times the risk of …” messages to be the preferred delivery mechanism, but these are guilt-triggering and scaremongering. Yes, the risk may be 2x/3x/4x that of a ‘normal’ weight person, but when the risk was very, very small to begin with, it’s still a very small risk when multiplied.
The negative Glucose Tolerance Test (GTT) result in my first pregnancy properly shocked me. I was convinced I’d get gestational diabetes; everything I’d read gave the impression I was really high risk and it was practically inevitable! I was cross and upset to discover that statistically my risk had only ever been 9.5%; if I got 90.5% in an exam, I’d be pretty happy with that!
It’s no wonder some HCPs put high-BMI pregnant women through the ordeal of multiple GTTs (seven is the worst I’ve heard so far…) because they don’t believe the negative results. They’re raised on a diet of the same alarmist propaganda I was, before I started researching for myself! Being overweight or obese is highER risk. Not high risk.
If someone is already pregnant, you’re not suggesting they try to lose weight (because we know that’s not safe), so is there any point in even mentioning the increased risk? If you’re taking a woman’s blood pressure, and let’s be clear, we routinely monitor all pregnant women’s blood pressure; does you need to say it’s slightly more likely to be problematic because she’s heavy? Some HCPs love to bang on about it. But the pregnant woman isn’t in a position to change that situation (bar having a termination), so telling her how much more risky her pregnancy is only serves to increase feelings of guilt and anxiety.
What to do/say instead:
Being a plus-size friendly professional doesn’t mean you ignore the risks, but that you present them in a way which doesn’t misrepresent them. So, if you’re mentioning the increased risk of gestational diabetes and recommending a Glucose Tolerance Test, explain that it’s most likely going to come back negative, but the consequences are serious enough to make it worth checking.
If you do need to mention an increased risk – perhaps while explaining that you’d like to recommend a certain procedure, mention the absolute risk of something happening, not just the relative risk vs a ‘normal’ weight mum. Then that gives us the context we need to understand and make an informed decision.
If you’re concerned about something ‘because of the risk of X’ but you can check for it and rule it out, then do so! It’s frustrating to hear ‘we want to … because of the risk of…” e.g. high blood pressure’ when you can easily check my blood pressure and then act accordingly.
If we do experience a complication, please don’t assume it is due to our size. Smaller women experience complications too! Just be matter of fact and explain the problem. It’s irrelevant now how or why it occurred, not that you would even know. What matters is how it’s addressed.
Top Tip #6: Non-Stigmatising Imagery & Words
If you’re involved in the publication of information leaflets, what are you using as imagery? You might be a plus-size friendly professional, but what about the literature you hand out and that is on display? The media standard for any obesity story is headless fat bodies, burgers, coke, chips, and sugary foods! Please don’t fall into this stereotypical and stigmatising trap. Fat people have heads too, and we don’t all slob about eating fast food all day!
There are free image banks you can access for pictures of larger people, helpfully listed here on The European Association for the Study of Obesity’s Image Bank page. (I’ve used several on this page!) If you’re working for a trust or a department that does use stigmatising imagery, please point them in this direction if they need help.
What to do/say instead:
What words should you use when referring to someone’s obesity? Obese, overweight, high BMI, large, big? I’m asked this by professionals eager to get the balance right, and I’m glad they care enough to do so, but I’m afraid there’s no single, simple answer. We’re all different, with different preferences and opinions of words, often based on how they’ve been used towards and against us in the past.
I tend to use a variety of ways to describe bigger bodies on this site, as I’m well aware that there is no one universally acceptable term. I’m certainly reclaiming the word ‘fat’, which I didn’t tend to do in the early days, but #fatacceptance campaigns have made me feel differently about the word. That doesn’t mean I want it used against me, though!
In a medical setting, highER BMI (it’s not an absolute!) is preferable and less stigmatising to most than obese/obesity. In a less formal document/setting larger bodies/larger size, bigger/heavier mums etc. can feel more comfortable, but everyone’s an individual. You could ask, but to be honest, the less you focus on my weight, the better; talk to me about my baby, and my options, not my size!
Top Tip #7: Be very wary of jokes
I really think some HCPs come unstuck because they’re looking to keep consultations light hearted and pleasant, and that’s no bad thing! But it’s tricky to know how a joke will land when you’re unfamiliar with the audience.
Some of the most insensitive comments I’ve heard undoubtedly had good/humorous intentions (road to hell, and all that…). For example:
this baby’s going to be coming out wearing school uniform, he’s so big!
words of a sonographer, reported in our Parenting Science Gang research
The mum reporting this conversation wasn’t entertained; she was terrified! And the baby’s birth weight at term was average. So extra anxiety induced for no reason. (see here for information on the unreliability of scan measurements as a predictor of birth weight).
What to do/say instead:
Steer away from exaggeration and hyperbole as humorous devices. Stick to the facts, present them sensitively. If we want someone to make jokes at our expense, we’ll buy front row seats at a comedy night. We’re looking for support and reassurances, please, not pithy one-liners, which you’ll forget you even said, but we might remember with shame and embarrassment for the rest of our lives.
Top Tip #8: Just treat us as you would anyone else!
Probably one of the most powerful things you can do as a plus-size friendly professional is to maintain an expectation that everything will progress normally. You’ve done this a lot more times than we have! We need your reassurance that we can expect things will be fine, but that you’re also keeping an expert eye out in case they don’t; as you would for any expectant mum or birthing person.
Many women, not just fat ones, are very apprehensive about pregnancy and birth, especially if it’s our first time or we’ve had previous negative experiences. Thank you for treating us with dignity and respect, and reassuring us that our bodies were designed for this!!
