If Fat Could Kill

I get such a variety of emails and messages and stories since I started Thick Me Up. Some of them are heartwarming, but some of them give me this inner rage fuel to keep going, keep writing, and keep shining a light into these dark places. This story was a particular doozy.

I was told about a doctor who told a fat woman with stage 4 kidney disease that she would not get a transplant from him because she was fat. His words were, “You will not get a transplant from me. Do you think I will cut through all that fat to get to your kidney?” The line is so ugly it almost feels unreal, except it is real, and that is exactly why it fuels me. She had waited ages for that appointment, had flown all the way to another state. She went in hoping for a kidney… a kidney she needed to live… and came home with the kind of humiliation that lasts a lifetime. A lifetime which, in her case, was being cut short because she was fat.

BMI has never been a clean measure of anything that matters here. If BMI determined the people who didn’t get kidneys, or other organs they needed, then a BMI cutoff of 35 excludes roughly 53 million U.S. adults, and a cutoff of 40 still leaves out about 25 million, using the 2024 adult population estimate and NHANES prevalence data (Emmerich et al., 2024; U.S. Census Bureau, 2024).

So when a transplant doctor hides behind a BMI threshold, it is not drawing a neat line between safe and unsafe bodies. It is deciding that a very large number of people can literally be left to die.

Weight discrimination has been associated with a nearly 60% increased risk of mortality, even after accounting for BMI, physical activity, and underlying disease burden (Sutin et al., 2015). The stigma itself is doing work. It gets under the skin and it changes behavior. It changes whether people return to care, whether they trust the next doctor, whether they keep trying when a system keeps telling them they are too much and somehow still not enough (Lavelle et al., 2022).

There is probably a non-zero number of you reading this and thinking, quietly to yourself, that the doctor from this story isn’t just espousing fatphobia flippantly, right? That there is clearly some data to justify excluding fat people from surgeries, or organs, or, you know, living.

The data actually says the opposite.

The claim that fat people cannot survive surgery, or that a higher BMI makes a transplant too risky, does not hold up. A 2015 UK Renal Registry study tracked over 17,000 kidney transplant recipients and found that every single BMI group,including the highest, had significantly better survival than patients who stayed on dialysis. There was no significant difference in patient or graft survival between the BMI groups (Krishnan et al., 2015). A meta-analysis of over 200,000 kidney transplant recipients found that higher BMI was not a barrier to survival or success. In fact, patient survival actually favored heavier recipients (Lafranca et al., 2015). A review of over 83,000 transplant patients found that fat recipients survived at the same rates as thin recipients (Hill et al., 2015). And a 2023 study confirmed that survival was not significantly different across BMI classes in kidney transplant recipients (Bellini et al., 2023).

My friend Liz mentioned to me that she’d heard that they use BMI because surgery and anesthesia is “more dangerous” for people who are fatter. The data still doesn’t support those societal assumptions. A 2023 meta-analysis of nearly 1.9 million surgical patients found that patients with obesity (including class I, II, and III) had lower 30-day mortality rates than patients with normal BMI after general surgery (OR 0.75, p < 0.0001). Even in emergency surgery, obesity was associated with lower mortality. And there was no significant difference in complication rates between class I/II obesity and normal BMI patients (Cullinane et al., 2023).

Fat people survive transplants. Fat people survive surgery. The bodies that doctors claim are too risky are the same bodies that the evidence says will do just fine (MacLaughlin et al., 2019). What we are looking at is a system that has decided, without evidence, that certain bodies do not deserve care. And the consequences of that decision are not abstract. They are people going home without kidneys. They are people dying on dialysis because a BMI number in a chart told a doctor that they were not worth saving.

This is what fatphobia looks like when it is baked into policy. It does not have to announce itself as discrimination or hatred. It can hide behind a threshold, behind a “standard of care,” behind a sentence like “we just want to make sure you are safe.” But the data says otherwise.

The AMA itself has acknowledged that BMI is not a reliable measure of health on its own (AMA, 2023). The metric that underpins these exclusionary policies was never designed to measure individual health in the first place (Heymsfield et al., 2024). It was built by a mathematician in the 1830s to describe the “average man,” who, for him, was white male Europeans, and white male Europeans alone, not to predict across populations in general who would survive a transplant.

Being fat does not ruin your organs. It does not mean your kidneys are shutting down or your liver is failing. Most fat people are walking around every day with perfectly functional organs, going to work, raising kids, living their lives. Studies have repeatedly found that many people with higher BMIs have healthy blood pressure, cholesterol, insulin sensitivity, and liver function (Scientific American, 2024).

So here is the part people like to shrug off. Fatphobia gets treated like a lesser form of discrimination, as if it is just vanity talk, a joke about willpower, or a sensitivity issue instead of something that changes who gets believed, who gets treated, and who gets left out of care. That shrug is part of the harm. If you keep calling it not a real problem, then you never have to face the fact that it is sitting inside the system, shaping decisions, and making some people sicker while everyone else gets to pretend it is harmless.

So here is the question I keep circling back to: if the evidence says fat people survive, if the evidence says BMI is not a reliable measure of individual health, if the evidence says weight stigma itself kills, then why are we still letting a completely arbitrary number on a chart decide who lives and who dies?

Neutral sounding rules do not become fair just because they are rules. If I told you that organ allocation policy, something that is supposed to be objective and science-based, also discriminates against Black candidates, you might be outraged. But this is, in fact, true, and it has been documented across repeated policy efforts (Kim et al., 2022). Racial inequities have persisted despite policy changes, showing that the system itself can hide bias while looking like a neutral process. By relying on BMI as a gatekeeper for organs, medicine does the same thing. It sounds objective while still deciding that some people are socially acceptable to deny, delay, and discard.

We have let a bigoted, arbitrary metric do the emotional work for us. It gives prejudice a number, gives our disgust a doctrine, give our desire for superiority a medical cosplay. Once that happens, people do not have to defend fat exclusion as hatred, they can just call it “logic.”

American Medical Association. (2023). AMA adopts new policy clarifying role of BMI as a measure in medicine [Press release]. https://www.ama-assn.org/press-center/ama-press-releases/ama-adopts-new-policy-clarifying-role-bmi-measure-medicine

Bellini, M. I., Deurloo, E., Consorti, F., & Herbert, P. (2023). Body mass index affects kidney transplant outcomes: A cohort study over 5 years using a steroid sparing protocol. Frontiers in Endocrinology, 14, 1106087.

Cullinane, C., Fullard, A., Croghan, S., Elliott, J. A., & Fleming, C. (2023). Effect of obesity on perioperative outcomes following gastrointestinal surgery: Meta-analysis. BJS Open, 7(4), zrad026.

Emmerich, S. D., Fryar, C. D., Stierman, B., & Ogden, C. L. (2024). Obesity and severe obesity prevalence in adults: United States, August 2021-August 2023. NCHS Data Brief, 508.

Heymsfield, S. B., Sorkin, J. D., Thomas, D. M., Yang, S., Heo, M., McCarthy, C., Brown, J., & Pietrobelli, A. (2024). Weight/height : Mathematical overview of the world’s most widely used adiposity index. Obesity Reviews, 25(S1), e13842.

Hill, C. J., Courtney, A. E., Cardwell, C. R., Maxwell, A. P., Lucarelli, G., Veroux, M., Furriel, F., Cannon, R. M., Hoogeveen, E. K., Doshi, M. D., & McCaughan, J. A. (2015). Recipient obesity and outcomes after kidney transplantation: A systematic review and meta-analysis. Nephrology Dialysis Transplantation, 30(8), 1403-1408.

Kim, I., Martins, P. N., Pavlakis, M., Eneanya, N. D., & Patzer, R. E. (2022). Past and present policy efforts in achieving racial equity in kidney transplantation. Current Transplantation Reports, 9(2), 114-118. https://doi.org/10.1007/s40472-022-00369-y

Krishnan, N., Higgins, R., Short, A. H., Zehnder, D., Pitcher, D., Hudson, A., & Raymond, N. T. (2015). Kidney transplantation significantly improves patient and graft survival irrespective of BMI: A cohort study. American Journal of Transplantation, 15(8), 2095-2102.

Lafranca, J. A., IJermans, J. N., Betjes, M. G., & Dor, F. J. (2015). Body mass index and outcome in renal transplant recipients: A systematic review and meta-analysis. BMC Medicine, 13, 174.

Lavelle, K., Zukauskaite, A., Jamieson, S., & Reilly, J. (2022). A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network. Obesity Science and Practice, 8(3), 325-335.

MacLaughlin, H. L., & Campbell, K. L. (2019). Obesity as a barrier to kidney transplantation: Time to eliminate the body weight bias? Seminars in Dialysis, 32(4), 325-331.

Scientific American. (2024, June 25). People who are fat and healthy may hold keys to understanding obesity. https://www.scientificamerican.com/article/people-who-are-fat-and-healthy-may-hold-keys-to-understanding-obesity/

Sutin, A. R., Stéphan, Y., & Terracciano, A. (2015). Weight discrimination and risk of mortality. Psychological Science, 26(11), 1663-1669.

U.S. Census Bureau. (2024, December 19). Net international migration drives highest U.S. population growth in decades [Press release].