How we see the world shapes who we choose to be — and sharing compelling experiences can frame the way we treat each other, for the better. This is a powerful perspective.
As a doctor, I have a professional duty of candor. This means it’s my responsibility to be open and honest with you when something goes wrong with your care.
It’s with this duty in mind that I want to swallow my pride and admit something.
I’ve judged patients based on their size. I’ve deemed overweight patients less worthy of compassion because I considered them to be responsible for their ill health. I’ve treated symptoms such as pain with scepticism despite having no good reason to do so.
I’d love to justify all of this by just saying I didn’t realize what I was doing, yet that wouldn’t be true. What I now know to be blatant weight stigma I thought was just being “cruel to be kind.”
I was wrong. I’m sorry.
Prescribing weight loss isn’t without risk
Let me explain where I stand before we continue. Weight can have a negative effect on a person’s health. I’m not here to pretend that’s not the case.
But the more I learn about the complex relationship between weight and health, along with the inherently problematic nature of weight loss itself, the more I find myself steering clear of it in favor of encouraging other health-promoting behaviors such as exercise.
My job as a doctor is to try and improve the health of my patients. But if I indiscriminately prescribe weight loss without an understanding of the nuance and potential harm my advice can have, I’m not doing my job properly.
Let’s think about this in a different way: High blood pressure can increase the risk of having a stroke, heart attack, or both. We often prescribe medication to try and reduce these risks.
If a drug came along that promised to reduce blood pressure but ended up doing the opposite in more than half of those who took it, doctors wouldn’t even consider continuing to prescribe it.
Despite the exact rates being difficult to clarify, it’s commonly accepted that eating disorders carry the highest mortality rate of any mental illness. Sounds like a pretty solid risk to be aware of to me.
The idea that the health benefits of successful weight loss far outweigh the risks has a fair bit of unpacking that needs to be done.
Scientific literature suggests that more than half of people who lose weight through dieting regain it within five years, with at least a third of them ending up at a higher weight than they started at. It’s likely that outside a study, this number is higher.
Why? Because people who take part in weight loss studies are inherently better supported than those attempting to lose weight on their own. Having someone check in with you on a regular basis makes a massive difference, especially when that person is a registered dietitian or nutritionist.
Will losing weight always improve health? Our supposed “gold standard” BMI measure is terrible, especially for weight-related health. That “healthy” range between 18.5 and 24.9? Utter nonsense. The BMI scale is only useful at the extremes, and since when are we in the habit of using the extremes to make blanket rules?
When we try and work out at what size someone’s health will actually improve through weight loss, the answer is a lot less obvious than what you might first think.
Trying to explain why the rate of sustainable weight loss is so poor is something that researchers have written numerous papers on, but it always comes back to the multifactorial nature of obesity itself: energy intake, low physical activity, poor sleep hygiene, genetics, poverty, food deserts, etc.
When only one of these factors is addressed, should we really expect the rest to just stop having an effect?
Health is multifactorial. Weight loss can improve health, but it won’t always. Remember that.
It’s OK to hold both in tension.
Blanket weight loss prescription contributes to weight stigma
As doctors, our entire practice is about balancing risk. Prescribing medication? Benefit versus risk. Performing an operation? Benefit versus risk. Advising weight loss is no different, yet we often don’t see it as such.
Instead of leading the change from a weight-normative to a weight-inclusive approach to health, we’re trailing far behind. Doctors, nurses, psychologists, and medical students have all been shown to harbor negative attitudes toward their fat patients, including believing them to be lazy, undisciplined, and unattractive, to name but a few.
It’s concerning how early on this starts too. A survey of more than 4,500 medical students showed that the majority exhibited implicit (74 percent) and explicit (67 percent) weight bias.
This is incredibly concerning and needs to change. When a person is discriminated against or stereotyped due to their weight, it has numerous negative health effects, both mental and physical.
Weight stigma has inherent potential to negatively influence the quality and content of the care that patients receive.
First do no harm
What about the argument that this is all canceled out by the fact that weight stigma “encourages individuals to lose weight”? Well, the literature would disagree with that.
For the more scientifically astute among you, almost all of these associations were independent of BMI. This leads to the question: “What if weight stigma had more of a negative impact on health than overweightness itself?”
I don’t have the answer to that, but I’m going to keep asking it.
If we as healthcare professionals are going to discuss weight loss with our patients, we need to get much better at it, and fast. Otherwise we may be doing them more harm.
Dr. Joshua Wolrich, BSc (Hons), MBBS, MRCS, is a full-time NHS surgeon in the United Kingdom with a passion for helping people improve their relationship with food. One of the few men in the industry addressing weight stigma and diet culture, you can find him on Instagram regularly combating spurious nutrition information and fad diets while reminding us that there’s so much more to health than our weight. Keep an eye out for his upcoming podcast, “Cut Through Nutrition,” for an in-depth look at the appropriate use of nutrition in medicine.