So I have decided that it is time for an apology, and it’s going to be a big one. The observant among you may have noticed that there is a new heading on the main menu of my website entitled “Other Voices”. Since I started becoming more vocal on social media, people have been getting in touch to share their stories with me. And some of them have trusted me enough to share them with all of you too.
I feel honored and privileged to have been trusted in this way, but the whole process has left me pretty heartbroken. Because time and time again, I hear the same thing. In my opinion, there is no question we doctors are failing miserably, and for some unknown reason no one seems to be doing anything about it.
There’s a social injustice taking place here that needs to be addressed. And more importantly, there is a long overdue apology that needs to be made. So I am going to go ahead and make it.
Why we need a big, fat apology
It all started a couple of weeks ago when Cosmopolitan released the cover of their Feburary edition which had people of different sizes posing on the front cover above a title that said “this is healthy”. And thus began a slew of commentaries, including several notable TV “doctors”, who were all very keen to get their two cents in.
Apparently placing a picture of a large woman exercising on the front of a magazine is actually a way of glorifying ob*sity and it is irresponsible and dangerous. Coupled with the near daily reminders that COVID kills ob*se people and that is why the UK and the USA have higher death rates than the rest of the world, it all got a bit too much.
Because you can’t be fat and healthy, right?
Wrong. That’s the biggest load of crap I have ever heard and I’m sick and tired of our politicians and journalists and, worse of all, the scientific community spreading this lie.
The Big, Fat COVID Debate
Let’s start with the basics. Ob*sity does not increase your risk of dying from COVID. There is a definite link between the two, but that’s all we know right now. Even Public Health England admits that the evidence is insufficient to draw any real conclusions. And that was back in July. Since then there have been studies that have shown that it has absolutely no impact on hospitalization, ventilation or death rates.
Which begs the question, why? Why is there a link between body mass and serious COVID when one is not causing the other. And this, ladies and gentleman, is the bit that nobody wants to talk about. Because it is awkward and uncomfortable and the impacts people in positions of power and authority.
Because serious COVID is also linked to poverty. It is linked to race and ethnicity. It is linked to level of education. And what do these groups all have in common? Well, amongst other things, they have all been shown to receive poorer quality healthcare.
What’s that you say? Surely I can’t possibly be implying that the medical profession does not provide equal care for all? Why yes, yes I am. That is exactly what I am saying.
Why medical fatphobia kills people
When a person in a larger body visits their GP, they are having to fight against the weight stigma and fatphobia that has influenced said GP’s attitude towards them. The doctor takes one look at them and subconsciously decides that they are lazy and lack self-discipline. It’s called size bias and I have already blogged about this.
What? You thought your doctor was above that? Don’t kid yourself. Studies have shown just how prejudiced doctors are towards their patients based on their size and body weight. And there is no question that it affects their diagnosis and treatment plan. Hence inequalities in healthcare provision.
Not only that, but it also affects the doctor-patient relationship. And that is equally as damaging. Time and time again I hear patients say to me “I would have come sooner but I was afraid you were going to blame it on my weight”. Listen to what the patient is saying.
“I was afraid you were…”
This tells me that they don’t trust me. They don’t feel able to open up. The lines of communication have broken down and I’m willing to bet they will be less inclined to follow my advice as a result. We call that poor compliance and we often mistakenly assume that it is down to the patient, when in actual fact the responsibility may lie primarily with the doctor.
“I would have come sooner but…”
This tells me that they have been actively avoiding me. And this is something that we need to start talking about. Let’s all use our common sense for a moment. When you put off seeing your doctor because you are worried that they are going to blame it on your weight, you are inadvertently putting your health at risk.
Especially during the COVID pandemic. Because this disease can cause patients to deteriorate rapidly, and a delay of just a few hours can make all the difference. Furthermore, data from our last pandemic (H1N1 or swine flu) showed that delayed presentation was a really important factor in the link between body weight and severity of the illness.
What you say versus what people hear
It’s easier to blame the individual, isn’t it? Nobody wants to call the medical profession into question. Most people wouldn’t dare. But I’m not most people. I am one of them. And I think that gives me the right to say something.
When doctors tells a patient that they need to lose weight, we are taught to believe that we are doing the right thing because part of our job description is to hand out lifestyle advice. But I respectfully disagree.
Firstly, I may think I am doing right by the patient. But what the patient hears is:
You’re the reason that you are unwell.
You ought to be ashamed of yourself.
I am not interested in helping you until you meet my standards of what is acceptable.
You are wasting my time.
You deserve to be sick.
You’re going to die soon and there is nothing we can do to help you.
Don’t come back until you’ve changed.
Fairly and Without Discrimination
Now look, it may seem like I am being hard on my fellow healthcare professionals, but I do know that almost all of them are good people. We don’t want to hurt our patients. We got in to this profession to help people. So is is easier to just accuse the patient of overreacting or imagining things.
[Just like when we say things like “racism is not the issue” or “women have just as many rights as men”. Riiiiiight.]
Let’s be real for a second. I’m willing to bet that there are many doctors who do believe that fat people are wasting their time. That they are to blame for their own illness and don’t deserve the same treatment that their thinner counterparts do. I’m sure there are lots of people out there that would agree with them.
But that’s irrelevant. Because in order to hold a license to practice medicine, we have to uphold the key principles outlined by the GMC. They include the duty to do no harm and to treat all patients and colleagues fairly and without discrimination.
In fact, every year we undergo an appraisal in which we have to demonstrate that this is the case. In other words, people don’t need to prove that we are discriminating against them. The burden of proof is on us.
This is how we are supposed to do it
So here’s a set of questions I believe a doctor needs to ask themselves before handing out weight loss advice:
- What are the risks of advising weight loss? These include the risk of damaging the doctor-patient relationship, putting a strain on the person’s mental health, and the metabolic consequences of long-term dieting.
- What are the actual proven benefits of advising weight loss in this individual situation? If you’re talking about heart disease, use the QRISK calculator. If it is a musculoskeletal condition, what do the actual studies show?
- On the balance of things, do I believe that the benefits of advising weight loss in this particular situation outweigh the risks? Seems simple enough, but you can’t stop there.
- Is there a chance that I am allowing my own prejudice and preconceived ideas about this patient’s health to cloud my clinical judgement?
- Am I confident that my own failings and inadequacies as a well-intentioned but nevertheless flawed clinician have not resulted in a lazy diagnosis and treatment plan?
- Do I understand how weight stigma has influenced this patient’s life and have I taken the time to get to know them as an individual rather than just seeing the number on the scale?
- Am I prepared to believe them when they say that they are doing the best they can, and can I accept that ‘best’ does not always equate to weight loss for a variety of reasons?
It doesn’t end there
And here’s the kicker, folks. Even if I answer yes to all 7 of these questions, I still don’t get to hand out weight loss advice. Why? Because I’m not a parent or a life coach. I’m a clinician. It is not my job to simply dispense advise and be done with it. This is not the 1950s, and doctors no longer get to sit on high and tell people what to do.
A doctor’s job is to help our patients to make their own individualised, informed choice. That means outlining a set of options going forward including the option of no treatment. For each one, we must explain the risks and benefits and ensure the patient has understood what we have explained to them. Finally, we must respect their autonomy and continue to act in their best interest no matter what they chose to do.
[I took my first ethics and law class over 20 years ago, but Professor Len Doyal had literally written the book on medical ethics and I listened avidly to every word that came out of his mouth.]
The Big Fat Apology
That’s how we were taught to practice medicine. That’s the standard we should be holding ourselves up to. We can’t tell people that we “never want to see that number on the scale again” or we “don’t want our time wasted”. We can’t tell people that they “need to lose weight or else” unless we have the evidence to back it up. And we never really have the evidence to back it up, because the evidence just isn’t out there.
Enough is enough. This needs to end. We cannot keep practicing like this without being challenged. It’s not fair. It’s not right. And it’s not in line with GMC regulations. Which calls in to question our fitness to practice medicine.
So I promised you a big fat apology, and I am sorry that you have had to wait until the end before I delivered. As you can see, I had a few things to get off my chest first. But here goes.
To every single person reading this who has ever felt judged, belittled, dismissed or despised by their doctor or nurse of other healthcare professional. To anyone who has ever received unsolicited weight loss advice or felt that their weight was unfairly blamed for something that turned out not to be the case.
I. Am. Sorry.
On behalf of the entire medical profession, I am sorry. We failed you. You deserve better. Now tell us how to fix it.
No seriously, tell us how to fix it. Comment in the box below. Get in touch. Get involved. I’d love to hear from you.
This is actually revolutionary and I am so thrilled to have read it and borne witness to the start of something so worthwhile.
I remember being 17 and a young male doctor looking at me with disgust and telling me that my hair loss had to do with my weight gain and implying if I went on a diet I would be thinner and have more hair. My Bmi was 27.5 at the time. Weight loss never made my hair grow back either as one had nothing to do with the other. I just had crappy genetics.
I think education is key and that’s an odd thing to say about some of the most educated people in the country. Nevertheless I do think it is true. Mandatory training in how to tackle fat phobia and avoid discrimination.
Thank you so much for you honesty. I have had this issue with the medical professionals all my life and at the moment have lost 6 stones so I can have a hip and knee replacement. Now I can see the benefits of being smaller and the specialist I see now treats me with respect but I have had so many in my life that haven’t. I am nearly 63 years old and have always been larger than what was seemed to be ‘ normal’ let’s hope that things will change , it starts with you and a few like you. Keep up the good work and thank you again x
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It’s not ‘Obesity-related diseases’ that worry me. It’s yet another obesity-related misdiagnosis, and next time it might be serious.
One day something serious might happen, and It’ll be dismissed. And because you’re the experts, I’ll believe you. But it won’t be your fault, because of Bolam/Bolithio. Medicine is similarly ‘institutionally’ prejudiced.
Good, innit.
I think the problem is the whole way healthcare is run.
CCG’s(alot of them aren’t healthcare workers,just council costcutters who must lower budgets!),and this then gives control who gets what-if ur overweight ur GP will not refer to someone who specilaises,so hormonal conditions like Hypothyroidism and Cushing’s Disease get gazumped by inneffective medication like Levothyroxine(not easing symptoms) and Diabetes is the answer to make everyone guilty it is their fault,and dish out Metformin and Insulin.
Things like “the NHS is overun” is because hospitals are continually closing and are dealing with more and more people,as the population is going up.
Then also there is drug companies that seem to control alot of decisions by GP’s with nothing to back up.
Thin people aren’t allowed to be told just eat,or called skinny,addicts are not allowed to be called ‘lifestyle choices’ or druggies,but people who are overweight are just called lazy,told to stop eating or a drain to the NHS.
Noone says providing people with Methadone as a waste of money.
Can I ask whether you apply the same logic to handing out advice to stop smoking? It’s manifestly clear that it’s possible to be a smoker and healthy, at times, if you take snap shots of a person’s life. The issue is that the condition (smoking) will almost certainly lead to further, potentially more serious, complications in a person’s life.
The doctor is not passing judgement upon a person when they give them advice on how to maximise their morbidity free life, as I think you must know. To take a simple matter of best advice like ‘try to lose weight for your own health’ and make it into a matter of insult or injury is disingenuous at best.
I’m afraid you have very little understanding of how much judgement doctors pass on their patients. There is very little evidence to show that longterm smoking is good for your health. There are hundreds of studies that show that body fat is not as bad as we think and on occasion it can be beneficial to us. We call this the ob*sity paradox. I am not aware of a smoking paradox. Please take the time to educate yourself on the facts before claiming things that aren’t true.
I am not sure where you have located the claims that are untrue in my question? I simply asked whether the same logic can be applied to the two pathologies? The statement that an individual can both be a smoker and be healthy at a single point in their life is not one, I’d have thought, that requires much proving. Consider a person who has just had their first cigarette – they are not manifestly less healthy at that exact moment than they were just prior to having the cigarette but the long term outcome is, as you say, negative.
Studies demonstrating that body fat ‘is not as bad as we think’ are a far cry from an endorsement of being overweight as healthy. Do you concede that there are many thousands of studies which associate long term obesity with increased morbidity?
I do feel as though you have sidestepped the crux of my question, perhaps deliberately, As a doctor, and as someone who is therefore to be considered something of an authority in this matter, could you just address whether it is possible that doctors are providing this advice with good intentions in mind?
I agree that smoking your first cigarette is not the same as long term smoking. That’s why doctors measure pack years (number of years you smoked 20/day. So if you smoked 10/day for 10 years, it is 5 pack years). If you look at studies on BMI and weight in relation to disease, there are SO many flaws with a lot of the data that they use. There is also increasing evidence that there is no correlation between fat and illness (it’s called the ob*sity paradox). There is very little decent evidence that shows that weight loss improves your general health. And finally there is quite a bit of evidence to show how damaging intentional weight loss can be long term (disordered eating, eating disorders, worsening mental health, reduced metabolism and weight GAIN, insulin reistance etc). So whilst I acknowledge that doctors are under the assumption that they are doing the right thing (ie. they are aware of an ASSOCIATION between weight gain and illness so therefore assume weight loss is the solution) I believe that they are doing more harm than good. Furthermore, it is their responsibility to report the risks of intentional weight loss to patients, and on the whole I do not believe that they are doing this.
Thank you so much for your blog, which I have just found. I’m also a GP in a larger body. I know those around me think that I am just justifying my existence when I take a HAES approach – almost an excuse for me to not have to lose weight. The trouble is, I HAVE lost weight – almost twice my body’s current weight has been lost in the last 40 plus years, but of course regained, as we know well that it will be. Also an eating disorder, which I am finally becoming free of – because I am no longer letting weight have the hold on me that it used to. Thanks again!
I’m so glad that there’s finally a doctor who’s into Health at Every Size. I wish every doctor had your knowledge and clarity of vision.