I keep banging on about weight inclusive medicine, but I’ve realised that a lot of people don’t actually know what the term means. Worse still, I am not entirely sure I know what the term means. So to quote one of my favourite bands of the 90s
Let’s tell it how it is, and how it could beLet’s Talk About Sex (Salt’n’Pepa)
How it was, and of course, how it should be
Weight Inclusive Medicine For Doctors
The first part of this blog is written to my fellow doctors. Whether you are a GP like myself, or a radiologist or a surgeon or an anesthetist or [insert specialty here]. In fact, it goes beyond doctors. I imagine it applies to all healthcare professionals, although I am by no means an expert.
To all the non-healthcare professionals reading this, please don’t skip ahead. I believe it is essential that everyone understands what they can and should expect from their doctor, so I have tried to make all this information as accessible as possible. I am hoping that it will help to give you an understanding of how to advocate for yourself. In an ideal world, that would not be necessary because your HCP should be advocating for you. But we can table that discussion for another day.
In the meantime, here goes.
All people have the right to be treated fairly and without discrimination
Not only is this the moral and ethical gold standard, it also makes up part of Domain 4 in the GMC guidelines “Good Medical Practice”. Every single doctor is obliged to demonstrate that they abide by all of these principles. Failure to do so constitutes a breech of their duty of care, and this should be addressed yearly as part of the appraisal process.
We don’t get to pick and chose whom we treat fairly. We don’t get a free pass to discriminate against fat people just because we believe we are doing what is in their best interest. It doesn’t work that way. Discrimination is defined as “the unjust or prejudicial treatment of different categories of people”. Every time we allow our own explicit or implicit anti-fat bias to cloud our judgement or interfere with our professionalism, we are discriminating. It really is that simple.
Theoretically, I could end it there. But I won’t because I have a lot more to say.
Health is not a moral obligation
Every single person on the planet is entitled to respect and care, irrespective of their health status. I keep hearing doctors moaning about how much harder their job is to perform on patients who inhabit bigger bodies. Supposedly ultrasound scans are so much harder to perform, which somehow give us the right to discuss “body habitus” all over our radiology reports. Fat patients are so much harder to intubate according to most anesthetists. I once heard a doctor complain that her back was hurting because of all the fat patients she had to examine on a daily basis.
Guess what guys? We get paid large amounts of money to do the jobs we do. You say fat patients are harder to scan or to intubate? Well try harder. Your equipment isn’t designed for fat patients? Get better equipment. Your back hurts? Do a manual handling course, ask occupational health for an ergonomically balanced chair and visit a chiropractor.
Stop complaining. Patients are not our children. We have no right to ask them to meet us halfway. Nor do we have the right to put any expectations on them. This is the job we signed up to. If you don’t like it, I suggest you get another one.
Doctors shouldn’t be telling patients to lose weight
Yes, you heard me right. Doctors shouldn’t be telling their patients to do anything. Have you forgotten your training? We are supposed to be providing individualized, holistic care by arming our patients with all of the correct up-to-date clinical information so that they can make an informed choice.
Remember that? Informed consent? It’s kind of one of the backbones of medicine. It’s not a suggestion, it’s a legal expectation. So if we want to advise weight loss to our patients, we have to first gather all the facts (aka take a history and don’t just assume that the person sitting in front of you eats too much and doesn’t do any exercise). Then we have to present them with all of their options including the option of no treatment, taking care to describe both the benefits and risks of each one.
Yes, there are risks associated with weight loss
“There are no risks involved in prescribing weight loss!” I hear you cry. Sure about that? Not only is intentional weight loss ineffective in the long term in up to 95% of patients, it is also associated with long term weight gain. In fact, the more you diet the more likely you are to be fat down the line, irrespective of your original body weight. True story.
In addition, intentional weight loss is a risk factor for poor mental health and eating disorders. So we need to make sure our patients know that not only is their diet likely to be ineffective in the long term but it also comes with some pretty scary risks associated with it.
And what about the option of non-treatment? Is it possible to be healthy and fat at the same time?
Why, yes! Yes it is.
Weight normative medicine is in direct opposition with our duty of care
When I think back to the medical ethics and law lectures that I attended at university, I remember being taught about the fundamental principles of beneficence (acting in the patient’s best interest), non-maleficence (do no harm) and body autonomy.
We have already discussed the short term and long term harm associated prescribing weight loss. However, this does not mean we should stop promoting positive health behaviour. Health promotion is part of our role as doctors, but weight loss is not a behaviour. Physical activity, adequate sleep, stress reduction and good nutrition are all health behaviours. But none of them are weight dependent. Optimising them may lead to weight loss, but this should never be their goal or purpose.
It is therefore perfectly possible to promote health without even mentioning weight. In fact, I believe that should be the only way we promote health. Because once we start weighing patients and promoting weight loss, we are causing harm. We are promoting poorer mental health, disordered eating and weight gain. And we are sitmgatising patients which is dangerous.
Weight Stigma is dangerous
Weight stigma damages the patient/doctor relationship. It leads to a breakdown in communication, a loss of trust, reduced compliance and avoidance behaviour. When a patient fails to seek medical attention in a timely manner because they are afraid of being stigmatised by us, they are putting their lives at risk. And whose fault is that exaclty?
Not only that, but every time we refuse a patient treatment before they lose weight we are stripping them of their body autonomy. Every time we insist that they bring their BMI down to a certain number before we permit them treatment, we are breaching their basic human rights. And that goes against one of the very core principles that we were taught so long ago.
There is no such thing as one-size-fits-all healthcare
Applying blanket statements or enforcing a one-size-fits-all rule is just lazy medicine. Patients are all individuals, and we would all do well to remember that. You cannot work in the best interests of your patient if you don’t know anything about them. That’s why the first thing we are taught to do when we start our clinical placements is to take a good history.
That includes a past medical history, a medication history, a social history and a family history at the very least. So when it comes to lifestyle promotion, your first thought should be “let me take a history”. Whilst it is socially acceptable to judge a person by their outward appearance, we cannot allow ourselves to bring that in to the consultation room. Because whenever we judge a person according to their appearance we are discriminating against them. You cannot tell anything about a person’s health or lifestyle just by looking at them.
Weight has nothing to do with the first law of thermodynamics
Some of you don’t appear very convinced. That’s probably because you genuinely believe that weight gain is a simple matter of energy intake and expenditure. You have been fooled into thinking that the rules of thermodynamics apply here. If that’s the case, my friend MJ Finklestein would like to remind you of the following:
The first law of thermodynamics requires a closed environment. The second you introduce another element, you change the mass/energy balance. Talk to someone with a physics degree and they will explain to you how farting breaks the “closed environment” required.
Doctors may be smart, but sometimes we can be pretty dumb. Most of us haven’t touched a physics textbook since we were 16 years old (18 if you’re slightly masochistic like me). The laws of thermodynamics are far more theoretical than they are an explanations of living things. Because life is messy, and there is no such thing as a closed environment in nature. There are always external forces that we need to take into consideration, and when it comes to weight gain this is no different.
Here is a list of things that impact our weight:
- History of childhood trauma (ACE score)
- Medical history
- Medications (Iatrogenic weight gain)
- Chronic dieting
- Environment (Socioeconomic Status, Education, housing, access to healthcare)
I could go on but you get the picture. How can you have a conversation with a patient about their weight without addressing all of the above? Whenever you tell a single mother of 3 who works two jobs and is struggling just to make ends meet to spend more time at the gym, you are failing them. Whenever you tell a bipolar patient who is gaining weight as a result of the medication you prescribed to just “eat less and exercise more”, you are failing them.
It’s not good enough.
You need to do better.
Health is complicated
If you’re still not convinced, I imagine that is because you have spent your life believing that fat is bad and you simply cannot contemplate practicing medicine in a way that allows fat patients to continue to be fat. What about their blood pressure? Their diabetes risk? The socioeconomic burden on the NHS?
You think of all those theoretical future diabetics out there that are going to cost the NHS a fortune. Perhaps you focus on all the time you have picked up fatty liver on a routine ultrasound or struggled to examine a patient because of their size. Or maybe you’re thinking about all those people with knee pain or back pain who would never have these problems if they lost a few pounds. Because carrying around all that extra weight has to have such a big impact on your joints, right?
Need I remind you that health is complicated? Diabetes is not caused by being fat. And how many patients with fatty liver on their ultrasound go on to develop cirrhosis? As for pain, ask any physiotherapist worth their salt and they will tell you it is all about the biopsychosocial model. Plenty of straight sized people have knee pain, and plenty of fat people have no joint pain at all. Please don’t buy into the rubbish you read in magazines. Extra weight around the joints has not been clinically proven to cause arthritis.
What is health anyway?
Need I also remind you that health is not just physical. It is emotional, mental, social and environmental too. As a GP, I spend a lot of time talking to patients about their mental health. If you don’t, then you are probably missing something. Just think about all of the common health conditions that are impacted by stress, anxiety and low mood. Irritable Bowel Syndrome, Fibromyalgia, CFS, and chronic pain, to name a few.
Also, depression is the second leading cause of years lived with a disability worldwide, behind lower back pain. In a study undertaken in 2013, depression was found to be the primary driver of disability in 26 countries. In 2014, approximately 20% of people in the UK aged 16 and over showed symptoms of anxiety or depression. Now I’m not suggesting we stop bullying fat people and start bullying depressed people instead! I’m just pointing out that mental health is important. And just so we are clear, weight normative medicine is impacting people’s mental health.
What is Weight Inclusive Medicine?
Some of you may be asking yourself, “what exactly is a weight inclusive approach?” Well first let’s take a look at the proper definition, shall we?
A weight-inclusive approach attempts to improve patient access to health care by recommending that health care providers recognize weight-normative biases (e.g., stereotypes that higher-weight patients must have, and lower-weight patients do not have, diseases often associated with obesity) and practices (e.g., prescribing weight-loss diets to higher-weight patients regardless of their physical health) within health care settings and challenge them in their own interactions with patientsThe Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss (Tylka et al, 2014)
In my own practice this means removing weight talk from the conversation. I don’t weigh patients unless it is absolutely clinically necessary. If I do have to weigh them, I explain why I am doing it and suggest they look away unless they don’t want to. I spend a lot of time reassuring patients that their weight is not to blame for their presentation and it will not be influencing their care. I even go as far as to correct patients when they label themselves as something negative or apologise for their own body. Not in my consultation room you don’t!
Weight Inclusive Medicine For Patients
So I’m now going to spend the rest of my time answering one of the most common questions I get asked:
I think the best way to answer this question is to take a look at the types of stigma that people commonly experience and ways to navigate them.
The ignorant one
Ever been in a situation where someone has either made some flippant comment about your weight or done something insensitive that has made you wish the floor would just swallow you up? It could be something small like asking you to don a gown that doesn’t fit or attempting to take your blood pressure with a cuff that is too small. Maybe they’ve used insensitive language in your medical notes or correspondence. There are hundreds of different ways that healthcare providers can cause offence without realising it.
First thing you have to do is take a deep breath say to yourself is “it’s not me, it’s them”. As I mentioned in last week’s post, the majority of healthcare providers have a degree of anti-fat bias. Translation: they think they are better than you. Yup, I said it. This is particularly true of thin, white male doctors who come from privileged backgrounds. And before people start getting upset with me, I’m not just being a fat angry feminist here like my critics regularly like to accuse me of. I am just reporting the facts. No need to shoot the messenger.
I don’t know about you, but it’s these little micro-aggression that get to me the most. Their effects build up over time and put me off seeking medical attention when I need to. And whenever I find myself in a situation like this, I tend to freeze up. I may be a mouthy brat most of the time, but in cases of severe stress the majority of people either flee or freeze. That’s just human nature. Very few of us are able to fight for ourselves in these situations, and that sucks.
Bring a friend or bawl like a baby
One way to get around this is to bring an advocate along with you. A friend or family member who will have no problems telling your healthcare provider where to go if they harm you in any way. You do not need to ask permission to bring an advocate with you in almost all situations (although COVID is making that a lot harder).
The other thing you have to remember is that you are under no obligation to hold it together in these situations. Feel free to burst into tears or let your healthcare practitioner know exactly how their words or actions have impacted you. Most of us are quite capable of compassion and empathy when we allow ourselves to look beyond our bias. Not only will this give you an opportunity to advocate for yourself, but it will also be a teaching moment for the HCP.
The really nice one
Some healthcare practitioners are really nice. They never bring up weight and never seem to mention lifestyle interventions whenever they see you. I’m talking about the kind of person who is more than happy to prescribe a pill or write a referral letter but does not appear particularly invested in discussing certain things with you. They might be overly friendly or understanding, sometimes to the point of patronising.
I know this particular type of HCP well because until recently, I used to be her. What I didn’t realise is that bias doesn’t necessarily manifest itself as unkindness. By refusing to engage in conversations with patients about lifestyle for fear of offending them, I was doing them a disservice. Did you know that implicit anti-fat bias is really common in fat people? Of course it is. We’ve been told to hate ourselves and our bodies all our lives. It goes without saying that we will allow this to cloud our clinical judgement.
In my case this manifested itself in a refusal to acknowledge the elephant in the room. Don’t get me wrong, I’m not talking about weight loss here. I’m talking about my unconscious fear and dislike of fatness that translated into a certain level of discomfort when it came to having health and lifestyle conversations with my patients. Instead I tended to ignore them altogether. On the plus side, I very rarely caused offence. But I was still operating from a place of deeply rooted bias. And that wasn’t fair on my patients because often they wanted to talk about things and I wouldn’t let them.
Never be afraid to ask questions
I think the best way to avoid this is have a clear idea in your mind of the questions that you want to ask before you enter the consultation room. It helps if you have them written down, and feel free to share them right at the beginning. Make sure the questions are specific and do not invite conversations about weight loss. For example you might ask “is there any kind of exercise I could do to improve my symptoms”?
The dismissive one
If you’ve ever been fat, there is no way you have gotten through your whole life without experiencing this at least once. Healthcare practitioners love to blame things on weight. Got a sore toe? It’s because of your weight. Worried about a rash? It’s because of your weight. Struggling to get pregnant? Lose some weight, and then we’ll talk.
Even if you have an advocate with you and have written everything down on a list in advance, there’s very little you can do when a doctor decides that the issue is weight-related. How are patients supposed to question their doctor’s diagnosis and treatment decisions? The answer is it is really tricky, but here are some standard questions that you can try.
- What evidence do you have that this is weight related?
- Could my symptoms be caused by something other than my weight because I would like to discuss these too?
- What would you tell a patient in my situation who had a “normal” BMI?
- What are the risks of weight loss? (Chances are they won’t have an answer for this and that’s when you can break out all your amazing knowledge and quote some papers!)
- I’m already doing all I can when it comes to my diet and activity levels, so what else can I do?
How to get the doctor to take you seriously
It helps if you’ve written these questions down so that you have something to refer to in the moment. It also helps if your advocate is well versed in these questions so that they can step in anytime you feel like you’re struggling to advocate for yourself.
Another option is to make it very clear to your healthcare practitioner from the outset of your consultation that you wish to be treated in a weight inclusive manner. You can either do this by telling them straight out at the beginning or speaking to them in advance and asking them to make a note of it in your medical records. I suggest people consider writing to their doctor ahead of time and I have cobbled together a suggestion for what you might consider including in that letter.
I’m happy to you to copy and paste my quote below, and please consider linking it back to this post for further information.
I would like to request that all of my healthcare practitioners adopt a weight-inclusive approach when treating me. I have a history of [you can use this opportunity to mention any previous issues you may have had with chronic dieting, mental health or disordered eating]. As a result, I find it extremely challenging to access health care because of my previous experiences of weight shaming and stigma. I would therefore ask that you take the time to recognize how weight-normative biases and practices affect our interactions and take active steps to avoid these.
Studies have shown that weight stigma will affect my ability to trust you, communicate with you, comply with your advice and seek you out in the future should my health deteriorate. This will inevitably lead to poorer health outcomes for me, and that is something we are all keen to avoid. I would therefore ask you to refrain from discussing my weight during the consultation or prescribing weight loss. I do not consent to being weighed unless it is essential for my care (in other words you cannot treat me without it).
Whilst I am happy to discuss my lifestyle and engage in health promotion, please ensure that this focuses on behaviour rather than weight loss. Finally, I would ask you to treat me in exactly the same way that you would treat a patient with a BMI between 18 and 25. [If you have any other specific requests based on personal experience you can add them on here]Can be copied without permission but please consider linking it to the author
The demanding one
There are some health professionals who will refuse to treat you until you lose some weight. In most situations this is completely unacceptable, but there are more and more instances where local/national guidance prevents patients with a particular BMI from accessing care. This is particularly relevant in fertility treatment and routine surgical procedures, and is something that the entire medical profession needs to collectively address. There is very little evidence that losing weight prior to a surgical procedure will benefit your health in the long term. There is, however, some evidence that it will damage your health and that is something I will cover in more detail in another post.
That being said, you are always entitled to question your healthcare decisions. So one thing you can get in the habit of asking is, “how do I appeal? Who do I talk to?” There is no need to concern yourself with offending your HCP. It’s not your job to keep them happy. In some instances, you can simply ask for a second opinion. In others it may be a more formal process. Either way, our word is not law. We are all human beings, capable of making mistakes and coming to the wrong conclusions. If you’re not satisfied with the conclusion of your visit, ask what you can do next.
The abusive one
Some healthcare professionals, and I use the term “professional” very loosely here, are just plain mean. They make jokes at their patient’s expense and they are cruel. Here are just a few examples that I have heard over the last few weeks that have really shaken me to my core:
- A OBGyn telling a woman who had just delivered a stillborn baby that she ought to lose weight before she tries again.
- A dentist asking a man who was helping his plus-sized disabled sister into the examination chair, “what’s her problem?”
- A gastroenterologist advising a patient that her weight loss and abdominal pain were a good thing because she could “stand to lose a few pounds”. Turns out she had cancer.
My inbox is filled with hundreds of these stories and I struggle to get my head around it. Tales of people who were not bathed or turned properly during a hospital stay to the point that they developed bed sores. Of patients who were denied blood pressure medications because they were “too fat” and didn’t deserve them. One woman was actively fat shamed during a pelvic exam. Another on a ward round after recovering from a cancer operation.
How to complain
There is only one word I can think of to describe this kind of behaviour and that is abuse. As far as I am concerned, the only way to deal with it is to complain. In the UK, you have several options for complaining and I will briefly cover them specifically for doctors working in England (as this is the extent of my knowledge):
- To the doctor in question, usually through a practice manager or equivalent in secondary care. If you are not sure, just ask a member of staff how to file a complaint. You can do so over the telephone, via email or website, or in writing. In general, I would suggest the latter.
- To the local commissioning board. These are called Clinical Commissioning Groups (CCG) and you can find your local one here.
- Via the Patient Advisory Liaison Service (PALS)
- To NHS England. Ideally you complain to the individual in question before approaching the NHS, as it is much simpler this way.
- To the GMC. This is really only appropriate if you believe that a doctor is in breach of their duty of care and meets the requirement of a GMC investigation. The GMC will not investigate minor complaints that can be resolved on a local level, and they don’t usually forward them on either. [FYI, they also don’t police doctors on social media unless they are breaking the rules, which is why loads of people have supposedly reported me but it hasn’t gone any further.]
What should I write?
When writing a complaint be sure to include your contact details and the details of the event in question (when, where, with whom etc). It helps if you can describe what took place, how it made you feel, and what you would like to happen next. This could be an apology, an investigation, a change in practice/policy, or any number of things. However, it should not be about financial compensation. If that’s what you are looking for, you’re gonna need a lawyer (I would also ask you very politely to consider unfollowing me if you’re only in it for the green since I really don’t have anything nice to say to you).
You don’t have to be formal and you don’t have to make sure it is polished before you send it. Every complaint must be taken seriously, and you should always be advised what to do if you are not happy with the way that it was resolved.
It’s really important to note that this is a blog post written by a fat doctor who is fed up with all the weight shaming and anti-fat bias that takes place within her profession. These are my own thoughts and opinions. I am not speaking on behalf of the NHS or my employers, and I am simply sharing from my own experience and expertise. So please don’t take my word for gospel. I can assure you that it was written in the spirit of genuine concern and honesty but I am just a GP who happens to be a fat angry feminist. That is all.
If you found any of this helpful or have any questions or thoughts that you would like to share, then please consider filling in a comment below. You can also subscribe to my mailing list so that you never miss another thrilling post again [eyeroll emoji].