Questions for Higher Weight Patients and Their Healthcare Providers

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Our current medical view of weight and health is deeply muddied by weight loss industry involvement. I created this list of questions as a guide to interrogation. It can be used by or with healthcare practitioners, or by anyone who wants to take a critical look at our current weight and health paradigm.

Should simply being higher-weight be considered a diagnosis?

The concepts of “ob*sity” and “overweight” rest on the idea that simply existing in a higher-weight body constitutes a disease diagnosis regardless of actual symptomology or cardiometabolic profile. Now, there is no shame in having a disease, but that doesn’t mean that simply being higher-weight qualifies. In truth, this idea does not stand up to basic scrutiny. It is not scientific thinking, especially considering the health issues that higher-weight people have are also experienced by thinner people - in fact, if higher-weight people have an increased risk of health issues, it may be because of their increased exposure to weight cycling, weight stigma, and healthcare inequalities.

Is intentional weight loss an ethical, evidence-based intervention?

Often the assumption that body size is a disease is followed by the assumption that the “cure” is weight loss. Even if someone believes that simply existing in a higher-weight body is a disease, in order for weight loss to be an ethical recommendation there would need to be a proven effective does, and more importantly, there would have to be an evidence basis to support the idea that it was possible for the typical patient. Let’s look at this:

What would be the correct “dose” of weight loss?

Even if someone believes that weight loss is “treatment” then we need to know the dose. Note that the answer here is often inconsistent with the diagnosis, such that a provider will buy into the idea of “overw*ight” and “ob*sity” based on (the deeply flawed) BMI as the diagnostic criteria, but will then try to claim that “successful treatment” is an amount of weight loss that doesn’t actually impact the diagnostic criteria. For example, someone who is “diagnosed” as “ob*se” based on their BMI can lose weight, still be in the “ob*se” BMI category. Their healthcare provider/research/others may consider them a “success” even though the actual “disease diagnosis” has not been impacted.

Most pervasive is the myth that 5-10% of body weight loss (and I’ve even seen as low as 3-5%) creates “clinically meaningful health benefits.” This is not what the evidence shows (in fact, the research that is used to support this fails to separate the impact of the small amount of weight loss from the impact of the behavior changes that preceded it.) I have a specific post about that here if you want to dig further into this.

To put some numbers to this, let’s say a 5ft 4in, 350-pound person goes to the doctor. They are “diagnosed” as “ob*se” and prescribed weight loss of 5-10% of their body weight. Let’s say that they are able to do that (even though, as we will see momentarily, they are extremely likely to regain the weight.) In fact, let’s say that they lose (at least short-term) the full 10% (35 pounds) and now weigh 315lbs. They are considered a success. But if a 5ft 4in person who weighs 315lbs walks into the doctor’s office, they will be “diagnosed” as “ob*se” and will be told that they need to lose 5-10% of their weight. This is not scientific thinking.

In fact, the idea of 5-10% weight loss creating “clinically meaningful health benefits” is not based on research but on attrition, as the weight loss industry (including those within the healthcare system) has repeatedly set targets for “clinically meaningful” weight loss, utterly failed to reach those targets, lowered the targets, and repeated the cycle.

Is there research that demonstrates that this amount of weight loss actually improves health, separate from behavior changes?

A lot of weight loss research (which, let’s be clear, typically fails to meet the basic requirements for ethical research) rests on the 5-10% myth such that it doesn’t even TRY to show health benefits, it relies on the unproven assumption if people lose weight they’ll be healthier. Even if it does show health changes, typically the research fails to make the distinction between the health benefits of behavior changes (that precede weight loss) and the weight loss itself.

Is there research that demonstrates significant, sustained weight loss for at least five years?

Whatever amount of weight a practitioner thinks someone should lose (and, again, it should at least be consistent with their diagnostic criteria,) in order for this to be an ethical, evidence-based recommendation they should be able to point to strong research that shows that amount of weight loss sustained long-term (rather than just weight cycling.) That research does not exist - I have a guide to analyzing the research here.

What is the failure rate of intentional weight loss?

Again, this is basic information that should be known and disclosed about any kind of treatment. About a century of data finds that intentional weight loss fails the vast majority of the time.

What about research that shows the benefits of health-supporting behaviors separate from weight loss?

Understanding that weight and health are two separate things (since there are people of all sizes at every point along the health spectrum) and that health is not an obligation, a barometer of worthiness, or entirely within our control) there is research showing the independent benefits of health-supporting behaviors.

What is the risk-benefit analysis?

If weight loss is the “treatment” then we should look at the risks vs the benefits. We know that about 95% of the time not only will the treatment fail, but that failure, known as weight cycling (or yo-yo dieting in the colloquial) is independently correlated with harm. In terms of benefits, among the small percentage of people who do manage to lose weight, it’s not clear if the body size change, or the behavior changes that preceded it, are actually the reason for any health changes.

If the patient has actual diagnoses or symptoms (besides simply existing in a higher-weight body,) what is offered to thin patients in these same situations?

People of all sizes get the same symptoms/diagnoses. Often thin people get an ethical, evidence-based treatment while fat people get a “prescription” for weight loss which isn’t just unlikely to work (to create weight loss or greater health) but means that any actual treatment can be delayed, sometimes long-term or even permanently if the weight stigma they experience leads that patient to disengage from care.

Would the practitioner be comfortable documenting their differences?

One of the things I teach patients is that if they ask for a diagnostic or treatment option and the practitioner denies it because of their size, they should ask the practitioner to document the denial in their chart. If a practitioner isn’t comfortable documenting the ways in which they treat higher-weight patients differently than lower-weight patients, then they shouldn’t be doing it. (Of course, if they are comfortable with it that’s another problem that needs to be solved.)

We have to keep asking these questions because our current paradigm around weight and health is based far more on what will be profitable for the weight loss industry (which has wheedled its way into every level of public health and healthcare) than science (or logic).

If you want additional support around dealing with weight stigma at the doctor’s office, I’m teaching a workshop with Shelby Gordon on exactly that. A video of the talk and Q&A will be provided to all registrants and there is a pay-what-you-can-afford option. Details and registration are here.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.