What If My Patient Wants To Lose Weight?

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This is one of the most common questions I get from healthcare practitioners, and it happens in a couple different scenarios.

In the first, it’s someone in healthcare who is claiming that they can’t transition to weight-neutral care because their patients/clients want weight loss.

In the other it is someone in healthcare who is moving toward or already working from a weight-neutral paradigm. They are having the realization that weight loss attempts are highly unlikely to be successful, and can cause great harm to their patients, but their patients still live in a world that tells them that weight loss is the “cure” for everything from health conditions to dating woes and that their healthcare practitioner can help them.

Let’s start here - patients don’t want weight loss out of nowhere. Often they got the idea…wait for it…from healthcare practitioners. Part of solving the harm that has been done around this is acknowledging that healthcare practitioners (many of whom have been misinformed themselves) have misinformed patients and created patients who think weight loss is the only path to health, and who blame themselves for all their failures to lose weight long-term (even though the research is clear that this is what happens to almost everyone.)

When a patient asks for weight loss, it’s a huge opportunity. This conversation gives you the chance to help someone shift their thinking in a way that helps them to release internalized stigma and move to a path to support their personal health goals that has a success rate of more than a few percent.

So, this is a serious and exciting conversation to get to have with your patients.

I suggest starting with a question like “what are you hoping that weight loss will do for you?”

Be prepared for the patient to be surprised by this. Their healthcare experiences up to this point have likely focused on the idea that changing their body size is, by far, the most important thing they could do for their health, so the first part of the conversation is to give them a chance to articulate what they believe about weight loss.

Their answers are likely to fall into one or more of three main areas:

• Prevent and/or treat health issues

• Improve mobility/fitness/ability

• Solving weight stigma

Let’s take these one by one.

Prevent and/or treat health issues

This is an opportunity to educate about the research, and start the discussion to provide new, evidence-based options:

“The idea that weight loss will prevent or treat health issues has become really popular, but as I’ve studied and learned more, I’ve learned that it’s not really an evidence-based method. First of all, because of the way that human body deals with intentional weight loss attempts, they almost always result in short-term weight loss and long-term weight gain [you can see here if that’s been your patient’s experience and reassure them it’s not their fault] Plus, thin people get all the same healthcare issues that fat people do, so being thin can’t really be a certain preventative or cure.

The good news is that the same evidence-based [behavioral interventions, treatments, etc.] work for people of all sizes. What do you think about us working together to focus on your health, rather than trying to change your weight?”

Improve mobility/ability/fitness

Patients/clients often ask for weight loss because they’ve been told that it’s the only way to increase their mobility, ability, self-care etc. This can often be sound like “I don’t want to get out of breath so fast” or “I want my knees to stop hurting when I walk” or “I’m having trouble reaching to wipe”

I recommend starting with options that can solve the problem right away (or at least as fast as possible) include mobility/assistive devices. Then you and they can consider working on strength, stamina, and flexibility, balance, physical and/or occupational therapy etc. depending on their priorities, desires, and goals.

Because of ableism in our culture, there can be stigma associated with the use of these tools (including among healthcare practitioners.) If you find that is the case for you, then make sure you are actively doing the work to correct it, and be there to help your patients/clients with this as well in whatever capacity is appropriate for your practice.

Even if they are going to work on other options which might possibly increase their mobility/ability/fitness long-term, mobility and assistive devices can often help much more immediately (unfortunately depending on whether or not the patient/client can afford them and/or get them through their insurance coverage.) Make sure that you are familiar with mobility devices and assistive devices so that you can have a helpful conversation about this with your patients/clients.

 If the patient/client is asking about mobility and or fitness because of their current strength, stamina, and/or flexibility then those are all things that can often be improved independently of size. There are a lot of myths about this, even among fitness professionals some of whom still believe, for example, that they shouldn’t work on strength with higher-weight clients because they don’t want them to get heavier. This is a tremendous disservice, since strength work can often create improvement in mobility.

Here again you can point out that there are people of all sizes who struggle with strength, stamina, and/or flexibility and that while weight loss attempts almost always fail, working to improve strength, stamina, and flexibility can help people of all sizes. If this is within your scope of practice, then create a plan based on the client’s needs, current situation, and movement preferences. Otherwise consider referring them to a weight-neutral/body affirming fitness professional, physical therapist etc. as appropriate for their situation.

If they are talking about ability then you have a chance to address ableism in a way that can help rid them of shame and help them become more empowered. Point out that people of all sizes have disabilities and that there is no shame or blame in that. Then discuss their specific goals and options for achieving those goals. Here are a couple of examples:

If a patient says that they are having trouble reaching to wipe, a weight loss suggestion is not only unlikely to help (especially long-term since they are extremely likely to gain back any and all weight that they lost) but it leaves the patient/client in a situation that may be harmful while they try to change their body size. So first, think about ways to solve the issue immediately – you can discuss tools and aids that can assist with the wiping process. Then, if it’s appropriate to their situation and they are interested, you can also discuss flexibility work and techniques that might improve their ability to reach. If that’s outside of your scope of practice, refer them to a weight-neutral healthcare and/or fitness professional who can help.

If a patient says that they want to get out and about more, but they can’t because of mobility issues, first consider options to solve the problem quickly – like mobility aids, canes, walkers, wheelchairs, scooters etc. If they want to, you can also look at an appropriate program strength, stamina, flexibility etc.

Again: We need to make sure we’re doing our own work around ableism. Often folks, including healthcare practitioners, can have implicit ableism that drives us to want to focus on making someone “able-bodied” first (and at any cost,) rather than helping them reach their goals as a disabled person. That drives a lot of recommendations that fat disabled people try to become thin (based on the often-mistaken belief that it will “solve” their disabilities) rather than working to help people be accommodated and supported on their own terms and in the bodies they have. It’s important that we not allow ableism to drive patient-care decisions.

Solving weight stigma

This happens when a patient expresses that they want to become thinner so that they will receive better treatment in society. This is, perhaps, the most difficult for healthcare practitioners to deal with. First, we have to acknowledge that truth – weight stigma is real and it does real harm. In addition to the barrage of negative messages they get about themselves and their bodies, fat people are hired, paid, and promoted less, are subjected to healthcare and other inequalities, and are the frequent victims of shame, stigma, bullying, and oppression including at the hands of authority figures, healthcare practitioners, the government, and more.

The idea of losing weight to escape this suggests that oppressed people should do whatever it takes to appease their oppressors. Put simply: give the bullies your lunch money and hope they will stop beating you up. 

Beyond the civil rights issue of having to change one’s body to avoid mistreatment, the fact is that weight loss is highly unlikely to work long-term. Which means that each attempt is likely to result in short-term weight loss (and the accompanying praise and compliments) followed by long-term weight gain (at which point all the praise and compliments become shame and insults) not to mention the health harms of weight cycling. Then there are drugs and surgeries that risk the patient’s life and quality of life, and still often end up with weight regain along with horrific, possibly lifelong, side effects.

So if your patient/client asks you to help them lose weight to avoid stigma, you can gently point out to them that’s what they are doing. Then be honest that there aren’t good options when it comes to trying to lose weight. Consider connecting them with Size Acceptance community, encourage them to follow folks on social media who are thriving in spite of weight stigma, let them know that while weight stigma is real, they can choose to stop fighting their body on behalf of weight stigma and start fighting weight stigma on behalf of their bodies.

Always Come Back to Informed Consent

If your client insists that they want to try weight loss then you may have a choice to make. If you decide to try to help them, then you are responsible for providing informed consent, which includes making sure that your patient/client knows that there is about a 95% chance that they will lose weight short term and gain it back long-term, with an up to 66% chance that they will gain back more than they lost. You should reinforce this throughout their initial weight loss phase, knowing that they will be getting a lot of praise and positive reinforcement for a change that is virtually guaranteed not to last.

You can also try a technique of meeting them where they are, and then steering them to more weight-neutral interventions and focus (for example, creating goals around behaviors rather than body size, etc.) and continuing to suggest that they focus on supporting their body and let it settle at whatever weight it settles at.

If you are prescribing drugs or recommending surgery, you should take responsibility for being very clear about the possible side-effects (including if they are irreversible) and either provide, or encourage your patients to seek out, experiences not only of people who are happy with the results, but also the experiences of people who have horrific lifelong side effects and would give anything to take those decisions back, as well as the family and friends of those who did not survive the experience. For myself, I don’t think it’s ethical to suggest that it’s worth risking clients lives and quality of life for weight loss, but at the absolute least the patient should understand that is what they are doing, and should be aware that their are other options (not just for health, but also for surviving and thriving in a fatphobic world.)

Patients may want weight loss. It’s likely that they’d also like to be able to fly. Still, even if they make a convincing case that being able to fly would solve their joint pain, it’s still not ethical to tell them that either is likely to happen.

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More research:

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’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.