What is the healthcare obsession with weight?

Why the healthcare obsession with weight as the ultimate explanation for all ills? Less than two weeks ago, I posted this meme on the BigBirthas Facebook group.

Cartoon showing medics through the ages - the first in the 14th Century saying 'witchcraft, probably', the second in the 19th Century blaming female hysteria, and the 3rd in the 21st Century saying 'there's nothing wrong with you, but try weight loss' - healthcare obsession with weight
(If you’re the originator of this image, please let me know so I can credit you properly! A reverse Google image search returned no leads!)

While intended as a joke, the old ‘many a true word spoken in jest’ certainly fits here. It didn’t take long for a group member to experience the 21st Century panel very clearly.

The quote below was posted in the BigBirthas Facebook group. Though it’s not on topic with regards to pregnancy, It does show how poorly some professionals understand their role or the available science with regards to BMI, dieting, obesity, eating disorders and just being a decent human being who can listen with empathy, and do the job they are being paid to do?

I’m sharing it here (with permission) because this healthcare obsession with weight helps no-one. In fact, there’s good evidence that it’s harmful. This message needs sharing widely. Unless you’re a specialist in nutrition, particularly eating disorders and mental health, then you have no business making the kind of repeated suggestions this person experienced today (Content Warning):

Post in the BigBirthas Facebook group (CW)

Just coming to shout into the void somewhere where people might get my frustration with weight obsessed healthcare professionals.

I went for an ENT appointment for persistent sinus problems today. Basically I started having sinus problems at the beginning of Covid, and understandably there were no treatments available for minor nasal problems then. So it was 18 months before it got dealt with properly, and they need *something*. Widening? Flushing? Something like that.

I saw a genuinely lovely registrar doctor. She asked if I had thought about losing weight, and I explained that I had Binge Eating Disorder. She asked if that prevented me from losing weight, and I explained the binge/anorexia cycle. Later on she suggested that I just try a diet, not going into anorexia, because that might help. I explained that trying ‘normal’ dieting in my later teens was what gave me a blooming eating disorder in the first place, and how it works in cycles, and leads to longer term weight gain.

She said ‘but all your weights when you have seen a GP have been fairly normal’ so I explained that often I do not seek medical care unless I am a normal weight – I delay care, or insist on telephone appointments, or I purposefully binge/starve for a few weeks so I am in their parameters before I have an appointment. She suggested I just ‘lose weight with a diet’ 3 more times in the appointment. Argh!

I’m pretty sure my sinuses are not overweight. And I have come out of the appointment both determined never to eat again and desperately wanting to stop at the first supermarket and eat all the sugary shit whilst sitting in the car in the car park. Again!!! And with my sinuses still feeling crappy.

Why does every interaction with a healthcare professional involve discussions of weight?

Post on Big Birthas Facebook group 1st November 2021

Weight discrimination has consequences

It’s easy to see why. If the healthcare obsession with weight overrides a professional’s ability critically assess the problem, it will take longer to diagnose.

If the patient decides to avoid healthcare as a result, the issue will take longer to diagnose and treat.

And if the comments made trigger relapse or a bout of mental ill health, this is definitely not the ‘first, do no harm’ mantra that is supposedly drilled into medics on day one of training.

So why are some health professionals still doing this?

Is the healthcare obsession with weight simply ignorance? Arrogance? Laziness?

Decades of study by specialists in food, nutrition, and behaviour make it clear that obesity is not a simple issue. There’s definitely no one-size-fits-all solution either.

We wouldn’t expect a medic to pass comment on any other medical issue we might have outside of their specialism, so why is it that our weight is an open invitation to explore whatever half-baked theories they may harbour about weight management?

If we exhibit other traits, we wouldn’t expect a medic to treat every issue as connected to them, so why is it OK with weight?

Many healthcare professionals have internalised fat bias

Research has shown that “Medical students have high levels of both implicit (unconscious) and explicit (conscious) weight bias at the start of medical school, and many are unaware of their bias related to weight.

Studies of US physicians in practice have found that 1/3 characterized patients with obesity as sloppy and lazy, 45% had a negative attitude toward individuals with obesity, and only 56% perceived themselves as competent to treat obesity in their medical practice.
Moreover, implicit and explicit weight bias were positively related in a study of physicians, indicating that relative to other types of prejudice (e.g., race, sexuality, disability) weight bias is more socially acceptable”. There were strong links with feelings that people with obesity are placing unfair burdens on healthcare systems.

Making Every Contact Count

Sadly, institutionalised weight bias exists in the UK too. There’s been an NHS initiative since the early 2010s called “Making Every Contact Count” (MECC). This encourages professionals of all disciplines to “support people to make changes to their physical and mental health and wellbeing”.

MECCs concept – to take opportunities to publicise services which already exist to those who may benefit but may not be aware of them is, in principle, not a terrible one. (e.g. stop smoking, physical activity, weight management, mental wellbeing). After all, people are unlikely to request a referral to something they don’t know exists!

The plan is that the professional should briefly (30 seconds) advise that a lifestyle change might offer benefits. If open to the idea, advise that there are services that can help, and provide encouragement and information. If the patient doesn’t want to engage, the professional should back off:

Text for professionals advising what to do if the patient receives the interaction positively, neutrally, or does not want to engage.
Excerpt from ‘Let’s Talk About Weight’ infographic for professionals

MECC – poor training and misleading messages

In my opinion it is the pushing of schemes such as MECC, and professionals’ misunderstanding of the process and purpose which leads to interactions like the one today. The messages of ‘refer on to specialist support if interested’ and ‘back off if they’re not’ aren’t getting through. Moreover, professionals are dabbling in giving advice for which they are not qualified or experienced. Far from being a positive influence, such conversations have the capacity to do harm.

The trouble is, the MECC concept is often delivered briefly (and clumsily). It’s usually a very small component of a brief annual training session which is basically a colossal dump of information. MECC’s session may be delivered in just 15 minutes! Perhaps it’s unsurprising if some take it to mean ‘take every opportunity to nag patients’, particularly if they already harbour innate weight prejudice. That was never supposed to be the plan.

What MECC is not (from the MECC Resources Factsheet) with "staff telling somebody what to do and how to live their life" highlighted.
MECC Resources Factsheet

Poor evidence

It doesn’t help, of course that the MECC message itself rehashes old tropes for which there is poor evidence. The landing page of the MECC website states:

“Around 40% of the UK’s disability adjusted life years lost are attributable to tobacco, hypertension, alcohol, being overweight or being physically inactive”.

NHS Make Every Contact Count website

There is simply no good evidence that being overweight is a cause in itself of ill health. In fact, a 2014 meta-analysis of data found that it was fitness, not fatness, that was the better predictor.

Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis

But here it is again. Classic correlation vs causation. Stated as fact on a website, on the ‘Let’s Talk About Weight’ excerpt I posted above, and in a programme rolled out to hundreds of thousands of professionally qualified NHS staff over the past few years.

There are some great NHS staff who do ‘get it’, of course! This is a snippet of an excellent Twitter thread by an NHS dietitian:

But it only takes one professional, poorly informed and overstepping their boundaries, to cause people real harm. It needs to stop.

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