Dear Laura… What if I need to lose weight for medical reasons?

Hey team - welcome to ‘Dear Laura’ - a monthly column where I fashion myself as an agony aunt and answer the questions that readers submit. If you’d like to submit a question for me to answer next month - then you can leave it as a comment below or submit it here.

I’m happy to answer Qs about anti-diet nutrition, developing a more peaceful relationship to food and weight-inclusive health, body image challenges, and, of course, challenges with feeding your kiddos. Please give as much detail as you’re comfortable with and let me know if you’d like me to include your name or keep it anon.

Please remember that these answers are for educational purposes only are not a substitute for medical or nutritional advice; please speak to your GP or a qualified nutrition professional if you need further support. (I have a limited number of family nutrition spots available from January - if you’d like to work with me then you can email hello@laurathomasphd.co.uk to book a preliminary call to see how I might be able to help you.)

This month I’m answering two questions:

• How do I go about losing weight for health reasons? (Specifically knee pain!)
• How do I get my kid’s teacher to stop saying chocolate is ‘unhealthy’?

OK, LFG

First up:

Dear Laura…

How do I go about losing weight if it’s advised for health reasons? Eg my knees would benefit if I lost some weight. But I don’t want to get obsessed with diets or with a particular end goal.

*takes deep breath*

*sits down*

*exhales slowly*

Ok, so. Two things I want to say before we get into this. And we’re really going to get into this. First is that what you do with your body is your choice. It’s not my job to judge people for pursuing intentional weight-loss. My job is to give you enough information to make an informed decision.

Second thing is, I also suffer from chronic joint pain - which is what I *think* you’re talking about based on your question. So, I get it. I get how vulnerable being in pain makes you. And the desperation to find relief. I see you.

And I think there are very few medical reasons where weight loss is your first or only option.

Let’s backup a bit. It’s not a secret that virtually every common chronic disease is blamed on weight. We know that for people even a little bit in the ‘overweight’ or ‘ob*se’ range of the BMI scale, and frankly sometimes even ‘normal weight people, will be advised to lose weight as the first line recommendation - particularly for something like knee pain. In fact, in the UK, we have something baked into consultations with healthcare professionals where they are obligated to mention one of a few ‘health behaviors’ to you, regardless of what you come in for. Got a sore throat? Here’s your antibiotics and, oh by the way, would you like a voucher for Slimming World?

There are two reasons why weight-loss ideology is so prevalent in health care:

• Anti-fat bias baked into research
• Anti-fat bias baked into medical training

When it comes to the relationship between weight and health, we assume that it’s a linear one. Our expectation is that higher weight automatically equates to worse health. This is often the way weight is discussed among public health professionals, medics, and in the media. But the picture is a lot more complicated than that. I’m not going to go into all the details here, but I think it’s helpful to share that there is a ‘U’ shaped relationship between weight and health.

That is to say that the highest risk of illness and death is at the ‘extremes’ of weight - both lower and higher body weight. Having a BMI around 40 carries a similar risk as having a BMI <18.5 - but we rarely hear about the ‘dangers’ of being underweight. And again, counter to what we are told, the nadir, or lowest point of that curve isn’t at a ‘normal’ weight range, but at a BMI between 25-30; a number considered to be ' ‘overweight’’. Many studies show, quite compellingly, that things like cardiorespiratory fitness plays a more important role in shaping our ‘health’ than weight (remember that health is also complicated). This makes sense right? I bet you know some thin people who aren’t especially fit, and some fat folks who are.

The second thing to pay attention to is how anti-fat bias colours our interpretation of studies. There is often an association between weight loss and improved, let’s say cholesterol, or blood glucose management. This often gets attributed to weight loss, per se. And not changes in behaviour, like more sleep, better nutrition, or more exercise which also seem to negate ‘risk’ of higher weight. .

Another way this shows up, is that researchers rarely consider the impact of anti-fat bias on health - they don’t control for the effects of prejudice and stigma which we know have an enormous impact on people’s wellbeing. And this is by no means exhaustive, but the WHO acknowledged that some of the consequences of anti-fatness are: poor body image and body dissatisfaction; low self-esteem and self-confidence; feelings of worthlessness and loneliness; suicidal thoughts and acts; depression, anxiety and other psychological distress; disordered eating and eating disorders; avoiding physical activity; stress-induced pathophysiology; avoidance of medical care. All of these have an enormous impact on individual health and wellbeing. And particularly if you are experiencing pain, avoiding physical activity and losing mobility can confound the issue. Researchers studying weight loss rarely measure the impact of anti-fat bias in their studies. If you don’t measure something then you can’t quantify the impact it has on the outcome of your study. You can’t tell if being fat in and of itself causes disease, or if it is a byproduct of living in a world that dehumanises and violates fat bodies every single day.

I won’t say too much about anti-fat bias in healthcare because I covered it recently on an episode of the podcast with Dr. Molly Moffatt - give it a listen because it’s really good. But briefly, doctors, nurses, dietitians, nutritionists and other health professionals have been shown to harbour more negative beliefs about their fat patients compared to thin patients; spend less time with and provide less treatment options to fat folks; they ask less questions and provide less information. I mean, in my own training, I was told to assume that fat people were lying when they gave you a food diary. So yeah. Violence towards fat folks is normalised. Pathologising of fat bodies is normalised, despite what we know about how BMI is bullshit. And doctors are only given one blunt tool to support higher weight clients: diets.

It is absolutely not surprising that fat people delay coming to the doctors until a symptom has progressed to a point where it is much more difficult to treat. This for sure contributes to worse outcomes that again, get blamed on being fat, rather than what is really going on; medicalised anti-fat bias.

So, why did I go on this detour? Well, it’s important to understand where the idea that you *have* to lose weight to support your health is coming from. Is it based on the assumption that fat is ‘unhealthy’? Is it advice from a doctor who hasn’t offered you any other tools? Is it based on flimsy research? My guess is that the answer to all three is probably yes.