Health at every size – making medicine weight inclusive

UK-based doctor, Dr Natasha Larmie is on a mission to make medicine weight inclusive. Inspired by the Health at Every Size movement, Natasha is campaigning to take the weighing scales out of general practice and focus instead on health promoting behaviours.

Last year, as the pandemic escalated worldwide, UK GP Dr Natasha Larmie embarked on a new weight loss journey. “I’m 40 years old and since I was in my early twenties, I have been considered overweight or obese,” says Natasha. “When all the data came out about obesity and severe COVID, I started to panic. I hadn’t weighed myself in a very long time, but I thought if I am going to do it, today is the day.”

Natasha discovered her BMI was over 40 and began a diet using the NHS weight loss plan which limits calorie intake and aims to promote safe and sustainable weight loss. “It worked beautifully, and I lost two and a half stone in three months. I went down from a BMI of 40.1 to much lower – probably lower than I had been in a while,” she says.

But three months later, Natasha found herself spiraling due to depression. “It wasn’t just the diet, but the diet was the catalyst, and I really began to struggle. I wanted to give up but a very good friend of mine told me that instead of abandoning it, I should talk about my experience, tell the truth and tell people what I was struggling with.” Through her online blog fatdoctor.uk, Natasha documented her journey which led to the discovery of the Health at Every Size community.

“People were reaching out to me and saying, ‘yes I totally understand what you’re going through’ and I would find out more from them and they’d be part of Health at Every Size.”

Health at Every Size 

Pioneered by Lindo Bacon, the HAES community supports people of all sizes in adopting healthy behaviors, recognising that health outcomes are driven by a range of social, political, economic, and environmental factors. The movement opposes the war against “obesity” which it emphasises is not about health but stigmatising fat bodies.

“The body mass index (BMI) which is used to define obesity was invented nearly 200 years ago by mathematician Adolophe Quetelet and it was never designed to be used as a measure of health,” explains Natasha. “There are numerous studies that show without doubt, BMI is useless. It was based on white Western Europeans but is now used to influence key healthcare decisions such as access to surgery and IVF for all ages and ethnicities.”

Despite several studies showing individuals with high BMIs are metabolically healthy and have a significantly lower risk for cardiometabolic abnormalities, change is yet to happen in healthcare. “We would never use such a useless screening tool in any other area of medicine, so why do we still use BMI?” Natasha says.

“I knew that weight stigma wasn’t a good thing, but I don’t think I appreciated what the philosophy of Health at Every Size really meant until recently.

“When I started to look at Lindo Bacon’s research, I realised that actually I had got my approach to ‘obesity’ completely wrong. Using weight as an indicator of health is a new phenomenon and morality plays into it.”

The problem, she believes, starts with confirmation bias. “We all believe that fat is bad, so we look for evidence that fat is bad. This means that when evidence comes along on the contrary – we just dismiss it. For example the ‘obesity paradox’, we call it a paradox because no one wants to believe it could be right. Universally almost all of us have this confirmation bias that fat is bad and that brings stigma into the GP consultation.”

For most doctors that bias is implicit, she says. “They don’t know they’re doing it but for some people it is explicit, so we are discriminating within the consultation. You look at a patient and see they are overweight, and you make decisions about them without doing further assessments. There are studies that show physicians were less inclined to do cervical and breast cancer exams in bigger patients than they were in smaller patients.”

Day-to-day, Natasha says she sees weight bias affect the doctor-patient relationship in general practice. “I know that if I bring weight into the conversation, even just by mentioning it or weighing a patient or telling them that they need to lose weight, I stigmatise them, and that patient loses their trust in me.”

Patient compliance to doctor’s advice is another challenge. “If you tell a patient to go and do some exercise and explain the benefits, the patients leave the room and think ‘yes I am going to go out and exercise.’ However, if you shame them, tell them they are overweight and give the same speech about exercise – the patient has stopped listening. They have no interest in what you’re saying because you’ve hurt them.

“If the main goal of the doctor’s conversation is to encourage physical activity why do they have to bring weight into it? The outcome will be the same. If you bring weight into the equation, they’re less likely to comply so the doctor has actually done the exact opposite of what they set out to do.”

The next issue is patients then begin to avoid seeing the doctor. “I cannot tell you how many patients come to see me and say, ‘I would have come to see you sooner, but I was afraid you were going to blame it on my weight’. That scares me because it means that they are not coming when they need to be seen.”

In the age of COVID-19, Natasha believes this could be a key factor between body weight and severe outcomes. “During the swine flu epidemic, obesity was considered a risk factor. But analysis of the data later showed it was not body size but delay in care that created the increased risk. My concern is years from now there’ll be a paper published that once it adjusts for delayed presentations shows that of all the ‘obese’ people who died of COVID-19, the delay was responsible for some of those deaths.”

Medical avoidance can lead to delayed diagnosis and poorer health outcomes across all disease areas, she adds. “A patient gets a bit of abdominal pain and thinks ‘I’m not going to go see the GP – they’ll blame it on my weight’. What if the pain was because of cancer? What if you waited two months and then your cancer spread?”

While Dr Larmie is aiming to find common ground with medical colleagues, she has encountered resistance. “I think some are receptive to the message but some not so much because they believe being fat is an issue of virtue. It is hard to change their mind because I think there are some people that don’t see fat people as equal to thin people.”

Challenging the status quo

Challenging the efficacy of dieting also threatens the weight loss industry which often contracts with the NHS for weight loss initiatives. “If I can’t choose to be fat or thin, then the weight loss industry cannot convince me to buy their products. I am anti-diet culture because it’s not about saying diets don’t work; people can lose weight of course but that’s not the point. The question is can they keep the weight off? Studies show they’re very unlikely to.”

“If you start saying weight isn’t always a choice. It is something determined in part by nutrition and exercise but predominantly by your sex, genetics, hormones, whether you’ve had a baby, or you’ve gone through the menopause, have a particular medical condition, or you’re on a particular medication etc. There are so many factors and a lot of that is not choice. A lot of that is just life – you have no choice.”

In the UK, patients visiting their GP are assessed around four lifestyle factors – smoking, alcohol, physical activity, and weight.  “I would argue that the fifth should be chronic stress and chronic stress reduction,” says Natasha. “Mental health and physical health are very much interlinked. We use a tool to assess people’s smoking and alcohol, but we don’t ask about their diet, we calculate their BMI instead of asking people, what kind of diet do you eat? How much physical activity do you do? Shouldn’t those be standard questions?”

Natasha’s mission, with other allied healthcare professionals, is to make medical practice weight inclusive. “As a doctor, I think it is my responsibility to practice medicine fairly and without discrimination. What is in the best interest of our patients is to never do harm and give patients their own autonomy. Those are the fundamental principles of medicine but we’re breaking every single one of these through weight stigma.”

As one of a small group of medical professionals in England speaking out on the issue, Natasha is urging the pharmaceutical industry to assess internal fat phobia and avoid capitalising financially on the side effects of medications that induce weight loss, such as semaglutide.

“I would love the industry to ask themselves if they are challenging themselves to be anti-fat phobic. Are they being weight inclusive? We need to address those issues and the most important step is recognising that there is a problem.”

“If people want to change their body then fine but they shouldn’t feel pressured into doing it and health shouldn’t be used as an excuse. We never would say we are getting a nose job for our health. There is a lot of scaremongering with weight which is untrue and that’s the part I find uncomfortable.”

For the NHS, taking weighing scales out of the GP room will result in focusing on health at every size, she concludes. “If we make medicine weight inclusive, all we’re saying is we don’t weigh people anymore. We do not make our medical decisions based on weight and stop using weight as a measure of health. Of course, that sounds simple, it is not easy at all, but it can be done over time. These are the debates we need to have for public health policy and make part of the public agenda.”