Why there’s no point telling me to lose weight

I have been studying the stigma of obesity and I have been guilty of being discriminatory myself. Thinking weight loss was simply a matter of calories intake being greater than expenditure; and that everyone could just change their eating to healthy low fat and sugar choices (with calorie reduction) and commence or do more exercise. I now realise that there is much more to it than that from experiences in my family as well as formal study. I want to compliment Emma on an excellent portrayal of her experiences with health professionals so far. I am very happy for Emma that she has overcome her low self esteem and has found enjoyment in exercise. I sincerely hope that she does not have to suffer any more negativity and is happy in her skin from hereon in. Best wishes Emma

I think the answer is partly in your title: telling someone something that they know already is pointless. There is a big difference between unsolicited health advice and working with a patient to achieve a goal that is important to them. Most smokers want to quit smoking but can't, or find it difficult without support. Should we wait until patients present with COPD or lung cancer before we offer smoking cessation services?

My colleagues and I at King’s College London have been analysing hundreds of reflective accounts by senior medical students of consultations with obese patients. These reveal that broaching the subject in a way that leaves the patient in control, such as "would you like to talk about your weight today?", "do you have any concerns about your weight/are you happy about your weight?" can lead to some amazing conversations with patients who described, as you do, feeling previously judged and hounded. The agenda for the consultation is still being led by the patient, but it doesn't require the doctor to be entirely passive.

That being said, if a patient answers no to the first question (and especially if they are in recovery from Binge Eating Disorder!) there should be some way of respecting the patient's preference for how they would like to be approached about the subject, or not, in the future.

Emma Lewis has written an excellent article demonstrating the stigmatising and negative effects on health of well-meaning but ultimately insensitive and flawed interventions on the “problem” of overweight and obesity by GPs. Notwithstanding the important issues Emma raises, a significant further problem may well be the common conflation of these two categories.

Emma describes herself as having a lifelong BMI of over 30, thus falling into the “obese” category. Yet, in a rapid response Simon Howard suggests that one of her key messages is not supported by the evidence because many “overweight” people do not recognize their own overweight [1]. Of course, the evidence to support this focuses on a BMI of 25-30 [2], not the obese category of a BMI of 30+. Commonly in the media, everyone with a BMI of over 25 is condemned as “fat”, this despite increasing and converging evidence that the overweight BMI range of 25-30 has a lower all-cause mortality risk than the “normal” category of 18.5-25 [3, 4, 5].

One important “key message”, therefore, should be that many of those often labeled “fat” have a largely low-risk BMI of 25-30, and perhaps do not recognize themselves as “overweight” because the technical BMI definition of overweight bears little resemblance to a common understanding of what “fat” looks like, nor to a statistical elevated all-cause mortality risk. Perhaps, then, next time we read about the problem of overweight and obesity, we should ask of ourselves and others: Who are YOU calling fat?

[1] Howard SJ. One minor factual correction. Rapid response to: Lewis E. Why there’s no point telling me to lose weight. BMJ 2015; 350: g6845 (http://www.bmj.com/content/350/bmj.g6845/rr-35)
[2] Health and Social Care Information Centre (2013) Health Survey for England 2012: Adult anthropometric measures, overweight and obesity
[3] Flegal KM, Kit BK, Orpana H, Graubard BI. (2013). Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-analysis. JAMA 2013; 309(1): 71-82.
[4] McGee DL; Diverse Populations Collaboration. Body Mass Index and Mortality. Ann Epidemiology. 2005; 15(2): 87-97.
[5] Orpana HM, Berthelot JM, Kaplan MS, et al. BMI and Mortality. Obesity; 2010; 18(1): 214-218.

I read this article with great interest and agree with the first key message to 'focus on what the patient has come to see you about today'. Having worked as an FY2 in general practice this was something I always tried to do. However, it was incredibly difficult to see any patient without the patient management system alerting me to various QOF indicators and targets that needed to be met for the patient. Whilst GPs have an important role in promoting primary prevention of disease it is vital to recognise the challenge that this poses when the patient comes with their own agenda for the 10 minute consultation. And it is even more important to recognise how a discussion of other issues such as weight loss, exercise and smoking cessation may be perceived by the patient when they are consulting you about something unrelated.