Weight and Healthcare

I got the following question from reader Lynn:“I know that they use BMI for kids and I know that it’s different than what they do for adults, but I don’t understand how. Maybe you could write a newsletter about it?”Indeed I can Lynn, thanks for the suggestion! This gets a bit complex, so it’s going to be a two-part series. In part 1 we’ll look at the basics. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

As updated COVID vaccines and this year's flu vaccines roll out, I got a request from several readers to post about the need for longer needles for higher-weight people’s vaccinations. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

While progress toward weight-neutrality is absolutely being made, our healthcare is predominantly based in the weight-centric paradigm. This paradigm currently considers simply existing in a higher-weight body to be a disease and weight loss to be the cure. (Now, there is no shame in having a disease, it’s just that simply existing in a larger body does not qualify.) One of the most dangerous harms within this paradigm is the hypothetical future thin person fallacy. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Eil Lilly has recently announced that they are going to sell their weight loss drug, Zepbound, directly to consumers who can’t get insurance coverage and don’t qualify for other cost-lowering programs. They are going to do that through their private pharmacy Lilly Direct.The subject of whether drug companies should have their own pharmacies is a topic for another day.I’ve previously done deep dives into the research and claims made about these weight loss medications. I do not think they are going to live up to the hype and I think people aren’t getting appropriate informed consent around these drugs.Still, I believe in bodily autonomy and I think that people who choose to take these medications deserve a safe experience.What I want to talk about today is the catch of Lilly’s direct drug discount. That catch is the delivery system. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I got this question from reader Jenn:I was hate watching a workshop about “ob*sity” treatment and one of the people on the panel said that “ob*sity” isn’t a disease unless it impacts someone’s health. I don’t understand how that works?Thanks for the question Jenn. You don’t understand how it works because it doesn’t work. This is fully ludicrous and I’ve seen them make the claim in real time as well. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1, by reader request, I began a discussion of the NBC news article “Weight loss drugs like Wegovy may trigger eating disorders in some patients, doctors warn”. Today we'll complete that discussion. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Many of you asked me to write about the NBC News Article “Weight loss drugs like Wegovy may trigger eating disorders in some patients, doctors warn” by Liz Szabo, Marina Kopf and Akshay Syal, M.D. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!I received this question from reader Louise:I see you and other people talk about the weight loss industry, but what does that mean? Is it just drug companies and places like weight watchers? Do doctors who recommend weight loss count? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we talked about a Medscape Today article that reader Antoni sent me about weight stigma in healthcare called “Weight Stigma is Bad Medicine.” The author, Mengyi (Zed) Zha, MD made important points about weight stigma, some of which aren’t often aren’t made. So there’s a lot of good in the article, which I appreciate.What Dr. Zha has written is brave (and she will undoubtedly get criticism from those who implicit or explicit anti-fat bias drives their thoughts about and interactions with higher-weight people.) I’m beyond grateful that she wrote this articleThat doesn’t mean I’m not going to push farther, though, because there is more to the journey here to reduce the harm done to higher-weight people by the healthcare system and the providers within it.So there are some issues with the article that I want to discuss. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Antoni sent me the following question.I saw this article posted on LinkedIn (Weight Stigma is Bad Medicine by Mengyi (Zed) Zha, MD in MedPageToday). I feel like the author made good points but it still doesn’t feel quite right to me. What do you think? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we started looking at a company called PrescribeFit that is focused on getting referrals from orthopedics office of higher-weight patients with musculoskeletal (MSK) issues. We looked at the scientific basis they are using as well as their promises around efficacy. Today, we’ll look at what they have available for providers. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This came up in our monthly subscriber Ask Me Anything and then from another email from reader Julie who wrote:“I hurt my knee playing soccer. After a lot of of imaging I was told it wasn’t surgical. I asked for a referral to physical therapy and my ortho referred me to PrescribeFit. I assumed it was physical therapy but it seems like it’s some kind of online diet thing. Can you tell me what’s going on?”I can try! Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Many of you have reached out asking me to write about Brandi Mallory and Mandisa Hundley’s deaths. Today is the day I’m going to do that. I want to start by saying that their deaths, regardless of cause, are a tragedy and my heart goes out to them and their families, friends, and loved ones. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I got the following question from reader Kyrie:I started having pain in my knee after I jumped out of a truck and twisted it. I went to my regular doctor and he referred me to an orthopedist. He (the orthopedist) told me that the only thing that could possibly help was to lose weight. I asked the question that I learned from you “what would you recommend for a thin patient in this situation?” The orthopedist said “I don’t have to talk to thin patients about knee pain.” Obviously that’s a complete lie, but what can I do as a patient when a doctor just says something like that? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Kellisa sent me the following question:I appreciate all the different things you write about, but some of my favorite newsletters are where you show how people and studies are paid for by the diet industry. I know this was a while ago, but I just found the newsletter you wrote about where you figured out that the person behind that “bill of rights” was actually a lobbyist for Novo Nordisk and I decided to ask this question. How do you find this stuff out? Are there any tips you can give to help someone like me “follow the money” as they say? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

As I discuss the issues of GLP-1 agonist and GLP-1/GIP co-agonist weight loss drugs Semaglutide (Ozempic/Wegovy) and Tirzepatide (Mounjaro/Zepbound)I’ve been increasingly hearing from people who are engaged in practices with these drugs that are not remotely evidence based. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!Reader Shauna asked “I just saw an article about the Body Roundness Index, is that as silly as I think it is?”The Body Roundness Index seems to be the weight loss industry’s response to finally having to (at least begin to) admit that the Body Mass Index (BMI) is nonsense. The BMI is a ratio of weight and height that has been used to pathologize bodies based on their size alone and has its basis in racism. I talked about that in depth in this piece.Earlier this year the AMA, which takes hundreds of thousands of dollars in donations from the weight loss industry, tried a little sleight of hand with this, admitting that there are serious issues with the BMI (which has been used as a justification for the much of the weight loss paradigm) but instead of acknowledging that simply pathologizing bodies based on shared size is an idea lacking scientific basis and merit that has done incredible harm, they instead said that we just needed more and different ways to pathologize bodies based on shared size.That brings us to the study Shauna sent me: “Body Roundness Index and All-Cause Mortality Among US Adults” published in JAMA (the Journal of the American Medical Association.)The authors reported no conflicts of interest, even though one of the authors, Qiushi Lin, MD, PhD, literally works for Sanofi Aventis which just had its weight loss drug preliminarily rejected by an FDA panel.Where the BMI is used to pathologize bodies based on weight and height, the The Body Roundness Index (BRI) uses height and waist circumference.The specific calculation they used is “364.2 − 365.5 × √(1 − [waist circumference in centimeters / 2π]2 / [0.5 × height in meters]2)”The use of mathematical formulas tends to lend these concepts an heir of scientific validity that they do not deserve. They explain that “Due to the lack of a reference range, BRI was categorized into 5 groups according to the 20th, 40th, 60th, and 80th quantiles to explore the association with all-cause mortality.”They find a “U-shaped association between BRI and all-cause mortality. Our findings provide compelling evidence for the application of BRI as a noninvasive and easy to obtain screening tool for estimation of mortality risk and identification of high-risk individuals, a novel concept that could be incorporated into public health practice pending consistent validation in other independent studies.”By this they mean that those at the lower and higher ends of this scale have higher all-cause mortality. As I’ve talked about before, one of the cornerstones of research methods is that correlation does not imply causation. The U-shaped association they found might be a valid correlation. The mistake happens if the assumption is that the BRI is the REASON for the increased risk and, when it comes to weight and health (particularly those of higher-weight people) that’s what typically happens. That’s what I think the problem is going to be. In our culture, there is a tendency to jump at any perceived “proof,” no matter how shoddy, that being higher weight causes health issues/is a health issue. What these researchers have found is an unexplained correlation between being at lower and higher weights and higher rates of all-cause mortality. What they absolutely have not found is that being at lower and higher weight CAUSES higher rates of all cause mortality. They don’t ever claim that they’ve found causation but then they conclude “a novel concept that could be incorporated into public health practice pending consistent validation in other independent studies” and not, for example, that causal mechanism(s) should be identified prior to foisting this formula on the public, it gives me the sense that they are jumping the gun here. I’m not going to do a deep dive into the methodology here because the concept is so deeply flawed at its base.I’ll start with those at lower BRI range. Their BRI could be due to extreme illness (including everything from cancer, to substance use disorders, to eating disorders and more )that are the actual reason for increased all cause mortality. What they may have found is that those in the lower BRI categories are more likely to be very ill which means their findings would not extrapolate to those at the lower end of the weight spectrum who are not experiencing illness. When it comes to higher-weight people, we know that experiences of weight stigma, weight cycling, and healthcare inequalities are all associated with increased all-cause mortality. People with a higher BRI are more likely to have these experiences. Not only did these study authors fail to control for these, they failed to even mention them. Without controlling for these possible confounding variables, what their findings may indicate is just that they’ve found even more evidence that experiences of weight stigma, weight cycling, and healthcare inequalities

This came up in our monthly Subscriber Ask Me Anything discussion and it’s something I get asked about a lot – how can you advocate for a fat* friend/family member in a healthcare appointment? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

The co-opting of concepts from weight-neutral health community to sell weight loss (or obfuscate the harm it causes) is rampant. We’ve talked about this with the concept of weight stigma and fake anti weight stigma events, PR campaigns, and marketing. In today’s edition of “words mean things” we’re going to talk about the co-option of the concept of weight-neutral. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In my recent quick guide to creating a size-inclusive office, I mentioned troncoconical blood pressure cuffs and I heard from a number of people in healthcare who said that they had never heard of them so I thought I’d write a follow-up piece. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we talked about the research (or lack thereof) around the ways in which GLP-1 drugs, taken in large doses for weight loss, might impact the absorption of other medications. Today, we’re going to hear from someone who was personally impacted by the issue. I received the following information from Jennifer Jonsson who gave me permission to publish it and use her name. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

One of the questions I’ve been getting a lot is about how the new GLP-1 weight loss drugs (Novo’s Semaglutide Wegovy) and GLP-1/GIP co-agonist weight loss drugs (Lilly’s Tirzepatide/Zepbound) can interfere with the absorption of other medications. In part 1 we’ll look at the information around this and in part 2 we’ll have a personal story of someone who experienced it. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Let’s start today with what P-hacking is, and then we can talk about why we needed to talk about it in the first place. Please note this is an overview, there are many more layers and complications to this, these are the basics. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 I talked about the WaPo/Examination piece “As ob*sity rises, Big Food and dietitians push 'anti-diet' advice…General Mills warns of “food shaming"; dietitian influencers promote junk foods and discourage weight loss efforts.” I discussed my experience with being interviewed, as well as some basics about the piece. Today I’m going to talk about their methodology, such as it is. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

The headline ran “As ob*sity rises, Big Food and dietitians push 'anti-diet' advice…General Mills warns of “food shaming"; dietitian influencers promote junk foods and discourage weight loss efforts.” (As is my policy, I don’t link to studies or articles that contain weight stigma, but I give enough information to Google.)Why am I calling it a hit piece? For two reasons, first because I know that the authors had every opportunity to provide a more balanced story, and second, because of their… let’s call it methodology.In this piece, I’ll talk about my experience with one of the authors. In part 2 I’ll examine their methodology. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we examined the massively misleading opening claim of the abstract of the new study “Long-term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial” by Ryan et al, published in the journal naturemedicine, and we looked at the magnitude of the conflicts of the authors. Today I’ll dig into the rest of the study. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

As you might imagine, I subscribe to a large number of medical publications and in the last couple of days I’ve been receiving updates from them falling all over themselves to breathlessly claim that weight loss was maintained for 4 years on Semaglutide 2.4mg (aka Wegovy) in the SELECT trial.The ways in which these claims are misleading are egregious and anti-science. In part 1 I’ll look at the initial claims and the people making them, in part 2 I’ll do a deeper analysis of the study. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!During the Q&A at a recent talk at a medical conference a healthcare provider at the end said “there is so much to do, what would you suggest is a good place to start?”There are plenty of places to start, but one that jumps to mind is in creating an accommodating office. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we talked about the long-standing, evidence-free phenomenon of “jump-starting” weight loss using some kind of short-term extreme food/caloric restriction. Today we have another version straight from the doctor's office. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I received the following question from reader Deena:I love when you talk about the funding and other conflicts of interest of the people who write studies. It seems obvious that you don’t think disclosures are adequate, so I’m just wondering - what do you think that disclosures should include?Deena is exactly right, I do not think that disclosures as they are currently done are anywhere near adequate. So today I’ll talk about what I wish research disclosures included. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part one we looked at the staggering conflicts of interest and issues with the efficacy in the Semaglutide 2.4 (Wegovy) cardiovascular trial (Semaglutide and Cardiovascular Outcomes in Ob*sity* without Diabetes DOI: 10.1056/NEJMoa2307563) especially as compared to the deeply misleading claims in Novo Nordisk’s “company announcement” publicity stunt prior to publication.Today we’re going to dig deeper into the data, what there is of it, anyway. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Today we’re going to talk about common advice that has long been a pet peeve of mine. It is advice that I, myself, have been given and that I’ve heard from countless people. It happens when someone (a fitness professional, a doctor, whomever) tells a higher-weight person that they should not lift weights/lift heavy weights/strength train etc. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In their zeal to medicalize and pathologize higher-weight bodies for profit, the weight loss industry (and the advocacy groups they fund, and the elements of healthcare they influence) have worked hard to claim that “ob*sity” is a disease and then manipulate the definitions of ob*sity to their best interest. Let’s look at some: Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Moving forward I’m going to be writing about efforts on a number of fronts that are trying to recommend weight loss and, in particular, weight loss drugs to older adults. Much of this is part of the weight loss industry’s holy grail of getting their drugs approved by Medicare, so I wanted to provide some basics around this today. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Every single day I hear from people who have had terrible experiences with healthcare providers. I often write about issues with overt weight stigma and the weight-loss paradigm in working higher-weight with patients/clients. Today I’d like to discuss things that often get said in front of these patients, but not to them. These things can cause significant harm, including damaging the relationship between the provider and the patient, making the patient less likely to be open and honest, and driving patient disengagement from care. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!This is the final in a three-part series about Tirzepatide (Brand name Mounjaro for Type 2 diabetes and Zepbound for Weight Loss.) In part one we discussed the basics of the drug, in part 2 we discussed the authors of this study and finally, in part three we’ll finish discussing the most recent study on Zepbound - SURMOUNT -4.(the text in italics is from the study itself.)SURMOUNT-4 was designed to find out what happens when higher-weight people (without type 2 diabetes) go on the drug for a while and then go off of it. The study was divided into two periods In the first 36 weeks all of the participants took Tirzepatide. Then there was a 52-week period during which subjects were randomly assigned to receive either tirzepatide, or a placebo.The basic findings, per the study:After 36 weeks of open-label maximum tolerated dose of tirzepatide (10 or 15 mg), adults (n = 670) with obesity or overweight (without diabetes) experienced a mean weight reduction of 20.9%. From randomization (at week 36), those switched to placebo experienced a 14% weight regain and those continuing tirzepatide experienced an additional 5.5% weight reduction during the 52-week double-blind period.Here's a graph that shows the average results:Some things to note:First, the graph clearly shows that people who go off the drug rapidly start regaining the weight they lost, and their weight was trending up when follow-up ended, suggesting that the weight regain will continue (as we’ve seen in about a century of research and in the history of weight loss drugs.) In addition to being exposed to the side effects of these drugs (some of which can be fatal) these people will also be subjected to the risks that come from weight cycling which include everything from increased risk of type 2 diabetes and hypertension to increased cardiovascular disease and overall mortality. This is important since there are any number of reasons why someone would have to go off the drug, from side effects, to expense, to availability.For those who remained on the drug, weight loss slowed considerably and by the end, had started to rise slightly, which means that the claim that weight loss will be permanent as long as people stay on the drug is not supported by the evidence.Let’s go beyond average results and get into some specifics - 783 participants were enrolled in the initial 36-week study in which all participants took Tirzepatide, but 113 discontinued the study drug before the 36-week stage even ended, most commonly due to an adverse event or participant withdrawal. So a little over 14% didn’t even make it 9 months on the drug, and that’s including the fact that the drug was started at a minimal 2.5mg dose and then increased by 2.5 mg every 4 weeks until a maximum tolerated dose of 10 or 15 mg was achieved.300 participants (89.5%) receiving tirzepatide at 88 weeks maintained at least 80% of the weight loss during the lead-in periodDid you catch that? First, 10.5% of the group who were still taking the drug during the one-year follow-up had already gained back more than 20% of the weight they lost in the first 36 weeks- again even though they were Still. Taking. The. Drug. As for the rest, they could well have been regaining the weight because of the way the study defined “maintaining.” For the purposes of this study, “maintaining” weight loss doesn’t mean that people lost weight and kept it off (as the word would be used in any reasonable context.) For this study, “maintained” just meant that they were regaining the lost weight slowly enough that by 52 weeks these participants hadn’t regained 20% of the weight that they lost in the first 32 weeks…yet. (This is one of those examples of words having different meanings in weight loss research.)Let’s take a look at side effects:A total of 81.0% of participants reported at least 1 treatment-emergent adverse event during the tirzepatide lead-in treatment period, with the most frequent events being gastrointestinal (nausea [35.5%], diarrhea, [21.1%], constipation [20.7%], and vomiting [16.3%]… [During the follow up period] Gastrointestinal events were more common in the tirzepatide group than in the placebo group (diarrhea, 10.7% vs 4.8%; nausea, 8.1% vs 2.7%; and vomiting, 5.7% vs 1.2%)Of course, the trial wasn’t long enough to determine long-term impacts. They also say :A significantly greater percentage of participants continuing tirzepatide vs placebo met the weight reduction thresholds of at least 5% (97.3% vs 70.3%), at least 10% (92.1% vs 46.2%), at least 15% (84.1% vs 25.9%), and at least 20% (69.5% vs 12.6%) from week 0 to week 88Let’s say the above another way: 2.7% of people who took Tirzepatide for 88 weeks, opening themselves up to side effects and unknown long-term consequences failed to lose even 5% of their body weight, 7.9% failed to lose even 10%, 15.9% failed to lose 15% and 30.

In part one I gave a summary of the drug Tirzepatide. Today we’re going to begin a look into the most recent study of Tirzepatide for weight loss under the brand name Zepbound - the SURMOUNT – 4 trial. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Zepbound (one of the brand names for Tirzepatide) is a newly approved “weight loss medication” (more on that in a moment) delivered by weekly injection. Today we’ll talk about the basics of the drug, and over the next two parts we’ll do a deep dive into the latest research. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Patty asked:”I’m confused, it seems like these new weight loss drugs have some dangerous side effects, but they are FDA approved so doesn’t that mean they are safe?”Thanks for the great question, Patty! Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

On the days when I need some hope and good news, I think about Medical Students for Size Inclusivity. In their own words “We are a community of medical students raising awareness about the harms of weight discrimination in the healthcare system. We believe all people, regardless of their weight, body shape, and size, deserve equitable medical treatment and the right to pursue health".They do incredible work, including the GLP-1 Agonist informed consent project that I’ve linked to here before.The fact that these incredible people are the future of medicine gives me more hope than I can say.Today in our “5 questions with…” series we have 5 questions with three amazing MSSI members! Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Barabara asked:”I’ve tried to look into the “science” Awaken 180 claims to rely on, but there’s not much to go on from their website. Similarly, I’ve tried to find out more about the founder, Paige Lopez, but only the basics seem to be available. Awaken 180 has quite a bit of traction in New England, and they have linked up with professional athletes, as well, which has broadened the appeal. Have you looked into Awaken 180, or would you be willing to do some digging? I would love to have some concrete feedback to help my clients assess all this, but I’m swinging in the dark. “Thanks for asking Barbara, let’s get into this! Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Lindsay sent this question in, and it’s one I hear a lot from healthcare practitioners in the Q&As after my talks:If I’m practicing patient-centered care, doesn’t that mean that if a patient’s goal is weight loss then I need to offer them weight management interventions?This is a tricky question, and I’m not going to make a yes/no pronouncement, but here are some things to think about... Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Content note: Many of you requested this piece and I think it’s important to talk about, but I also want to let you know that today’s piece might be a tough read. It discusses the lack of care for, and harm done to, higher-weight patients by Bellevue Hospital’s weight loss surgery program. Please take care of yourself.An expose by the New York Times has revealed that New York’s famed Bellevue Hospital is churning patients through its weight loss surgery program: Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I received the following request from reader Anisha:I like the in-depth reviews you have of the studies for Wegovy, but I’m talking to a lot of friends and family about this and it would help to have something that’s easier to read. If you are open to writing it you would have my thanks!You got it Anisha! This is a quick guide to Wegovy/Ozempic for weight loss. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

BMI-Based denials of care are about holding healthcare hostage for a weight loss ransom. A ransom that most people won’t be able to pay. Today I’m talking about resources that can be used to fight BMI-based denials for lumbar spinal surgery. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Happy 2024! I am ready for another year of writing about the intersections of weight science, weight stigma, and healthcare and I’m glad you are here reading! This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!I received the following question from reader Lisa:I notice that when you write about things that can hurt larger people’s health you usually mention weight cycling, weight stigma, and healthcare inequalities. I’ve read your posts for the first two – is there a post that describes the third one?Thanks for asking Lisa, I’ve been meaning to write this and you’ve given me the perfect gentle push! For the record the piece for the harm of weight cycling is here and the one on the harm of weight stigma is here.The idea of healthcare inequalities is difficult to quantify because it’s such a vast category. In terms of a definition, the one I’m going to use here is any way in which higher-weight people’s healthcare experiences differ from those of thin people to the detriment of higher-weight people.It’s always important to remember that when we discuss these inequalities we are clear that they don’t impact everyone equally, as people’s weight becomes higher their experience of inequality typically increases as well and, utilizing Kimberlé Crenshaw’s framework of intersectionality, those who have multiple marginalized identities will also face greater inequality in their individual marginalizations and at the intersections of them.Finally, I want to point out that thin people can face healthcare disparities as well based on things like marginalized identities and socioeconomic status. The comparisons I’m drawing here are about the typical experience of thin people and are not meant to indicate that thin people never face issues in accessing healthcare, just that as a group thin people are not systematically marginalized within the healthcare system because of their size.I also want to be clear that this is not an exhaustive list and I welcome you to add other examples in the comment section. I’m going to divide these up into groups to help give this conversation some structure.Practitioner BiasThis includes a lot of different things. Before I get into it, I want to point out that providers aren’t necessarily bad actors who just hate fat people (though, sadly, some absolutely are.) Many are simply a product of a healthcare system (including healthcare education) that is deeply rooted in weight stigma. Regardless of how they got to this place, these practitioners are responsible for the harm that they do.Some practitioners are operating out of implicit bias, which is to say that the bias is subconscious. Others are operating from explicit bias, they are fully aware of their negative beliefs and stereotypes about higher-weight people and they are working with higher-weight patients based on those beliefs and feelings. This can lead to a lot of negative impacts. Some examples:There is the classic (and far too prevalent) example of a practitioner who offers ethical, evidence-based treatments to thin patients for health issues, but sends higher-weight patients with the same symptoms/diagnoses/complaints away with a diet.There’s the “Occam’s razor” mistake. Occam’s Razor states “plurality should not be posited without necessity.” Said another way, when choosing between theories, the simplest one is usually correct. This gets applied to the care of higher-weight patients when providers don’t address individual health issues/symptoms/diagnoses/complaints for fat patients because they assume weight loss will solve them all (and/or they want to see what weight loss solves before attempting the ethical, evidence-based treatments that thin people would typically get for the same issues/symptoms/diagnoses/complaints.)Some practitioners assume that fat patients are lying if what they are telling the provider doesn’t match up with the provider’s stereotypes of people their size. These practitioners base decisions and recommendations on their stereotypes rather than what the patient is telling them.There are practitioners who, consciously or subconsciously, are reluctant to touch fat patients or manipulate their bodies which can impact everything from examinations to post-operative care.There are practitioners who think it’s worth risking fat people’s lives and quality of life in attempts to make them thin. Some of these practitioners take this further by deciding that they know better than fat people and so try to manipulate/trick/bully fat people into weight loss interventions (including dangerous drugs and surgeries) by almost any means necessary including intentionally failing to give a thorough informed consent conversation – blowing patients off with phrases like “all drugs have side effects” or “it’s nothing to worry about” rather than being honest about the risks and/or making threats about the patient’s health and life expectancy that are not supp

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!Part one of this was published on December 13, but this piece was pre-empted when the USPSTF put forth dangerous dieting recommendations for children (remember that the public comment period ends January 16.) In the past I’ve written pieces specifically about issues and mistakes that are made with terminology that is used…let’s call it differently in weight science as well as common statistics mistakes and mishaps. In part 1 I offered some additional terminology troubles today in part two we’re discussing statistics shenanigans. Using a percentage that seems high without proper context:In one example of this, early in the COVID-19 pandemic I saw a news report claiming that so-called “ob*sity”* was a risk factor for severe COVID because, in a particular city, 25% of severe negative outcomes were in people who are classified as “ob*se.” At first, that might seem like a large number, but that doesn’t justify calling being higher-weight a risk factor. In order to even begin to be able to draw conclusions from this, we have to at least know the total number of so-called ob*se people who live in the city - otherwise we have no way to know if 25% is higher or lower than the total percentage of this population. I looked it up and that number was 38%. Several things are issues here.First, if I were trying to draw conclusions from this (and I wouldn’t, more on that in a moment) I would conclude that being higher-weight is protective, since 38% of the community is higher-weight, but only 25% of the people with severe outcomes were. (Said another way, people who weren’t “ob*se” were 62% of the overall population but 75% of the severe outcomes.) That’s the main statistical issue here. You can’t use a percentage like this without contextualizing it.Moreover, I wouldn’t draw conclusions from this at all. First, because “ob*sity” is simply a ratio of weight and height. Making assumptions that since a group of people have some physical characteristic in common (like, in this case, height-weight ratio) then that physical characteristic is the reason for the difference in outcomes is on extremely shaky ground, scientifically speaking. In this example, since there are many other factors that can impact this result (including the fact that higher-weight people are at the mercy of a healthcare system in which practitioner weight bias is rampant and, even if that’s not an issue, the tools, best practices, pharmacotherapies and more, that are used are typically developed for thin bodies/excluding fat bodies) we don’t know what number of those severe outcomes were due to healthcare inequalities or other factors.Relative vs Absolute RiskNovo Nordisk recently used this one in their manipulative press release about the possible cardiovascular benefits of Wegovy. Relative Risk Reduction is the percentage decrease of risk in the group who received an intervention vs the group that didn’t receive the intervention. This number can be helpful to determine differences in outcomes between groups, but it’s not that helpful in determining individual risk. For that you need Absolute Risk Reduction.Absolute Risk Reduction is the actual difference in risk between the group that got the intervention and the group that didn’t. This helps us understand the likelihood that a given individual will benefit from an intervention.Relative risk reduction can often be a much larger number than absolute risk reduction and those who are trying to manipulate statistics (and those who don’t know about this - like reporters quoting a Novo Nordisk press release) can use relative risk reduction to make people believe a treatment has a greater effect than it actually does.Let’s use a super simplified example. Let’s say that 200 people who have Condition X are enrolled in a study to see if Medication Y reduces death from Condition X. 100 of them are given the medication (the intervention group) and 100 are not (the control group). At the end of the observation period, 1 person in the intervention group dies and 2 people in the control group die. The relative risk reduction (percent risk of death in the intervention group divided by percent risk of death in the control group, in this case .01 divided by .02) is 0.5 or 50%. That seems like a lot – a company with incredibly poor ethics might issue a press release saying that their drug reduced death by 50% without mentioning absolute risk.Absolute risk is calculated by subtracting the percentage of risk reduction in the intervention group from the percentage of risk reduction in the control group, or 2%-1% which is a 1% reduction. A much smaller number that more accurately predicts individual experience.So when a weight loss company gives a percentage of risk reduction, it’s important to ask if it is relative or absolute risk reduction they are talking about.For example, in the Novo Nordisk press r

In the past I’ve written pieces specifically about issues and mistakes that are made with terminology that is used…let’s call it differently in weight science as well as common statistics mistakes and mishaps. Today I’m offering an update on terminology as part 1 and in part 2 we’ll talk about the statistics. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I have written before about the various types of weight stigma that can impact healthcare including implicit weight stigma and bias (wherein people have negative beliefs and stereotypes about fat people and are acting on them unconsciously) and explicit bias (wherein people are fully aware that they have negative beliefs and stereotypes about fat people and are acting on them). Today we have a doctor who seemed to be going out of their way to demonstrate textbook explicit bias. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the second part of a series answering a reader’s question about weight loss industry “big think” strategies within healthcare. In part 1 we discussed how the weight loss industry strategically created a market by turning simply existing on the higher end of the weight spectrum into a so-called “disease diagnosis. “In part 2 we’ll talk about how they are relentlessly working to expand that market. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe