Right around the time Ozempic came out, I started to change the way I practice medicine. As the new class of weight-loss drug ushered in a highly medicalized era of Americans’ obsession with being thin, I decided I was done with trying to get my patients to lose weight.
Sometimes I call myself a « body-positive doctor, » but that isn’t it, exactly, because I don’t expect all of my patients to love their bodies at all times. With my students, I call it practicing « weight-neutral medicine. » I’ve found a great community of like-minded health care providers with the Health at Every Size movement, which promotes the idea that people can be healthy without focusing on weight loss.
This change started for me, as many of my major realizations do, from reading. I read memoirs by fat authors like Roxane Gay, Lindy West, and Kiese Laymon, who wrote about the many ways they were made to feel terrible about their bodies, often at the doctor’s office.
It was unsettling to recognize myself in some of the encounters they described. I had told my own patients, dozens of times: « Your knee pain might get better if you just lost a few pounds. » As if my patients hadn’t thought of that already. As if they hadn’t already tried.
Reading these books also forced me to reckon with my own relationship to my weight and my experiences in health care.
As a chubby teen, I remember a visceral unease before each appointment at the pediatrician’s office, the fear I felt stepping on the scale. I remember the doctor who chided my mom for buying 2% milk, not skim.
Then, when I lost weight in my 20s, appointments with the doctor were transformed. I could focus on the issues I wanted to discuss, rather than visits being dominated by talk of cutting calories.
My body continued to change over time, as most bodies tend to do, and in my 30s, my weight again became the focus of visits to the doctor.
When I was close to giving birth to my son, I remember a midwife telling me, « Nice work on not gaining too much weight during pregnancy! » I had spent the last nine months vomiting, paralyzed by perinatal anxiety, unable to eat much more than Saltines. This was what I was being congratulated for?
Changing how I talk about weight
Somewhere along the way, I vowed to no longer put my own patients through that same gauntlet. I had to change the way I talked about their weight.
Part of what made me change my approach, at least before Ozempic came on the scene, was realizing how ineffective I was. Most primary care weight counseling – that is, a doctor like me suggesting my patients hop on the treadmill more often – simply doesn’t work.
I also started reading more about the history of the body mass index and exactly how unscientific it is. The concept of BMI – weight relative to height – was developed in the 19th century by a Belgian astronomer and mathematician who wanted to define the « average man. » But his « average » was white, European and male, and didn’t take into account genetic differences or muscle mass.
If the origin of BMI sounds like quackery, that’s because it is.
Yet the field of medicine is fixated with this measure. In the electronic medical record I use at work, a patient’s BMI is labeled like a vital sign, highlighted red if it’s above 26. It’s the focus of countless lectures and test questions in our medical training. Weight is a cornerstone of our culture from day one of medical school.
Talk to any clinician, however, and they’ll share plenty of examples of how BMI misses the mark. I’ve cared for countless patients with a high BMI who have perfect blood pressure and glucose control, and thin patients with advanced diabetes. And major medical organizations are finally starting to acknowledge that a patient’s BMI isn’t always predictive of how healthy they are.
Mostly, I stopped fixating on weight because I want my patients to feel welcome in my office. Me telling them to lose weight isn’t effective, and those conversations often make them feel horrible. It can detract from more important medical issues we need to work on together. So why do it?
There’s a large body of research showing that doctors are some of the worst offenders when it comes to weight stigma, and patients are less likely to get the medical care they need when they feel judged for their body size. They’re also less likely to exercise and more likely to experience depression. I didn’t want to be a part of that.
I now try to focus on more rigorous measures of health and well-being: blood pressure, insulin resistance, joint pain.
I don’t pretend that diet and exercise are unrelated to those metrics. Cutting back on processed foods is a great way to prevent hypertension and diabetes. Getting active is the cornerstone of a healthy lifestyle – it can help you sleep, improve your mood, stop back pain. These things might help you lose a few pounds. But as a doctor – and in my own life – I try to focus on the health benefits, rather than making a certain body weight the goal.
The change in my clinical practice has been palpable. I see relief in my patients’ faces when they realize I’m not going to lecture them about their weight. I see how they confide in me and respect my advice.
« That’s why we like coming to you, Dr. Gordon, » said the mom of one of my teenage patients, when she told me her son finally felt enough confidence in his body to start playing sports. That’s the great irony of all of this: When doctors stop shaming patients about their weight, that’s often when they feel ready to make a change.
Ozempic forces new, difficult conversations
Then, of course, came Ozempic. A medicine that can make people thin, its introduction marked a new moment in our diet-obsessed culture: a treatment that actually works, unlike the all the scam diets and supplements that don’t. Slowly but surely, my patients started asking for it, and I’ve had to think hard about how it fit into my new, weight-neutral approach.
When patients tell me they want to lose weight, I ask them why. Weight loss isn’t always the cure-all they’re looking for.
Some tell me they want to be able to keep up with their kids. (Taking small steps to get more active is the way to do that.) Some tell me they’re worried about developing diabetes. (Cutting out soda is a better approach.) And some are brutally honest: « I want to be hot, Dr. Gordon. » That is hard to argue with. I hadn’t intended to practice cosmetic medicine, but here I am.
Still, I started to understand that it wasn’t my job to withhold Ozempic from my patients simply because it didn’t align with my ethos.
I remember tears streaming down the face of one patient, who had tried for years to make peace with her bigger body, but said she was sick of fighting for body acceptance. Even though her blood pressure and blood sugar levels were well-controlled, she was ground down by the fatphobia she experienced every day. She wanted Ozempic.
So when patients ask for it, I usually prescribe it. Part of practicing weight-neutral medicine, I’ve realized, is supporting my patients’ own sense of what their bodies need.
The medication is a mixed bag, it turns out. Some of my patients can’t stand the side effects. They tell me the nausea and vomiting aren’t worth it, that they’d rather stay fat than feel sick all the time.
Others lose weight quite easily, like one of the patients I first prescribed Ozempic for. Having lost close to 50 pounds, he came to see me the other day, bewildered. « People treat me like I’m a different person now that I’m thin, » he told me. That day, he wanted to talk about a new problem he was facing, something the Ozempic had unveiled: depression. He wasn’t fat anymore, but he still lives in a society that hates fat people, and he was seeing it with new eyes.
Many of my patients – and my physician colleagues – believe that losing weight will solve every problem, medical and otherwise. But weight loss isn’t always the miracle they assume it will be. It can be a distraction from the real issues.
We need more holistic approaches to health and wellness. We also need to end the shame of being fat, which makes it so much harder for people in bigger bodies to do the very things that keep them healthy: exercising, socializing, living life free of self-hatred.
Being a body-positive doctor in the age of Ozempic has made me realize, sadly, that I alone can’t stop the fatphobia that permeates our culture. As long as it exists, we’ll have a market for medicines that make people thin.
What I can do is try, with each patient I see, to make them feel comfortable and safe, and help them realize that being healthy may have little to do with how much they weigh.
Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. She’s on Twitter as @MaraGordonMD.