Doctors are Very Weird about Weight Loss
When "eating disorder" prevention overrides obesity prevention
For all the public health campaigns about the obesity epidemic, every doctor I saw growing up would have recoiled in horror at the actual behaviors that result in weight loss. “Eating disorder prevention” messaging overrode clinical reality.
Patient is concerned about her weight? Nah, she’s perfect just the way she is!
Patient is concerned about her visceral fat and BMI of 27? Oh no, a BMI of 27 is nothing. She has absolutely nothing to be concerned about.
Patient is concerned about her food intake and is tracking calories? Eating disorder.
Patient feels extreme distress about her out of control eating? Disordered thinking.
Patient is restricting her calorie intake to 1300 kcal per day? Definitely an eating disorder.
Patient wants to be thin for aesthetic reasons, as well as for health? Unrealistic beauty standards.
Patient expresses feelings of ugliness and inadequacy due to her weight? Unrealistic beauty standards, again.
Patient has just lost 20 pounds and gone from BMI 27 to BMI 24.8, but she wants to lose another 20 pounds? Absolutely not! She’s already a “healthy” BMI; wanting to lose more weight is an eating disorder.
Patient is upset that the doctor is dismissing all her concerns? Noncompliant and combative. Refer to psych for eating disorder and oppositional defiant disorder evaluation.
When I think back on my upbringing in the K-12 public school system, I got tons of messaging about the dangers of both obesity and eating disorders. This was the 2000s through the early 2010s, the height of “get out and move” campaigns to beat childhood obesity with exercise.
The most memorable campaign for me was Nickelodeon’s “Let’s Just Play” and “Worldwide Day of Play“ campaign. In 2006 and 2007, on the final Saturday in September, the channel actually went off the air from noon to 3pm. Instead of programming, the TV displayed a message encouraging kids to go outside.
I was a somewhat chubby kid. I was never obese, but I always felt a drive to munch on snacks day in and day out. When Kid Me heard these calls for 60 minutes of exercise, I pictured spending an hour jogging on the track during gym class. News flash: exercise is torture when you’re fat and out of shape.
There was no corresponding messaging about reading Nutrition Facts labels. No messaging about realistic calorie limits, or safe ways to lose weight. The standard advice was to never, ever try and consciously limit your calorie consumption. If you wanted to lose weight, you needed to exercise those excess calories away. Public health officials cared more about protecting kids from the mysterious specter of anorexia than protecting them from heart disease.
However, since in my mind exercise = torture, all I learned from these messages was that being healthy = torture = misery, so I resigned myself to be fat forever.
Meanwhile, there’s a saying in weight loss circles that “you can’t outrun your fork.” It is ridiculously easy to eat too much and have it counteract all that hard-won, torturous exertion. Did you know that a small muffin from Starbucks is 370 kcal? That’s an entire meal for me! (Don’t even get me started on nuts, guac, and nachos...)
I didn’t get better info until I was in college in the mid-2010s. I joined a little subreddit called r/fatlogic, which told me the following bombshell (roughly paraphrased):
You don’t need to cut out junk food. Just have a small piece of cake, instead of the whole thing. You can weight out your portions, track your calories, and you will lose weight by sticking to it.
I go into more depth in this post:
Long story short, I bought a food scale, downloaded MyFitnessPal, and started tracking my calories. As a mostly-sedentary-but-walked-everywhere college student, my daily needs were about 1800 kcal/day. I needed to stick to 1300 kcal/day to lose 1 lb/week. I did so, and the weight came off exactly as fast as it was supposed to.
And it was really hard! I was in a ton of psychological distress trying to resist my food noise. But that’s the thing: the psychological distress was in response to trying to resist junk food. Physically, I felt great. I wasn’t hungry at all; I was hitting all my nutrition goals and taking my vitamins. What I struggled with was food noise.
But that’s not how it looks for most people (even doctors). For most people, any distress around eating = anorexia. That’s completely backwards! That’s like looking at an alcoholic’s struggles to resist drinking and conclude that they have “teetotaler’s disorder.”
My roommates that semester suspected that I had an eating disorder. They’d witness me weighing my portions, tracking calories, and being visibly upset in the presence of junk food. When they expressed concern, I would pitch MyFitnessPal along the lines of, “Yeah, I type in everything I eat, and it adds up the Nutrition Facts for me! It lectures me when I don’t get enough vitamin C for the day.” I knew to hide my distress. They didn’t get it.
In hind sight, I probably did have an eating disorder. Just not the one everyone was desperate to label me with.1
In the spirit of “should you reverse any advice you hear?” what overweight girls like me needed was more encouragement, more acknowledgement of food noise, and yes, advice that sounds suspiciously like something straight out of MyProAna. I did not need to be told that I was beautiful and perfect just the way I was—because I wasn’t. And I could tell that I wasn’t. I didn’t feel uplifted; I felt patronized.
My heart goes out to people who struggle with anorexia and bulimia. But messaging about eating disorders wasn’t what I needed—and it wasn’t what my overweight peers needed, either.2
The biggest effect of the GLP-1 revolution is that doctors get to witness massive, sustained weight loss without issue. Since weight loss is now psychologically easy, patients don’t have to rigorously track and record calories anymore. There’s no explicit calorie limits, no need for rigid tracking, and no food noise-related emotional distress to report. Everything happens in the background, without thinking. They never become visible enough to be pathologized.
But it shouldn’t have taken a pharmaceutical breakthrough. It didn’t need to be this way.
Further reading:
Binge eating disorder (BED) might as well not exist, for all the public health messaging it gets.
What’s extra ironic is that all those PSAs about anorexia/bulimia didn’t really help them, either. It’s almost like eating disorders are complicated, and can’t be “fixed” or “prevented” with some patronizing feel-good messages.
I feel like this is a generalized problem in medicine (certainly in nutrition): doctors know *what* they want their patients to do, but have no idea *how* the patient can successfully go about it. No thoughts given to the science of behavioral modification.
Medical doctors are accidentally selected along a number of unusual traits. The ones who make it through med school must be able to function on very little sleep, eat not when they are hungry but when they’re given the chance, prioritize enormous amounts of work over anything else. They are not well trained in how to help people who aren’t like them.
We fret so much about whether we are chanting the correct slogans AT children. Maybe it's time to listen to what each one is saying about their own experience, take it seriously, and respond to them directly.