Today on the podcast I’m joined by Dr. Molly Moffat - A GP who practices medicine from a weight inclusive, neurodiversity affirming lens, celebrating both diversity of bodies and of minds.

In this episode, we are talking about how Molly moved away from recommending diets and weight loss to her patients, towards an anti-diet, weight-inclusive approach, focused on treating individuals with care and compassion. We get into what exactly medical anti-fat bias is and why it's so harmful, and she has some really lovely suggestions for how to talk to patients who come in with the idea that they have to lose weight for medical reasons.

Find out more about Molly’s work here.

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Here’s the transcript in full:

INTRO:

Molly: Fat folk don't go and see their doctor when they need to. And you know, I don't need to explain why that is a concern. That is a concern. It means that diagnoses are missed, diagnoses are made late, and it absolutely contributes to stress, mental health, physical health and health inequity in an already marginalised group of people.

Laura: Hey, and welcome to the Can I Have Another Snack? podcast, where we talk all about appetite, bodies and identity, especially through the lens of parenting. I'm Laura Thomas, I'm an anti diet registered nutritionist, and I also write the Can I Have Another Snack? newsletter. Today I'm talking to Dr. Molly Moffat. 

Molly is a GP with a special interest in learning disability and autism. She practices medicine from a weight inclusive, neurodiversity affirming lens, celebrating both diversity of bodies and of minds. She's neurodivergent herself and has three children. 

In this episode, Molly and I are talking about how she moved away from recommending diets and weight loss to her patients towards an anti diet, weight inclusive approach, focused on treating individuals with care and compassion. We get into what exactly medical anti-fat bias is and why it's so harmful, and she has some really lovely suggestions for how to talk to patients who come in with the idea that they have to lose weight for medical reasons. I really loved talking to Molly and I think you're going to enjoy this episode.

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All right, team, here's my conversation with Dr. Molly Moffatt. 

MAIN EPISODE:

Hey Molly, can you start by telling us a little bit about you and the work that you do? 

Molly: Sure, yes. So I'm a GP, although I actually only do one day of general practice at the moment. I have a special interest in learning disability and autism. I've been working in that field for a few years, and I've recently started working in paediatrics, doing some neurodevelopmental assessments, and I also do some teaching for medical students. 

The reason I'm here is because I do my very best to practice in a weight inclusive manner, so I'm not worried about fat bodies, but I'm really worried about the way fat bodies are treated, particularly when they're trying to seek healthcare.

Laura: Yeah, that's what you're here to talk about today, but I feel like we could probably have a whole other conversation about neurodivergence and feeding differences and all of that stuff, but I will try and rein myself in because, yeah, like you said, I really wanted to talk to you about how fat bodies are perceived and how they're treated in medical settings.

So I'm wondering if you could kind of take us on a bit of a journey with you. Can you set the scene for us? You're a medic, straight out of training, going into your GP specialisation. At that point, what do you believe to be true about the relationship between weight and health?

Molly: Okay. So I mean, all of my medical school teaching, all of my junior doctor training, and my GP training was absolutely based in this weight normative approach.

So the idea that weight was a marker of health, and that we should be pursuing weight management for our fat patients. And there was never any discussion around where that came from. So, you know, it was just stated as a fact that ‘ob*sity’ came with all of these comorbidities and put people at increased risk of X, Y, and Z.

And, like I say, I never remember – and I'm really confident it didn't happen – any discussion around where the evidence behind those statements came from, and the fact that actually...it was really complex and that maybe there were some other factors at play that cause that association between body size and certain diseases.

And I also never remember any conversation about weight stigma and the impact that that can have on people's health.

Laura: Okay. Well, there's so much that I could kind of, like, tease out of what you just said there, but I think the sort of headline for me is just how this information was presented to you as complete certainty. I think if I'm kind of reading between the lines, or what I've even learned in my own training, that as weight goes up, the worse the health outcomes, right? Like in this linear sort of fashion. It sounds as though you learned something similar, but the evidence behind that was never really presented or unpacked or challenged in any way.

And that's the part that I find most, like, terrifying because as medics you should be, like, challenging the evidence and not just, like, swallowing it whole and, you know, swallowing information whole and not kind of having any critical thought around it.

Molly: I know, I agree. And of course there were things that we critically appraised and we were taught how to critically appraise, but the world of ‘ob*sity’ was just something that was presented as a fact.

And I feel so sad that I kind of missed out on all of those years of a greater understanding of how complex it was.

Laura: You also mentioned weight stigma, which we'll come back to in a second, but coming back to this idea of how complex it is. So what were some of those messages that you received that oversimplified the relationship between weight and health?

You know, I've kind of mentioned this idea that as weight goes up, that health invariably goes down. I'm wondering what other kinds of things that you picked up on that sort of reinforced those ideas.

Molly: Yeah, I mean, absolutely kind of ‘eat less and move more’ was something that we spouted. And, you know, when we were kind of practicing role play scenarios, one of the tick boxes was ‘give lifestyle advice’.

Part of that was, you know, absolutely eat less and move more. And, you know, assumptions around a person's lifestyle and diet again was very much part of that message. That people were fat because they didn't exercise and they ate too much.

Laura: And then they also lie to you, right, about how much they've eaten?

That's…at least, that's the thread that we got in nutrition training, is that people who are higher weight, they're almost always lying about their dietary intake. And so you are already…I mean, think about how problematic that is, that you're already going in with the assumption that this person is lying to you about, you know, their lived experience, like, what does that do from the perspective of forming any kind of therapeutic relationship to go in with that understanding and assumption?

Molly: Yeah, no, I agree entirely and, you know, let's think about when people are presenting to a healthcare setting, they're generally a bit nervous and anxious and feeling quite vulnerable and they are essentially quite powerless in that situation. And then imagine that they're also giving you information and telling you about their lifestyle and that's being doubted. It's horrible, isn't it?

Laura: Yeah, it's really, really messed up when you slow it down and think about it. I'm wondering if there were any particular moments or specific patients that you remember that started to change that understanding a bit for you? That kind of threw a kink in that really simple narrative of ‘weight equals health’, and ‘calories in equals calories out’ and you know, we just need to go on a diet and then everyone will be thin?

Molly: Yeah, I mean, my path towards kind of health at every size was quite convoluted. And actually it began with an interest in lifestyle medicine. So I was feeling quite…

Laura: Oh, a detour into lifestyle medicine! Okay. The plot thickens.

Molly: Yeah, the plot thickens. Absolutely. So. You know, I was feeling quite demoralised by the fact I was seeing a lot of chronic disease and that people were not getting any better and they were coming back to see me and I was giving them lots of medications and, you know, often those medications would come with fairly significant side effects. And so I guess what lifestyle medicine offered me, or what I thought it offered me, was the opportunity to really get to the bottom of those problems without the need for medication and the kind of idea that prevention was better than cure.

And it appealed to me from a holistic perspective, you know, this was an opportunity to kind of see the person as a whole, rather than just focusing on an individual symptom. So I was actually really excited and really motivated. But what I found with time was that, first of all, I became more uncomfortable with the dynamic that was being played out, which was me as this middle class professional who carried a significant amount of privilege telling people how to live their lives that with time felt more icky.

And also that people weren't able to do all the things we were discussing, or if they did do…follow the advice that I was giving them, it wasn't really making them feel any better because, hey, you know, there are these things called social determinants of health, which actually great…you know, carry a greater significance than personal behaviours.

Laura: I'm just wondering for people who maybe aren't familiar with like, the world of lifestyle medicine, if you could say a little bit more about that and kind of the type of advice that you were giving people, like when you say lifestyle advice, what exactly does that mean? And I understand it's like a whole range of things, but yeah, I'm curious to hear how you applied that in your practice.

Molly: So, I mean, it was looking at kind of core areas. Those core areas were: sleep, stress management, nutrition, and exercise and, you know, within the nutrition arm, I'm really sad to say that weight loss played a part of that. 

And, you know, whilst I tried to make that as individualised as possible to the person in front of me, inherently, there is an element of elitism really with lifestyle advice, I feel that, again, just didn't really quite sit right with me. And I actually found myself feeling a bit irritated. If I'm honest, I was feeling irritated that people weren't doing what I was asking. And luckily I had the insight to acknowledge that, you know, that was a me problem, not a them problem.

What I realised was that I wasn't really irritated with them. I was just really frustrated that, you know, here was what I thought was this chance to really make people's lives better. And actually it wasn't having the impact that I thought it would.

Laura: It's almost as though…and this is totally my perspective and my, I think, a little bit of prejudice against lifestyle medicine.

But there…it’s kind of this underlying assumption that people need you to tell them what to do because they don't know any better.

Molly: Yeah, they don't know. Oh, it's so patronising. 

Laura: Yeah. And it's like a kind of a knowledge deficit. 

Molly: Absolutely. 

Laura: When most people, they do understand the importance of sleep and they do understand, like, it's helpful to, like, move their bodies in some way and to eat some vegetables.

Molly: Absolutely. That rings true so much with me. You know, I hear these conversations where people are talking about healthy weight management and you know, the suggestions are, well, ‘let's teach people how to cook’. And I just think, oh, for goodness sake. You know, it's so patronising to assume that people don't know how to cook and that you're kind of…it's this kind of saviour complex that, well, let's teach them how to cook because they don't know that and therefore their life's going to be okay.

They do know how to cook, but what if they've, you know, got three jobs because they need to work three jobs in order to pay the bills? They don't have time to cook.

Laura: What if they just don't like…because they've got their own cultural background, they cook food in a very different way than how you cook food or like there's a whole number of reasons why like that might just not only fall flat but It could be problematic for some people. You know, especially if they're like, well, ‘my doctor is telling me I need to do this, but this doesn't really align with either my values or you know, what I'm able to access or have time for the competing messages that I'm getting from within my family’ or whatever it might be.

So there's a lot of idealisation I think that goes on in the lifestyle medicine community and not a deep enough understanding of social determinants of health, like you said.

Molly: I think that's the big, big part that's missing in lifestyle medicine and the recognition…recognition of the social determinants of health.

Laura: Absolutely. And even just like the understanding that even if everybody did eat whatever Rangan Chatterjee is spouting off that we should eat, it doesn't mean that our health will all kind of play out along the same lines. 

So we were going through your journey.

Molly: Yeah, so I was talking about lifestyle medicine and feeling just a bit uncomfortable with the whole thing.

And of course at that time I was nurturing a special interest in neurodiversity, kind of recognising my own neurodivergence and my children's neurodivergence. And so eating disorders were kind of very much on my radar. And so intuitively I just didn't like the idea of creating any kind of fear or anxiety around food that just felt wrong.

And, you know, that's what we were doing when we were talking about nutrition, the world of nutrition is also extremely confusing. And it was confusing for me. You know, you have all these people giving really compelling arguments as to why their diet is the best. And they're able to give you all this evidence that backs up their claims.

But the kind of general theme, yes, is that we are creating this fear and anxiety around, often, whole groups of food.

Laura: I mean, wow. There's so much that we could say even about that. Like I got a message from a parent the other day who was like, I feel like I need to have a degree in nutrition to feed my child.

I was just like, yeah, that's how fucking convoluted we have made nutrition with all the kind of competing expert voices who are shouting about, you know, their diet as being the best diet and even like among amongst paediatric feeding professionals and, well, just feediatric…did I just invent a new word?! Paediatric dieticians and nutritionists, there's, you know, there's a right and a wrong way.

And like you say, it really creates a lot of fear and anxiety about messing up. And it plays into our fears about not being a good enough parent. And yeah, it really, like, tugs on a lot of different parts of us. Where did it go from there then once you had this kind of recognition of like, well, I don't want to be adding fuel to the fire of eating disorders, disordered eating and making food scary for, you know…I'm thinking about patients of yours that might be neurodivergent where food might already be really scary.

Where did it go from there?

Molly: Where it went from there is that I went on maternity leave.

Laura: Get out of there!

Molly: Yeah, exactly. So I went on maternity leave with this kind of feeling of disconnect and that something wasn't right and I needed to do something. And of course maternity leave provided me with the opportunity to listen to lots of podcasts and read lots of things while sat feeding a baby. So that's how I actually stumbled across health at every size. 

You know, the kind of the parenting path that I've chosen to take meant that I was already aware of, you know, division of responsibility and intuitive eating and kind of food neutrality and body neutrality. So I was already, already aware of those. And, you know, I was…again, intuitively the idea of the language that I was using around food and bodies with my children was very important.

So I think I actually listened to a podcast. I think it might have been the Full Blooms podcast that I listened to. And I think was being interviewed on that. And that was the first time I heard the words kind of anti diet and health at every size. And yeah, when I have a special interest, I really have a special interest. So, you know, 158 podcasts later, um, yeah, there I was. 

And, you know, there I was in this state of…a combination of so many feelings of kind of frustration, guilt, sadness, anger, disbelief. Yeah, you know, I kind of had this very strong sense of justice and feel things very deeply and it…I found it very consuming to begin with. This feeling that I'd been getting it wrong and why are more people not talking about this? Why is this not more mainstream? And really, people should be talking about this. And I wanted to tell everybody I knew about this because this is so important.

Laura: I've heard a similar version of that story from not just other medical professionals, but also clients of mine who are like, why, why isn't everyone talking about this?

And they want to kind of. become these little social justice warriors and really just, like, shout it from the rooftops. But what I really appreciated, Molly, there, was just you talking about all the complexity of the feelings that came up for you, because I think oftentimes, particularly if you're in the medical profession or any kind of allied health profession, because you're in that caring profession, your automatic line of thinking is often, wow, I've caused so much harm.

And, and you feel an immense amount of guilt for continuing to prescribe diets when you're learning that diets don't work and you think about all the encounters you've had with patients that might have inadvertently increased their experiences of stigma and harm. And again, we'll come to talk about that more in a bit.

I suppose my point is really that…of course you're going to feel that way and that doesn't have to be where it ends being kind of stuck with those feelings of guilt. And so hopefully there was also like a glimmer of hope in there as well? 

Molly: Oh gosh, yes. 

Laura: Well, I'm wondering as well, because it sounds like you were quite disenchanted before you went on maternity leave. So did this feel like, okay, this is something that…this is a missing piece of the puzzle for me, for my practice going forward?

Molly: Absolutely. Yeah. Yeah. And I have complete conviction about it. And I did at the time and I still have now, you know, this is absolutely the way I want to practice. And I do have hope.

And I do think that in 20 years time, maybe even 10 years time, we are going to change the way we look at weight and weight management, well, weight management, you know, will not be a thing.

Laura: Just abolish weight management.

Molly: Yeah, absolutely. 

Laura: You've used the term health at every size and I'm wondering if you could just give a brief kind of like, explainer of what health at every size is for people who haven't encountered it before. Or weight inclusive healthcare, you know, like whatever feels more comfortable for you.

Molly: Yeah, I mean, I guess let's talk about the kind of weight-inclusive, the weight inclusive approach, which is probably what I feel kind of most comfortable with. 

Laura: Same. 

Molly: Yeah. So the idea that weight isn't a marker of health, and that people of any size deserve good quality, compassionate, equal access to healthcare, that weight loss isn't possible for most people, and that actually trying to achieve weight loss brings with it lots of concerning things like, a, you know, problematic relationship with food, risk for eating disorders, and weight cycling, so weight going up and down, which again is bad for us, along with stress, and again, stress is not good for us.

Laura: Yeah, so there's, there's a lot to even think about within there, but I think that even that first idea is really radical and it shouldn't be, right? That first idea of like, people of all sizes deserve equal access to healthcare and it should all be delivered with compassion and care. And I think most of us, at least those of us who have thin privilege, for us that's more or less a given.

Although, you know, I've had plenty of shady encounters with doctors, but in general, you know, I am treated well, whereas, and certainly stories I've heard from clients and, you know, fat activists and people online is that that is…and that's, this is what bears out in the evidence as well, is that that is not guaranteed.

That people of a higher body weight can walk into a GP surgery, maybe they're seeking care for, I don't know, a sore throat or a pain in their hand. And to call back to your earlier point about how you have to make these, like, lifestyle recommendations. Patients who are of a higher weight, regardless of what they present for, are almost often given a prescription for weight loss, or they might even be handed a coupon for Slimming World, right?

Like the NHS partners with Slimming World too, and some other weight loss companies. But even if that's not what that person came in for, or even if that person said in no uncertain terms, I do not want to talk about weight loss. weight. That's not what I'm here for. I don't want to diet. The doctor generally won’t respect that boundary. Um, yeah.

Molly: And what's so sad is that I see patients preempting that. So I have patients that come to me who will say, ‘I know I need to lose weight’, or ‘I know I'm a bigger girl’, you know, it's almost like…because they are so anticipating me saying it and so nervous about that conversation, that they kind of want to say it, so it's out the way.

Laura: Yeah. What do you think that's about? What do you think's going on there?

Molly: Well, I mean, I think they're feeling vulnerable and anxious. And as I said, they are so used to their doctor saying something about their size that it's almost like they kind of just want to get it out of the way. If I say it, then they won't say it.

Laura: Yeah, almost like a defence, it sounds like.

Molly: Yeah, absolutely. And it, you know, it's so sad.

Laura: And how do you approach that with a patient then if they, if they start a consultation off like that, I'm kind of jumping ahead of myself here a little bit, but thinking about, you know, how from this new perspective of, of being a weight inclusive doctor, do you approach that conversation and start to kind of, you know, take them on a, in a slightly different direction than, than they might have been accustomed to.

Molly: So it's not easy and it's something that I'm still kind of trying to work out. And of course, you know, bearing in mind, I have 10-15 minutes with these people. And of course, it's not like they come to me and they say, Oh, you know, tell me what you think about my weight, or do you think I need to lose weight?

They come to me with the assumption that I believe they should lose weight, and they, you know, usually they will come about something else like, you know, a chest infection or a sore throat, and their weight will... come up as part of that consultation. You know, that kind of respectful two way dialogue is a really important part for me of the weight inclusive approach.

And, you know, in the same way that I feel very strongly that a weight centric consultation is horrible because it's that kind of didactic, this is what you must do. Similarly, you know, me just telling somebody, you don't need to lose weight equally wouldn't sit right with me. And of course, I'm very hyper aware in that scenario of my own thin privilege and how insensitive of me it would be to just kind of, you know, dismiss them and say, you don't need to worry about your weight because that would be really kind of minimising their experience.

And of course they have had to worry about their weight because their size has meant that they have faced many obstacles and horrible things happen to them and discrimination and so I think it's really important to kind of acknowledge that. So what I try and do is to actually apologise and say, I'm so sorry that anybody has made you feel that your body is flawed and needs fixing. I don't believe that. 

And I explain my background and I say, you know, I spent the last few years learning a lot about weight science and reflecting, and as a result of that learning, I now don't see weight as a marker of health and I don't recommend weight loss to my patients and I explain the reasons for that.

Laura: Oh my God. I feel kind of emotional hearing you say that just because of just how powerful it would be, I mean, for anyone to hear that who's, you know, had concerns about their weight, but particularly for, for fat folks and, and like, I'm thinking specifically of, of a couple of clients of mine in the past, who've just had horrendous experiences with their GP, even when I have preemptively written to the GP saying, like: ‘this person has a history of disordered eating and we're not pursuing intentional weight loss for these reasons. Here's all this science that you can read to say why this isn't a good idea’, and then still had, you know, yeah, just horrendous experiences. 

And so yeah, just to have a GP who is so compassionate and understanding. First of all, you're signalling that you're a safe person to them. And secondly, you're signalling that you can come and talk to me about this stuff. Like, even if they're not there about their weight, they want to get their antibiotics for their chest infection and just get out of there. But in the future, if that comes up, they know that they can come to you and approach you. And it's just, it feels like a really powerful thing to me.

Molly: People do cry, actually. I've had a few people cry when I've said that.

Laura: I bet they do. Yeah. I hope that any other GPs listening are frantically taking notes at this point of a little, a little spiel that they can say to their clients. 

And, and has that gone on to open up any other conversations with patients? Or kind of, you say that people get emotional, but what besides that is the response?

Molly: like I say, emotional that that's not something they've ever heard anybody say before. And I guess kind of relief. I mean, at the same time, you know, I fully recognise that they will have had a lifetime of being told different things. So, you know, it will take a lot of time for them to completely change their thinking. But yeah, people do come back and have come back to speak to me about it.

And, you know, normally what I say is, how would you feel about us instead thinking about certain health behaviours and how we can talk about those, but without weight loss being the goal? And I, I give them that to kind of think about really.

Laura: And how do you make it so that that doesn't end up feeling like an earlier lifestyle medicine conversation?

Molly: And I'm very conscious of that too. And I guess I make sure that I point out that the reason I don't want weight loss to be the goal is because when weight loss does become the goal, actually those behaviours... become quite unhealthy. As I said, I'm not quite sure I've got it right just yet. I'm constantly trying to think in my head how I can script these things in a way that does mean that people are going to come back to see me to talk about it because I want to talk to everybody about it and I want them to come back and see me, and like you say, for them to feel safe.

Laura: Yeah. And I mean, fundamentally your job is to help people care for themselves and to offer them care. So yeah, you, you also can't be sort of, you can't completely ignore, you know, health promoting behaviours, but I suppose like, at least for me, it's eliciting from the individual what is important to them and what feels doable for them.

So it's like really basic motivational interviewing stuff. Yeah. Yeah. How can we work from where you already are. And again, it speaks to that piece that a lot of times people already know the things that they need to do. And so it's just supporting them with the changes that they already want to make or not make and holding space for that as well. And offering them the medication if that's actually what they need.

Molly:  And there being no shame around that, you know? 

Laura: Absolutely. Yeah. Wow. It's like a whole new way of doing medicine. 

So we've talked about a little bit around this concept of weight stigma, because there's a sort of very particular experience of weight stigma that happens in medical settings, or we could also use the words anti fatness to, I think, better describe weight stigma.

And yeah, just a sort of side note, weight stigma tends to be a very, like, neutered term that is used in academia, whereas I think in, in critical fat studies and, and in fat liberation spaces, they're more and more using the word anti-fat bias, which really speaks to what that is. 

Can you explain a little bit more of what that means and how it plays out in a medical setting and how it is so harmful and damaging for people's health?

Molly: Yeah. I mean, what we're referring to there is, as you say, the anti-fat bias that people who work in healthcare carry. So meaning a preference to thin bodies and kind of prejudice towards fat bodies. And that's experienced by fat people as weight stigma, that's really, really concerning and it can present in many ways, but it's, let's give you some examples of what that can look like in a GP surgery.

So that can look like a fat person coming to see their GP and, as you said earlier, having every symptom put down to their weight, weight loss being the answer for everything. It can mean a fat person losing weight and that weight loss being celebrated, rather than that weight loss being considered the red flag that it should be and being investigated correctly. It can look like there not being the right equipment available, so therefore the necessary examination doesn't take place, the right investigations don't take place. It can look like the treatment options that are available for thin people not being available or accessible to fat people. And, you know, all of this means that fat folk don't go and see their doctor when they need to.

And, you know, I don't need to explain why that is a concern. That is a concern. It means that diagnoses are missed, diagnoses are made late and it absolutely contributes to stress. Mental health, physical health, and health inequity in an already marginalized group of people. I find it so concerning.

Laura: When you list it all out like that, it just puts it into perspective how healthcare for...fat people is anything but care. It's anything but health. It's, yeah, prejudice, and marginalisation and, yeah, violence. I think a lot of times. Yeah. Because it can kind of, I was just thinking of another example of what people have told me that they've had to go for like two or three oral glucose tolerance tests in pregnancy, because their doctors have, are just baffled that these people aren't…

Molly: Couldn't possibly be diabetic…

Laura: Couldn't possibly be diabetic... Because there's an assumption, I think made about what fat people's health should be. 

Molly: Absolutely. 

Laura: You know, I want to caveat this whole conversation by saying that nobody owes anyone health and yeah, health is, is morally neutral, right? 

Molly: Absolutely. Yeah. 

Laura: But there is a very pervasive idea that fat people cannot also have, you know, markers that we would traditionally consider to be within normal range or are healthy by virtue of the fact that they're fat. But I think what the evidence shows us over and over again, when we really dig through it, is that independent of your body size, you can have markers of health. Like, cardio respiratory health, low cholesterol, or like within the healthy range, not have type 2 diabetes, not have high blood pressure. But I think the assumption that I hear from medical colleagues is that people will invariably have those things if they're a higher weight.

Molly: Yeah. And you know, when we think about children, I see that, that we have a child who, in terms of their kind of metabolic health markers is healthy. And yet because they are a certain weight that's pathologised and they are treated as if they are a pathology, whereas actually there is nothing wrong with them when you look at their blood results and their blood pressure.

Laura: Yeah, because I did want to ask you a little bit about, about kids, if that's okay.

I realize it's a bit of a detour, but I'm, I'm curious to hear if you were the parent of that child that you mentioned who might be a higher body weight, but you know, otherwise there's nothing there to worry about. Or even if there is something to worry about, you know, do you have any advice for parents of how to navigate health care and, you know, have these approach these conversations with their GP, you know, to say, like, ‘I don't want to focus on their weight. What else can we do to support this child?’

Molly: Yeah, I mean, I think that's what you've just said is a really good way of framing it. 

Laura: I just realised I just answered my own question!

Molly: And, you know, I really, really feel for parents in this situation because it must be such a horrible confrontation. To be faced with health care professionals who are telling you that you need to do something about your child's weight, and yet you have a child in front of you and you're worried about how they feel about their body, how they feel about themselves. And I guess, you know, the sad thing is that many parents do believe what a doctor says to them, and so would put their child on a diet, which just horrifies me and breaks my heart of what we're doing to children when we do that. 

But yeah, I mean, I think as you posed it perfectly, you know…’I'm happy to talk about health behaviours, but I'm not happy to focus on my child's weight and the reasons for that are that I don't want my child to develop an eating disorder and my child's relationship with their body and food is really important to me.’

Laura: That's a really brave thing, a really brave thing to have to do as a parent. I mean, I know trying to like stand up to…I remember declining to be weighed at my booking appointment for the maternity pathway, and the nurse was just so aggressive with me. She was just like, ‘computer says no’. And I was like, but I don't have to do this. But I was in such a like, fragile state. 

Molly: Of course. Of course. Yeah. 

Laura: Trying to push back on a healthcare professional when they're not receptive to it. And also, like, there's some weird stuff there, but like, if you decline a test, which is basically what I did decline, they should respect that. And they didn't. So that's like a whole other thing. But my point is that pushing back on a, on a healthcare, an authoritative, an authoritative healthcare provider is really, really challenging.

So I think to step into that space as a parent is, it's really hard.

Molly: Really, really hard. Absolutely. I do not underestimate that at all. You know, I recently got told that I shouldn't be breastfeeding my two and a half year old and. You know, I approached that situation as a doctor with privilege, and I found that very difficult.

Laura: Oh, so a healthcare professional told you?

Molly: Yeah, yeah. What? That it currently wasn't offering any nutritional value. And so, yeah, I mean, you know, I'm not trying to compare that to how it must feel as a parent of a fat child, but, uh, you know, I understand that. Yeah. Confronting somebody in a position of authority is extremely, extremely difficult.

And I wish people didn't have to have those conversations.

Laura: Well, I hope you told them where to shove it with, with their comments about feeding. 

Molly: I pulled down my top and latched them. 

Laura: Love it. Okay. Well. Yes, as a still feeding a preschooler, I totally, totally respect your decision to, to keep feeding. And yes, also if you have any tips for how the fuck to get them to self-wean…! 

Molly: No, sadly not, no! 

Laura: Uh, he'll stop one day, I keep telling myself. 

We were just talking a bit about how anti fatness presents itself in the medical setting and how people are less likely to have their experiences believed, they are less likely to be offered the follow up…what's the word, the medical word, I'm struggling to find the medical word, like the assessments and…

Molly: Investigations? 

Laura: Thank you, that they, they might need. Weight loss is often celebrated when it's a red flag for, you know, if it was a thin person, it would be definitely a red flag, but that just doesn't register. There's, I say ‘avoidance’ kind of in quotation marks, avoidance of healthcare and kind of ‘noncompliance’ again in inverted commas because they are such loaded problematic terms, because they put the blame on the individual instead of on the medical professional who is often perpetrating violence against that person. And so, yeah, I just want to kind of give that caveat. Yeah. And it can encourage…or it can mean that people die. Like it's, it's often a case of life, life or death because people understandably don't want to go see their GP.

There's a really powerful piece, I'm not sure Molly, if you've read it, by Marquisele Mercedes in Pipewrench Magazine, where she's talking about not just the intersection of anti-fatness and medical care, but also anti-blackness because there's a another layer here when someone is racialised about assumptions made about like their pain threshold and, and tolerance. And it's a really eye-opening read if you haven't already read it. So I'm gonna link to that in the show notes just to give people like more, yeah, a kind of deeper understanding of some of these issues. 

I'm curious to hear, since you've adopted more of a white inclusive approach, if you've had any pushback from your colleagues and if you have, how do you handle that?

Molly: So actually, I haven't. Not that I know about, not that anybody has spoken to me about, and actually, I...

Laura: You're just keeping it under your hat because you're just alone in that GP room. You don't have to, like, deal with other doctors on a ward.

Molly: I mean, that does help, absolutely, that I do have a lot of autonomy. And yes, I'm in my room and I see my patients. I did do a presentation to my colleagues about weight inclusive care, which I was really nervous about. And isn't that funny? Because... You know, I was thinking about the fact I was far more nervous doing that than I would be doing other presentations and, you know, these days I do a fair amount of presenting, and I kind of unpicked that. 

I thought, let's think about the crux of what I'm saying here and the crux of what I'm saying here is, you know, the point I made earlier that people of all sizes deserve compassionate, good, equal access to health care, which really, I would hope that most, yeah, doctors are on board with, members of the caring profession would be behind.

But yeah, so the presentation went well and, you know, people came to speak to me afterwards and said, it kind of made them think, and they'd be really interested in knowing a little bit more. So that was positive. I mean, as GPs, the idea that weight loss isn't sustainable is something that we see day in, day out. And so I don't think that's too difficult for GPs to get behind.

Laura: Okay. And just to kind of expand on that point a little bit, because I know we've, we've talked around this idea that diets don't work. And again, I'll link to a piece that I wrote about the diet cycle and, and this sort of why diets don't work, but just to give like a really quick overview of what the weight science literature tells us is essentially there are – and this is simplifying things, and Molly, feel free to jump in and like expand on anything I'm saying, but what happens when we go on a diet is sort of twofold. 

First of all, so we reduce the amount of food that we're consuming, right? That's the fundamental premise of any diet. They all work the same way, right? ‘Work’ initially, at least initially. So you might initially see a little bit of. of weight loss, but then your body starts responding to that by dialling up your hunger and appetite hormones, because what it's trying to do is defend your genetically determined set point weight, right?

This blueprint that we have for…I like to think of it as a kind of comfortable zone that our bodies will, like, prefer to be in because there's usually always some fluctuation within that, right? Like our weight just kind of goes up and down on its own through various, you know, stages of life. But overall it likes to stay within a window, shall we say.

If we're trying to push it down below that comfortable window, our body will respond by amping up hunger and appetite hormones to drive up our appetite, to get us up off of our asses to go and find some food, right? Like it's an evolutionary mechanism. So that's why you kind of end up diving headfirst into a bread basket or, you know, I always say like you find yourself elbow deep in a tube of Pringles if you're, if you're on a diet, like that, that's what can happen. And it's because there are these biological mechanisms driving that. 

If for some reason you are able to kind of ride that out, you maybe develop some unhealthy coping mechanisms to sort of essentially ignore your hunger, then what can happen is that your body has another mechanism to try and make up for that, which is to slow down your metabolism. Right, so it can kind of…either you can get more food to defend your set point weight, or all the functions in your body can sort of slow down. It often starts with what are considered non essential functions, like reproduction. So you might notice that you're, if you're menstruating, that your period becomes irregular, your hair might kind of become less thick, your nails might get, I mean, your skin might get a bit dull, but then because your body can't sort of say, okay, turn off this system, but leave all the other ones on, you'll notice it kind of like playing out in, in other areas.

So somewhere that I see kind of play out a lot is digestion, which I think we can all agree is an essential function, but you start to notice, you might notice it as like IBS type symptoms, constipation, bloating, diarrhoea, all of these things can be a function of not having enough to eat. So, as your metabolism is slowing down, you will obviously get this plateau in weight loss or your weight might start to increase or you could have both things happening kind of simultaneously where your metabolism is dialling down and then at the same time your hunger hormones are dialling up so you have what I call ‘the fuck it effect’ where you know it's like the floodgates open and you're just raiding the fridge. 

And it's kind of funny but also it's a really distressing experience for people sometimes, if you don't understand what's going on, which is…it's your primal biological urge to eat is kind of overtaking you and you were just trying to meet your needs however you want, but it can feel really chaotic and out of control and oftentimes we label it as like food addiction or comfort eating sometimes, or like, yeah, we pathologise it somehow, even when that's not really what's going on.

So that was…more of a detour than I wanted to go on, but I thought it was important to explain a little bit of the mechanics as to why diets don't work. Did you have anything you wanted to add to that, Molly?

Molly: No, I think you have summarised that perfectly. My headline would be, bodies are very clever, don't underestimate them.

Laura: Absolutely. Yeah, that is a way better way of putting it. 

But so, medical colleagues, they don't have too much difficulty understanding or kind of appreciating that weight loss is not sustainable. So they see that day to day in their practice. So they…it's an easy sell? 

Molly: Yes, it's an easy sell. Exactly. 

Laura: When you kind of go back and fill in, like, some of the stuff that probably should have been taught in medical school, but for whatever reason wasn't…I say probably should have been taught. I mean, definitely should have been taught in medical school, but wasn't. What other kinds of, like, questions or what things did you come up against when having these conversations with colleagues?

Molly: So yeah, that is an easy sell. The harder sell is around the idea that, well, ‘ob*sity’ being a thing and, you know, it's associated co-morbidities. Also, what is tricky…so even after I'd kind of finished the talk and had a conversation about it, the conversation turned to, but we do need to think about how safe it is to refer somebody with a BMI of over 30 for any replacement.

So, you know, the kind of idea that the research that is at the core of, you know, our approaches and the weight centric approach is full of bias and quite frankly, fat phobia. And that's when I start to feel very conspiratorial, which I hate.

Laura: I know exactly what you mean. Yeah.

Molly: But I think it's a, you know, it's a really important part of the puzzle, and people really need to appreciate that, that actually research, you know, I think Fiona Willer described it as “a persuasive piece of writing”, which I think's a really important way to look at it, because that's what, you know, research really is. And that, you know, people are generally trying to prove a point when they start a piece of research. And because we live in this inherently fat phobic society, people are generally trying to prove that fat is bad.

Laura: And so what you're saying is there, and there's a great paper that explores this, there's a BMJ paper that explores all the underlying assumptions in weight research, all these biases that Molly is describing.

They filter through into the research that we get. So it becomes this like, circular, like, self fulfilling kind of thing, where we are looking for problems with higher weight and worse health outcomes. So we find them, right? Like it becomes this yeah, very… 

Molly: Confirmation bias. 

Laura: Exactly. That's, that's the right word I was looking for.

So I'll link to a couple of papers that for anyone, for like medical students or even nutrition, any allied health professionals who are interested in learning more about this, because it's a lot to kind of take in. And we're, I feel like just getting to the tip of the iceberg here.

Thank you for reading Can I Have Another Snack?. This post is public so feel free to share it.

Molly: And I guess the other point to make about the research as well that people really need to appreciate is that it's, you know, I've said before, but it's really complex.

And so, you know, let's take the example of post operative complications of a knee replacement. And by the way, I haven't really done a deep dive on this, so….I'm just kind of using it as an example rather than it being something I know a lot about, but, you know, let's imagine that there is an increased association between post operative complications in somebody with a high BMI after a knee replacement.

Is that as simple as a person's fat and therefore they're going to be at risk of post operative complications, or is it that they are really stressed in a hospital because they know that they're going to be made to feel bad about their body size? Is it that they didn't have the right equipment available to carry out the operation or to, you know, anesthetise that person? Is it that anti fat bias has played a part in the treatment that they've received post operatively? 

We really, really need to be digging deeper and looking at the complexities around these kind of headlines that form the part of, yeah, our management.

Laura: So yeah, what you, what you're talking about there is the sort of potential confounding variables that don't get measured for, that help explain the relationship between X and Y.

Yeah. But we just…we see the X and the Y and we don't see all the – this is a terrible analogy – all the other letters, but we're looking for cause and effect, but we're not actually looking at all the other complicating factors that might result in that outcome. I think. Because our, like, primal monkey brains love simple explanations for things, right? They don't want things to be complicated, but they are way more complicated than they first seem. 

So, last thing I want to ask you about is...Whether you have any advice for medical students or even physicians who are bumping up against anti fat bias, either in their training or with their colleagues?

Molly: Well, I guess I really hope there are people in the medical profession listening to this who do share our beliefs and, you know, I'd love to hear from you because solidarity is really important. You know, it can feel quite lonely. I guess my advice would be to kind of stick to your guns and hold on to those values and know that you are keeping people safe and you will mean that people feel able to come and see you who wouldn't otherwise have felt safe coming to see you. And that's really important. 

And you know, when I'm doubting myself or feeling a bit exhausted by swimming against the tide, what I tell myself is, well, let's think about the alternative. And the alternative is not something that I can entertain. In terms of conversations with colleagues, I mean, podcasts, I really find useful as a way of kind of signposting people to snippets of information and also talking about yourself. So, you know, people are more receptive if you kind of critique your own bias as opposed to critiquing theirs.

Laura: Yeah, exactly.

Molly: So, you know. A conversation like, you know, I'm thinking about a medical student sat in clinic with somebody saying something like, ‘Oh, I've been thinking about my own anti-fat bias, or I've been thinking about weight stigma and how I might be contributing to that and how that's something I'd really like to address’. You know, that kind of thing just plants that seed, doesn't it? And means that, whether they react perfectly in the moment may mean that that person then has to think about it themselves and reflects on it themselves and does a bit of reading.

Laura: Mm hmm. Yeah, absolutely. And you can always, you know, if they are open to, to reading more, like, like I said, you could, I'll link to some papers that you could share with them doing a journal club around those papers or like you did, Molly, a presentation that can also be ways to open up conversations within a department or you know, a university setting or something like that, where you can all be kind of working through some of this stuff together, rather than sort of siloed on, on your own. Because I think it can feel really lonely if you're the only little salmon swimming upstream.

Molly: It's really hard work, isn't it? Really hard work being the pariah.

Laura: Yeah, absolutely. But I'm really grateful for everything that you're doing. And you know, even if we don't change anyone else's minds, just the fact that you're showing up for your patients the way that you are is so important. So yeah, thank you for that work. 

At the end of every episode, my guest and I share something that they have been snacking on. It could be anything you like, a show, a podcast, an actual little snack. So what have you been snacking on lately, Molly?

Molly: So I have a television show that I've been watching that I'm actually able to share. I have a very specific criteria when it comes to television shows that I'm willing to watch because I'm such an empath that I can't bear watching anything that involves, you know, people being treated badly or humiliated or murdered, you know, anything like that. No, and it also has to be very relatable. I can't, my brain just cannot, you know, get into kind of wizardry and magicians and stuff. I have been watching Couples Therapy, which is a documentary on BBC iPlayer, which films couples going through therapy. And it's like reality TV, but without the vacuous….

Laura: The drama. Yeah, okay.

Molly: Yeah. And yeah, without the drama. So, I mean, there is drama, but it's a really kind of measured drama, and I just love watching the process. I love seeing the dynamic and seeing how it all pans out. I think the therapist is amazing. Oh. And it's fascinating. 

Laura: So these are real, these are real therapy sessions? They've not been staged?

Molly: They've not. No. No.

Laura: Oh wow. It's wild. It's real. I have no idea how they got that through any kind of ethics, but…

Molly: Yeah. Yeah. Good point. But it's, but it's…

Laura: I mean, it sounds interesting. Who doesn't want to listen in to other people's therapy sessions?

Molly: Yeah. I mean, I didn't watch it thinking, oh gosh, I feel really bad that this person is doing this on didn't, it didn't feel like that. It actually felt really, you know, therapeutic.

Laura: Like I did a documentary with BBC. a long time ago now and there was like a clinical psychologist on the support staff team so I figure that there has to be like someone…that person who's, yeah, just like making sure everything is contained and everyone is safe and yeah like, yeah, no one is, like, baring their soul on national TV who is gonna regret that they said those things. So that sounds really interesting. 

Okay, so my snack is sort of, I think, well, really related to what we have been talking about. So the book that I have been reading at the moment is called Sugar Rush: Science, Politics, and the Demonization of Fatness. It's by Karen Throsby, who is a sociologist and it is a bit more on the academic side, but it is so fascinating.

Basically what she's done is a content analysis of like 500 odd different newspaper articles and books from about, I think just before the implementation of the sugar tax, or maybe when the sugar tax was being debated, all the way through to like 2020 with Boris Johnson's latest round of anti ‘ob*sity’ policy.

She's just tracing kind of like the history of the sugar tax and the way that the media talks about it and some like key anti sugar figures and some of the, like, the rhetoric around sugar and how it has been kind of like socially constructed. And it's also linking it to the demonization of fatness as, yeah, the subtitle suggests.

But what I found really interesting is just how she talks a lot about these ideas that are written into policy documents that are so kind of assertive and confident and definitive that are the similar things that you and I have been talking about in this podcast about the relationship between weight and health that are just in all of these policy documents are just like, like, given at face value and there's no further sort of exploration of the science and I'm only kind of the first couple of chapters, but I'm really enjoying it.

It's really good. It appeals to my, like, super nerdy nutrition brain where I want to understand the trajectory of all of these policies and how they all kind of interlink and build on one another. And it also has a fair amount of Jamie Oliver bashing. So I'm here for that. So yeah, Sugar Rush by Karen Throsby. So I will link to Couple's Therapy. Is that the name of your show? Couple's Therapy on iPlayer and Sugar Rush in the show notes. 

All right, Molly, before I let you go, can you let everyone know where they can find out more about you and your work?

Molly: So I am on Instagram as @antidietGP, um, similarly on Facebook as Anti Diet GP. Be great to see you there. 

Laura: All right, I will link to both of those in the show notes so people can come find you and yeah, let us know what you think of this episode and thank you so much again for your work, Molly. It was really good to talk to you. 

Molly: Oh, thank you.

OUTRO:

Laura: Thanks so much for listening to the Can I Have Another Snack? podcast. You can support the show by subscribing in your podcast player and leaving a rating and review. And if you want to support the show further and get full access to the Can I Have Another Snack? universe, you can become a paid subscriber.

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Can I Have Another Snack? is hosted by me, Laura Thomas. Our sound engineer is Lucy Dearlove. Fiona Bray formats and schedules all of our posts and makes sure that they're out on time every week. Our funky artwork is by Caitlin Preyser, and the music is by Jason Barkhouse. Thanks so much for listening.

ICYMI last week: When Your Friend Announces They’re on a Diet…

* Rapid Response: Why I don’t like ‘this food does a little/this food does a lot’

* Dear Laura... How do I stop wishing for the past and accept myself now?

* Bandit Standing on the Scales is Not Even the Worst Part of Bluey

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