"I wanted to love my body, but I also secretly wanted to lose weight."
Body acceptance is hard. Doctors don't have to make it harder.
Since publicly embracing my identity as a “body positive doctor,” I’ve had a lot of primary care patients come to see me to talk about their weight. I’ve always had patients who embrace weight-neutral medicine, and I’ve always had patients who are still laser-focused on weight. But now, there’s a new category: people who want to accept their bodies, but who also still kind of want to be skinny.
Over the last few years, I’ve grown a pretty loyal “health at every size” following, patients of all body sizes who don’t want to focus on the number on the scale. When I describe what health at every size (HAES) is, I usually say, “It’s basically not yelling at your patients for being fat.” I remember working with a mentor during my family medicine training who had a patient who told her, “I come to see you because you’re a HAES doctor.”
At the time – it was probably 2015 – my mentor didn’t know what HAES was. The patient was responding to the doctor’s compassion, her non-judgment, her intuition that it just wasn’t therapeutic to badger the patient about weight. Now, this doctor has a thriving HAES practice in the Midwest, but I always remember that moment. She didn’t need the activist movement or the weight-inclusive terminology – although those things are enormously helpful – to just be a kind doctor.
In addition to patients who don’t want to talk about weight, I have a lot – a lot – who do. I would estimate that the majority of my patients have no clue what the health at every size movement is, and have absorbed the message that bigger body = unhealthy. Each visit, I try to gently undo this myth, and talk about all the other metrics I like to track instead of BMI – blood pressure, mood, mobility, glucose tolerance – but the fatphobia is deeply, deeply internalized.
“I just want to get healthy, Dr. Gordon,” they say. “How can I do that if I’m big?” Those patients I try to approach with compassion and patience, and we work together to define their goals. It takes time – something I don’t have a lot of, in primary care – but it’s worth it.
Lately, I’ve noticed a new pattern in my practice. Patients seek me out because they want a non-judgmental doctor – which I try hard to be. “I read your article!” they say. “I was so excited when I saw you were in the area!”
And then, they ask for Ozempic.
To be clear, I prescribe Ozempic – more appropriately known as semaglutide, or a GLP1 agonist – all the time. I don’t think it’s therapeutic to withhold a medication from my patients because I’m on a body-acceptance mission – they may not be, and my job is to honor their bodily autonomy. Semaglutide also has genuine medical benefits other than weight loss, particularly for patients with diabetes and cardiac disease.
(As a side note, I find some of the black-and-white framing around semaglutide in the media sort of silly. I feel like journalists either hail it as a wonder drug, or they call it an agent of evil big pharma. It absolutely has side effects, we absolutely live in a fatphobic society, we absolutely have a multibillion dollar diet industrial complex that markets semaglutide on the premise that people should hate their bodies – and it absolutely can be a lifesaving medication.
Medicine is complicated, and GLP1 agonists are complicated, too! I wish my patient with a BMI of 27 and zero medical problems didn’t live in a world where she felt like she was supposed to lose weight. That doesn’t also mean I don’t think these meds can be incredibly helpful for a patient with advanced diabetes and heart failure.)
But when my otherwise healthy patients – patients with no other indication other than a BMI over 26 – ask for semaglutide in the same breath they tell me how much they love my weight-neutral approach, I’m left thinking about what it all means.
I told a friend of mine about this phenomenon. She’s a thoughtful, reflective person who has been working with a body acceptance therapist, and she laughed. “That’s exactly what I was looking for when I first started therapy,” she told me. “I wanted to love my body, but I also kind of secretly hoped it would help me lose weight.”
Perhaps this paradox isn’t surprising. We want to love our bodies, but it would also be great if we lost 25 pounds. We’re ok with fat acceptance, but only up to a certain weight. I’ve had scores of patients tell me that they “love their curves,” they just want to “lose the belly.” Or they feel empowered by their thick thighs – if only they had a little bit less cellulite. The nuances are complex and ever-changing, as our body ideals change and pop culture reflects back an elusive, always unachievable goal.
In my clinical practice, I try to look at it as a step in the right direction. Ending widespread fatphobia is really, really hard – my patients won’t be there overnight after watching a few fat fashion influences on TikTok. And if I’m honest, I’m not there myself, for my own body, yet. We’ve been told for years that our bodies are wrong, they’re unwieldy, they’re bad. It’s normal to have contradictory and fluctuating feelings about them. This sh*t is hard.
But even if my patients are glad to have found a doctor who doesn’t actively body shame them, some of them are still doing it to themselves. And that is much harder to wrestle with. When I tell them, “Hey, you know, I don’t care about the number on the scale,” many of my patients respond: “Well, I do.”
So the fact that patients are flocking to health at every size doctors is great, even if they’re still hard on themselves. They are sick of judgment, of shame, of feeling miserable in the presence of a clinician who is supposed to care for them. We doctors have to do better – and we can.