“Hey Mara!” he wrote. “Do you know any doctors in the area that do longevity medicine?”

I stared at his text for a minute, a little puzzled. Was he just looking for a primary care doctor? Or for something else? Isn’t longevity medicine what all primary care doctors do, by definition?

I wrote back. “I think most primary care doctors want to help their patients live long lives! What do you mean, exactly?”

He wrote back. “Basically I want someone who goes beyond the standard testing. Who really helps me understand my body.”

Hmmm. What was he getting at? And then I realized, a little embarrassed it had taken me this long to sort it out.

He was a longevity bro, and he wanted a longevity bro doctor.

What, you may ask, is a longevity bro? If you don’t know the answer: Congratulations, you probably have a healthy relationship with the internet and your own body.

Longevity bros exist both online and IRL, although the culture is fueled by social media. They sell hacks and gimmicks for living a long life. They promise, both implicitly and explicitly, that with the right combination of money and willpower, you can outrun death.

They usually start their sales pitches with phrases like this: This is what your doctor isn’t telling you.

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Longevity bro culture isn’t new. It’s a longstanding Silicon Valley trend, favored by the wealthy elite. (Read this thoughtful article on Bryan Johnson, the original longevity bro, whose catchphrase is “Don’t Die.”) Their “hacks” and “proprietary algorithms” continue to surprise me with their creativity. Full body MRIs. Plasma transfusions. LED lights. Lots and lots of blood tests.

But over the last decade or so, I’ve gotten the sense that there’s an imagined democratization of longevity bro culture.

It’s no longer just for people who can afford celebrity doctor Peter Attia’s services, who reportedly charges upwards of $100K a year to serve as a personal longevity physician to the stars. (Peter Attia has been disgraced for consorting with Jeffrey Epstein, including using some vividly misogynistic terminology that I won’t type here but you can easily find online for the curious or masochistic.)

Now you, too, for a mere $399 can put your poo in a cup, get it genetically sequenced, and earn the right to buy “custom-formulated supplements!”

It can be easy to mock. But as a primary care doctor, I’m also curious about it. It speaks to our collective anxieties.

People perceive that longevity bro culture is meeting their needs. Part of the reason it’s so popular, I fear, is that in primary care, we’re failing to do just that.

What’s the difference between regular, evidence-based longevity medicine — arguably the whole point of primary care — and this aggressive, consumerist subculture?

You know it when you see it, that’s for sure. There’s something clearly different about what Peter Attia does and what I do, with my 20-minute appointments and my earnest recommendations for getting enough sleep and a mammogram.

I’ve identified a few themes that emerged as I googled “what is longevity medicine” and found myself in some dark, weird corners of the internet. Here are a few ideas I’ve been considering.

1. Lack of scientific rigor. This is a prerequisite. Longevity bro culture is, by definition, not based on scientific evidence. What they’re selling is that they’re cutting edge, “ahead” of the research and “ahead” of mainstream medicine. They offer you something that appears unavailable at “regular” doctors.

2. A mythology that human health is under voluntary control. This is another key ideology within their messaging. Without it, why would you ever buy their products? Otherwise we’d have to confront the existential crisis of the randomness of death and disease. That doesn’t sell supplements very well.

3. … And a mythology that the health of the individual is unrelated to the health of the community. This is the part that makes me feel the most despair. They market personal health as something you can buy online, not as something deeply interdependent with our families, our communities, and nature.

4. Longevity bro culture is booming, not coincidentally, as a moment when the health of the natural world feels so precarious. I’m not surprised that these wellness hacks are so popular as we’re confronted with daily reminders — both online and when we step out the front door — that the health of our planet is profoundly fragile. I know snake oil salesmen existed long before climate change did, but I can’t help but sense a connection between the vulnerability of our planetary health and the explosion of interest in optimizing our personal health.

5. Tests that don’t change management. This is a mantra I teach my medical students: Every test should change management. As in, there’s no point in ordering a blood test or imaging that doesn’t change something in the way we approach the patient. If you test positive for chlamydia, I’m going to prescribe you antibiotics, not just sit there and do nothing – that’s why we screen for it. But longevity bro culture is full of tests that don’t seem to really do anything. I was reflecting on the $399 poop test and really trying to give it the benefit of the doubt. If somebody got it done, maybe knowing they lacked diversity in their gut flora would help them eat more vegetables? But they — hopefully — are eating vegetables anyway. They don’t need the test to tell them veggies are good for them.

Doctors love to complain about all this wellness nonsense. We can be a little snooty and dismissive about it sometimes, to be honest. I have been known to text screenshots of wellness products to doctor pals, mocking the chumps spending money on these things.

But I’ve been challenging myself recently to get curious. Because people love this stuff. And they don’t exactly love coming to the primary care doctor.

It’s not like traditional, corporate primary care is doing a great job meeting our patients’ needs. Of course wellness culture is appealing!

The grifters are capitalizing on a lot of serious deficiencies in our traditional medical models. We doctors have left it wide open for them.

The thing is, primary care is longevity medicine.

When I diagnose you with hypertension and prescribe you a blood pressure cuff and a medication — the whole point is to help you live longer! (And live better, ideally without a heart attack or kidney disease caused by hypertension.) When I do your Pap smear, the whole point is to catch cervical cancer early enough to treat it.

There is decades and decades of good-quality research to show that both those things prolong life and — critically — prolong quality of life.

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So why do people think of primary care clinic as so unsexy? Why are the poop kits winning?

Because primary care feels qualitatively different than longevity medicine.

A big part of it, I fear, is the sheer amount of administrative nonsense that it takes to engage with a primary care doctor in the U.S. health care system. The figuring out if they take your insurance. The waiting on hold at the call center. The feeling motivated to make an appointment, then being told you need to wait 3 months to be seen. The trying to figure out how much things will cost, then still getting a surprise bill. The traveling to a separate location to get your labs drawn.

“It felt like they didn’t really want me there.” That’s how a friend put it recently, reflecting on her experience establishing care with a new primary care doctor:

Then take the longevity hacks. The websites and branding are sleek, the credit card payments seamless.

But I think there’s something even deeper at play.

Coming to the doctor feels like getting scolded. Buying a supplement online feels like being welcomed into an exclusive club.

A friend sent me this hilarious TikTok video, where an OB/GYN named Dr. Fatima Daoud “rebrands” the standard medical treatments in labor and delivery as “wellness medicine.”

It’s tongue-in-cheek, but she’s on to something.

I’m not sure what this means for my practice. I can’t, with a straight face, sit there and call your cholesterol medicine an “cardio-boosting superfood made from a proprietary blend of all-natural ingredients.” I just can’t.

But I do think primary care can be less paternalistic. Sometimes it can feel like doctors are trying to bully their patients into taking certain medications rather than treating it like the autonomous decision that it is.

(The reasons for this are complex. The dynamic is emphasized in our training. We learn that we aren’t good doctors if our patients don’t do what we say. Practicing doctors are also explicitly graded and paid based on whether or not our patients take the medications we recommend and complete the tests we order.)

Might we instead treat the doctor-patient relationship as a partnership, as an invitation?

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What do you think? What, exactly, is the difference between longevity bro culture and regular primary care? What could we doctors learn from them?

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I had just published an NPR column about why treating hypertension is more complicated than meets the eye. I thought maybe they wanted me to talk about it. Finally, primary care would be getting credit for our role as the unsung heroes of blood pressure!

Silly me. They invited me to “debate” Ozempic.

The proposal was this: I would be taking the “con” side of this argument.

GLP1s are game-changers and should be prescribed widely.

If I accepted, I would be arguing against an electrophysiologist, an ultra-specialized heart rhythm doctor. (Who probably doesn’t do much prescribing of GLP1s, for the record — electrophysiologists mostly do procedures. In my experience, cardiologists usually punt the prescribing of GLP1s to primary care doctors so we have to deal with all the insurance paperwork! Sorrynotsorry! It’s true.)

I thought about it for about ten minutes. I asked if we could change the structure of the discussion, and the conference organizers said no. They wanted a debate that would “spark controversy” and “get people interested.” (I guess even cardiologists need click bait-y headlines to get people to come to events rather than the conference hotel pool.)

And so: I said thanks, but no thanks. Here’s why.

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I was invited to the conference, I suppose, because I’ve written publicly about being skeptical about Ozempic and other GLP1s. When I wrote an essay about my attempts to be a “body positive doctor in the age of Ozempic” in 2023, the response was swift and overwhelmingly positive.

People were sick of body shame in the doctor’s office. We doctors can do better. And our patients deserve more.

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I stand by what I wrote for the most part, but the landscape of health care is also changing. My thinking continues to evolve. (Willingness to adapt is an essential quality in a doctor, I’d argue.)

Even though you might assume “she’s against GLP1s” from reading the headline, I’m actually not. At all.

In fact, I’ve never not prescribed GLP1 agonists. The class of medication has been around since 2005. I’ve been prescribing them since I became a doctor in 2015. I’ve said many times that I’m grateful to the researchers who developed them. They’ve helped many of my patients. They appear to be safe for most people, and while they do have side effects, many of my patients tolerate them quite well.

They indeed can be, in the words of the cardiology conference organizers, “game changers.”

More and more scientific studies are coming out showing the benefits of GLP1s for conditions like metabolic dysfunction-associated liver disease, kidney disease, heart disease. They’ve been FDA-approved to treat sleep apnea. It’s hard to ignore the fact that they seem quite helpful for a variety of conditions that affect my patients.

I’ve never tried to “ignore” the medical benefits of GLP1s. I gladly recommend them to many of my patients and have done so for years.

What I’m skeptical of is the way doctors and patients alike have started to treat the experience of “being fat” — a highly subjective, cultural, and historical condition — as an objective medical disease.

Medicine has a long history of mixing up the biomedical, the cultural, and the cosmetic.

Many readers of my newsletter will be familiar with the work of Dr. Sabrina Strings, a sociologist who wrote the book Fearing the Black Body. Strings meticulously traces the origins of fatphobia to anti-Black racism and argues that medical justifications about the risks of obesity followed from this racist and misogynistic “othering” of Black bodies — not the other way around.

In other words, the racism came first. Then the fatphobia. Then, the veneer of medical respectability about fearing for the health of fat bodies.

So when doctors use body mass index to classify everyone with a BMI over 25 as diseased — that’s the language, “obesity and overweight as disease” — it’s a terribly blunt instrument, and a legacy of the kind of racist pseudoscience that Strings so elegantly tracks in her book.

The result is that patients show up in my primary care clinic telling me they “feel fat” and they want a medication to treat it.

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Just the other day, I saw a patient who was experiencing a lot of stress in her life. Her marriage had recently ended, and she was solo parenting two young children. She worked two jobs, one during the day as a surgical scheduler, then in the evenings as a packer at an Amazon warehouse. Her landlord was raising the rent and she was starting to panic.

She felt tired all the time. “Maybe I have a vitamin deficiency?” she asked me. “Could we check my B12 levels?”

Sure, I told her. It’s easy to check B12 and treat it if it’s low. But it was clear to me her stress and sleeplessness was an issue far beyond the narrowly biomedical. We reviewed labs she had recently completed: normal cholesterol, normal blood sugar, normal kidneys and liver. Blood pressure was beautiful.

“But look at me, Dr. Gordon,” she said, physically grabbing her own abdomen and shaking it at me. She started to cry. “I am so fat. My whole life just feels so out of control.”

I looked at her BMI in the medical record: 28, putting her in the “overweight” category. (A category which some studies posit may actually be more protective against early death compared to being so-called “normal weight.”)

I’ve known this patient for years, so I was blunt in my next question.

“You’re a healthy weight. Your labs are normal. When there’s so much other stress in your life, what makes you want to focus on weight loss right now?”

She laughed and shook her head.

“Because my life is a mess,” she said. “And yet I’m still fat. Making myself less fat feels like one thing I can control. It’s ridiculous, I know.”

At least we ended the visit laughing, together, at the absurdity of it all. I told her I wouldn’t withhold a GLP1 if she met criteria for it and wanted to use one.

I’m not in the business of rejecting my patients’ bodily autonomy.

But I just wasn’t sure a GLP1 would cure what ailed her. My patient was “feeling fat.” And to her, “feeling fat” had become a metaphor for the very real stressors in her life.

GLP1s are great for a lot of things, but they aren’t great at fixing that feeling. (Trust me, I’ve cared for a lot of patients who have told me they still hate their bodies even after substantial weight loss on a GLP1.)

And I worry that if doctors reinforce this — by saying, “Sure, yes, that feeling of fatness is a biological problem in your body, here’s a medicine to treat it” — we are justifying fatphobia and the racism and misogyny that inform it.

That’s not to say adipose tissue can never be harmful. As I’ve been writing and thinking about this topic, I’ve found the concept of “adiposity-based chronic disease” — a term offered as an alternative to “obesity” by the American Association of Clinical Endocrinologists — quite helpful.

At first glance, it seems like obesity by another name. But I actually think it’s much less stigmatizing and much more rigorous.

Obesity is defined by a BMI of 30 or above. Adiposity-based chronic disease is quite different: it describes chronic diseases that are mediated by dysfunctional adipose tissue.

Adipose tissue dysfunction is complex. It involves inflammation, release of free fatty acids, and glucose intolerance. Critically, this dysfunction doesn’t increase at a linear rate based on your BMI — or how “fat” a patient is “feeling.”

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People with a normal BMI can have significant adipose tissue dysfunction, revealed by lab abnormalities like glucose intolerance, liver inflammation, or hypertension. And people with a supposedly abnormal BMI can have no evidence of cardiometabolic disease.

If you’re skeptical, join me for just one afternoon in primary care clinic. I have a lot of elderly patients with advanced diabetes and heart disease, many of whom are quite small. If I focused too narrowly on their BMI, I’d miss diagnosing and treating them.

GLP1s are excellent at treating adiposity-based chronic disease. That’s why I immediately knew I couldn’t show up at a conference and argue against widespread prescription of these medications — I recommend them daily to my patients with diabetes, metabolic dysfunction-associated steatotic liver disease, heart disease.

“Why does everything have to be a debate?” a friend bemoaned when I told her about the invitation to the cardiology conference. “Couldn’t it just be a discussion?”

Talking about GLP1s and body size in such a black-and-white way reduces the subtleties of clinical medicine — which is by definition quite subtle — to talking points. If I agreed to this debate, I’d be the quack who doesn’t believe in science.

The thing is, I’d actually love to go to a cardiology conference to talk about my work fighting against diet culture in medicine and working to make health care welcoming to people of all body sizes.

I would love to talk about how I don’t think prescribing GLP1s is incompatible with what I call “anti-diet medicine.”

Being an anti-diet doctor means, quite simply, that I don’t yell at my patients to lose weight. I generally allow my patients to bring up weight loss, if it’s one of their health goals, rather than me pointing out their BMI. I do aggressively test for and treat adiposity-based chronic disease. I tell my patients I love vegetables, daily walks, and the idea that strength training is for all bodies.

My work is about helping my patients understand that they can be kind to their bodies and they can work to keep their bodies healthy. Both things can be true.

My patients deserve that nuance.

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What do you think? Is anti-diet medicine possible in the Ozempic era? How do you conceptualize body kindness and health in your own life?

My patient went to the ear, nose, and throat doctor to talk about their sinuses. Their sinuses! The ENT started telling them to lose weight! What gives?!

Once you start to see how doctors zoom in on weight and body size, you can’t unsee it. It’s literally everywhere in health care. It’s like that fight you can’t stop bringing up with your spouse, that hangnail you know you should leave alone but just keep picking at.

Doctors cannot leave weight alone.

If you’re stuck seeing a doctor who won’t stop nagging you about your weight — because it’s hard to find a new one, or because it’s a specialist you need to see for other medical reasons — I have some ideas for you.

My latest Real Talk With A Doc column at NPR is about how to advocate for yourself if you want to talk to your doctor about topics other than weight.

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As an anti-diet primary care doctor who takes a size-inclusive approach with my own patients, I often hear from people who feel belittled and shamed by this narrow focus on their body size.

“Every single time I would go into the doctor’s office, it was: ‘She’s overweight,’” Jessi Rice Greenlow told me. “’You need to get her into sports. You need to reduce her food.’”

Now Greenlow is a health coach who helps families navigate weight stigma. But as a child, Greenlow said, every doctor’s appointment turned into a discussion about making her smaller.

“That shaped what our home life looked like and what I was allowed to think about myself,” Greenlow said.

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It was such a pleasure to talk with Jessi for the piece — she had such a refreshing, empowering, and common-sense approach to this issue.

If your doctor initiates a discussion about weight that doesn’t feel welcome, Greenlow suggested having what she calls “pocket phrases” ready to turn the conversation towards these other health metrics and habits.

“Practice beforehand,” Greenlow said. “When you go into the office blind, that can be kind of challenging, and you might freeze up.”

Here are a few of the phrases she’s used with doctors:

“I’m not comfortable talking about my weight every appointment.”

“What else can we talk about?” or “What other tests are available that would be a success marker?”

I know it can seem intimidating to push back against your doctor, but I promise you — we’re humans, too! And we like hearing from our patients about what works and what doesn’t. A simple, “No thanks, I’d prefer not to get weighed” is often all it takes to steer the conversation towards the health goals you want to focus on.

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I sometimes get asked if it’s safe to focus on topics other than weight. “If I don’t track my weight, how will I know if I’m healthy?” I’ve had patients say.

There are many other evidence-based health metrics you can focus on instead. Obsessing about weight is not only harmful for your mental health, it isn’t particularly scientific.

In 2025, the Lancet published a major report on obesity, and the very first line acknowledges that BMI provides “inadequate information about health at the individual level.” Doctors are increasingly moving away from a narrow focus on weight and instead towards more expansive — and more research-backed — metrics instead.

When my own patients come in for a checkup, I usually with this question: “What are your goals?” What it means to be “healthy” is different for every patient, so I try to take the time to explore what a full, flourishing life looks like for them.

For example, many of my patients want to add more vegetables to their diet and cut back on ultraprocessed foods. This is generally a great plan to feel good and reduce the risk of cardiometabolic disease. But for a person in recovery from an eating disorder, focusing too much on diet can be psychologically distressing. It might be healthier for that patient to take a break from worrying about food.

And your health goals can change over your lifetime. Exercise may be really challenging if you’re caring for a young child, and sleep will take priority. But in the menopausal transition, exercise may be your top goal if you’re looking to prevent bone loss.

Instead of BMI, here are some key topics I usually discuss with my patients:

1. Blood pressure. Get this checked at least once a year, more often if you have a diagnosis of hypertension. High blood pressure is extremely common but is trickier to diagnose than meets the eye — stay tuned for my next Real Talk With A Doc column on this not-super-sexy-but-super-important topic.

2. Mental health. It’s hard to be your best physical self without the foundation of a positive mood. I always try to ask my patients about how they’re doing.

3. Movement and mobility. I like to reframe exercise not as punishing 3-hour gym sessions but rather as little movement "snacks" that can fit in throughout your day, things like gardening or a daily walk with a friend.

4. Sleep. Oh my God I love to sleep. Please, please, please talk to your doctor if you’re struggling with this.

5. Glucose tolerance. I check most of my patients for signs of pre-diabetes or diabetes. This can be a health challenge for people of all body sizes.

6. Cardiovascular disease risk. I usually use the American College of Cardiology’s PREVENT Calculator to help understand my patients’ risk of developing cardiovascular disease and whether or not they’d benefit from medications to prevent it. I’ll also sometimes recommend a coronary calcium CT scan in ambiguous cases.

7. Cancer screening. Also not sexy, but super important.

What measures of health and well-being do you like to use in your own life? And doctors — anything you’d add?

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My first step was to google Tamron Hall. I had a vague idea of what her show was all about, but let’s be honest — I’m not her target audience. (It airs mid-afternoon on weekdays when I’m, um, seeing patients.) I didn’t want to accidentally walk into some Fox News hellscape without knowing what I was getting into.

My second step was to panic text a very fashionable friend. What am I going to wear?!

I sent a few other anxious emails to some people I trust, waffling about whether or not I should go through with it. What if I look dumb? What will it be like to show my body on TV? What if I stumble over my words?

In the end, I decided to go for it, and I’m glad I did.

But TV, I learned, is not for the faint of heart, and I have a lot of things I wanted to say and couldn’t. That’s why I’m writing a book, I guess! And that’s why here, I’m sharing a few questions I wish they had asked me — and what I’d say in response.

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Going up to New York for the day was unexpectedly lovely. It’s rare for me, in this season of my life, to have a few hours to myself to walk around lower Manhattan on a gorgeous early fall day. (You know what I did with those few hours? I went to the brick-and-mortar store of a very fancy French brand whose clothes I stalk online and found, to my dismay, that all the sweaters looked really poorly made! I guess that saved me some wasted online shopping.)

I was obviously wearing my sneakers and a backpack to do this, so when I arrived at the studio where Tamron Hall is filmed, the producers who were tasked with fetching me did not recognize me. I said, “Um, I’m actually a guest on the show!” And they told me to get in line for the audience. LOL. Once we got it sorted out, they were very apologetic.

Luckily hair and makeup saved the day and helped me transform from tourist-sneaker-mom-Mara to I-go-on-TV-all-the-time-Mara. While I was getting beautified, I got to talk to some of the other guests, several of whom were actual models. (If you had asked me, a few years ago, if I thought I would be on national TV with a bunch of models…)

Somebody asked me if I “make content.” I said I didn’t really know how, so this very hip young woman recommended I hire somebody else to do it for me.

And then I gave her my real answer: “I’m a doctor, and a writer, and I want to make health care welcoming to people with all types of bodies.” (As an aside, I am reluctantly coming around to the importance of *serious* writers and thinkers sharing their work on the Internet. You might even see me posting some videos on Instagram. Try not to laugh at me too much.)

My interview with Tamron was shockingly short. It was wild to spend hours getting my hair and makeup done, listening to pump-up music in my dressing room, practicing my brilliant answers to her piercing questions… And then talk for about 60 seconds about a topic I wasn’t expecting. Tamron, of course, was unbelievably glamorous and very nice.

So here’s what I wish she had asked me.

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1. Is body positivity dead? There’s some debate in the body positivity world about the best term to describe the ideal way of relating to our bodies. The brilliant calls it “body reflexivity.” My medical colleagues at call it “size inclusivity.” In my book, I’m exploring an idea I call body justice. I’m actually pretty equal opportunity about the language; I don’t nit pick when I describe my work as long as people understand I want to end body hierarchy and fight against body shame. But to understand if body positivity is dead, we have to understand what body positivity is. I think of it as a movement that fights for our ability to relate peacefully and pleasurably to our own bodies. That doesn’t mean we have to feel great about our bodies at all times. But it does mean that we treat our bodies with gentleness, with curiosity, and with care. That isn’t dead; we need that sense of care now more than ever.

2. Can you love your body and still want to be healthy? The question implies that treating your body gently — kindly — is somehow “giving up” on the pursuit of health. “Letting yourself go.” In practice, I think kindness towards your body is actually a necessary component of being healthy. So many of my patients live with an ambient sense of body shame, and I see the way it chips away at their health. They spend their days crippled by insecurity rather than doing the things they want to do. They’re so preoccupied by their body’s flaws that they don’t stop to appreciate what their body can do. That’s not any way to live.

3. What does it mean to be a size-inclusive doctor? Simply put, I don’t yell at my patients to lose weight. That’s my tongue-in-cheek definition, which is surprisingly revolutionary. That doesn’t mean I am unwilling to address my patients’ concerns about body size. That doesn’t mean I refuse to have conversations about weight. But I won’t nag my patients about hopping on the treadmill more often. That’s a promise.

4. Has being a size-inclusive doctor changed in the Ozempic era? Yes and no. I got started on my size-inclusive roadshow after an essay I wrote for NPR went viral. Since it was published in 2023, my thinking has evolved. I’ve gotten much better at navigating the nuances of respecting my patients’ bodily autonomy — and a very common desire to lose weight; we live in a very fatphobic society, after all! — and also planting the seeds of a more holistic vision of what it means to be healthy beyond getting to a BMI of 25. I have said it many times and I’ll say it again: I have prescribed GLP1 agonists for years, and I’m very grateful to the researchers who developed them. They are very, very good at lowering blood sugar, protecting the heart, preventing kidney disease and reducing liver inflammation. But GLP1 agonists don’t treat body shame. They don’t help us feel grateful for what our bodies can do. They don’t fight fatphobia or misogyny or racism or ageism. They don’t bring us peace with our bodies.

5. You’re writing about body justice. What is that? I draw my inspiration from the reproductive justice movement, which has its origins in Black intersectional feminism and moves beyond the binary of pro/anti abortion towards a more holistic conceptualization of reproductive health and parenting. (Please go read about it; it has transformed the way I practice medicine.) What does that mean in terms of body image? Rather than thinking about body positivity as a binary — you can either choose to love your body, or choose to hate it — I want a world where we end body shame and where we all have the resources we need to keep our bodies healthy. That means fighting against fatphobia and access to fresh foods and safe green spaces to move our bodies and sleeping enough and tackling systemic stress. It’s a rejection of the idea that body positivity is at odds with being healthy, that we must somehow hate our bodies in order to keep them in check. It’s a tall order, but it’s worth it.

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And of course, at the end of my not-exactly-glamorous day of TV, I got a soft serve ice cream. Highly recommend.

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But now, in my work as a size-inclusive primary care doctor, I'm having to re-learn all of that — or learn it for the first time now, as a doctor ten years into practice. I'm realizing that the principles of caring for people with eating disorders apply to all of my patients. Because while not everyone meets the stringent diagnostic criteria for an eating disorder, disordered eating is incredibly, incredibly common. And doctors often make it worse, even with an offhand comment congratulating someone for losing weight.

That's why I was so eager to read ’s powerful new book Slip: Life in the Middle of Eating-Disorder Recovery. It showed me how much I still have to learn about the way that medical care intersects with mental health and body image. (Mallary is a journalism professor at the University of Texas, Austin, and I also loved nerding out with her about journalism ethics!) She was kind enough to speak with me; below, find our lightly edited conversation. You can find more of Mallary’s work on Substack or at her website here.

Mara: As a doctor, I felt almost indicted by your book. When you were a child, developing more and more disordered eating, you write about all the adults in your life — including your doctors — who didn’t intervene even as it became pretty clear that you were sick. Why do you think it was so hard for the adults who cared about you to help you?

Mallary: Eating disorders are very enigmatic and hard to understand, and family members and friends initially didn't even know that I was struggling with an eating disorder, because we each had our own misconceptions about who struggled with eating disorders and who didn't, and what they looked like. My father thought that only adults struggled with eating disorders, because his only point of reference was the death of singer-songwriter Karen Carpenter, who had died in 1983 due to complications from anorexia. So he didn't think that adolescents struggled with anorexia. I thought that people with anorexia didn't eat anything at all. And so I was still eating something, not nearly enough, but I was still eating something. So I thought, “Well, I'm not anorexic.”

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Mara: There was a huge disconnect between cultural ideas about eating disorders and the young person in front of them, who was clearly suffering.

Mallary: For several months, my father would often say, “Why can't you just eat? What is going on?” So my father knew, certainly, that something wrong was happening, but didn't really know why and couldn't make sense of it. So he took me to the pediatrician, who essentially told me that my food restriction was a passing phase and he didn't have really any cause for concern. And interestingly, I was able to obtain my old medical records. It was very clear that I had lost weight from one appointment to the next. So several months later, my father took me back to the pediatrician. I had lost more weight during that period, and the pediatrician, again, said, “This is just a passing phase. Don't worry about it.” And so my father knew something was wrong, and to his credit, ended up talking with a family friend who said, “I think Mallary has an eating disorder.” And then finally, after about a year of having struggled with food restriction, I was admitted to Boston Children's Hospital and finally got a diagnosis of anorexia nervosa.

Mara: In my own practice, I feel a real sense of not wanting to alarm families, or not wanting to pathologize behavior that could be a variant of normal. I think a lot of doctors want to reassure.

Mallary: Research shows that the sooner a child gets treatment, the better the long-term prognosis. So I often look back and wonder what would have happened had I gotten care initially during that first pediatrician appointment, rather than having to wait even longer to actually get the care that I needed. And that's a question that I'll never have an answer to.

Mara: You write about how you experienced a lot of positive reinforcement with some of the early behaviors you exhibited around restriction and weight loss. Doctors often praise weight loss or “healthy eating.” It made me feel sad to think about how the adults in your life might have been causing you harm.

Mallary: I spoke with one doctor who treats adolescents with eating disorders, and he said that on many occasions, when he sees someone who comes to him with an eating disorder, it actually began from having been put in a weight loss plan by their pediatrician. The pediatrician prescribed weight loss, but without really any clear guidance as to how to go about it and without follow up. So lo and behold, the child ends up losing weight, but then gets in an energy deficit and ends up losing weight to the point where they've descended into an eating disorder. We need to be really careful. Children are at the age where they should be gaining weight. But also, if there’s no follow up and no real clear guidance for the child and the caretaker, then it can become this very slippery slope.

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Mara: There’s a huge focus in health care on preventing and treating childhood obesity, but not a lot of focus on how that might contribute to disordered eating.

Mallary: We know that some people with eating disorders have a BMI in the obese range. There is, of course, overlap between those two things. I surveyed over 700 people for my book, and 51% of the people I surveyed faced weight discrimination while receiving either medical care or eating disorder treatment. There's so much emphasis on obesity in med school, and yet most medical doctors are only receiving between zero and two hours of training on eating disorders, which is mind boggling when you consider that 30 million Americans will struggle with an eating disorder at some point in their life.

Mara: I’ve had patients tell me they didn’t feel thin enough to have an eating disorder.

Mallary: Sometimes there’s shame, for instance, when a man has an eating disorder, because there’s this sense that it's a woman's disorder. These long-standing stereotypes can actually silence people, and they can make it so a lot of individuals aren't actually able to get the care that they need. Eating disorders affect people of all different genders, races, ethnicities, body types. One of the interesting parts of the book for me was talking with folks who struggle with atypical anorexia. That’s a bit of a misnomer, because some providers argue that it's actually more typical than atypical. It's essentially where someone meets all the diagnostic criteria for anorexia nervosa, except that they're not clinically underweight. Often they are told that they don't have a problem, or sometimes they are denied insurance coverage or treatment because they don't have a low BMI.

Mara: How do you think about the difference between an eating disorder and disordered eating? Once you start to recognize diet culture, which encourages disordered eating, you start to see it in so many nooks and crannies. It’s really normalized. Whereas I don’t think everybody has a clinical eating disorder.

Mallary: With an eating disorder, people are experiencing extreme behaviors and physical side effects. They are often in cognitive ruts where essentially everything related to food and weight and body size is taking up the majority of their mental space to the point where they don't feel like they have any control over their thoughts or their bodies and behaviors. It is accompanied by this sort of “out of control” feeling.

The line between disordered eating and eating disorders is very blurry. And I talked with many individuals who for a long time felt like they were, quote, “struggling with disordered eating” because it is normalized in a lot of ways. A lot of people talk about how they have fraught relationships with food, but didn’t think they were sick enough to have an eating disorder.

Mara: You were in a residential treatment program for a year and a half when you were a young teen. As a mom, that breaks my heart, imagining being away from my child for that long. How has the treatment philosophy for anorexia changed since the 1990s?

Mallary: The thinking was that the child needed to be extracted from the home in order to get better. And that harkened back to this idea that mothers were often to blame for children's eating disorders. And there was even a term known as “parentectomy,” which was this idea that children needed to be removed and that was the only way they could recover.

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Mara: How does being a parent influence your advocacy work?

Mallary: I think multiple times a day about the fact that I don't want to pass my eating disorder on to my kids. It is a worry that just weighs on me a lot, and it's hard to shake. So a lot of what I've been doing lately is talking with them about how all bodies are worthy of respect. I also talk with them about how all kinds of foods fuel our bodies, how it gives us energy to play, to move through our days, because I don't want them to think that foods are either bad or good. It can be so easy for children to then ascribe moral values to food, where they think, “Well, I'm bad if I'm eating bad food, and I'm good if I'm eating good food.”

Mara: A friend texted me a photo of her child at daycare, placing cut-out pictures of foods in “healthy” and “unhealthy” categories. Her kid was about 2 and a half at the time.

Mallary: I want to help my kids to see their worth and value based on who they are, as opposed to what they look like. When my daughter turned nine a few months ago, I made her a mirror. It was a wooden mirror I got online in the shape of a flower. On each petal I painted a word that described who she was: creative, empathetic, caring. I love when I catch her looking in that mirror, because I told her that when she looks in the mirror, I want her to see who she is.

Mara: I’ve been thinking a lot about how GLP1 agonists like Ozempic might intersect with disordered eating in many of my patients. Doctors have conceptualized a BMI over 30 as a “disease” that should be treated, often with a GLP1. But we don’t always do a great job screening for eating disorders or even disordered thoughts about food.

Mallary: We do know that individuals who are on these drugs can be triggered by them if they've had experience with an eating disorder, and so we need to be really careful about the messaging that we're sharing. I interviewed one person for the book who's been open about being on a GLP1 for diabetes. She has struggled with anorexia and binge eating, but is very solidly in her recovery, and has been for many years. But as she started taking this drug, she found that she didn't have an appetite, she didn't want to eat, and she found herself getting into more of these cognitive ruts around food. She could sense the eating disorder coming back. She told her doctor, “I need to be on a lower dosage. I’m not eating lunch.” And the doctor said, “It’s okay if you don’t eat lunch.” And she responded by saying, “It is not okay if I don’t eat lunch. As part of my recovery, I need to be able to eat regular meals.” Even offhand comments like that, that may seem innocuous, could actually be quite triggering for individuals who've had lived experience with an eating disorder.

Mara: In your book, you write about “the middle place” between sickness and recovery. In medicine, we have such a binary approach: You’re either healthy or you're ill. It can be so limiting. How has this framework helped you in your recovery?

Mallary: It’s so much easier when we can treat disorders that have a definitive end, or that have clear pathways toward recovery and clear markers of recovery. It's really important to recognize that with eating disorders, they can be chronic, but also eating disorders can be disorders that come and go and ebb and flow throughout life, depending on experiences that we have. For me, full recovery always felt like this perfectionistic ideal. The field very much pushes for “full recovery” for everyone, and yet we don't exactly know how to define that.

We are in a society that is steeped in diet culture. We are in a society that has this normative discontent, which means that the vast majority of people in our society have some level of discontent with their body. So that's the society that we're recovering into. So what does full recovery look like in that? Recovery is not a fixed state. It is something that is ongoing and that we have to contend with for the rest of our lives, where we’re going to have these moments when we’re slipping, but those slips don't have to be grounds for failure. They can really be opportunities for growth.

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Thank you so, so much for sharing such intimate and powerful details about your recovery, . Please buy her amazing book!

That’s a great thing! Menopause is having a moment, and I’m here for it. When I was a trainee, I remember feeling terrified of any conversation about hormones or hot flashes. Now, the narrative has changed: menopause is a major life change, and doctors need to treat it as such. I’ve learned a lot about menopause in the last few years.

But amongst the cultural and medical shift towards taking menopause more seriously — well, unfortunately there are a lot of scams. There are menopause influencers selling supplements and weight-loss programs. There’s misinformation and deliberate lies.

And there’s a whole lot of body shame. As I started taking a peek into the world of online menopause advocacy, I realized that so much of the discourse was about fear of changing bodies: fear of getting fat, getting old, becoming irrelevant. Many menopause influencers capitalize on those fears in order to make a buck. And that, to me, seems like the exact opposite of what it means to advocate for women’s midlife health.

That’s why I was thrilled when the great asked me to join her on her Burnt Toast podcast to talk about menopause and how we can think about this major life transition without body shame. Our conversation was too long for just one episode, so part II will be coming shortly.

(Also! I love the work of , an OB/GYN who writes about menopause and is fiercely dedicated to science and facts. Check out her newsletter for rigorous, evidence-based information about women’s health.)

Listen to my conversation with Virginia here, and find a transcript below.

Burnt Toast by Virginia Sole-Smith

Dr. Mara Will Not Sell You a Weighted Vest

You’re listening to Burnt Toast! Today, my guest isMara Gordon, MD…

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a year ago · 27 likes · 8 comments · Virginia Sole-Smith and Mara Gordon, MD

Episode Transcript:

Virginia

When I put up the call out for listener questions for this, we were immediately inundated with, like, 50 questions in an hour. People have thoughts and feelings and need information! So I’m very excited you’re here. Before we dive into the listener questions, let’s establish some big picture framing on how we are going to approach this conversation around perimenopause and menopause.

Mara

I should start just by introducing myself. I’m a family doctor and I have a very general practice, which means I take care of infants and I have a couple patients who are over 100. It’s amazing. And families, which is such an honor, to care for multiple generations of families. So, perimenopause and menopause is one chunk of my practice, but it is not all of it.

I come from the perspective of a generalist, right? Lots of my patients have questions about perimenopause and menopause. Many of my patients are women in that age group. And I have been learning a lot over the last couple of years. The science is emerging, and I think a lot of practice patterns amongst doctors have really changed, even in the time that I have been in practice, which is about 10 years. There has been a huge shift in the way we physicians think about menopause and think about perimenopause, which I think is mostly for the better, which is really exciting.

There’s an increased focus on doctors taking menopause seriously, approaching it with deep care and concern and professionalism. And that is excellent. But this menopause advocacy is taking place in a world that’s really steeped in fatphobia and diet culture. Our culture is just so susceptible to corporate influence. There are tons of influencers who call themselves menopause experts selling supplements online, just selling stuff. Sort of cashing in on this. And I will note, a lot of them are medical doctors, too, so it can be really hard to sort through.

Virginia

Your instinct is to trust, because you see the MD.

Mara

Totally. There’s a lot of diet talk wrapped up in all of it, and there’s a lot of fear-mongering, which I would argue often has fatphobia at its core. It’s a fear of fatness, a fear of aging, a fear of our bodies not being ultra thin, ultra sexualized bodies of adolescents or women in their 20s, right?

This is all to say that I think it’s really exciting that there’s an increased cultural focus on women’s health, particularly health in midlife. But we also need to be careful about the ways that diet culture sneaks into some of this talk, and who might be profiting from it. So we do have some hearty skepticism, but also some enthusiasm for the culture moving towards taking women’s concerns and midlife seriously.

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Virginia

The cultural discourse around this is really tricky. Part of why I wanted you to come on to answer listener questions is because you approach healthcare from a weight inclusive lens, which is not every doctor. It is certainly not every doctor in the menopause space. And you’re not selling us a supplement line or a weighted vest, so that’s really helpful. So that’s a good objective place for us to start!

Here’s our first question, from Julie:

It’s my understanding that the body naturally puts on weight in menopause, especially around the torso, and that this fat helps to replace declining estrogen, because fat produces estrogen. I don’t know where I’ve heard this, but I think it’s true? But I would like to know a doctor’s explanation of this, just because I think it’s just more evidence that our bodies know what they’re doing and we can trust them, and that menopause and the possible related weight gain is nothing to fear or dread or fight.

Mara

Oof, okay, so we are just diving right in. Thank you so much for this question. It’s one I get from many of my patients, too.

So I looked into some of the literature on this, and it is thought that declining estrogen—which happens in the menopausal transition—does contribute to what we call visceral adiposity, which is basically fatty tissue around the internal organs. And in clinical practice, we approximate this by assessing waist circumference. This is really spotty! But we tend to think of it as “belly fat,” which is a fatphobic term. I prefer the term “visceral adiposity” even though it sounds really medical, it gets more specifically at what the issue is, which is that this particular adipose tissue around internal organs can be pathologic. It can be associated with insulin resistance, increasing risk of cardiovascular disease, and risk of what we call metabolic—here’s a mouthful—metabolic dysfunction associated steatotic liver disease, which is what fatty liver disease has been renamed.

So I don’t think we totally understand why this happens in the menopausal transition. There is a hypothesis that torso fatty tissue does help increase estrogen, and it’s the body’s response to declining estrogen and attempts to preserve estrogen. But in our modern lives, where people live much longer than midlife, it can create pathology.

Virginia

I just want to pause there to make sure folks get it. So it could be that this extra fat in our torsos develops for a protective reason —possibly replacing estrogen levels—but because we now live longer, there’s a scenario where it doesn’t stay protective, or it has other impacts besides its initial protective purpose.

Mara

Right? And this is just a theory. It’s kind of impossible to prove something like that, but many menopause researchers have this working theory about, quote—we’ve got to find a better term for it—belly fat. What should we call it, Virginia?

Virginia.

I mean, or can we reclaim belly fat? But that’s like a whole project. There is a lot of great work reclaiming bellies, but we’ll go with visceral adiposity right now.

Mara

Anyway, this is an active area of menopause research, and I’m not sure we totally understand the phenomenon. That being said, Julie asks, “Should we just trust our bodies?” Do our bodies know what they’re doing? And I think that’s a really philosophical question, and that is the heart of what you’re asking, Julie, rather than what’s the state of the research on visceral adiposity in the menopause transition.

It’s how much do we trust our bodies versus how much do we use modern medicine to intervene, to try to change the natural course of our bodies? And it’s a question about the role that modern medicine plays in our lives. So obviously, I’m a fan of modern medicine, right? I’m a medical doctor. But I also have a lot of skepticism about it. I can see firsthand that we pathologize a lot of normal physiologic processes, and I see the way that our healthcare system profits off of this pathology.

So this is all to say: Most people do tend to gain weight over time. That’s been well-described in the literature. Both men and women gain weight with age, and women tend to gain mid-section weight specifically during the menopausal transition, which seems to be independent of age. So people who go through menopause earlier might see this happen earlier.

This weight gain is happening in unique ways that are affected by the hormone changes in the menopausal transition, and I think it can be totally reasonable to want to prevent insulin resistance or prevent metabolic dysfunction in the liver using medications. Or can you decide that you don’t want to use medications to do that; diet and exercise also absolutely play a role. But I think it’s a deep question. I don’t know, what do you think? Virginia, what’s your take?

Virginia

I think it can be a both/and. If everybody gains weight as we age, and particularly as we go through menopause transition, then we shouldn’t be pathologizing that at baseline. Because if everybody does it, then it’s a normal fact of having a human body. And why are we making that into something that we’re so terrified of?

And I think this is what we’re going to get more into with these questions: It’s also possible to say, can we improve quality of life? Can we extend life? Can we use medicine to help with those things in a way that makes it not about the weight gain, but about managing the symptoms that may or may not be caused by the weight gain? If the weight gain correlates with insulin resistance, of course you’re going to treat the insulin resistance, because the insulin resistance is the concern. Does that mean weight loss is the thing we have to do? Not necessarily.

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Mara

Totally. I define size inclusive medicine—which is the way that I practice medicine—as basically not yelling at my patients to lose weight. And it’s quite revolutionary, even though it shouldn’t be. I typically don’t initiate conversations about weight loss with my patients. If my patients have evidence of metabolic dysfunction in the liver, if they have evidence of diabetes or pre-diabetes, if they have high blood pressure, we absolutely tackle those issues. There’s good medications and non-medication treatments for those conditions.

And if my patients want to talk about weight loss, I’m always willing to engage in those conversations. I do not practice from a framework of refusing to talk with my patients about weight loss because I feel that’s not centering my patients’ bodily autonomy. So let’s talk about these more objective and less stigmatized medical conditions that we can quantify. Let’s target those. And weight loss may be a side effect of targeting those. Weight loss may not be a side effect of targeting those. And there are ways to target those conditions that often don’t result in dramatic or clinically significant weight loss, and that’s okay.

One other thing I’ll note that it’s not totally clear that menopausal weight gain is causing those sort of metabolic dysfunctions. This is a really interesting area of research. Again, I’m not a researcher, but I follow it with interest, because as a size-inclusive doctor, this is important to the way that I practice.

So there’s some school of thought that the metabolic dysfunction causes the weight gain, rather than the weight gain causing the metabolic dysfunction. And this is important because of the way we blame people for weight gain. We think if you gain weight, you’ve caused diabetes or whatever. This flips the narrative on its head. Diabetes is a really complex disease with many, many factors affecting it. It’s possible that having a genetic predisposition to cardiometabolic disease may end up causing weight gain, and specifically this visceral adiposity. So this is all to say there’s a lot we don’t understand. And I think at the core is trying to center my patients’ values, and de-stigmatize all of these conversations.

Burnt Toast by Virginia Sole-Smith

Dr. Mara Will Not Sell You a Weighted Vest

You’re listening to Burnt Toast! Today, my guest isMara Gordon, MD…

Listen now

a year ago · 27 likes · 8 comments · Virginia Sole-Smith and Mara Gordon, MD

Virginia

I love how Julie phrased it: “The possible related weight gain in menopause is maybe nothing to fear, dread, or fight.” I think anytime we can approach health without a mindset of fear and dread and not be fighting our bodies, that seems like it’s going to be more health promoting than if we’re going in like, “Oh my God, this is happening. It’s terrible. I have to stop it.”

And this is every life stage we go through, especially as women. Our bodies change, and usually our bodies get bigger. And we’re always told we have to fight through puberty. You have a baby, you have to get your body back as quickly as possible. I do think there’s something really powerful in saying: “I am going through a big life change right now so my body is supposed to change. I can focus on managing the health conditions that might come along with that, and I can also let my body do what it needs to do.” I think we can have both.

Mara

Yeah, that’s so beautifully said. And Julie, thank you for saying it that way.

Virginia

Okay, so now let’s get into some related weight questions.

I was just told by my OB/GYN that excess abdominal weight can contribute to urinary incontinence in menopause. How true is this, and how much of a factor do you think weight is in this situation? And I think the you know, the unsaid question in this and in so many of these questions, is, so do I have to lose weight to solve this issue?

Mara

Yes. So this is a very common refrain I hear from patients about the relationship between BMI and sort of different processes in the body, right? I think what the listener’s OB/GYN is getting at is the idea that mass in the abdomen and torso might put pressure on the pelvic floor. And more mass in the torso, more pressure on the pelvic floor.

But urinary incontinence is extremely complicated and it can be caused by lots of different things. So I think what the OB/GYN is alluding to is pelvic floor weakness, which is one common cause. The muscles in the pelvic floor, which is all those muscles that basically hold up your uterus, your bladder, your rectum—all of those muscles can get weak over time. But other things can cause urinary incontinence, too. Neurological changes, hormonal changes in menopause, can contribute.

Part of my size inclusive approach to primary care is I often ask myself: How would I treat a thin person with this condition? Because we always have other treatment options other than weight loss, and thin people have urinary incontinence all the time.

Virginia

A lot of skinny grandmas are buying Depends. No shame!

Mara

Totally, right? And so we have treatments for urinary incontinence. And urinary incontinence often requires a multifactorial treatment approach.

I will often recommend my patients do pelvic floor physical therapy. What that does is strengthen the pelvic floor muscles particularly if the person has been pregnant and had a vaginal delivery, those muscles can really weaken, and people might be having what we call genitourinary symptoms of menopause. Basically, as estrogen declines in the tissue of the vulva, it can make the tissue what we call friable.

Virginia

I don’t want a friable vulva! All of the language is bad.

Mara

I know, isn’t it? I just get so used to it. And then when I talk to non-medical people, I’m like, whoa. Where did we come up with this term? It just means sort of like irritable.

Virginia

Ok, I’m fine having an irritable vulva. I’m frequently irritable.

Mara

And so that can cause a sensation of having to pee all the time. And that we can treat with topical estrogen, which is an estrogen cream that goes inside the vagina and is an amazing, underutilized treatment that is extremely low risk. I just prescribe it with glee and abandon to all of my patients, because it can really help with urinary symptoms. It can help with discomfort during sex in the menopausal transition. It is great treatment.

Virginia

Itchiness, dryness…

Mara

Exactly, yeah! So I was doing a list of causes of urinary incontinence: Another one is overactive bladder, which we often use oral medications to treat. That helps decrease bladder spasticity.

So this is all to say that it’s multifactorial. It’s rare that there’s sort of one specific issue. And it is possible that for some people, weight loss might help decrease symptoms. If somebody loses weight in their abdomen, it might put less pressure on the pelvic floor, and that might ease up. But it’s not the only treatment. So since we know that weight loss can be really challenging to maintain over time for many, many reasons, I think it’s important to offer our patients other treatment options. But I don’t want to discount the idea that it’s inherently unrelated. It’s possible that it’s one factor of many that contributes to urinary incontinence.

Virginia

This is, like, the drumbeat I want us to keep coming back to with all these issues. As you said, how would I treat this in a thin person? It is much easier to start using an estrogen cream—like you said, low risk, easy to use—and see if that helps, before you put yourself through some draconian diet plan to try to lose weight.

So for the doctor to start from this place of, “well, you’ve got excess abdominal fat, and that’s why you’re having this problem,” that’s such a shaming place to start when that’s very unlikely to be the full story or the full solution.

Mara

Totally. And pelvic PT is also underutilized and amazing. Everyone should get it after childbirth, but many people who’ve never had children might benefit from it, too.

Virginia

Okay, another weight related question. This is from Ellen, who wrote in our thread in response to Julie’s question. So in related to Julie’s question about the role of declining estrogen in gaining abdominal fat:

If that’s the case, why does hormone replacement therapy not mitigate that weight gain? I take estrogen largely to support my bone health due to having a genetic disorder leading to fragile bones, but to be honest I had hoped that the estrogen would also help address the weight I’ve put on over the past five years despite stable eating and exercise habits.

That hasn’t happened, and I understand that it generally doesn’t happen with HRT, but I don’t understand why. I guess I’d just like to understand better why we tend to gain abdominal fat in menopause and what if anything can help mitigate that weight gain. I’m working on self acceptance for the body I have now, and I get frustrated when clothes I love no longer fit, or when my doctor tells me one minute to watch portion sizes to avoid weight gain, and the next tells me to ingest 1000 milligrams of calcium per day, which would account for about half of the calories I’m supposed to eat daily in order to lose weight or not gain more weight.

It just feels like a lot of competing messages! Eat more protein and calcium, but have a calorie deficit. And it’s all about your changing hormones, but hormone replacement therapy won’t change anything.

Ellen, relatable. So many mixed messages.

Dr. Mara, you spoke to what we do and don’t know about the abdominal fat piece a little bit already in Julie’s question, so I think we can set that aside. But yes, if estrogen is playing a role, why does hormone replacement therapy not necessarily impact weight?

And what do we do with the protein of it all? Because, let me tell you, we got like 50 other questions about protein.

Mara

I will answer the first part first: I don’t think we know why menopausal hormone therapy does not affect abdominal fat. You’re totally right. It makes intuitive sense, but that’s not what we see clinically. There’s some evidence that menopausal hormone therapy can decrease the rate of muscle mass loss. But we consider it a weight neutral treatment. Lots of researchers are studying these questions. But I don’t think anybody knows.

So those messages feel like they’re competing because they are competing. And I don’t think we understand why all these things go on in the human body and how to approach them. So maybe I’ll turn the question back to you, Virginia. How do you think about it when you are seeking expertise and you get not a clear answer?

Virginia

I mean, I’m an irritable vulva when it happens, that’s for sure. My vulva and I are very irritated by conflicting messages. And I think we’re right to be. I think Ellen is articulating a real frustration point.

The other thing Ellen is articulating is how vulnerable we are in these moments. Because, as she’s saying, she’s working on self-acceptance for the body she has. And I think a lot of us are like, “We don’t want weight loss to be the prescription. We don’t want to feel pressured to go in that direction.” And then the doctor comes in and says, “1000 milligrams of calcium a day, an infinity number of protein grams a day. Also lose weight.” And then you do find yourself on that roller coaster or hamster wheel—choose your metaphor. Again, because we’re so programmed to think “well, the only option I have is to try to control my weight, control my weight, control my weight.” And you get back in that space.

What I usually try to do is phone a friend, have a plan to step myself out of that. Whether it’s texting my best friend or texting Corinne, so they can be that voice of reason. And I would do this for them, too! You need help remembering: You don’t want to pursue intentional weight loss. You’re doing all this work on self-acceptance. Dieting is not going to be helpful. So what can you take from this advice that does feel doable and useful? And maybe it’s not 1000 milligrams of calcium a day, but maybe it’s like, a little more yogurt in your week.

Is there a way you can translate this to your life that feels manageable? I think it’s what you do a great job of. But I think in general, doctors don’t do a great job with that part.

Mara

Yeah, I bet you Ellen’s doctor had 15 minutes with her. And was like, “Well, eat all this calcium and definitely try to lose weight,” right? And then was rushing out the door because she has 30 other patients to see that day.

I think doctors are trying to offer what maybe they think patients want to hear, which is certainty and one correct answer. And it can feel hard to find the space to sort of sit in the uncertainty of medicine and health and the uncertainty of like our bodies. And corporate medicine is not conducive to that, let’s put it that way.

Virginia

But so how much protein do we need to be eating?

Mara

I have no idea. Virginia, I don’t think anybody knows.

I think exercise is good for you. It’s not good for every single body at every single moment in time. If you just broke your foot, running is not a healthy activity, right? If you’re recovering from a disordered relationship with exercise, it’s not healthy.

But, movement in general prolongs our health span. And I’m reluctant to even say this, but, the Mediterranean diet—I hate even calling it a diet, right? But vegetables, protein—I don’t even want to call them healthy fats, it’s just so ambiguous what that means. But olive oil. All those things seem to be good for you. With the caveat that it’s really hard to study the effects of diet. And this is general diet, not meaning a restrictive diet, but your diet over time. But I don’t think we know how much, how much protein one needs to eat. It is unknowable.

Virginia

And that’s why, I think what we’ve been saying about figure out how to translate this into something that feels doable in your life. It’s not like, Oh, olive oil forever. Never butter again.

Mara

Of course not. I love butter. Oh, my God. Extra butter!

Virginia

Right. Butter is core to the Burnt Toast philosophy. I know you wouldn’t be coming here with an anti-butter agenda.

Mara

Oh, of course not. Kerry Gold forever.

Virginia

But it’s, how can you take this and think about what makes sense in your life and would add value and not feel restrictive? And that’s hard to do that when you’re feeling vulnerable and worried and menopause feels like this big, scary unknown. But you still have the right to do that, because it’s still your body.

Mara

Beautifully said.

Virginia

Well, this has all been incredibly helpful. Let’s chat about things that are bringing us joy. Dr Mara, do you have some Butter for us?

Mara

I had to think about this a lot. The Butter question is obviously the most important question of the whole conversation.

We have been in a heat wave in Philly, where I live, and it’s really, really hot, and we have a public pool that is four blocks from our house. Philly actually has tons of public pools. And there’s one four blocks from my house.

So I used to think of pool time as a full day, like a Saturday activity. Like you bring snacks, you bring a book, you lounge for hours. But our city pool is very bare bones. There’s no shade. And so, I have come to approach it as an after work palate cleanser. We rush there after I get my kid from daycare, and just pop in, pop out. It’s so nice. And pools are so democratic. Everybody is there cooling off. There’s no body shame. I mean, I feel like it’s actually been quite freeing for my experience of a body shame in a bathing suit, because there’s no opportunity to even contemplate it. Like you have to hustle in there to get there before it closes. There’s no place to put your stuff. So you can’t do all those body shielding techniques. You have to leave your stuff outside of the pool. So you have to go in in a bathing suit. And it’s just like, all shapes and sizes there. I love it. So public pools are my Butter.

Virginia

We don’t have a good public pool in my area, and I wish we did. I’m so jealous. That’s magical.

Since we’re talking about being in midlife, I’m going to recommend the memoir, Actress of a Certain Age: My Twenty-Year Trail to Overnight Success by Jeff Hiller, which I just listened to on audiobook. Definitely listen to it on audiobook.

Obviously, Jeff Hiller is a man and not in menopause, but he is in his late 40s, possibly turned 50. He’s an actress of a certain age, as he says. If you watched “Somebody Somewhere” with Bridget Everett, he plays her best friend Joel. And the show was wonderful. Everyone needs to watch that.

But Jeff Hiller is someone who had his big breakout role on an HBO show at the age of, like, 47 or something. And so it’s his memoir of growing up as a closeted gay kid in Texas, in the church, and then moving to New York and pursuing acting and all that. It’s hilarious. It’s really moving. It made me teary several times. He is a beautiful writer, and it just makes you realize the potential of this life stage. And one of his frequent refrains in the book, and it’s a quote from Bridget Everett, is Dreams Don’t have Deadlines, and realizing what potential there is in the second half of our lives, or however you want to define it. Oh my gosh, I loved it so much.

There’s also a great, great interview with Jeff on Sam Sanders podcast that I’ll link to as well. That’s just like a great entry point, and it will definitely make you want to go listen to the whole book.

Mara

I love it.

I will briefly say one thing I’ve been thinking about during this whole conversation is a piece by the amazing Anne Helen Petersen who writes Culture Study, which is one of my favorites of course, in addition to Burnt Toast. She wrote a piece about going through the portal. That was what she calls it. And she writes about how she’s talking with her mom, I think, who says, “Oh, you’re starting to portal!” to Anne. And I just love it.

What she’s getting at is this sort of surge of creativity and self confidence and self actualization that happens in midlife for women in particular. And I just love that image. Whenever I think of doing something that would have scared me a few years ago, or acting confident, appropriately confident in situations. I’m like, I’m going into the portal. I just, I love it, it’s so powerful, and I think about it all the time.

Virginia

Well, thank you so much for doing this. This was really wonderful.

Mara

Thank you so much, Virginia. I’m such a fan of your work. It has been so meaningful to me both personally and professionally. So it’s such an honor to be here again.

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Emily Malek, the scientist played by Alexis Bledel, escapes her life as a handmaid in Gilead and seeks asylum in Canada. She’s endured unspeakable physical and emotional trauma. So when she arrives in Toronto, she sees a doctor for an evaluation. She then emerges after the appointment, bewildered.

“They told me my cholesterol is high,” she says.

Oof. Is that what doctors do? Nag our patients about their cholesterol, no matter how horrific the circumstances?

Unfortunately, many of my patients seem to think so.

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As a primary care doctor, it’s my job to think about both preventive care — which, yes, includes monitoring my patients’ cholesterol — and what doctors call “problem-based care.” That means when my patients come in to talk about issues like back pain or asthma flares, I’m also gently encouraging them to get their mammograms done.

(As a brief aside, insurance companies try to distinguish between problem-based and preventive care, which has always struck me as out of touch with the way most people access primary care. The Affordable Care Act mandated that preventive care — like cancer screening or smoking cessation visits — should be accessible without any co-pay or deductible costs borne directly by the patient. Sounds great, right? It mostly is, but most people come in for their preventive “physical” with at least a few aches and pains they want to discuss with the doctor. As soon as a patient brings up a “problem,” the visit is no longer considered preventive care, and people are often surprised by the co-pays they’re expected to pay.)

Navigating the balance between preventive care and my patients’ urgent concerns is an art, not a science. If a patient is in distress because she’s about to get evicted, it can come across as callous to change the subject: “Hey, let’s do your Pap smear!” That Pap smear, of course, can detect cervical cancer in its earliest stages, which can prevent serious illness and death. So it’s important, but may not feel important in the moment compared to the impending eviction.

Lately, my patients have been going through some serious shit. I guess we all are, what with the state of the world and everything, but things have seemed extra tough as of late in the small, low-income city where I work. People come in for a checkup, and all of a sudden we’re talking about their fears of getting deported or losing their house; the risk of getting shot by a cop or losing their job to a robot.

The stress is chronic, and it’s also acute. You can see the lines of worry on people’s faces. We keep tissues ready for the tears in every exam room.

And yet weight keeps coming up. My patients can’t seem to shake the sense that that is what you do at the doctor’s office. They see primary care as an audit of their body size.

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These conversations wax and wane. And yet they often meander back to weight, in a nonlinear train of thought that’s sometimes hard for me to follow. Weren’t we talking about something else? Why did weight come up, again?

I saw one patient recently who had sought asylum in the United States from a politically repressive country, and his wife and young daughter remained there. I asked to see a picture of his child, and he showed me a smiling toddler on his phone, sitting in a garden filled with lush flowers. In New Jersey, he works in a factory, where he spends long hours moving equipment in the same repetitive motion, over and over.

“I want to eat the bread we eat at home,” he told me. “It reminds me of my daughter. But I’m worried it has too many calories.” He was fearful of getting fat in this country, he said.

I glanced at his chart. Over the last year, he had gone from a BMI of 25 to a BMI of 26.

“You should eat the bread,” I told him.

Another recent patient was tearful as soon as I walked into the room, grieving the unexpected death of her sister in a hit-and-run accident. She was hurting, it was clear, with the loss of her sister and many, many other stressors: money, a pulmonary nodule that had just been picked up on a lung cancer screening test, wanting to move to her own place, the outrageous cost of her asthma inhalers.

We had a long and rambling conversation, in which I said very little. But she kept circling back to her body size.

“If I could just lose some weight, it might be easier,” she said.

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As a size-inclusive doctor, I’m not the one initiating these conversations about weight. My general practice is to not bring up my patients’ body size, except in rare circumstances. It’s most certainly not my style to chastise my patients about their weight when they’re suffering so acutely.

But these patients’ expectation is clear. They’ve internalized the message: No matter what horrific things are going on, primary care is the place you go to get yelled at about your weight.

Of course, I am happy to discuss what my patients want to discuss. If patients want to pursue intentional weight loss, I’m always willing to have that conversation. (I’ve had it about ten times this week, already!) My goal is never to dismiss my patients’ concerns, about body size or anything else.

What worries me is the way weight creeps in to so many conversations, and how people confuse fatness with so many other issues — medical and otherwise.

These conversations are about painful, difficult issues that don’t have a quick fix. In turning the discussion to weight loss, I worry people believe — often unconsciously — that losing a few pounds will be a miracle solution that makes all those other problems go away.

That, of course, is diet culture talking, the superstitious belief that getting thin will solve everything. It puts the onus not on systems, but on individuals. It absolves us of our collective responsibility to each other, because you just weren’t trying hard enough to cut the calories.

Does this internalized fatphobia come from the culture at large, and patients are hoping that medicine can address it? Or have doctors been so persistently fatphobic over time that a primary care visit has become synonymous with a body size evaluation, and people just expect it?

I’m not sure I know the answer. But I know these conversations often make me feel sad. And when patients hope weight loss will be a panacea, I feel even sadder.

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A note about patient confidentiality: Trust is at the core of all of my relationships with my patients, and as such, I don’t share their stories publicly. Any story you read here — or in any of my writing that isn’t in the electronic medical record where I write thousands of words a day, ha ha — either has details removed so patients can’t be identified, details changed, or is a composite story that combines information from multiple patients.

The essence of every story I share is true.

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Why are doctors so bad at being nice to fat people?

This was a question posed to me by a therapist named Cassie Krajewski who invited me on to her (fabulous!) podcast to talk about size-inclusive medicine.

I was floored by the question, then floored that I was floored. In all of the work I’ve been doing over the last year, going on my roadshow about fatphobia in health care, I had never been asked this question before. It was so obvious, and so smart.

Why do doctors suck so much at this basic — and I would argue, not too difficult — thing?

As Cassie pointed out, doctors do really hard things. We take difficult exams. We make decisions under pressure. Some doctors do literal brain surgery. (Not I, but that’s probably for the best.)

Yet many neurosurgeons, known for having the hardest possible job in the world, are not known for these fundamental skills: Make fat people feel welcome. Make them feel comfortable. Don’t make them dread coming to see you. Don’t make them feel overwhelmed with self-loathing at the mere idea of being in your presence.

They’re skills I’m teaching my three-year-old: Be gentle. Treat others as you’d like to be treated. Are those things really harder than brain surgery? Unfortunately, it seems like they might be.

Study after study shows that doctors and nurses are some of the worst offenders when it comes to making people in bigger bodies feel stigmatized and unwelcome.

What is going on? I’ve been mulling over Cassie’s question over the last few days, and posed it to a few fat-friendly physician friends. Collectively, we’ve come up with a few ideas about why this is so difficult for doctors.

Here are a few theories:

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1. Doctors are humans, products of the culture in which we live. Although we like to think of ourselves as scientists — and some of us are! — doctors are human beings, living in a culture of our own creation. We imagine that we’re rational and objective, guided by data every step of the way. But if that were the case, we’d all have long-abandoned fatphobia, because the data are pretty clear: it doesn’t help people get healthier. (And helping people be healthy is our job.) This explanation is both as simple and as complex as it gets. Our culture is fatphobic, and doctors are humans living in it. Fatphobia so deeply ingrained that it’s hard to even see it, unless you look closely. As an anthropologist friend likes to say, “Culture is everything!”

2. They think perpetuating stigma helps make their patients healthier. Thankfully, I think this is a very small minority of health care providers, but they can be loud. This is the medicalized version of trolls who post “stop glorifying ob*sity” on the social media accounts of fat people… living. A vocal minority of doctors think it’s good to stigmatize bigger bodies. For example, some (prominent!) bioethicists writing in (prominent!) medical journals have gone so far as to argue that “parents [of children with weight above a certain percentile on the growth charts] should be dealt with directly and with feeling but also delicately and with some finesse, much like a diplomat dealing with a recalcitrant political regime up to no good but also sometimes prickly to talk with.” (His tone… Vomit emoji. He’s clearly never, ever counseled a family at a well-child visit.)

3. Doctors think they’re helping people lose weight, and they think that’s a good thing. Luckily, I think perspectives like Daniel Callahan’s, above, are quite rare. The majority of fatphobic doctors, I think, are doing something harder to pin down. They don’t think of themselves as discriminatory — who does? — but they think instead they’re tackling the “disease” of ob*sity head on. They think they’re helping people lose weight. And they think helping people lose weight is always, unequivocally good. I was recently interviewed by the Washington Post, and my segment on their daily podcast was preceded by a story from a Post reporter who went to see the doctor with a broken wrist, and was told, “Hey, have you thought about trying Ozempic?” Every fat person has one of these stories. Although that anecdote is particularly egregious, I have to imagine the doctor thought he was offering up a helpful factoid. I have to imagine he thought he was being compassionate.

4. Weight is easy to observe, so commenting on it gives doctors the illusion of insight. I was chatting with a friend the other day about his experiences with weight stigma as an “underweight” teen, while he was in the process of being diagnosed with Crohn’s disease. While his doctors were struggling to figure out how to help him, they’d return again and again to his weight: “You need to eat more,” they’d say. It struck me as a clear example of doctors who clearly had no idea what was going on, but they were trained to “fix” a “problem.” They couldn’t identify the problem or the solution, so they turned his weight into a problem, and turned “eating more” into the solution. Doctors have a hard time with uncertainty and ambiguity. It’s antithetical to the way we’re trained, where there’s always a right answer to the multiple-choice question.

5. Fatphobia helps doctors ignore our own mortality. In so much of my experience in health care, the culture of medicine works hard to create a false dichotomy between physician and patient. We talk about illness and wellness as if they’re opposite phenomena without overlap, and we talk about physician and patient as if they’re separate categories — as if we aren’t all patients, too. We talk about “healthy” behaviors and “noncompliant” patients all as part of an elaborate mythology to convince ourselves that preventing disease is under our control, not an existential interplay between genetics and fate. Fatphobia fits nicely into this unspoken worldview: by blaming our bigger-bodied patients for their health problems, we retain a vision of control. We are shielded from confronting our own mortality, from the randomness of it all.

These aren’t excuses, far from it — fatphobia in medicine causes harm, full stop. I’m working hard to undo it.

But before we can start thinking about solutions, we have to better understand the problem. This post is a first stab at trying to understand what continues to perpetuate this widespread and deeply damaging fatphobia in medicine.

I’d be curious to readers’ ideas, too. Why can’t health care providers just get it together when it comes to caring for patients in bigger bodies? Please share your thoughts in the comments.

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I was recently interviewed in ’s newsletter, Weight and Healthcare! This was a huge honor, since her work has profoundly influenced the way I practice medicine. I’d be honored if you’d give it a read.

A note on terminology. You’ll often hear me use the word “fat.” It can be a jarring term, if you aren’t used to hearing it, since for so long it has been used as an insult. Believe me – I’ve spent many years of my life avoiding it at all costs. I’m well-versed in euphemisms. 

Taking my cues from the brave fat activists who came before me, however, I am officially reclaiming the word. I try to use it, as you’ll hear in the fat positive community, as a “neutral descriptor” – a term like “tall,” or “brunette.”

You’ll hear me use the word “fat” to describe bodies in general, and specific bodies of people who have embraced the term. I do not, however, use it with my patients who haven’t first acknowledged that it’s a word they’re comfortable with. To many, it is still an insulting pejorative, and therefore I only use it to describe people who have consented to it. 

If you live in a bigger body, I invite you to try out the word “fat” to describe yourself. You might find it freeing. There’s a whole world of body liberation that awaits you.

Please read and let me know what you think.

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Now, onto a topic I’ve been curious about for a while: fat stigma and the electronic medical record.

I was chatting about size-inclusive medicine with one of my medical students sometime last year, and she told me a story that stuck with me.

She had recently been to see her own primary care doctor, and she had a straightforward visit: blood pressure check, birth control prescription, check-in about her mood. The student, who was very physically active and a fan of endurance sports, hadn’t felt body shame at all. In fact, nothing about her body size or nutrition or exercise had come up in the visit.

She checked out, and she looked at the reams of paperwork she had received. (Side note: why is the paperwork you get after a doctor’s visit the health care equivalent of a CVS receipt?!)

There it was. Diagnosis: obesity.

And then pages of generic advice about “how to get to a healthy body mass index” and how to exercise more and cut calories.

The student, who presumably knows how to take care of her body appropriately for the triathlons she was fond of doing, had a good chuckle about it.

But it made me wonder what was going on. Her doctor hadn’t made her feel stigmatized or even talked about her weight at all. Yet there it was, documented as part of her permanent medical record. It’s a super specific form of medical fatphobia: doctors who don’t bring up weight during their conversation with the patient, then sneak it into the patient’s chart.

What gives? The answer, my friends, is money. It’s always money.

See, fatphobia is so deeply ingrained in the culture of medicine that obesity is not merely considered a risk factor for developing disease (which is debatable and not totally clear), it’s actually considered a disease in and of itself.

We doctors see this language everywhere, particularly around Ozempic: “Let’s de-stigmatize obesity! Treat it like the chronic disease that it is, with a medicine you take for life!”

And any disease has an ICD-10 diagnosis associated with it. What the heck is an ICD-10 diagnosis, you ask? Let’s get into the weeds a bit, here. They’re from the Medicare Bible, otherwise known as the International Classification of Diseases (Version 10).

It’s a list of everything one might possibly get diagnosed for, designed to make it easier to standardize and compare. There’s a lot in there — ranging from Z03.9, or “No Diagnosis,” to W57, “Bitten or stung by nonvenomous insect and other nonvenomous arthropods.” I use these every day, mostly by typing a few key words into the electronic medical record and clicking on the most accurate ICD-10 that pops up.

It’s mostly used for billing our patients’ insurance. It’s also used for research and, to a certain extent, actually communicating about medical decision-making with other health care providers.

Since Medicare — and frankly, most doctors — consider obesity a disease, there is absolutely an ICD-10 diagnosis associated with it. In fact, there are many different obesity-related diagnoses, for specific BMI ranges and whether or not comorbidities are associated.

And of course, the more ICD-10 codes we document, the more complex our patients appear. The more complex they appear, the more we get paid for them.

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Here’s a friendly little guide to billing and coding for obesity that I found online. No wonder your doctors are eager to slap an obesity diagnosis in your medical record, even if they don’t think it’s they need to discuss in the visit.

Funny to see who created this image: check out the image in the lower right hand corner! (Psst: It’s Novo Nordisk, makers of Ozempic! Cha ching!)

For my health care wonks: it gets worse. Even deeper in the maze of health care coding and billing, we find yet another reason why doctors are eager to label their patients as “obese.” Obesity is considered a “Hierarchical Conditional Category.”

These are specific diagnoses designated by the Centers for Medicare and Medicaid Services that are supposed to estimate how “high risk” our patients are.

A doctor sneaks in an obesity diagnosis, her patient’s “risk adjustment factor” score goes up. And with certain insurers and payment models, a higher “RAF” score = more $$.

It’s relevant specifically for something called “value-based payment.” You can literally get a PhD in this, so I’ll keep it brief, but basically, insurers pay a hospital system an “up front fee” for patients based on their complexity — which, yep, is defined in part by obesity. This is in opposition to the traditional fee-for-service model, where the more frequently patients are hospitalized, the more money we make.

In value-based care, a hospital system “bets” that it will be able to make a net profit on the patient, theoretically by investing in primary care and working to keep the patient healthy and out of the hospital. Another strategy to make money for value-based care is to also invest in bureaucrats who remind primary care doctors to document HCC codes as often as possible so our patients bring in more money. “Don’t forget to code for obesity,” they say.

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You can see that fat-positive doctors are up against a ton of obstacles when it comes to removing stigmatizing language from the medical record.

Still, I basically don’t document obesity any more. (There are a few exceptions, of course, since medicine is complex and there might be reasons why it’s necessary.) Not listing obesity in the chart doesn’t change the way I take care of patients, and it has the very real possibility of causing harm.

I tweeted about this approach, and of course, got a range of interesting responses.

I was glad for the discussion, and genuinely interested in the range of responses. (I kind of miss the good old days of #MedTwitter, when it was less a space for Elon Musk-style misinformation and more about sharing ideas and expertise across medical specialties, but… )

Still, we managed to have an interesting debate about this. A lot of #MedTwitter folks seemed up in arms that by not documenting obesity, we were ignoring an important risk factor for disease.

I’d argue, of course, that the link between elevated BMI and risk of early death is a lot more complicated than we acknowledge. But even if you are convinced there’s a linear relationship between BMI and the risk of disease, I still don’t think it’s necessary to document every risk factor in my patient’s chart.

Biological sex is a risk factor for certain diseases. If you’re biologically female, you’re at higher risk for breast or ovarian cancer, right? So is race — a reflection of the complex interplay of genetics, epigenetics, racism, social determinants of health, and other factors. But I don’t list my patients’ race as a diagnosis, nor their sex. Wouldn’t that be weird if your doctor did that?

So for now, my plan is to avoid all the electronic pop-ups commanding me to add obesity to my patients’ charts, avoid the glaring red BMI flag.

I’m curious: fellow size-inclusive docs, how do you address obesity in documentation? Or has anyone experienced stigmatizing language in their own medical record?

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