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Weight and Healthcare: Daily Summaries Delivered
by with Ragen Chastain
Examining the intersections of weight science, weight stigma, and healthcare and what evidence, ethics, and lived experience teach us about healthcare and public health best practices for higher-weight people. weightandhealthcare.substack.com
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- 2 weeks ago7 min
When Weight-Centric Healthcare Becomes Coercive Part 1 - The Basics
I received the following email that I’m sharing with permission:I’m [name], I’m a family doctor and I recently attended your excellent pediatric grand rounds presentation at [organization.] I’ve been a fan of your work for a while and you did not disappoint! During the Q&A you talked about bodily autonomy in a coercive system. I would love to see you write about that on weightandhealthcare.Thanks, and I am happy to! Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Oct 14, 20267 min
Do GLP-1s Help With...?
A lot of the questions I’m getting during Q&As right now (from healthcare providers AND from patients) are about possible uses for GLP-1s - from blood pressure to alcohol and substance use disorders to Binge Eating Disorder to lymphedema and lipedema and more- “Do GLP-1s really help with…” is becoming a very common question, and I think that’s by design.There are reasons for this - many of those reasons I would argue are being purposefully created by the drugs’ manufacturers, so today I’ll break down some of what’s happening and then tell you what questions we would need answers to in order to know if GLP-1s really help with… Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Oct 10, 202616 min
Freedhoff’s Feelings Aren’t Facts - Part 2
In Part 1 we started looking at a commentary piece in Medscape by Dr. Yoni Freedhoff called “The Bell Tolls for the Diet Era.” In part 1 we looked at his big feelings about medical professionals who dare question the use of GLP-1s for weight loss. Today we’ll look at his big feelings around weight-inclusive work and fat acceptance. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Oct 7, 202620 min
Freedhoff’s Feelings Aren’t Facts - Part 1
If the name Yoni Freedhoff sounds familiar, it may be from the Natasha Wiebe’s guest post about her experience going to an “ob*sity” summit. She recounted:“Yoni Freedhoff is a physician from Ottawa and I had seen him featured in at least one documentary on ob*sity and on other media platforms. I had low expectations, and he exceeded those. At the beginning of his talk, he shared the question that he had asked of a number of Large Language Models (like ChatGPT and Claude): how much weight a person could lose today given these latest WL drugs and bariatric surgery? They all gave some answer around 95% of excess weight. He then proceeded to talk about this as if this were science.”It seems that Dr. Freedhoff has a lot of opinions he would like to share because he wrote a commentary piece for Medscape called “The Bell Tolls for the Diet Era.” Of course, no power on this earth will convince me to give it traffic so I’m not including a link. I’ve given you enough information to google it if you want and I’ll break it down here with commentary. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Sep 30, 202611 min
Hernia Repair and Higher-Weight People Part 3- Dealing with BMI-Based Denials
In part 1 I started writing about the basics of hernias in higher-weight people, including the fact that these surgeries are common targets for BMI-based denials of care, where a higher-weight patient’s healthcare is held hostage for a weight loss random. In part 2 we dicussed the issues with the weight loss recommendations that are so commonly given to higher-weight patients when their care is held hostage for a weight loss ransom. In part 3 I’ll give some ideas about how to advocate if you are in this situation as well as some research to help back you up. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Sep 26, 20268 min
Hernia Repair and Higher-Weight People Part 2 - The Realities of Requiring Weight Loss
This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In Part 1 we discussed the basics of hernia repair for higher-weight people. In part 3 we’ll discuss the options for fighting BMI-based denials for hernia care. While I take the stance that people of all sizes deserve equitable care, in Part 2, I want to talk about the issues with these weight loss recommendations (this is a piece I’ve been meaning to write for a while so I’m incuding it in this series, but know that this isn’t just about hernia repair but about anytime weight loss is recommended or required for a patient to be “optimized” for surgery.) Today we’re going to look at it from the perspective of someone who agrees with these recommendations (which I d not) and/or of somene who is so desperate for care that they are willing to try to pay the weight loss ransom (which is a valid choice, but one that patients should never be coerced into making by a healthcare system that holds their care hostage.) Even in these circumstances, there are multiple issues with these weight loss recommendations including feasibility, side effects, and long-term prognosis.Feasibility and Side EffectsThe first question to ask is the feasibility of the requirement. “Optimization” for surgery doesn’t happen in a vacuum and it doesn’t matter if something would make the patient’s surgery easier or improve their outcomes if it is not possible and/or if it harms the patient more than it helps them. Despite this, the feasibility/likelihood of the patient experiencing the required weight loss is, in my experience, far too often not discussed or even considered.I have met with patients who were told they needed to lose 40% of their body weight whose surgeon told them to eat less and exercise more. This is an “intervention” for which about a century of research has found the likelihood of losing even 5% of body weight is quite low and the likelihood of maintaining it is incredibly small (though we’ll get to that.) The doctor might as well have told the patient to grow 6 inches to change their BMI sufficiently.Enter GLP-1s. Here again we’re seeing patients being prescribed these drugs not based on the drugs’ actual capacity to create (at least short term) the required weight loss but based on the sincerely held personal belief of the provider that any amount of weight can be lost with these drugs.In the recent research article that Angela Meadows, Louise Adams, and I published on GLP-1s for weight loss, we included tables in the supplemental materials that include information for all of the phase 3, placebo-controlled trials of GLP1-s for weight loss. One of the reasons I am glad these tables are out in the world is so they can be used in these discussions.As the tables show, about half of people don’t ever reach average weight loss in these trials with around 5-15% failing to lose even 5%. For semaglutide, the STEP 1 trial only looked at weight loss up to 15%, and 49.5% of the subjects failed to lose even 15% of body weight over 68 weeks and in the STEP 3 trial, even when combined with a restrictive diet, 64.3% of subjects failed to lose even 20% of their body weight over 68 weeks. For tirzepatid, the SURMOUNT 1 trial included weight loss up to 25% and 63.8% of the people on the maximum dose (15mg) failed to lose even 25% of their body weight over 72 weeks. In the 2-year weight loss analysis of the SELECT trial ( Ryan et al., 2024) 95.1% of patients failed to lose 20% of their body weight, average weight loss was down to 10%, and at four years the study had lost 89.5% of participants! Other studies showed significant loss of muscle mass as part of the weight loss.You can find the tables here in the supplemental materials. If you are being told to use GLP-1s to qualify for healthcare I also have a case study here that offers more information and some specific scripting that you can use.Then there is the recommendation for weight loss surgery
- Sep 23, 20268 min
Hernia Repair and Higher-Weight People Part 1 - The Basics
One of the more complex situations that I often get asked to write about, or asked to help advocate for, is hernia repair in higher-weight people. This situation can be quite complicated and a lot depends on the person, their specific condition, and their situation. The goal of this three-part series is to offer a starting point for discussion and advocacy. In part 1 we’ll look at some of the basics around hernias, hernia repair in general, and hernia repair (or lack thereof) in higher-weight patients. In part 2 we’ll look at the issues with the common weight loss recommendations higher-weight patients often receive, and in part 3 we’ll look at specific concepts to advocate for care and research to provide some support. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
- Sep 16, 20269 min
When Medical Weight Stigma Costs Thousands of Dollars
I write about many different examples of weight stigma in healthcare including BMI-based denials of care in which healthcare is held hostage for a weight loss ransom. Sometimes these BMI-based denials don’t mean that a procedure is denied everywhere, but that it is denied in a certain facility. One common example of this is when a procedure is requierd to be done in a hospital rather than an ambulatory surgery center. This can be make the procedure much more difficult to schedule and exponentially more expensive. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
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About Weight and Healthcare
Examining the intersections of weight science, weight stigma, and healthcare and what evidence, ethics, and lived experience teach us about healthcare and public health best practices for higher-weight people. weightandhealthcare.substack.com
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