Warning: This article contains descriptions of an eating disorder, which some readers might find upsetting

Three years ago I was prescribed weight loss medication by my GP because of sudden and dramatic weight gain that was badly affecting my self-esteem. The medication made me shit myself repeatedly over three months. Notably, I lost no weight on the medication and instead made myself even more miserable by focusing on my inability to do so.

I consider myself to be fat positive. I have suffered with various eating disorders. So it’s fair to say that none of this is straightforward for me.

I am telling this story now because what shocks me is that I was prescribed this medicine with no subsequent, proper support or supervision. All that happened was that the nurse said: “Are you ready to start this journey and love your body again?” Those words stuck with me. Weight loss is often referred to as a “journey”, as though there is a “correct” destination, but reality is more complex than that.

At no point during what the nurse described as my “journey” was I monitored. This troubles me because according to the National Institute for Health and Care Excellence (NICE), which oversees NHS prescribing guidelines, the medication has common potential side effects including anxiety, urinary tract infections (UTIs) and hypoglycaemia (low blood sugar).

At the time of writing, I reached out to NICE to ask whether additional support and monitoring ought to be prescribed alongside this medication.

A NICE spokesperson said: “NICE recommends doctors only prescribe [the medication] as part of an overall plan for managing obesity in adults. Only those who meet certain criteria, mainly they have a BMI of 28 kg/m2 or more with associated risk factors, or a BMI of 30 kg/m2 or more. The effect of drug treatment must also be monitored, and lifestyle advice reinforced through regular reviews. Doctors should consider withdrawing drug treatment if people have not reached weight loss targets, set at an initial 5% of their initial body weight. Different criteria apply to those with type 2 diabetes. The potential benefits and limitations of the use of drug treatment for longer than 12 months should be discussed with the patient. NICE does not recommend the co-prescribing of [the medication] with other drugs aimed at weight reduction.”

NICE did not, however, comment on mental health support.

We find ourselves living through strange times. After decades of diet culture shaping our ideas of what “healthy” and “desirable” bodies are supposed to look like (tall, thin and lithe), we supposedly have an antidote: body positivity. Sometimes, however, diet culture collides with the values of self-love and women find themselves – as I did – in no man’s land.

If you google “body positive weight loss” there are over 68 million hits. You’ll be disheartened but unsurprised to learn that the top result is a branded blogpost by a company peddling weight loss medication which gives “advice” on how to lose weight and “remain body positive“. This medication, I should note, uses the same active ingredient as the weight loss medicine I was prescribed by the NHS to, as they put it, “treat obesity“. 

The evidence surrounding measures of obesity is contradictory and doesn’t necessarily tell the full story of a person’s health. I want to understand both why I was prescribed medication to lose weight and why I was prescribed it without proper physiological or psychological support.

Now, let’s start by acknowledging that a person’s reasons for wanting to lose weight are never straightforward. And while we’re at it, let’s look at the fact that measures of weight are contested. BMI (body mass index), for example, which is often used as a measure of obesity, is not always accurate because of the calculations it makes based on a person’s height and weight. This isn’t just theoretical. We know that BMI overestimates fatness and health risks for Black people and underestimates health risks in Asian communities. This is not noted on the NHS website, which says only that “Black, Asian and other minority ethnic groups have a higher risk of developing some long-term (chronic) conditions, such as type 2 diabetes” – implying that you should actually be more mindful of your BMI if you are not white. Then there is the fact that so much of the research around BMI focuses on people assigned male at birth, not taking into account the ways that fat percentage differs for people assigned female at birth.

Dr Natasha Larmie is a weight inclusive GP known on Instagram as the Fat Doctor. Her platform focuses on tackling the damaging effects of the diet industry and medical weight bias on the fat community. “I have never had a patient who benefited from taking [the medication you were given] and I hated taking it myself,” she tells me over email.

Dr Larmie continues to explain that there is no significant proof that any weight loss – through prescription medicine or otherwise – can improve a person’s health. “Lifestyle changes may lead to an improvement in health, but that is independent of weight loss,” Dr Larmie confirms. “There is evidence that lifestyle changes can improve health in the long term independent of weight loss (see the Health At Every Size (HAES) principle and intuitive eating).”

Looking back, the shame I feel about resorting to the weight loss medication that the NHS prescribed me wasn’t tied up solely with my stools; it was also to do with the sense of hypocrisy that I experienced while taking it. I was emptying myself faster than ever before but I felt full of dread and self-hatred.

It is already complex to be a fat person and want to lose weight for personal reasons. It is even harder to feel that you’re failing the fat community because you want to lose weight.

Speaking to me over email, a spokesperson from the eating disorder charity Beat tells me that regardless of the person’s size, “weight loss can be very harmful to people with or vulnerable to eating disorders, and is not something we would advise without consulting a doctor or care team.”

This advice feels especially poignant for fat people, who are told repeatedly by our government, the media, our families and friends that weight loss should be one of our main goals in life. From charity-run fat shaming campaigns plastered on billboards across the country to financial rewards from the Tories for shifting weight, it is impossible to escape the unrelenting suggestions that our fat bodies are not good enough.

With the proper support, however, a person’s experience can be more positive than mine was. Twenty-eight-year-old Hank* lives in London. Unlike me, he underwent medically supervised weight loss through a specialised NHS programme two years ago and tells me how he felt healthier not just physically but mentally, too. 

“My main trigger was being diagnosed with sleep apnoea (a condition that physically obstructs a person’s ability to breathe while sleeping and is common in plus-size patients) but there were other factors too,” he tells me. “I struggled with binge eating and had absolutely no confidence.” 

“I did months of intensive therapy, then was accepted onto this programme,” Hank continues. “The best bit about it was feeling validated, I was never made to feel like a failure or ashamed. The attitude was that ‘you are still capable of working and living and maintaining relationships but for whatever reason you want to lose weight and we’ll help’. And it worked for me.”

For Hank, a nonjudgemental and properly supported approach to weight loss was crucial to his ability to lose the weight he wanted. Sadly, his story feels like an anomaly. When considering weight loss and diet culture more broadly, the tone is always pointedly fatphobic because the point is, in essence, to not be fat. 

Herein lies the rub. It has perhaps been put best by fat liberation writer Aubrey Gordon.

She explained to Nylon that fat people must “understand and consent to the idea that our bodies are universally undesirable” but that there is no way to talk about weight loss “without talking about the inherent superiority of thin bodies over fat bodies.” This argument against the hierarchy of bodies is one that I wholeheartedly believe in but often struggle to apply to myself.

I don’t want to harm my community with any actions that involve me pursuing weight loss but, at the same time, I don’t want to live in turmoil, struggling with that desire to lose weight.

I put this to Dr Larmie. “We live in an inherently fatphobic society,” she said. “In an ideal world, no one would feel the pressure to lose weight, but we don’t live in an ideal world.”

“There are a number of reasons why people desire weight loss,” she continued. “Denial of surgery or treatment, fear of othering, bullying and peer pressure being among them. I don’t believe in judging a person’s individual motives for weight loss. Instead I believe in trying to tackle the inherent prejudice and oppression against fat people within society, particularly within the medical field, that leads people to attempt weight loss in the first place.”

In an essay published on Medium three years ago, titled “What Fullness Is“, fat feminist writer and social commentator Roxane Gay revealed she had had a gastric sleeve in January 2018. I vividly remember reading this when the news broke across plus-size Twitter and feeling extraordinarily let down. I reread that essay while researching this article. I found myself feeling more empathy than anger towards Gay.

Whether this is an understanding brought about through my own experience, which has involved going down rabbit holes of gastric sleeve TikTok late at night to mentally torture myself, is hard to say. Either way, my heart hurts knowing what Gay has been through while my head fully understands her rationale.

“[Trolls] remind me, every chance they get, that I am fat: more than, but less than. Every single day, I am confronted by how people really see me,” Gay wrote. “I am confronted by the fact that no matter what I achieve, I will always be fat first. I will always have this weakness; it will always be easily exploited.” 

“After more than 15 years of refusing it, I made the decision to get weight-loss surgery on an ordinary day. At home in Lafayette, Indiana, a young man yelled at me to move my fat black ass while I was crossing a grocery store parking lot to my car. It was the last straw,” she continued. 

Gay did not take that decision in order to assimilate to thin ideals and it doesn’t represent a giving up on long-held ideas about beauty standards. It was about survival. It was about needing, as many of us do, to change in order to survive. 

The decision to lose weight as a fat person doesn’t exist in the realm of shouty online discourse about the need for all fat people to love themselves and “fuck everyone else”. It exists because living as a fat person is exhausting and harrowing. It exists because nonstop abuse is a reality, hurled not just from within our own heads but from the majority of the outside world. Indeed, Gay commented that her decision to undergo surgery was not made in contradiction to the many years she has spent advocating for fat liberation but was influenced by her own struggles with disordered eating.

I realise that this makes my preoccupation with my weight more complicated than your average soul’s but the reality of living with this specific kind of mental illness while existing in a fat body is, again, not just the struggle of disliking your body but of knowing that millions of others hate it too. On top of that, speaking out about disordered eating is met with disbelief and disdain. So I know that there is no easy way to have a conversation about weight full stop.

That said, what I want to draw attention to is the fact that fat people who “talk the talk” but don’t “walk the walk” are viewed badly by our society. Roxane Gay is not the only one who has had to defend her decisions to lose weight or exercise. The singer Lizzo has felt compelled to do the same. We must be more empathetic and remember how much fat shaming fat women are subjected to.

Shame and stigma result in silence. Silence can be harmful. It leads to young women like myself resorting to weight loss medication – which can further damage our sense of self – and feeling too embarrassed to seek help.

At the same time, I wish that those who seek to lose weight in order to gain the privileges of being thin (or in other cases, the privileges of simply being less fat) would keep their decision discreet. We don’t need any more faux inspirational, fatphobia-fuelling speeches like those of Rebel Wilson, who also felt compelled to defend her weight loss. The decision to lose weight is a highly personal decision for any fat person. Keeping it personal means that others won’t feel the need to change their body to fit in.

Finding ways to live in the world in a body that society actively hates is harrowing. Pretending it’s as simple as “loving your body” ignores this fact. Individuals shouldn’t be shamed for their choices but that should go hand in hand with fighting for collective liberation.

*Name changed to protect anonymity.

If you are struggling with an eating disorder, please call Beat on 0808 801 0677. Support and information is available 365 days a year.

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