The Lancet Public Health paper covered nearly 50 million adults and named, with unusual specificity, exactly which conditions act as gateways into long-term ill health, how fast people progress through them, which communities are most exposed, and where the trajectories diverge. The Health Foundation data showed us the consequences of decades of getting this wrong: healthy life expectancy falling, a 20-year gap between the richest and poorest areas, the UK near the bottom of comparable wealthy nations.

Read together, these two datasets do something remarkable. They don’t just describe a problem; they point directly at the specific conditions, specific environments, and specific population groups where intervention would have the greatest effect. They are, in the language of behavioural science, a precise problem definition. The kind we rarely get. The kind that should be the starting point for a completely different kind of prevention strategy.

And yet, almost immediately, the commentary and coverage around both studies collapsed the findings back into familiar territory, lifestyle behaviours, individual choices, and above all that single loaded word: obesity. The precision gets lost. The specificity gets compressed. And we find ourselves back in the same conversation we have been having for decades, with the same implied solution: people need to do better.

I’ve worked in behavioural science long enough to know that this moment, when precise evidence gets flattened into a broad category, is exactly where prevention goes wrong. That instinct was sharpened for me while working for the Behavioural Science Unit in Wales, people who spend their professional lives unpicking exactly why well-intentioned interventions miss their mark. The answer, more often than not, is that the problem was never clearly defined in the first place. Or worse, it was defined clearly, and then someone generalised it back into something more manageable, more familiar, and far less useful.

This piece is about that moment. About what we risk losing when we compress. About what behavioural science tells us we should be doing instead. And about the uncomfortable truth of whose behaviour actually needs to change, and why that question keeps not getting answered.

Behavioural science starts with one question

The Lancet data gave us eight named conditions. Specific progression rates. Specific demographic patterns. A map. Behavioural science starts by asking: what do we do with a map this precise?

Before any intervention, before any campaign, before any policy, behavioural science asks something deceptively simple: whose behaviour, what behaviour, in what context, and with what barriers?

That’s it. That’s the starting point. It sounds almost embarrassingly straightforward. And yet it is extraordinary how rarely it gets applied, because our instinct in healthcare is to reach for the one-size-fits-all solution, the broad category, the familiar label. Precision feels complicated. Generalisation feels manageable.

But when you look honestly at the architecture of current prevention policy through this lens, it starts to look very shaky indeed. We are designing interventions based on definitions so broad they tell us almost nothing about what to actually change.

Take obesity. Start with the first question. Whose behaviour?

Whose behaviour are we trying to change? There are three answers, and we keep avoiding all of them

When obesity prevention is discussed, in policy documents, in public health campaigns, in clinical guidelines, the assumed answer to ‘whose behaviour?’ is almost always the same: the individual’s. Eat less. Move more. Make better choices.

This assumption is so deeply embedded that it rarely gets stated out loud. It’s just the water we swim in. And it shapes everything downstream, which interventions get funded, which outcomes get measured, which people get blamed when nothing changes.

But apply the behavioural science lens properly and three different answers emerge. Each one implies a completely different problem. Each one demands a completely different response. And each one points the finger at a completely different set of people.

The first answer is the individual. If obesity is primarily a matter of personal behaviour, eating, movement, lifestyle choices, then the intervention target is the person. This is where most public messaging lives. It’s also where the evidence is weakest. We have decades of individual-focused interventions and a population that is, by every measure, less healthy than it was. If individual behaviour change were sufficient, we would know by now. The early evidence on GLP-1 medications is instructive here. When you intervene at the biological level, regulating appetite and metabolism directly, people’s relationship with food changes in ways that decades of behavioural messaging never achieved. That’s not an argument for medication over prevention. It’s an argument that we fundamentally misunderstood what we were asking individuals to override.

The second answer is the system. If obesity is a population-level signal of exposure to harmful environments, cheap ultra-processed food, sedentary by design, diet culture that profits from failure, then the behaviour we need to change belongs to the food industry, to government, to planners, to commissioners. These are behaviours in the strict sense: specific, observable, and changeable. The food industry’s marketing behaviour. The government’s regulatory behaviour. The planning system’s decisions about what gets built where. We almost never name these as the target. We should.

The third answer is the clinical system. If obesity is, as the emerging biological evidence suggests, a chronic defended state, a physiological condition in which the body actively resists weight loss, then the behaviour we need to change is the health system’s. How it assesses. How it treats. How it talks to patients about their weight. My doctoral research at UWE sits precisely here, examining how patients and healthcare professionals understand weight-inclusive approaches, and what becomes possible when the clinical framing shifts.

Here is the problem. We are running all three of these simultaneously, without ever choosing between them, without naming which one we are prioritising, and without being honest about why we keep defaulting to the first one when the evidence most strongly supports the second.

The word that’s blocking us

This is where obesity becomes the barrier rather than the description.

The word is currently doing three incompatible jobs. It functions as a biological term, a clinical descriptor of a dysregulated weight state. It functions as an epidemiological risk marker, shorthand for a cluster of conditions associated with body size. And it functions as a moral category, a visible, socially legible sign that an individual has made bad choices.

These three definitions do not just sit uncomfortably alongside each other. They actively undermine each other. The biological definition points toward clinical intervention and systemic support. The epidemiological definition points toward structural and environmental change. The moral definition points toward individual blame.

And in public discourse, the moral definition wins almost every time. Not because it’s the most scientifically defensible, it isn’t, but because it’s the most convenient. It’s cheaper than structural reform. It’s politically safer than regulating industry. And it lets the systems most implicated in producing poor health continue largely undisturbed.

And here is what I think needs to be said directly: this is not a semantic problem. It is a structural one. When a single word is simultaneously a biological diagnosis, an epidemiological risk marker, and a moral judgement, it doesn’t just create confusion, it creates cover. Cover for the food industry to point at bodies rather than products. Cover for government to point at individuals rather than food environments. Cover for health systems to offer lifestyle advice rather than structural support. The word obesity has become remarkably convenient for everyone except the people it purports to describe. Until we either define it with genuine precision, being explicit about which definition we are using and why, or retire it from prevention discourse altogether, we will keep building interventions on foundations that were never stable to begin with.

What the data is telling us, if we’re willing to listen

The Lancet study makes this tension impossible to ignore. Nearly 50 million adults. Eight conditions accounting for most first diagnoses. Progression rates that accelerate sharply with deprivation. And, most strikingly, and most underreported, multimorbidity rates in Black communities that are consistently high regardless of socioeconomic status. That last finding alone should prompt a serious rethink of the ‘fix deprivation, fix health’ narrative. It suggests that deprivation is not the only structural driver in play, and that a prevention strategy built around a single axis of disadvantage will miss whole communities entirely.

The Health Foundation data compounds this. A 20-year gap in healthy life expectancy between the most and least advantaged areas. The UK near the bottom of comparable wealthy nations. Healthy life expectancy falling even as overall life expectancy holds steady, meaning we are accumulating years of illness, not years of living.

None of this is explained by individual behaviour.

All of it is explained by structural conditions. The research was careful, structural, precise. It was the discourse around it, the headlines, the commentary, the policy reflex, that reached for obesity, and in doing so pulled the analysis back toward the individual, back toward the body, back toward the implicit question of what that person did wrong.

This is the waste. We had the map. We had the specificity. And we compressed it back into a category that tells us almost nothing useful about what to do next.

What honest prevention would actually look like

If we applied basic behavioural science principles to this problem, genuinely, rigorously, without flinching, what would change?

First, we would define the behaviour. Not ‘reduce obesity’ that’s not a behaviour, it’s an aspiration. We would name the specific conditions we are trying to prevent, the specific environments producing them, and the specific system behaviours that need to change. The Lancet data gives us a starting point: eight gateway conditions, all linked to the food environment and smoking, all amenable to structural intervention.

Second, we would identify the real barriers. Not willpower. Not motivation. Not health literacy.

The real barriers are a food system engineered for overconsumption, a built environment designed for sedentary living, a commercial ecosystem that profits from both the problem and the proposed solution, and a political economy that makes structural reform expensive and individual blame cheap.

Third, and this is the part that requires the most honesty, we would name whose behaviour actually needs to change most.

The food industry’s marketing behaviour. The government’s regulatory behaviour. The NHS’s clinical behaviour around weight. These are the high-leverage targets. These are where the evidence points. And these are precisely the targets that current prevention policy consistently fails to reach.

The people with power have reasons not to look harder

Here is the uncomfortable answer to why the precision keeps getting lost.

The knowledge exists. Behavioural scientists, researchers, public health professionals, health psychologists, clinicians, the list goes on. There is no shortage of people who understand this problem clearly and can articulate what needs to change. The issue is not ignorance. It is not even inertia, exactly.

Consider the clinician sitting across from a patient. They may well understand that the food environment, not the individual, is the primary driver of what they are seeing. But they are constrained by what commissioners fund, what guidelines permit, and what the system around them is designed to deliver. And commissioners? They are constrained by what government prioritises, what budgets allow, and what the political climate makes possible. And government? It is constrained, or perhaps more accurately, influenced, by the industries whose commercial interests depend on the problem staying exactly where it is: located in the individual body, managed one person at a time, never quite solved.

The people with the power to truly shift the system, not the clinicians doing their best within it, not the commissioners working within what they are given, but the governments and industries sitting upstream of all of it, have structural reasons to keep the focus on individual behaviour. Individual blame is commercially convenient. It protects markets. It avoids regulation. It keeps the weight loss industry, the ultra-processed food industry, and the diet culture complex operating without serious scrutiny.

And so the precision gets lost. Every time. Not by accident. Because imprecision serves a purpose.

I think many behavioural scientists, public health professionals, clinicians, and researchers have been asking these questions quietly for a long time. Quietly is no longer sufficient.

Behavioural science has the tools to define this problem properly, to identify the real behavioural targets, map the actual barriers, and design interventions at the level where change is most possible. But those tools require honesty about where the leverage really sits. Not in telling individuals to try harder. Not in campaigns that gesture at complexity while targeting the person.

In the behaviour of food systems, commercial interests, regulatory frameworks, and the institutions that shape the environments in which millions of people have no choice but to live.

We have the map. We have the data. We have the analytical framework to use both properly. The question is whether we are finally willing to follow them to the right destination, or whether we will compress this moment, as we have compressed every moment before it, into something more convenient, more familiar, and far less useful.

And frankly, it is long past time that the people with the power to act stopped hiding behind a word, and started answering the question.

As always, I welcome your thoughts. I don’t have all the answers, and there is much I’m still working through, but writing about it is how I learn, and I hope it provides some clarity for others asking the same questions. If this resonates, or if it doesn’t, I’m open to polite challenge and genuinely welcome it. Particularly if I come away knowing something I didn’t before.

*A note on language: I use the word obesity throughout this piece deliberately and with some discomfort. I have written separately about why the word itself feels uncomfortable for me at the clinical and personal level, and if you want to understand that discomfort before reading on, that piece is worth reading first. I use it here because it is the word being used in the policy and research, and examining what it does requires naming it directly.

Grief for how much life women lose trying to become acceptable.

I grew up in an era where thinness was presented as the answer to almost everything. To be slimmer was to be more worthy, more attractive, more successful, more disciplined, more lovable. Many women of my generation learned early that our bodies were not something to inhabit peacefully, but something to monitor, manage and shrink.

And even when we intellectually reject those messages, they don’t simply disappear. They live quietly in the nervous system. In mirrors. In comparison. In the unconscious belief that our bodies are still being assessed.

I look at teenage girls now and I recognise the same fear many of us grew up with, the fear of taking up too much space, of not being attractive enough, desirable enough, disciplined enough.

Except now those pressures arrive earlier, louder and through devices they carry in their hands all day.

Girls are growing up believing their bodies are projects before they’ve even had the chance to simply live in them.

For a while, I genuinely believed things were changing. There was more conversation about body image, more awareness of eating disorders, more discussion about mental health and self-worth beyond appearance. I felt hopeful that perhaps the next generation of girls might grow up with a little more freedom than many of us did.

But lately, if I’m honest, that hope has felt shaken.

I recently wrote about the cultural conversation around GLP-1 medications and the rapid return of shrinking culture. What troubles me is not the existence of these medications themselves, but the wider message surrounding them. Once again, we are watching society celebrate smaller bodies as moral achievements. Once again, Hollywood is shrinking. Once again, women’s bodies are becoming public projects for discussion, aspiration and applause.

And millions of young people are watching.

That is heartbreaking to me.

Because I know what it feels like to spend years believing your body is the thing standing between you and acceptance. I know the quiet exhaustion of self-surveillance. The bargaining. The striving. The feeling that if you could just get your body ‘right’, perhaps you could finally rest.

But the rest never really comes, because the target keeps moving.

Be thin, but not too thin.

Young, but not trying too hard.

Natural, but wrinkle-free.

Confident, but never too much.

It is exhausting to live inside standards designed to keep women preoccupied with themselves.

And what saddens me most is not only the pressure itself, but how much life disappears beneath it. How much joy. How much presence. How many moments women lose because they are busy evaluating themselves instead of inhabiting themselves.

I see it everywhere now. In healthcare. In schools. In conversations between women. In teenage girls who already speak about food, bodies and worth in ways that sound painfully familiar.

I don’t want another generation of girls to inherit this.

I don’t want them inheriting the belief that their value lives in their appearance.

I don’t want them inheriting constant self-monitoring as normality.

I don’t want them inheriting shame disguised as ‘health.’

I don’t want them inheriting lives made smaller in pursuit of smaller bodies.

And yet, despite all the evidence of harm, the voices reinforcing these standards often remain the loudest, most profitable and most rewarded.

Some days that leaves me feeling deeply tired.

But perhaps today is not for fighting every battle.

Perhaps today is simply for remembering that our worth was never supposed to be earned through visual acceptability.

So before we head into the weekend, this is your reminder:

Your body is not a lifelong audition for acceptance.

I hope this weekend brings moments where you forget to monitor yourself.

Moments where you laugh without thinking about how you look.

Moments where you eat, rest, swim, walk, notice flowers, feel sunlight on your skin and remember there is a human being underneath all the conditioning.

That human being was always enough.

When I hear the word obesity used as a health term, I feel immediately that the person writing has undermined their own argument.

Not because the issue isn’t real. Not because the suffering isn’t real. But because obesity, stripped of its clinical veneer, means one thing: fat. And fat tells me nothing about a person’s health. It tells me about their size.

Think about what we don’t say. We don’t say ‘a person living with high blood glucose’. We don’t say ‘a person living with hypertension, or insulin resistance, or elevated inflammatory markers’. We don’t say ‘a person living with disrupted cortisol, or sleep apnoea, or non-alcoholic fatty liver disease’. These are the actual health markers. The measurable, specific, treatable things. The things that tell us something clinically meaningful about what is happening inside a person’s body.

Instead, we say ‘obesity’. And in doing so, we say nothing about their health and everything about their size.

Every single one of those markers can exist in a thin body. Every single one of them can be absent in a fat body. And yet we have built an entire public health infrastructure on the premise that size and health are the same thing, and they are not.

The Blindspot

I want to say something here, and I’m going to resist my instinct to soften it.

There is something genuinely encouraging happening in healthcare right now. A growing number of professionals are questioning the language we use around weight. They are choosing kinder words and softer, more compassionate framings. That shift matters. It signals awareness that something isn’t working, and awareness is always where change begins.

But I am shocked, and I use that word deliberately, by the blindspot that remains.

Because here is what I am seeing. People are being invited into services based on their weight, surrounded by a weight loss narrative dressed in kinder language, and then told ‘this isn’t a diet’. The individual is still the problem to be fixed. The intervention is still the same. The mechanism of harm is still intact.

You cannot ask someone to stop focusing on their weight while the entire reason they are sitting in that room is their weight.

The currency of thinness

And let’s be honest about what weight loss means in this society. It isn’t just a health outcome. It is currency. It buys value, worth, success, and belonging. To be thinner is to be more. We know this. We feel it. And so when we tell someone sitting in a weight management programme ‘don’t focus on your weight’, what we are actually asking them to do is opt out of one of the most powerful social reward systems there is. Alone. Without support. While we change nothing around them.

We are asking individuals to do the hardest possible psychological work while the environment that shaped their relationship with food, their body, their sense of self, remains entirely untouched.

And here is what troubles me most. There are brilliant, experienced people in this field, clinicians, researchers, public health professionals, who are naming the real problem. The food environment. The systems. The structures. They are not wrong, and they are not being ignored because their argument lacks merit.

So why is nothing changing?

The treatment that causes the harm

Let me tell you what the evidence actually says.

Chronic dieting, the repeated cycle of restriction, regain, restriction, is not a personal failing. It is not a lack of willpower or commitment. It is a documented, serious public health concern. And yet it remains almost entirely unaddressed in the research literature, sitting in an uncomfortable gap between what we know and what we continue to prescribe.

What we know is this. High protein diets, ketogenic diets, calorie-controlled programmes, extensively researched, extensively delivered. And in the long term? Between 80 and 95% of people who lose weight through dieting regain it. All of it. Often more.

But the numbers don’t capture the full cost.

Because alongside the weight regain comes something we talk about far less. Disordered eating. Yo-yo cycling. A relationship with food and with one’s own body that is measurably worse than before the intervention began. Depression. Anxiety. In some cases, clinical eating disorders. Physical consequences too, increased cardiometabolic disease, suppressed immunity, severe hormonal disturbance (Kurucz et al, 2024).

We are not talking about the side effects of a failed treatment. We are talking about the direct consequences of the treatment itself.

And then we refer someone to a weight management programme and tell them it isn’t a diet.

I need us to sit with that for a moment.

The referral pathway exists because of their weight. The programme exists to change their weight. The language has softened, the calorie counting may have been quietly dropped, the practitioner is genuinely trying to be kind. And it is still, mechanically, an intervention designed to make a fat person less fat. Delivered in a system that has done nothing to change the environment that shaped their body in the first place. And asks them, once again, to fix themselves.

That is not compassion. That is harm with better branding.

The hidden curriculum

And then there is the question of who is delivering these interventions and what they have been taught to believe.

The research on weight stigma within healthcare is not comfortable reading. Studies consistently find implicit anti-fat bias in primary care physicians. In one North American study, 87% of doctors were found to harbour implicit bias against higher-weight colleagues, and yet when asked directly, most reported low levels of bias. They were not aware of what they carried.

This is not an anomaly. It is a pattern that begins in training. Medical education has long promoted a view of fatter as lesser, reducing the complexity of body weight to a simplistic, individual-blaming narrative. Medical students observe the denigration of higher-weight patients by faculty and staff. It becomes part of the hidden curriculum. Something absorbed rather than taught, which makes it harder to see and harder to shift.

In one UK study, only 2.1% of medical students expressed neutral or better attitudes toward fat people (Shaw & Meadows, 2022).

Let that land for a moment.

These are the people who will go on to deliver care. To make referrals. To sit across from a patient and decide, consciously or not, what kind of person they are and what kind of help they deserve.

And the consequences of that bias are measurable. Experiences of weight stigma are associated with real psychological and physical harm, independently of body size. Not because of the weight. Because of how the person is treated as a result of it.

Even something as seemingly minor as labelling a young person as overweight has been linked to disordered eating, unhealthy weight control behaviours, and long-term weight gain. The label itself causes harm. And we are handing it out at scale, including, heartbreakingly, to children, referred through national programmes because someone measured them and decided their body was a problem to be solved.

Weight stigma in this context is not an unfortunate side effect of the intervention. It is woven into the fabric of it. It shapes the referral, the clinical encounter, the language of the programme, and the way the person sitting in that room understands their own body and their own worth.

We cannot make that compassionate by choosing kinder words.

First, Do No Harm

I have been in rooms this week where people are working hard, genuinely hard, to do better by their patients. I have watched them wrestle with a system that doesn’t give them much room to move. I have respect for that struggle. I do.

And I am still going to say this.

If the size of a person’s body is the reason they are in your room, if their weight is what triggered the referral, what shapes the intervention, what defines the outcome you are working towards, then I would ask you, gently but directly, to pause. To ask yourself what you are actually treating. To consider whether the harm you are trying to prevent might, in some measure, be the harm you are delivering.

First, do no harm. It is the oldest instruction we have. And in this context, I think we have lost sight of it.

Why I’m saying this

Many people carry memories that seem small on the surface. Comments about their body. Being shamed for taking up space. Being made to feel that their worth, health, or acceptability was tied to weight.

For some, those moments do not disappear. They shape relationships with food, with movement, with healthcare, and with themselves.

There are people living with severe distress around eating and body image who are overlooked because they do not fit the ‘right’ weight criteria. People denied support because their suffering is not visible enough through the lens of BMI or body size.

A system built around weight can fail to recognise pain unless it appears in an approved body. It can look directly at someone struggling and decide they do not qualify for help.

And the impact goes far beyond healthcare. A persistent focus on weight can erode self-worth, create shame, disconnect people from their bodies, and make everyday existence feel like something to apologise for.

We can, and we must, do better.

Eating disorder campaigners took to the streets yesterday (18th April 2026) to demand better. But the problem of BMI-based gatekeeping stretches far beyond mental health services, and it is costing people their lives, their mobility, and their dignity.

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A note on language:

Throughout this article I use the word ‘obesity’ because it is the term embedded in clinical guidelines, policy documents, and the research I am drawing on. I use it reluctantly. The word tells us almost nothing about an individual’s actual health, whether they have high blood pressure, elevated HbA1c, arthritis, or any specific condition that might genuinely affect their care. Increasingly, clinicians and researchers agree. The Lancet Diabetes & Endocrinology Commission (2025) concluded that BMI-based measures of ‘obesity’ provide inadequate information about health at the individual level, and a 2023 theme issue of the AMA Journal of Ethics devoted itself to medicine’s over-reliance on BMI and the harms this causes. I have written more about my discomfort with this word, and the clinical and ethical reasons for it, here. Throughout this piece, quotes around ‘obesity’ and ‘overweight’ are a deliberate reminder that we are dealing with a label, not a diagnosis.

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On 18th April 2026, something important happened.

People marched to demand that eating disorder services stop using body weight to decide who is worthy of treatment.

At the heart of the Dump the Scales campaign is a hard, uncomfortable truth: people who are not thin enough are being turned away and left to become more unwell. Some are dying. There is no softening that.

I want to honour that. Not dilute it, not redirect it.

But I do want to widen the lens. Because what those marchers are confronting is not an isolated failure. It is part of a much broader pattern running through our healthcare system, one most people don’t see until it affects them personally.

BMI is being used to ration healthcare. NICE says it shouldn’t be, and patients have rights they are not being told about.

Body Mass Index, the formula that divides weight by height squared, was never designed to measure individual health. It was developed in the 1800s as a population-level statistical tool. And yet today, across NHS England, it is routinely used as a gatekeeping device: a number that determines whether you are allowed access to treatment.

Research suggests that 34% of NHS Clinical Commissioning Groups have implemented policies restricting access to elective surgery based on BMI or smoking status. The list of affected procedures is longer than most people realise: hip and knee replacements, IVF, hernia repair, varicose vein surgery, tonsillectomies, spinal surgery, and, in some cases, surgeries where there is no BMI cut-off.

We are often told that conditions like osteoarthritis, hernia, gallstones, and spinal degeneration are linked to ‘obesity’. But losing weight does not remove the need for surgery.

For joint replacement, the position is even clearer. NICE guidance explicitly states that BMI should not be used to restrict access. And yet it still is.

At least 10% of Integrated Care Systems continue to apply strict BMI thresholds, delaying or denying surgery unless patients meet criteria or engage in weight management programmes.

The justification is familiar: weight loss improves outcomes.

In some very specific contexts, there is limited evidence for this. But across the wide range of procedures where BMI thresholds are applied, the evidence is far weaker than the policies suggest, and in some cases, the logic breaks down entirely.

Take gallstones. Rapid weight loss is a known risk factor. So we end up in a situation where patients are told to lose weight before surgery in a way that may directly worsen the condition they are waiting to have treated.

The assumption, delay care, weight will reduce, outcomes will improve, does not hold up consistently under scrutiny.

For joint replacements, data from the National Joint Registry shows that surgery is safe and cost-effective for patients with higher BMI. BMI threshold policies reduce access, increase the likelihood of people turning to private care, and show no meaningful population health benefit.

Alongside this sits something harder to quantify, but no less important: the moral language of deserving treatment.

Research with women denied NHS-funded IVF on the basis of BMI found that they were not only blocked by policy, but subjected to a narrative that their weight was within their control, and that they needed to change their bodies to earn access to care.

Deserved. As if healthcare were a reward.

This is not neutral clinical reasoning. It is moral judgement, dressed in clinical language. And it mirrors exactly what eating disorder campaigners are pushing back against: the idea that your body determines your worth, your effort, your right to be treated.

We also know that weight stigma itself is a stronger predictor of poor health outcomes than BMI.

Patients consistently report that their weight becomes the focus of every interaction. That decisions are made without them. That their autonomy is reduced, sometimes removed entirely.

And this does not stay in the consulting room. It shapes referrals, delays treatment, and determines whose suffering is allowed to continue.

This is also a question of wealth

When access to NHS care is restricted by BMI, there is always an alternative for some people. They can pay privately.

Research shows that privately funded patients wait half as long for surgery. Those in the most deprived 20% wait the longest and are least likely to access private care.

At the same time, people living in more deprived areas are significantly more likely to be in bodies classified as ‘obese’ and to develop long-term conditions earlier.

So the people most affected by BMI-based gatekeeping are also the least able to bypass it.

They wait. Their conditions worsen. They are told to return when they have lost weight, while being offered weight management services with waiting lists stretching years, and in some areas, no access at all.

And this is the part we rarely say out loud: the long-term outcomes of these services (weight management), in their current form, are poor.

So we come back to a fundamental question: what was the NHS built for?

It was built on the principle that care should be provided based on need, not the ability to pay.

BMI-based gatekeeping does not honour that principle.

So what can we do?

First, we make this visible. Most people do not know that NICE guidance prohibits BMI thresholds in joint replacement. They do not know there is no BMI cut-off for cataract surgery. They do not know what they are entitled to.

And systems rarely rush to correct that.

If you are a patient and you are told to lose weight before accessing treatment, ask for the policy in writing. Ask what specific risk your weight introduces for that procedure, and what the evidence is for that risk in your case. Ask whether the weight management support offered has evidence for sustained long-term outcomes, because often, it does not.

If you are a clinician or commissioner, this is more direct.

Stop using BMI as a proxy for worthiness. Stop presenting rationing decisions as clinical necessity when they are not. Shared decision-making, real shared decision-making, is not optional. It is a standard of care.

The marchers behind Dump the Scales are asking for something very simple.

Not special treatment. Not the removal of clinical risk.

Just to be treated as patients, not problems to be fixed before care can begin. You can sign and share their petition for action here.

That is not a radical demand.

It is what the NHS was built to do.

As always, I’d love to hear your thoughts!

References

[1] AMA Journal of Ethics (2023), vol. 25(7) Theme issue: medicine’s over-reliance on BMI.

[2] Pillutla V, Maslen H, Savulescu J. Rationing elective surgery for smokers and obese patients. BMC Medical Ethics (2018)

[3] GIRFT / Royal College of Ophthalmologists. High Flow All Complexity Cataract Surgery Pathway (2022). NHS England.

[4] Reviewing the evidence for restricting elective surgery for obese patients. Clinical Resource Efficiency Support Team, NHS South West Senate (2013)

[5] NICE guidance on joint replacement surgery - states that BMI should not be used to restrict access to hip and knee replacement.

[6] McLaughlin J et al. NIHR Doctoral Fellowship (2024), University of Bristol - National Joint Registry analysis. Published via NIHR ARC West, January 2025.

[7] Muir R & Hawking MKD. ‘How do BMI-restrictive policies impact women seeking NHS-funded IVF?’ Reproductive Health (2024)

[8] Ryan L et al. ‘Weight stigma experienced by patients with obesity in healthcare settings.’ Obesity Reviews (2023)

[9] Kirkwood G & Pollock AM. ‘Outsourcing NHS surgery to the private sector.’ Int J Social Determinants of Health and Health Services (2025)

[10] Health Foundation. Quantifying Health Inequalities in England (2022). health.org.uk

[11] London Assembly Health Committee Call for Evidence on Weight Loss Medication (September 2025) NHS waiting times for specialist weight management up to five years in some areas

“The cognitive experience of food looming large in the mind is not new. What is new is calling it noise, and framing its reduction as a therapeutic goal.”

I keep hearing the term food noise, you probably do, too.

And increasingly, I find myself uneasy with it.

Not because I don’t recognise the experience it is trying to describe, I do. For some people, thoughts about food can feel constant, intrusive, distracting, even exhausting. When eating feels emotionally loaded or tightly controlled, the mental pull toward food can become genuinely distressing.

That experience is real.

But I keep coming back to a more uncomfortable question:

When did thinking about food become something we need to eliminate?

Food is not a peripheral part of human life. It is biology, culture, memory, pleasure, survival, connection, routine, identity. Of course we think about it.

We think about what to eat for breakfast. We think about lunch in the middle of a workday. We think about the meal we’re looking forward to at the weekend. We think about food when we are stressed, tired, celebrating, grieving, or simply hungry.

This is not dysfunction. This is being human.

So I find myself questioning what happens when we take all of that normal mental activity and label it as noise.

Because noise implies something unnecessary. Something intrusive. Something to be silenced.

And once we accept that framing, the goal quietly shifts, from understanding our relationship with food, to trying to stop thinking about it altogether.

I’m not sure that’s psychologically helpful.

The rise of food noise, and where it came from

It is worth being precise about the origins of this term, because they matter for how we understand it.

Food noise did not emerge from clinical observation or a formal diagnostic framework. Researchers have noted that the original source is difficult to isolate and that the term appears to have originated from patient anecdotes that inspired wider conversation in the media and among clinicians. It is not clear who used it first, or in what context.

What we do know is that the phrase was first googled in November 2006, that search interest increased noticeably in the autumn of 2022, and that it peaked sharply in the spring of 2024, precisely alongside the mainstream rise of GLP-1 receptor agonist medications such as semaglutide and tirzepatide. Discussion of food noise has primarily emerged from the United States, and it gained significant cultural visibility when Oprah Winfrey used her 2024 television special to describe how weight-loss medication quiets the food noise.

Since then, coverage of the term has proliferated, and it has frequently been deployed by drug manufacturers as a way to entice potential customers.

This is the context in which food noise has been formalised. Not a construct that arose from decades of clinical study, but a piece of patient language that was picked up, popularised, and then, only relatively recently, handed to researchers to define and measure.

Still no agreed definition

What is particularly striking, for a term that now appears regularly in both media and clinical discussion, is that there is still no single agreed definition of what food noise actually is.

Three separate research groups have offered three distinct definitions:

The earliest published definition, proposed by Hayashi and colleagues in 2023, described food noise as ‘heightened and/or persistent manifestations of food cue reactivity, often leading to food-related intrusive thoughts and maladaptive eating behaviours.’ This framing positions food noise as essentially a response to external stimuli, something triggered by the food environment.

A second definition, published in 2025 by Diktas and Martin’s group at Pennington Biomedical Research Center, described food noise as ‘persistent, intrusive thoughts about food that are disruptive to daily life and make healthy behaviours difficult.’ Their definition notably removes the requirement for external food cues to be present at all.

A third definition, published also in 2025 by the team who developed the RAID-FN Inventory, reads: ‘persistent thoughts about food that are perceived by the individual as being unwanted and/or dysphoric and may cause harm to the individual, including social, mental, or physical problems.’ This version emphasises the subjective experience of distress more explicitly than the others.

Strikingly, the two 2025 definitions were developed separately and contemporaneously; neither group was initially aware of the other’s work.

These definitions overlap, but they are not identical. One centres on reactivity to cues. Another centres on disruption to healthy behaviour. A third centres on dysphoria and perceived harm. Which raises an important question: are we looking at a clear clinical construct, or a loosely defined label still being shaped, partly by commercial interest, partly by clinical observation, and partly by social media discourse?

When description becomes pathology

Before the term food noise existed, clinicians and researchers already had language for these experiences: rumination, intrusive thoughts, dietary restraint and rebound thinking, obsessive preoccupation with food in the context of eating disorders, and the cognitive load that tends to follow restriction and deprivation.

The RAID-FN Inventory’s developers themselves acknowledge this lineage, noting that food noise ‘resembles rumination’, defined by the American Psychological Association as ‘obsessional thinking involving excessive, repetitive thoughts or themes that interfere with other forms of mental activity. They also distinguish food noise from the pre-existing constructs of food addiction and food preoccupation, and note that the Food Preoccupation Questionnaire (developed in 2010) examines all possible valences of food-related thoughts, not only negative ones, and does not measure the persistent or inescapable quality that food noise is said to involve.

So the question I find myself returning to is not whether this is a distinct experience for some people, it may well be. The question is: what does the label food noise add that wasn’t already there? And, more importantly, what does it risk changing in how we understand normal human experience?

Because when we label food-related thoughts as noise, we are not just describing them. We are subtly redefining them as something undesirable. And once something is framed as undesirable, the next step is often suppression.

Try not to think about it. Try to quiet it. Try to get rid of it.

But psychology has been very clear on this for a long time: when we try to suppress thoughts, we often increase their intensity and salience. Not because something is wrong with us, but because attention and suppression do not work in quite that way.

What the measurement tools reveal, and what they don’t

Since 2024, two validated psychometric tools for measuring food noise have been developed, and looking at them closely is instructive.

The Food Noise Questionnaire (FNQ), developed by Diktas, Martin and colleagues, is a five-item scale. All five items load onto a single factor, suggesting the questionnaire captures a single unified concept. It demonstrated excellent internal consistency (Cronbach’s α = 0.93) and high test-retest reliability (r = 0.79). The items, drawn from the published literature, ask respondents to rate statements such as ‘I find myself constantly thinking about food throughout the day’, with the framing consistently positioning food thoughts as problematic occurrences to be identified and quantified.

The RAID-FN Inventory, developed by Dhurandhar, Allison and colleagues with funding from the direct-to-patient healthcare company Ro (which markets GLP-1 medications), takes a more multidimensional approach. Starting from 29 candidate items, the team refined the scale to a 23-item long form and a 7-item short form across four large studies. Factor analysis identified three distinct components: preoccupation (constant thoughts about food, even when not hungry), persistence (difficulty stopping those thoughts once they start), and dysphoria (the frustration, guilt, or distress that accompanies them).

The short form showed strong internal consistency (α = 0.90) and test-retest reliability (r = 0.89 over two weeks), and the scale is already deployed on Ro’s telehealth platform for patients seeking obesity treatment and in a clinical trial at Johns Hopkins measuring the effects of tirzepatide.

Looking at the draft item pool for the RAID-FN is illuminating. Sample items include: ‘I think about food all the time, even when I am not hungry or eating’; ‘When I am eating a meal, I am already thinking about what my next meal will be’; ‘When I start thinking about food, I find it difficult to stop thinking about it; ‘Even if I want to, I can’t stop thinking about food.’

Every item is worded to capture something distressing and unwanted. There is no item that asks whether food thoughts are sometimes pleasurable, anticipatory, or culturally meaningful. The construct, as operationalised, assumes that the experience is inherently negative.

This matters, because measurement tools do not just reflect a construct. They define it.

Two further observations from the validation research are worth pausing on. First, the FNQ found that women and people actively dieting reported significantly higher food noise scores, which raises a reasonable question about whether what is being measured is food noise as a stable trait, or the predictable cognitive consequence of dietary restriction. Second, the RAID-FN developers note a reliability finding that the food noise construct is likely stable as a trait, though the dysphoric aspect may be a more temporary state. In other words: the preoccupation is stable, but the distress fluctuates. This distinction, I would argue, matters enormously clinically, and it is not yet well understood.

The problem may not be the thoughts themselves

From a behavioural science and health psychology perspective, I wonder whether we are sometimes misidentifying where the problem lies.

It may not be the presence of food thoughts themselves. It may be the conditions that make food feel cognitively urgent in the first place:

• deprivation that makes food more salient

• restriction that increases attentional bias toward food cues

• emotional regulation being channelled through eating patterns

• anxiety and a need for control being projected onto food choices

• a chronic lack of trust in internal hunger and satiety cues

This is not a new observation. Ancel Keys’ Minnesota Starvation Experiment, conducted in 1944-45, documented precisely this: when 36 healthy young men were placed on a calorie-restricted diet and lost approximately 25% of their body weight, they exhibited pervasive obsessive preoccupation with food that dominated their cognitive and emotional lives. The thoughts did not arise from some pre-existing trait; they were the predictable response to sustained restriction.

It is worth noting that food preoccupation was identified as a key symptom of that cohort and has since been described as a feature of anorexia nervosa. The cognitive experience of food looming large in the mind is not new. What is new is calling it noise, and framing its reduction as a therapeutic goal.

If food thoughts are a downstream consequence of restriction, deprivation, or an anxious relationship with eating, then suppressing the thoughts is not the solution. Changing the conditions is.

What are we actually aiming for?

This is where the language of food noise becomes particularly important. Because it implicitly suggests a goal: a quiet mind around food. No preoccupation. No negotiation. No anticipation. No desire.

The clinical motivation for measuring food noise is explicitly tied to weight management. Researchers note that food noise ‘is being cited as one reason weight-loss attempts fail’ and that reducing it may help people succeed in long-term weight control. Validated scales are used as clinical endpoints in interventional studies, specifically in GLP-1 medication trials.

I am not questioning whether GLP-1 medications reduce intrusive food-related cognition. Anecdotally, many patients report this clearly. But I do think it is worth asking what we are communicating when we name that reduction as ‘quieting the noise’ because the metaphor positions the mental experience of food desire and food planning as something to be pharmacologically eliminated.

And I’m not convinced that this is what psychological health looks like.

A more useful goal might be a different relationship with food-related thoughts. One where thoughts can exist without urgency. Without shame. Without the need to act immediately or resist forcefully. Without being interpreted as evidence of failure or dysregulation.

This is closer to what we might call psychological flexibility, the ability to notice internal experiences without being dominated by them.

A thought about chocolate after a hard day does not need to be corrected. A desire for comfort food does not need to be eliminated. A moment of food anticipation does not need to become evidence of something being wrong.

They can simply be thoughts.

Why language matters

My concern about the term food noise ultimately comes down to language, and language’s power to shape experience, not just describe it.

When we repeatedly frame food-related cognition as noise, we risk teaching people that thinking about food is a problem, that hunger cues are interference, that desire is something to suppress, and that normality is something to override.

For people already struggling with eating, restriction, or body image, that framing can quietly add another layer of self-monitoring and self-judgement. The internal landscape becomes something to police rather than understand.

“How much am I thinking about food? Should I be thinking this much? Is this normal, or is this noise?”

There is something quietly troubling about a validated clinical questionnaire that asks people to rate how frequently they find themselves constantly thinking about food, in a culture that simultaneously markets highly palatable, heavily advertised food at every turn, promotes chronic calorie restriction as virtuous, and treats thinness as evidence of self-control. When the food environment itself is designed to create preoccupation, measuring the preoccupation as pathology may be pointing the clinical lens in the wrong direction.

A different way of seeing it

I want to be clear: I am not suggesting that persistent or distressing food-related thoughts are not real or not important. For some people, they are significant, and they deserve clinical attention.

But I wonder whether the most helpful clinical question is not how do we get rid of food noise, but rather: what is this relationship with food telling us about restriction, safety, emotion, and trust? And how can we help people relate to food thoughts with less fear and more flexibility?

Because sometimes the goal is not silence. Sometimes it is understanding. Sometimes it is permission. Sometimes it is rebuilding enough trust with the body that thoughts about food can come and go, like all thoughts do, without becoming a threat.

The eating disorder field has grappled with these questions for decades. Before the term food noise existed, the same experiences were described as the eating disorder voice, mental obsession, or rumination. Clinicians in that field have long understood that the aim is not to eliminate food thoughts, but to change the person’s relationship to them, to reduce the suffering they cause without making the thoughts themselves into an enemy.

That wisdom feels relevant here.

Closing reflection

Perhaps the issue is not that we think about food too much.

Perhaps it is that we have started to believe that thinking about food is something that should not be happening at all.

That standard, a quiet mind, free from food’s pull, liberated from desire, is now being measured, validated, and positioned as a clinical endpoint.

And I’m not sure that’s a standard we want to aim for.

Not clinically. Not psychologically. And not as a culture.

What do you think?

When I saw a GLP-1 supplement guide in British Vogue last week, I felt a specific kind of unease. Not surprise, fashion media has always had things to say about women’s bodies. But something about this particular combination stopped me. A medication with strict prescribing criteria, surrounded by affiliate links, luxury branding and Vogue-approved product recommendations. Clinicians lending their expertise to a shopping guide. The whole thing packaged in the aesthetic language of sophisticated self-care.

I’ve been trying to articulate why that specific combination troubles me. I think I’ve got there.

The placement is the message

The MHRA is unambiguous: GLP-1 medications are licensed to treat diabetes or manage weight where there is a clear medical need. They are explicitly discouraged, in the government’s own words, if you want to lose weight for aesthetic or cosmetic purposes.

Vogue is a publication that has spent decades producing aspiration around appearance. It does not simply reflect beauty ideals; it actively constructs them. It tells its readers, issue after issue, what desirable looks like. That is its purpose. That is why luxury brands pay to be in it.

So when that publication runs a guide to GLP-1 medications and supplements, with shopping links attached, it is doing something the clinical literature cannot. It is placing the pursuit of a smaller body inside one of our most powerful aspiration machines. It is making weight loss feel curated, sophisticated and socially endorsed.

That is a cultural act, not a health one. And the MHRA’s prescribing guidelines cannot reach it.

The article may be factually careful. That is almost beside the point. Context is not decoration; it is meaning. And in this context, the meaning is clear: shrinking your body is still a worthy project. We’ve just found more elegant language for it.

Let’s talk about who benefits

The article is, structurally, a commerce piece. It is built around affiliate links. Every expert quote leads, within a paragraph or two, to a purchasable product. The clinicians and nutritionists quoted are not simply sharing knowledge, they are lending professional credibility to a platform that sells things, in a format that rewards their visibility.

I want to be careful here, because I don’t think most of the individuals involved set out to cause harm. But I do think we need to be honest about the dynamic.

Appearing in Vogue as a health expert is not a neutral act. It builds a personal brand. It generates referrals. It positions you inside a particular market. And that market, wellness, aesthetics, weight management, has enormous commercial interests organised around the idea that women’s bodies require ongoing correction.

When professional expertise flows into that market without naming the conflict, something gets lost. The reader sees clinical authority. What they don’t see is the ecosystem of incentives that brought that authority into this particular space, in this particular format, at this particular cultural moment.

That is worth naming. Not to impugn individuals, but because the system only works if we don’t look at it directly.

The population-level risk we’re not talking about

Here is what concerns me most, as a health psychologist. Behaviour change research is consistent on one thing: what shapes our choices is not primarily information. It is what feels normal. What our social context tells us is expected, aspirational and rewarded.

Vogue is extraordinarily efficient at producing normative beliefs. When GLP-1 use is woven into the same editorial space as Paris Fashion Week and luxury skincare, it sends a signal that has nothing to do with clinical criteria. It tells readers: this is what health-conscious, appearance-aware women do now. This is ordinary. This is sophisticated. This is what people like you do.

We know, from decades of research, that exposure to aspirational weight loss content in high-status media is associated with body dissatisfaction, disordered eating attitudes and increased engagement with weight loss behaviours, particularly in populations already vulnerable. We are not starting from zero here. There is a substantial evidence base, and it is not reassuring.

According to the article, an estimated 1.6 million adults in the UK used GLP-1 medications between early 2024 and 2025. That number is growing rapidly, and awareness is growing even faster. The cultural conversation around these drugs is being shaped right now, in real time. The norms are being written. And some of them are being written in Vogue.

Diet culture has not disappeared. It has learned to speak in the language of metabolic health, body composition and doing it properly. The framing has changed. The ideology, that a smaller, tighter, more controlled body is the goal, has not.

What I think this moment asks of us

If you work in healthcare, nutrition, psychology or public health, I think the question this raises is not is this evidence-based? That question is necessary but not sufficient.

The harder questions are: what values does this content reinforce? What system does it serve? What happens to the people who consume it, not the patients in our clinics, but the much larger population who will read this article, absorb its framing, and quietly update their beliefs about what a healthy body looks like and what effort it requires?

We are watching a medication with genuine clinical and therapeutic value get absorbed into a media ecosystem whose organising logic is aspiration and acquisition. That process is not inevitable. It is being actively constructed, by choices that real people are making, including, sometimes, professionals who know better.

I am not interested in making anyone feel guilty. I am interested in whether we can see clearly enough to make different choices, about where we lend our expertise, whose platforms we legitimise, and what we are implicitly endorsing when we do.

Because culture-making has consequences. And right now, some of those consequences are being quietly written into the health of a population.

That seems worth paying attention to.

For a while, I wondered whether this discomfort was just a hangover from the way words like fat were used when I was growing up, as insult, warning, shorthand for failure. But I do not think that is it. My discomfort with obesity feels different. It is not that the word says too much. It is that it says so little, while doing far too much.

That is what finally made me want to sit down and examine it properly: its history, its clinical use, its assumptions, and the work it does in consulting rooms, headlines, policy documents, and in people’s minds. The more I looked, the less neutral it seemed.

I should probably say here that I write this with some hesitation. I am aware of my own position, and of the limits of what I can know from inside a body that is not read in the world in the same way as many of the bodies this word is used to describe. But discomfort can still be worth interrogating. And this one has been asking for my attention for a long time.

A disease by vote

In 2013, delegates of the American Medical Association (AMA) voted to classify obesity as a disease. What is less well known is that the AMA’s own scientific advisory body, the Council on Science and Public Health (CSAPH), had spent a year reviewing the evidence and recommended against it [1].

Their objections were substantive. There is, they noted, no single agreed-upon definition of what a disease actually is. More importantly, the primary tool used to identify obesity, the Body Mass Index (BMI), is a population-level statistical measure that was never designed to diagnose individual health. [2] It cannot distinguish between muscle and fat, nor tell you where fat is distributed, both of which matter enormously to health outcomes. [3] The council also raised a concern that medicalising obesity might actually undermine prevention, shifting the emphasis toward drugs and surgery and away from the social and structural conditions that shape people’s health in the first place.

Despite all of this, nearly 60% of delegates voted yes. The classification went ahead, backed substantially by organisations with a professional and financial interest in treating obesity as a medical condition, including the American Society of Bariatric Physicians and the American Association of Clinical Endocrinologists. [1] The science was not the deciding factor. A vote was.

And that matters, because disease labels do not simply describe reality, they shape it. Once a condition is recognised as disease, it begins to organise how people are seen, what treatments are funded, which industries expand, and what kinds of suffering become medically legible.

What the word leaves out

This matters because language shapes how we think. Once obesity became a disease category, it acquired all the apparatus of clinical diagnosis, codes, pathways, pharmaceutical pipelines, and the word hardened around a specific, narrow meaning. A person is either obese or they are not, based on a number derived from a 19th-century Belgian statistician’s observations about average body proportions, a tool, it is worth noting, that was never intended for individual clinical use. [4]

Here is what the word obesity does not tell you: what is actually happening in that person’s body, what their symptoms are, what brought them to where they are, what their mental health looks like, what their neighbourhood is like, whether they have access to affordable food, whether they sleep, whether they are safe at home. It tells you a number has crossed a threshold. That is all.

And even that threshold is conceptually slippery. In practice, the word obesity is used to mean several different things at once: a BMI category, excess fat mass, metabolic risk, disease burden, or simply a body deemed too large. Those are not interchangeable states, yet the label routinely collapses them into one. A threshold is not a mechanism, and a category is not a diagnosis.

It is a label that, as research in the field of weight stigma consistently finds, reduces a whole person to a single attributed characteristic, and one loaded with moral judgement at that. Studies show that even healthcare professionals hold strong implicit biases against people described as obese, rating them as less compliant, less motivated, and less worthy of time [5]. The word does not arrive in a room neutrally.

And this matters clinically. If a label invites bias, shame, diagnostic overshadowing, delayed care, or healthcare avoidance, then some of the harms associated with obesity may not arise solely from adiposity itself, but from the social and clinical consequences of being named and treated in this way. The question is not only whether obesity predicts harm, but what kinds of harm are produced by the label itself.

How the media makes it worse

Open almost any British newspaper on almost any day and you will find obesity framed in one of two ways: as a personal failing or as an epidemic requiring emergency intervention. Both framings locate the problem in individual bodies, and both carry an implicit verdict. Broadcast coverage is marginally more careful, but the visual language, headless bodies, close-ups of midriffs, images selected to communicate excess, does the stigmatising work even when the words do not [6].

When coverage does shift toward systems, ultra-processed food, food deserts, the economics of poor diet, the word obesity is used differently, as a consequence of structural conditions rather than evidence of personal failure. The same word, doing entirely different work depending on who is writing it and why.

Why I question whether obesity is clinically useful

I think this is where I finally found the language for my discomfort. When I sit with someone, whether we are talking about their relationship with food, their self-worth, their anxiety, or their physical health, the word obesity tells me almost nothing useful about who they are or what they need. It says nothing about their psychological history, their relationship with their body, the social conditions shaping their life, or what has brought them to this point. It groups together people with wildly different experiences, presentations, and needs, and offers no clear direction for how to actually help.

And from a psychological perspective, that vagueness has consequences. A label that carries the cultural weight that obesity does, saturated with judgement, often internalised as shame, can actively get in the way of therapeutic work before it has even begun [7]. People do not arrive at a consultation as a BMI score. They arrive with a history.

A diagnosis that tells you nothing about causation, nothing about the person’s actual experience, and points toward no clear pathway for support is not a diagnosis in any clinically meaningful sense. It is a category. And categories, as the weight stigma literature reminds us, exist not just to describe but to sort, and in sorting, to other and to judge [8].

At best, obesity often functions as a broad risk marker, a statistical shorthand for possible future health concerns, rather than a diagnosis that describes a specific pathology. But risk is not the same thing as disease, and treating the two as interchangeable creates both clinical confusion and unnecessary harm.

From a behavioural science perspective, this matters too. Labels shape identity, expectation, help-seeking, self-efficacy, and engagement with care. If a person comes to understand themselves primarily through a stigmatised disease label, that may not support behaviour change at all, it may instead reinforce shame, avoidance, hopelessness, or disconnection from their own health.

Is there a better way?

One obvious alternative is to name the conditions that actually matter clinically: type 2 diabetes, hypertension, obstructive sleep apnoea, non-alcoholic fatty liver disease. These are specific, actionable, and do not require a BMI threshold to diagnose. They describe what is happening, not what someone looks like.

The honest counterargument is that stigma travels. Diabetes carries its own weight of blame in public discourse, often framed, unfairly, and largely inaccurately, as self-inflicted. Any label applied to a condition associated with body size will risk absorbing the moral panic that currently surrounds weight. The problem may not be solvable at the level of terminology alone.

Part of the appeal of calling obesity a disease is understandable. Disease language can sound more compassionate than moral judgement, and in some settings it may improve access to care or reduce overt blame. But labels can do more than soften stigma; they can also intensify surveillance, widen the reach of medical intervention, and make larger bodies appear inherently pathological even when the person in front of you is metabolically well or simply in need of support that has little to do with weight at all.

More fundamentally, the disease label risks individualising what are often the cumulative effects of systems: poverty, food insecurity, chronic stress, trauma, disrupted sleep, medication effects, inequality, and environments that constrain rather than support health. When those conditions are collapsed into a diagnosis located in the individual body, medicine can end up treating the person while leaving the causes largely intact.

But terminology is not nothing. Words shape clinical encounters, policy decisions, funding priorities, and the everyday experiences of people sitting in waiting rooms wondering how they will be seen. The word obesity, built on a shaky diagnostic foundation, declared a disease by vote rather than evidence, and saturated with cultural judgement it was never meant to carry, seems to me to be doing more harm than good, in consulting rooms, in newsrooms, and in the minds of the people it is meant to describe.

We could start by being more precise.

What is actually wrong? What does this person actually need? Those questions will take us further than a label ever will.

How I have made peace with the word

I think part of my discomfort with the word obesity is that it tries to do too much at once. It is often used as though it describes both a body and a state of health, as though those two things are self-evidently the same. I do not think they are.

I have never been labelled obese myself. When my BMI was not within range, I was not thinking of myself as a disease category. I was just fat. And I was well. I was fat and healthy. That is not a contradiction, even if our current medical language sometimes makes it feel like one.

I think that is where some of my discomfort lies: in the gap between what the word implies and what real bodies, real lives, and real health actually look like.

There is no quick solution to that. But in practice, the way I work with it is simple. If it is necessary to refer to someone’s body size, I ask people how they describe their own body, because that is, first and foremost, a matter of language and identity. And then we move on to their health, we talk about their physical health symptoms, how they understand them, what matters to them, and what support they actually need.

To me, those are two different conversations. One is about description. The other is about health. And I think we do people a disservice when we pretend they are the same thing.

How do you feel about the word?

A note on the image: This is a stock image I found when I searched for, yes, you guessed it, ‘obesity’. I rest my case!

[1] AMA Council on Science and Public Health (2013). Is Obesity a Disease? CSAPH Report.

[3] Pomeroy, E. et al. (2013). Did the American Medical Association make the correct decision classifying obesity as a disease? PMC

[4] Eknoyan, G. (2008). Adolphe Quetelet (1796–1874) The average man and indices of obesity. Nephrology Dialysis Transplantation, 23(1), 47–51.

[5] Puhl, R.M. & Heuer, C.A. (2009). The stigma of obesity: a review and update. Obesity (Silver Spring), 17, 941–964. Semantic Scholar

Puhl, R.M. & Heuer, C.A. (2010). Obesity stigma: important considerations for public health. American Journal of Public Health, 100(6), 1019–1028.

[6] Puhl, R.M. et al. (2013). Headless, hungry, and unhealthy: a video content analysis of obese persons portrayed in online news. Journal of Health Communication, 18(6), 686–702.

[7] Pearl, R.L. & Puhl, R.M. (2018). Weight bias internalization and health: a systematic review. Obesity Reviews, 19, 1141–1163. Also: Puhl, R.M. (2023). Weight stigma and barriers to effective obesity care. Gastroenterology Clinics of North America.

[8] Meadows, A. & Daníelsdóttir, S. (2016). What’s in a word? On weight stigma and terminology. Frontiers in Psychology

It’s a phrase that landed this week and hasn’t left me. Coined to describe this year’s Academy Awards, where a notable number of women appeared visibly, strikingly thin, it sparked exactly the kind of debate we have come to expect. Are GLP-1s dangerous? Are they liberating? Should we be celebrating weight loss or condemning it? Are we body shaming or are we naming a health crisis?

And here is where I want to stop us.

Because we are having the wrong conversation.

Not because those questions don’t matter. But because we are so busy talking about the drugs, we are missing what the drugs are actually revealing. And what they are revealing is something that has always been true, but has never been quite this visible, quite this stark, or quite this urgent.

Women’s bodies are a barometer. They always have been. And right now, they are telling us something we cannot afford not to hear.

The barometer we keep ignoring

This is not a new idea. The shape of women’s bodies has always reflected the world they are living in, culturally, economically, politically. In times of scarcity, softness was aspirational. In times of plenty, restriction became the ideal. In the 1990s, heroin chic told us something about a generation that had absorbed the message that wanting less, needing less, taking up less space, was a virtue. Those messages didn’t stay abstract. They got inside people. They still are.

What GLP-1s have done is something remarkable and deeply uncomfortable at the same time. For the first time in history, the gap between those who can shrink and those who cannot is being pharmaceutically enforced and publicly displayed. A shrinking, visible elite, their thinness now chemically achievable rather than merely aspirational, setting a standard against which everyone else is quietly measured.

That is new. And it matters enormously.

Because we are not just watching bodies change. We are watching inequality made visible. And if we don’t name that, we will miss one of the most significant cultural moments of our time.

The irony we’re not naming

This week, a post calling for us to stop shaming people who use GLP-1s also stopped me in my tracks. The argument was compassionate and correct. We do not shame people for taking statins, for managing blood pressure with medication, for using any other pharmaceutical intervention for a health condition. So why are GLP-1s treated differently?

I agree. And yet.

There is an uncomfortable irony sitting underneath that argument that I cannot move past. Many of the same individuals being shamed for using GLP-1s have already spent years, sometimes decades, shaped by a culture that shamed them into wanting to lose weight in the first place. The shame didn’t begin with the medication. It began long before, in the messages absorbed from magazines and television and social media and, sometimes, from the very healthcare professionals now handing out prescriptions.

So we arrive here: shamed for our bodies, shamed for wanting to change them, and shamed for how we change them.

At some point, we have to ask what we are actually doing. And more importantly, what we are refusing to see.

Who gets to be thin

GLP-1 medications were developed to manage blood glucose in people with Type 2 diabetes. Weight loss was a secondary effect, observed, then commercialised, then rapidly repositioned as the headline offer. The people for whom these drugs were originally intended, those managing a serious metabolic condition, still frequently cannot access them. NHS waiting lists are long. Private prescriptions are expensive. The system is overstretched.

And yet on red carpets, on Instagram, in the pages of whatever glossy publication still exists, women who did not need these drugs for their health are using them to chase an aesthetic.

Jane Manfredi named it on Radio 4 this week as the skeletal elephant in the room. The thing we can all see and almost none of us will say, because we are so afraid of being accused of shaming that we have lost the ability to name harm.

But here is what that silence is costing us. Standards shift. Expectations rise. The gap between what is held up as ideal and what is actually attainable grows wider. And the people who most need support, the ones for whom this was never about aesthetics, are left further behind, measured against a standard they were never meant to reach and were never given the tools to meet.

That is not a personal failing. That is what happens when a system built on inequality is handed a new tool, and that tool gets captured by the people who were already winning.

What’s happening on the inside

At an individual level, the experience of GLP-1s is frequently described as relief. Relief from relentless hunger. Relief from the constant mental chatter about food. Relief from the exhausting, demoralising feeling of perpetually failing at something everyone around you seems to manage effortlessly.

That relief is real. It deserves to be taken seriously.

But we have to sit with what it tells us. Because what we call food noise is not purely biological. It is shaped by years of restriction, by internalised stigma, by a culture that has kept people locked in an exhausting cycle of thinking about food, bodies, and worth. The noise was not random. It was created. By the same culture that is now selling the solution.

When that noise quietens, it can feel life-changing. But if we don’t ask what created it in the first place, we will keep producing it. Just in people who can’t yet afford the silence.

This is our moment

Here is what I keep coming back to.

GLP-1s have, perhaps accidentally, created a window. A moment where the relationship between women’s bodies and the world they inhabit is more visible, more legible, and more urgently in need of examination than it has been in a long time. The inequality is visible. The shame is visible. The gap between the cultural ideal and the lived reality is visible.

We can use this moment to argue about medication. To debate for and against, helpful and harmful, necessary and excessive. And we will probably do exactly that, because it is easier and more familiar than the alternative.

Or we can use it to finally listen to what women’s bodies have always been trying to tell us.

About what we value. About who we protect. About the quiet, persistent ways we tie body size to worth, to discipline, to deserving.

This is not a small conversation. It is not a lifestyle debate. It is a question about the kind of world we are building and who it is being built for.

Women’s bodies are a barometer. Right now, they are telling us something important.

The question is, are we finally ready to listen?

This piece was prompted by the thinking of three people whose work landed for me this week: Lucy Jones, whose LinkedIn post on GLP-1 shame sparked the first thread; Jane Manfredi, whose Thought for the Day on Radio 4 named the skeletal elephant in the room; and Dr Kat Schneider, whose piece in The Psychologist brought the psychological complexity of this moment into sharp focus. Thank you to all three.

But buried within his argument is an assumption so deeply embedded it goes entirely unexamined, that weight is a reliable proxy for health. It isn’t. And when England’s Chief Medical Officer frames obesity prevention as the central goal of public health, the consequences are neither neutral nor benign.

Weight is not health. Health is not weight.

The evidence on this is substantial and growing. Metabolically healthy people exist across every body size. Conversely, people in smaller bodies develop heart disease, type 2 diabetes, and cancer. Weight tells us remarkably little about an individual’s health status without a far richer clinical picture. What does consistently predict poor health outcomes? Poverty. Chronic stress. Social isolation. Poor sleep. Lack of access to healthcare. Adverse childhood experiences. These are the determinants quietly absent from Sir Chris’s lecture.

Weight stigma is itself a health crisis

When we position larger bodies as the problem, even with compassionate language about food environments, we reinforce a culture of stigma that causes measurable harm. Weight stigma is associated with increased cortisol, avoidance of healthcare, depression, disordered eating, and yes, weight gain. Healthcare professionals who hold weight bias (and research shows most do) deliver worse care to fat patients. Conditions get missed. People avoid seeking help. The stigma is the barrier.

Sir Chris’s framing, however well-intentioned, adds institutional weight to a narrative that tells people in larger bodies that their bodies are the problem to be solved. That is not a clinically neutral message.

The food environment critique is right, but incomplete

The comparison to France is interesting, but it quietly sidesteps an uncomfortable truth: France also has significantly lower rates of poverty and inequality than the UK. The communities Sir Chris names, Wigan, Blackpool, are not struggling because of personal or cultural failure. They are struggling because of decades of economic disinvestment, food deserts, housing insecurity, and chronic stress. These are not weight problems. They are justice problems.

Focusing on what people eat, without asking why they eat it and what else is happening in their lives, is an incomplete and ultimately stigmatising analysis.

On GLP-1s specifically

The concern about over-medicalisation is legitimate. Treating a systemic social problem with a lifelong pharmaceutical intervention does deserve scrutiny. But it’s worth noting: for many people, GLP-1 medications are reducing inflammation, improving mental health, and addressing conditions entirely unrelated to weight loss. The drugs may matter, just not always for the reasons being discussed.

What we should actually be talking about

A genuinely health-focused public health strategy would ask: How do we reduce poverty? How do we make communities feel safe, connected, and supported? How do we ensure everyone has access to care that respects their body and their dignity? How do we address the chronic stress that drives so many of the health outcomes we’re misattributing to weight?

Sir Chris Whitty is a credible, intelligent, and largely well-meaning public servant. That’s precisely what makes this blind spot so significant. When the most senior medical voice in England centres weight as the measure of a healthy society, it doesn’t just miss the science, it actively causes harm to the people public health is supposed to protect.

We can do better. We must.

BBC Article: https://www.bbc.co.uk/news/articles/clyzx4eypv8o

Medical Journalists Association write-up: https://mjauk.org/2026/03/06/chris-whittys-tour-de-force-at-mja-annual-lecture/

Today, I want to take us somewhere different. I want to take us into the room. Into the room where weight management actually happens. Into the room where people sit, week after week, trying to improve their health by what they believe to be the silver bullet, losing weight.

___________

Imagine you are there.

___________

The session begins, as many do, with weighing.

The first woman walks in glowing. She seems kind, open, hopeful, there’s an energy about her, almost like excitement, as if she’s looking forward to seeing the result of the effort she’s been putting in. She steps onto the scale, and within seconds something changes. Her expression shifts. The energy in her body drops. What follows is distress, disbelief, the quiet scramble to make sense of a number.

She speaks about how hard she’s been trying, swimming, walking, doing everything she thought she was supposed to do. The questions come quickly.

What is she doing wrong?

She begins listing her week, item by item, as if building a defence. The woman who walked in moments earlier now looks lost. I need support, she says. I can’t do this alone.

What happens in that moment has a name in the research. When a person steps on a scale in a clinical setting and the number doesn’t match their effort, it can trigger what researchers call weight stigma, an experience of shame, judgement and failure that the evidence shows has real physiological consequences. Studies have found that exposure to weight-stigmatising situations raise cortisol levels, the body’s primary stress hormone, and that repeated activation of this stress response is associated with increased inflammation, disrupted metabolic function, and, with painful irony, weight gain (Tomiyama et al., 2018). The shame isn’t merely a side effect of the intervention. In many cases, it may be working directly against it.

The second participant enters the weighing area but deliberately avoids looking at the scale. Before the number has even been recorded, he begins explaining himself, listing what he’s done that week, as though he needs to justify his effort before the verdict comes in. He receives his number on a small piece of paper and quietly leaves the room.

Think about that for a moment.

The pre-emptive self-defence.

The need to account for yourself before being judged. This is what researchers describe as internalised weight stigma, where people absorb the cultural message that their body is a reflection of their character, their willpower, their worth. Pearl and Puhl (2018), in a systematic review of the evidence, found that internalised weight stigma is independently associated with disordered eating, reduced physical activity, depression, and anxiety. It doesn’t protect people from poor health outcomes. It predicts them.

The third participant has lost weight.

She speaks proudly about it, and the group congratulates her. But as she describes what helped, she mentions skipping meals, just not being hungry as if this is a good thing, something to be valued. The number has gone down, and so the behaviour is, implicitly, unintentionally, validated.

This is one of the quieter ways the framework fails.

When weight is the primary outcome measure, the system struggles to distinguish between sustainable, health-promoting change and behaviours that may cause harm.

A qualitative evidence synthesis of patient experiences in healthcare settings (Ryan, 2023) found that the experience of being monitored and judged by weight was itself a source of shame and distress, and that patients frequently described the clinical encounter as a barrier to, rather than a support for, their health. The number goes down. But we may not always know at what cost.

As the session continues, people begin to talk. They speak about comments strangers have made about their bodies. About avoiding activities because they don’t want to be seen while fat. About feeling they need to lose weight before they can start living their lives.

One participant says something worth sitting with.

Do it fat.

Her message is simple: go swimming, join the class, live your life now. It is a small act of resistance in a room where many people believe they have to change their bodies before they can fully participate in the world.

She is, perhaps, offering something the intervention itself is not: permission to exist as you are, and to pursue health from that place rather than towards it.

Now notice what else is in the room.

There is neurodiversity, hormonal conditions, long histories of struggling with food and eating. Some people are there not because they chose to be, but because they were told they needed to lose weight before they could access treatment, fertility treatment, knee surgery, other forms of care they needed. Weight loss has become the gatekeeper.

This matters, because the research is clear that being denied care on the basis of weight is itself a source of stigma that causes measurable harm. Sutin, Stephan and Terracciano (2015), drawing on data from over 18,000 participants across two large national studies, found that people reporting weight discrimination had a nearly 60% increased risk of mortality, independent of BMI. Tomiyama and colleagues (2018) later contextualised this finding as part of a broader case that weight stigma doesn’t sit alongside poor health outcomes, it actively drives them. The stigma isn’t a neutral administrative barrier. It is a health hazard in its own right.

When we talk about obesity policy or weight management services, we tend to talk about outcomes. But this room is a reminder that there is another layer we rarely discuss: the human experience of the intervention itself. What it feels like to step on the scale each week. What it feels like to justify your effort before the result is revealed. What it feels like to believe that access to the care you need depends on your ability to change your body.

These aren’t just emotional experiences. The evidence increasingly suggests they are clinical ones too. Shame, stigma and chronic stress activate physiological pathways that can directly undermine the health goals the intervention is designed to achieve (Tomiyama et al., 2018; Pearl & Puhl, 2018). We have built a system that, at its edges, may be making some people sicker in the process of trying to make them well.

This is why I keep asking the question:

If our goal is genuinely to improve health, not just to move a number, are we measuring the right thing?

And are we paying enough attention to what we are doing to people in the room, in the process of trying to help them?

Because once you’ve stepped inside it, it becomes very hard to believe the scale is telling us what we think it is.

References

Pearl, R. L., & Puhl, R. M. (2018). Weight bias internalization and health: A systematic review. Obesity Reviews, 19(8), 1141–1163.

Ryan, L., Coyne, R., Heary, C., Birney, S., Crotty, M., Dunne, R., Conlan, O., & Walsh, J. C. (2023). Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis. Obesity Reviews, 24(10), e13606.

Sutin, A. R., Stephan, Y., & Terracciano, A. (2015). Weight discrimination and risk of mortality. Psychological Science, 26(11), 1803–1811.

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, 123.

Which raises an obvious question.

If not weight, then what?

It is tempting to reach for a simple answer. The system was built around the wrong single thing, so surely we just need to find the right single thing. But that instinct is worth resisting, because it was exactly that instinct that got us here in the first place.

Weight won, in part, because it was simple enough to become a system. It fit on a leaflet. A GP could assess it in three minutes. An actuary could put it in a table. Any replacement that claims the same simplicity should probably be treated with some suspicion.

That does not mean we have no options. We have several. But they each come with honest trade offs worth understanding.

Behavioural health

The first candidate is to organise the system around what people actually do rather than how their body looks. Movement, sleep, nutritional quality, alcohol, stress management. These are the upstream factors that consistently predict health outcomes across populations and across body sizes. They are actionable and modifiable in ways that weight often is not.

The challenge is twofold.

First, behaviours are harder to measure consistently at scale. Second, and more importantly, a system organised around individual behaviour risks replicating the same trap that weight centricity created, just with different metrics. If the implicit message remains that health is a matter of personal discipline and the structural conditions that shape behaviour go unexamined, we will have changed the proxy without changing the paradigm.

Metabolic health

The second candidate is to organise the system around what is actually happening biologically. Blood glucose regulation, insulin sensitivity, inflammation markers, blood pressure, lipid profiles. These are mechanistically connected to disease in ways that weight simply is not. And crucially, metabolic health varies enormously at every body size, which immediately and cleanly breaks the assumption that weight and health are the same thing.

This is perhaps the most scientifically compelling option. The challenge is cost and access. These markers require clinical testing rather than a tape measure, which makes population level implementation harder. Though as technology develops and testing becomes cheaper, this barrier may be lower than it once was.

Functional capacity

The third candidate shifts the frame entirely away from appearance and toward lived experience.

What can a person do?

Their strength, cardiovascular fitness, mobility, energy, cognitive function, quality of sleep. Cardiorespiratory fitness in particular is one of the most powerful predictors of longevity and disease risk we have, and it is largely independent of weight.

There is something quietly radical about this option.

It moves the question from what does your body look like to what is your body capable of, and that is a meaningfully different conversation to be having in a clinical setting. The challenge is applying it equitably, without disadvantaging people with disabilities, chronic conditions, or life circumstances that limit certain kinds of physical capacity.

Social and structural determinants

The fourth candidate is perhaps the most honest and the most politically difficult. Organise the system around the conditions in which people live. Housing, income, social connection, psychological safety, access to green space, food environment. The evidence that these structural factors drive health outcomes is overwhelming, and largely dwarfs the effect of individual behaviours. You cannot meaningfully address population health while ignoring poverty, inequality, and the environments people are born into.

The challenge is that this requires the health system to engage with territory well beyond the traditional clinical frame. It asks medicine to have a view on housing policy, food systems, and economic inequality. That is uncomfortable, complex, and slow. But the discomfort of engaging with it is not a reason to look away.

The uncomfortable truth

Here is what sits underneath all of these options.

The reason weight won is not just that it was measurable. It is that it was simple enough to become a system. And any replacement that is more accurate will also be more complex.

So the real question may not be which single organising principle we should choose next. It may be whether we are willing to build a system sophisticated enough to hold complexity, rather than reaching again for a proxy that fits on a leaflet.

A composite framework built around metabolic health, functional capacity, and social determinants, measured together and weighted according to individual circumstance, would be more accurate, more equitable, and more connected to actual health outcomes than weight ever was. It would also be harder to reduce to a single number, a single message, a single intervention.

And that is precisely the point.

The lesson of weight centricity is not just that we chose the wrong simple thing. It is that we needed something simple and, in that need, chose something counterproductive.

The harder and more important question is whether the system can mature enough to operate without that kind of reduction. Whether it can hold the complexity of a human being, rather than flattening it into a measurement.

What this means in practice

Change at this scale does not happen through critique alone. It happens when an alternative is legible enough, evidenced enough, and practically grounded enough to generate its own gravity.

And that gravity is built by people already inside the system, working within the roles they already have.

If you’re a clinician, you don’t need to wait for the system to change before you change what happens in the room. You can ask about sleep before you ask about weight. You can measure blood pressure, resting heart rate, energy, function. You can notice when the consultation has become about the proxy rather than the person, and redirect it. None of this requires a new protocol or a new employer. It requires a decision about what you’re actually there to do.

If you’re a researcher, the most useful thing you can do right now may not be generating new findings, it may be framing existing findings differently. The evidence for reconsidering weight as an organising principle is already substantial. What it often lacks is a coherent narrative that makes it legible to people inside institutions. If you can write that narrative, in journals that practitioners actually read, you’re doing more than incrementally advancing the literature. You’re shifting what counts as common sense.

If you work in policy or public health, the temptation will be to wait until there’s a consensus framework to replace the current one. But consensus frameworks don’t arrive fully formed, they’re built, piece by piece, by people who are willing to articulate the alternative before it feels absolutely safe to do so. The most valuable thing you can contribute right now is probably not a new policy. It’s a clear-eyed account of where the current one is failing, written for people with the power to care about that.

It also means training institutions beginning to shift what the next generation of practitioners learns to see. And it means people inside the economic infrastructure of the current system being shown a migration path rather than a cliff edge.

None of this is quick. Paradigms rarely shift in a single generation. But they do shift. And the conditions for this one shifting are more present than they have been at any point in the last fifty years.

The question is no longer whether the current organising principle is working. The evidence on that is increasingly clear.

The question is what we are willing to build in its place, and whether we have the patience and the rigour to build it well.

The shift won’t come from outside the system. It will come from enough people inside it deciding, quietly and then loudly, that they’re willing to see differently.

That matters more than I can easily say.

“But we all know that we need systems.”

It nudged me back to the beginning.

We spend so much energy critiquing systems, navigating systems, reforming systems, that we rarely stop to ask why we built them in the first place.

That why is not historical trivia. It is diagnostic. If we understand the original problem a system was built to solve, we can see why it once made sense and why it might now be causing harm. We can also see what genuine updating would require, rather than just patching.

Why systems exist

The truth is simple. We do need systems.

They are how we manage complexity. From ecosystems and immune systems to healthcare and education, systems create rules, store memory, and recognise patterns. They stop us from having to solve every problem from scratch, every single time. Systems are how collective intelligence is stored and transmitted across generations. Without systems, we drown in detail.

But what happens when a system is built around the wrong organising principle?

Case study: How weight became the organising principle

The weight-centric model of health did not emerge from malice. It emerged from urgency. In the mid 20th century, heart disease was rising dramatically across Western populations. People were dying younger, and medicine didn’t have a clear answer as to why. The pressure to find one was high on researchers, on clinicians, and on public health systems. When the Framingham Heart Study began tracking thousands of people across decades from 1948, it was driven by exactly this need: find the factors, find something we can point to, find something we can act on.

Weight was one of the variables they could consistently collect. And when heavier bodies appeared more frequently in the disease statistics, it offered something medicine urgently needed. A visible, measurable, scalable candidate for cause. Not a proven cause. A candidate. But in the translation from research to policy, that distinction got lost.

The correlation was real. But correlation is not cause, and the system didn’t maintain that distinction carefully enough. It is a bit like noticing that people who carry umbrellas tend to get wet more often, and concluding that umbrellas cause rain.

Weight may often be a downstream effect of the same underlying conditions, poor sleep, chronic stress, processed food environments, sedentary work, that also drive disease risk. Because weight was visible and those upstream factors weren’t, weight got promoted from signal to cause without anyone formally making that argument.

BMI was convenient, measurable and cheap. Insurance systems needed a proxy for risk. Clinicians needed something actionable. Public health needed a simple message. The system coalesced around weight not because the science demanded it, but because it was the most scalable variable in an emerging epidemiological machine that needed simple, consistent, cheap data points. Convenience shaped the science, not the other way around.

The tragedy is not that the decision was made. The tragedy is that what was always a practical compromise, a workable proxy for a complex problem, gradually got treated as a fundamental truth. The scaffolding got mistaken for the building.

What followed was epistemic lock in. Research funding, clinical training, pharmaceutical development, public health campaigns, all built on that foundation. Not because anyone consciously decided weight was the only factor, but because systems generate gravity. They create incentives, careers, institutions and habits of mind that reinforce themselves.

The harms, weight stigma, healthcare avoidance, eating disorders, missed diagnoses, the conflation of thinness with health, were not the intention. But they became outcomes. And the system makes those harms hard to see clearly, because the people inside it were trained to see through its lens.

Once weight became the organising principle of healthcare, everything organised around it. Evidence was interpreted through it. Anomalies were explained away. Human health and wellbeing, the original concern, was quietly replaced by the proxy. The organising principle became invisible precisely because everything was organised around it.

The epistemological trap

So what would it take to change the organising principle, and what stands in the way?

This is the epistemological trap. It is not about intelligence or bad faith. The system does not just teach facts, it teaches you how to see. A clinician trained in weight centric medicine has developed intuitions and clinical reflexes that are weight centric all the way through. Asking them to abandon that is not like asking them to learn a new skill. It is closer to asking them to distrust their own perception.

Thomas Kuhn described this as a paradigm. Paradigms do not shift simply because contradictory evidence accumulates. They shift when anomalies become so visible that the dissonance is unbearable, or when a new generation arrives who were not trained in the old frame.

You cannot convert your way out of this. You need new entry points, new training, new metrics, new voices being centred.

The economic immune system

But the lens we are trained through isn’t the only barrier, there are others, mostly commercial.

In the example of weight loss, the industry surrounding it, for example pharmaceutical pipelines built around obesity drugs, insurance models, clinical infrastructure, and research institutions represent enormous concentrations of capital and employment. Money follows the paradigm, then protects it. And the people inside that economy are not wrong to feel threatened. Change genuinely is threatening. The resistance is not irrational. It is simply that the interests being protected are institutional rather than patient-centred.

The challenge is not to collapse the economy, but to migrate it. To allow expertise, infrastructure and investment to reorganise around a different organising principle.

What was the system built to solve?

If we go back to the beginning, the need the system was built to address was health. More specifically, the need to reduce preventable disease, manage population level risk, allocate limited healthcare resources fairly, and improve quality and length of life. Weight became a proxy for those goals because it was measurable and appeared correlated with them. But a proxy is not the same as the thing itself. If the true aim is human health and wellbeing, then the organising principle must serve that aim, not replace it.

What needs to change

The case for change rests on two things. First, demonstrating clearly that weight as an organising principle is failing on its own terms. That despite decades of weight-centric policy, interventions and messaging, population health has not improved in the way promised, and that stigma and shame may be compounding harm rather than reducing it. Second, offering an alternative organising principle that is just as legible, just as simple, and just as capable of generating gravity. Not the opposite of weight, but something more direct. Measuring and incentivising health behaviours, metabolic markers, psychological wellbeing, social determinants, functional capacity. If the original aim was to improve health, perhaps we need to measure health more directly.

Migration, not war

If we believe this change is important the fact remains that we cannot fight the system head-on. Systems defend themselves.

We need to honour the original need the system was built to serve and show that the current organising principle is no longer serving that need well enough. We need to offer a migration path, not just a critique. And we need to train a new generation inside a different lens.

For a long time I believed that the change I want to see would not happen in my lifetime. I am starting to think I might be wrong.

Paradigms do shift. Not quickly, not cleanly, but they do. And perhaps we are closer to that moment than we realise.

Just this week I was accepted to speak at the Division of Health Psychology Conference, where I will share the stage with Dr Angela Meadows, Helen James, Dr Rosie Webster and Katy Irving. Four professionally credible individuals who are not shouting from the sidelines, but working carefully and rigorously to raise awareness of the harms of a weight centric health paradigm and, more importantly, to articulate practical alternatives. That matters. It tells me this conversation is no longer fringe. It is entering the room. And when ideas start entering professional rooms with evidence, credibility and collaboration behind them, paradigms begin to loosen.

For all those who are open to starting to see the world through a different lens, who are ready to address that dissonance, I think something is shifting and I’m looking forward to seeing what happens next.

They are clinicians, psychologists, dietitians, researchers, public health and policy professionals. Many of them sit inside systems that still default to weight as the primary marker of health and success. They are thoughtful, evidence-led, and increasingly tired. Not because the work lacks meaning, but because pushing against a dominant narrative is, by its nature, lonely.

We are not a loud movement. But we are a persistent one.

What unites these conversations is not ideology, but unease. A shared discomfort with practices that continue to be framed as benign, even virtuous, despite mounting evidence that they cause harm. Not in fringe cases. Not rarely. But repeatedly, predictably, and disproportionately.

Weight-centric healthcare does work for some people, in some contexts, in the short term. That has never really been in dispute. What is far harder to sit with is what happens to those for whom it doesn’t, and how routinely those outcomes are dismissed as collateral damage rather than foreseeable consequences.

Disordered eating. Eating disorders. Weight cycling. Metabolic dysregulation. Shame. Anxiety. Depression. Disengagement from care. A narrowing of life. A reduction in quality of life that is rarely captured in outcome frameworks.

These mechanisms do not operate in isolation. They are amplified by diet culture, by the thin ideal, and by a broader social narrative that equates smaller bodies with moral success. When public figures promote injectable weight-loss in the name of health, even when health is already present, it becomes clear just how narrow our collective definition of health has become.

And yet, when this harm is raised, the response is often defensive. Or dismissive. Or framed as ideological rather than empirical. As though asking difficult questions about unintended consequences is somehow anti-science, rather than fundamental to it.

What I find myself wondering, again and again, is why this is so hard to shift.

The evidence is not hidden. The data on long-term outcomes, weight regain, psychological harm, and eating pathology are well established. Referrals to eating disorder services are rising. Many people referred to weight management pathways end up needing specialist eating disorder support. This is not an unfortunate coincidence; it is a pattern.

And yet, the paradigm holds.

Part of the answer, I suspect, has little to do with evidence and much more to do with power. Weight-centric approaches are institutionally comfortable. They align with commissioning structures, performance metrics, and deeply engrained beliefs about personal responsibility and control. They are familiar. They are legible. And they are still socially rewarded.

Challenging them requires more than data. It requires people, particularly those in senior, influential positions, to pause and reflect on the behaviours they are endorsing in the name of health. To consider not just intended outcomes, but downstream effects. To acknowledge that healthcare is never neutral, and that what we promote, we amplify.

This is not a call to abandon nuance. Nor is it a denial of complexity. It is an invitation to think more carefully, more ethically, and more systemically about the approaches we continue to legitimise.

GLP-1 medications have undoubtedly turned up the volume on weight loss as a goal. I hear professionals on LinkedIn say, almost casually, that thin is in again. Perhaps it never really left. But if anything, this moment makes reflection more urgent, not less. When tools become more powerful, the responsibility to use them wisely increases.

Every week, I speak to people who understand this. Who are trying, within their spheres of influence, to widen the conversation. To centre health without shame. To reduce harm, not just optimise metrics. We are a small but mighty network, and we are not going away.

Paradigm shifts are rarely comfortable. They ask us to question things we were taught, practices we’ve delivered, and systems we’ve helped sustain. But if healthcare is serious about doing no harm, then discomfort is not a reason to look away.

The question, now, is not whether weight-centric healthcare works for some. It is whether we are willing to take responsibility for the harm it causes many, and what we choose to do with that knowledge.

In every single appointment, reference was made to the size or shape of my body, and, more worryingly, my daughter’s.

What struck me most wasn’t just that these comments were made, but how they were framed. Almost always, they arrived dressed as compliments.

A larger lymph node was explained with:

“…the reason I can feel that is because your neck is lovely and thin.”

Light-headedness in a teenager was softened with:

“…when you’re lucky to be tall and slim, like you are, you can feel light-headed when you stand up quickly.”

Individually, these comments might sound benign. Kind, even. But after the sixth time of leaving an appointment, having had my body, or my daughter’s, casually appraised and positively judged, something began to feel uncomfortable.

I wasn’t offended or angry; I was uneasy.

This discomfort isn’t new for me. These recent appointments reminded me of a moment I’ve never forgotten.

When my youngest daughter was eight, she was a gymnast. She was very lean, with clear muscle definition, exactly what you’d expect from a child training intensively. Looking back, she was probably doing far too many hours for such a small body. At the time, we didn’t fully appreciate the toll it might take.

She became unwell and we saw a GP. During the examination, in front of her, he said:

“This is what every child should look like.”

I remember feeling shocked, then angry, and completely speechless.

Here was a eight-year-old girl, being physically examined while unwell, and her body was being held up as an ideal. Not her strength. Not her joy. Not her wellbeing. Her appearance. An appearance shaped by intense physical training that, in hindsight, hadn’t served her health particularly well at all.

That moment stayed with me. And these recent encounters have brought it sharply back into focus.

What concerns me is not that bodies are noticed in healthcare, that’s inevitable. It’s how deeply engrained the positive association with thinness remains, and how effortlessly it slips into clinical reasoning and everyday language.

Our bodies become explanations. Reassurances. Context.

Sometimes, even reasons not to look any further.

I’ve been sitting with this discomfort for a while, wondering whether I was being oversensitive. But when a pattern repeats across professionals, settings, and generations, it’s worth paying attention.

Because what I’ve started to notice is this: when healthcare encounters thinness, it often relaxes.

• Risk feels lower.

• Concern softens.

• Curiosity narrows.

In one appointment, there was a subtle suggestion that referral might not be necessary, after all, I’m slim. The unspoken logic hovered in the room: if you looked different, this might matter more. And that’s the part that worries me.

In my work, I often focus on weight stigma towards fatness, in healthcare and beyond. I’m very familiar with the ways larger bodies are over-scrutinised, moralised, and blamed. I knew, intellectually, that thinness also carries assumptions. But I hadn’t realised quite how powerful those assumptions were until I saw them play out repeatedly, in real time, and in front of my children.

Thinness, it turns out, doesn’t just escape stigma. It attracts reassurance. And reassurance is not the same thing as care.

When appearance becomes a proxy for health, we risk making quiet but consequential errors. Symptoms are normalised. Investigation thresholds shift. People are implicitly categorised as low concern before their story has fully unfolded.

This isn’t about bad clinicians. Every professional I met was kind, attentive, and well-intentioned. This is about something more insidious: the use of body size as a mental shortcut in a system already stretched for time and certainty.

And then there’s the learning that happens alongside the medicine.

Children don’t just hear explanations. They absorb values. They learn which bodies are praised, which bodies are scrutinised, and which bodies are assumed to be fine. Healthcare spaces are powerful teachers. When bodies are routinely commented on, even positively, children learn that their worth, their health, and their legitimacy are entangled with how they look.

From a systems perspective, this matters.

If thin bodies are assumed to be healthier, they may be under-investigated. If fat bodies are assumed to be risky, they may be over-surveilled and blamed. Either way, care becomes uneven, rationed not by need, but by appearance.

We often say we want holistic, person-centred, evidence-based healthcare. Yet moments like these reveal how deeply body-based heuristics still run, even in everyday consultations. Especially in everyday consultations.

I think the discomfort I’m trying to name is this: if thinness buys reassurance, then vigilance is being quietly redistributed. And that should give us pause to think.

This isn’t a call for clinicians to stop noticing bodies; that’s neither realistic nor necessary. It’s an invitation to notice what we do with that noticing. To ask ourselves when reassurance is evidence-based, and when it’s simply familiar. To stay curious, even when a body looks like it ought to be fine.

Because good healthcare doesn’t relax when it sees thinness, it listens.

And it does so equally, regardless of the body in front of it.

On the one hand, GLP-1 medications are being presented as proof that biology overrides behaviour. Appetite is hormonally regulated. Weight is physiologically defended. Behaviour change, we’re told, may not work in the face of powerful biological drives.

This framing is not without merit. It draws attention to what lifestyle-based approaches have often failed to account for: the body’s adaptive responses to weight loss, including metabolic adaptation and increased appetite following dieting, phenomena well documented in critical weight science.

On the other hand, we continue to argue, often in the same breath, that people on GLP1s need wraparound behavioural support to make these interventions work, to sustain outcomes, and to prevent relapse.

This contradiction is rarely examined. But it matters, because it reveals that while the tools may be changing, the story we’re telling ourselves has not.

1. The conceptual incoherence we’re not naming

The dominant GLP1 narrative goes something like this:

People have been fighting their biology. Appetite and weight are hormonally regulated. The failure of lifestyle interventions shows that behaviour change doesn’t work.

There is truth here. Decades of research show that weight loss via caloric restriction triggers strong biological counter-regulation: increased hunger, reduced energy expenditure, and hormonal changes that promote weight regain (Rosenbaum & Leibel, 2010; Sumithran et al., 2011).

But then comes the pivot:

People still need behavioural support alongside GLP1s.

This is where things become conceptually muddled.

If behaviour is genuinely overridden by biology, then what exactly is behavioural support doing? And, why does it suddenly become necessary, or effective once biology is pharmacologically altered?

What’s happening is not integration, but relegation.

Behaviour is no longer framed as adaptive, meaningful, or protective. Instead, it becomes:

• adherence support

• compliance management

• risk mitigation

• maintenance scaffolding

Behaviour is no longer an agent of change; it is positioned as in the service of biology. That is a profound shift, and one we haven’t been honest about.

2. Why we’re still talking in the same way

Given how disruptive GLP1s appear to be, it’s reasonable to ask why the conversation still sounds so familiar.

The answer is uncomfortable: GLP1s are pharmacologically disruptive but ideologically conservative.

They allow the system to:

• keep weight as the organising outcome

• preserve BMI thresholds and eligibility criteria

• maintain surveillance of bodies

• avoid confronting stigma and harm

• medicalise failure without re-examining values

In other words, GLP1s shift responsibility from individual behaviour to individual biology, but they do not challenge the weight-centred paradigm itself.

This matters because weight-centred care has consistently been shown to:

• increase stigma in healthcare settings (Puhl & Heuer, 2010)

• reduce patient trust and engagement (Mensinger et al., 2018)

• contribute to disordered eating and psychological distress (Tomiyama et al., 2018)

GLP-1s allow us to say, comfortably:

We were right all along, it was biology. No apology required. No reckoning with harm. No need to redesign systems.

3. What we say the problem is, and why we aren’t actually changing it

We often say the problem is:

• an ‘obesogenic’ environment

• limited access to healthy food

• social and economic determinants of health

• lack of effective support

Yet the solutions remain stubbornly individualised:

• take medication

• engage with behavioural support

• adhere better

• stay compliant

• don’t relapse

What we have not meaningfully implemented at scale includes:

• removing weight as a primary outcome

• redesigning services to reduce stigma

• measuring success via health, not body size

• addressing healthcare-induced harm

• shifting power away from surveillance and control

Despite decades of evidence that weight-normative approaches are ineffective long-term (Mann et al., 2007), we continue to double down, simply with better pharmacology.

We haven’t exhausted behaviour change. We’ve exhausted our willingness to change the system around it.

4. Why we must proceed with caution

There is an important risk here, and it needs to be named clearly.

GLP1s are helping some people:

• reducing food-related distress

• quietening relentless hunger

• improving metabolic markers

• restoring a sense of agency

To dismiss these experiences would be harmful and stigmatising in itself. But the danger lies in the story we attach to success.

If the emerging narrative becomes: Those who succeed are biologically corrected; those who don’t are still the problem. Then we have not eliminated stigma, we have simply repackaged it.

Weight-based hierarchies do not disappear just because they are pharmacologically mediated.

Caution means holding two truths at once:

1. some people benefit from GLP-1s

2. no intervention should become a new moral dividing line

5. What’s really missing: the evidence we don’t yet value

The most important question is not: Do GLP1s work? It is: What kind of evidence are we still not collecting, or not willing to act on?

We need evidence that decouples health from weight (this is where Cathy Liddiard's work becomes vital!).

Studies that do not treat weight change as the primary outcome, but focus instead on quality of life, metabolic health, functional capacity, psychological safety, and sustainability (Bacon & Aphramor, 2011).

We need evidence of harm, not just benefit

Long-term data on weight cycling, stigma exposure, healthcare avoidance, shame, and identity threat, including harm caused by interventions themselves (Tomiyama, 2014).

We need evidence that reframes eating as regulatory

Research that treats eating as a response to stress, emotion, identity, and threat, not simply intake, restraint, or adherence (Adam & Epel, 2007).

We need to treat non-engagement as data

Drop-out and resistance as signals about system design, not individual failure, something rarely taken seriously in intervention research.

We need system-level evidence

Studies that evaluate changes to language, access criteria, clinical practice, and commissioning, not just individuals operating inside unchanged structures.

This evidence already exists in fragments: qualitative research, lived-experience studies, trauma-informed care, weight-neutral interventions. What’s missing is permission, to fund it, publish it, and act on it.

6. What this really means

GLP1s have not resolved the tension between biology and behaviour.

They’ve exposed how narrow our imagination has become.

If behaviour only works once biology is corrected, then we have misunderstood behaviour entirely. Eating is not simply a problem to be controlled; it is a regulatory behaviour shaped by threat, meaning, context, and power.

And if weight remains the ultimate arbiter of health, then even our most advanced tools will continue to reproduce harm.

The real challenge ahead is not choosing between biology and behaviour.

It is building an evidence base and a healthcare system that finally understands why that was never the right choice in the first place, and why continuing to centre weight all but guarantees we repeat the same mistakes, again and again.

On one level, this doesn’t surprise me. In fact, I think it tells us something we’ve known for a long time, but often struggle to fully acknowledge in practice: the power of biology, and the relative limits of behaviour alone when biology is working in the opposite direction. I wrote about this here.

In many ways, it feels like the system is asking behaviour to do biology’s job.

What I hadn’t anticipated, though, was where this conversation would take me next. As the narrative around weight regain intensifies, I find myself thinking less about the drugs themselves and more about the very real human cost of the story we are telling alongside them.

I think there are two stories here that deserve our attention.

The first is the story of hope. For many people, these drugs arrive carrying the promise of relief, relief from years of blame, struggle, and perceived personal failure. For some, they offer the hope of finally fitting a societal ideal that has long been held up as synonymous with health, success, and worth. There is a great deal to unpick in that story: culturally, socially, and psychologically. It is an important conversation, just not the one I want to focus on today.

The second story emerges almost immediately after the first: fear. Specifically, the fear that follows when we begin to emphasise the likelihood of significant weight regain. Fear of weight gain is not occurring in a vacuum. It is deeply rooted in cultural norms and long-standing narratives about bodies, morality, and health. And we know that fear of weight gain is a powerful behavioural driver.

It was this second story that stopped me in my tracks, and took me back to earlier in my career, working in weight-management services.

At that time, I began to notice something that unsettled me. Behaviourally, many of the things weight-loss interventions were asking people to do looked strikingly similar to the behaviours I was seeing in individuals with eating disorders. Not in intent, but in practice.

It raised a question that has stayed with me ever since: how close to the line do we sometimes fly when we endorse certain weight-management behaviours, particularly when fear of weight gain is in the background?

I was reminded of a table I developed at the time, mapping commonly endorsed weight-management behaviours against eating-disorder mechanisms. I’ve shared an updated version of that table below.

I’m very aware that this is complex. I also recognise the genuine pressure within medical and public-health settings to continue pursuing weight loss as a route to improving health outcomes. This isn’t a critique of colleagues working in weight management, nor a dismissal of pharmacological approaches, although it’s no secret that I would personally welcome a reframing of weight management towards health markers rather than BMI and really I’d prefer we simply had health management, full-stop!

What I do think is worth pausing on, however, is the behaviours and conversations we are endorsing, particularly at a time when fear of weight regain is being amplified. Fear of weight gain is not a neutral motivator. Behaviourally and psychologically, we know it can drive rigidity, hypervigilance, and patterns that are difficult to distinguish from disordered eating.

My concern is not weight regain per se, but what people are doing in response to that fear, and the potential consequences for both mental and physical health if we fail to consider this carefully.

If GLP-1s are teaching us anything, it may be that sustainable health cannot rely on behaviour alone when biology is pulling so strongly in the other direction. They also highlight, quite starkly, the potential risks of the behaviours we are endorsing, or at least the way we are framing them.

This feels like an important wider conversation: not just about weight, but about the kinds of behaviours we are prepared to legitimise in the name of health.

I want to be clear that this reflection comes from a place of respect. The professionals I worked alongside in weight-management services were thoughtful, compassionate, and deeply committed to supporting change using behavioural science, intuitive-eating principles, and care. And yet, when all of this sits within a weight-management frame, I continue to feel that we are missing vital pieces of the puzzle, cultural, medical, and psychological.

I’ll be honest: this table still feels stark to me. When I first drafted it, I felt a real sense of unease about my own role and what I might be perpetuating, despite the best of intentions.

I’m sharing it now not as a definitive answer, but as an invitation to think together. My views are my own. They are not designed to be the only view, but to open a conversation. After all, we are all trying to support better outcomes, for ourselves and for the people we work with.

I’ve also included a second table that sketches out a weight-neutral alternative. It’s intentionally simple and very much a work in progress rather than a fully behaviourally specified framework, but it felt important to share it as a starting point and in the spirit of openness and conversation.

For me, as a Health Psychologist, Nutritionist and Behavioural Scientist, continually attending to the unintended consequences of our interventions feels essential. Not as a critique of intent, but as part of our responsibility when designing and delivering approaches intended to support health.

And, the real challenge, or what I suspect may be the real challenge, is to take away the focus on weight.

What do you think?

The first was simple, familiar, and deeply human:

Left with why, and what could I have done? (Thank you Michael Lafond)

The second was more unsettling, particularly for me as a behavioural scientist:

We hate the idea that our behaviours are not within our conscious control. (Thank you Lucie Byrne-Davis)

What followed was a thoughtful discussion between Lucie and Michael Visagie about automaticity, about how behaviour is shaped by biology, learning, and environment long before conscious decision-making gets involved. But sitting with these comments for longer, I realised they were pointing to something more fundamental than a technical debate.

They were exposing a shared discomfort.

As humans, and perhaps especially as humans working in healthcare, we want to do something to help. We want action. We want leverage. We want to believe that if we understand behaviour well enough, we can change outcomes.

And when outcomes don’t change, we don’t just feel frustrated.

We take it personally.

At an individual level, this becomes self-blame.

At a system level, it becomes escalation: more programmes, more rules, more pressure on behaviour to comply.

GLP-1 medications are forcing us to confront the limits of that approach, not because they fail, but because they work.

The idea we struggle to sit with

It is deeply uncomfortable to accept that behaviour is not always under conscious control.

If behaviour isn’t fully chosen:

• Effort doesn’t guarantee outcome

• Failure isn’t always informative

• Moral judgement loses its footing

This discomfort explains why morality creeps into health so quickly:

• People didn’t try hard enough.

• They weren’t motivated.

• They made poor choices.

But GLP-1s are quietly puncturing that narrative.

They don’t increase motivation or willpower. They don’t teach better decision-making. They change biological signalling, appetite, satiety, reward.

And when those signals change, behaviour appears to improve, often with far less effort than before.

That doesn’t mean behaviour suddenly became easier to control.

It means behaviour was never the main driver in the way we assumed.

Why ‘what can I do?’ may be the wrong question

When behaviour doesn’t change, the question that surfaces almost immediately is:

What can I do?

It’s a very human question. As helpers, clinicians, scientists, and practitioners, we are oriented toward action. Doing something feels responsible. Doing nothing feels like failure.

But I’m increasingly convinced this may be the wrong question, or at least an incomplete one.

Because what can I do? quietly assumes that behaviour was the right place to intervene in the first place.

A more revealing question might be this:

What is the system asking behaviour to do that it was never designed to do?

What the system has been asking behaviour to do

When you look closely, the answer is uncomfortably clear.

1. Override biology, indefinitely

People have been asked to eat less, ignore hunger, tolerate constant food preoccupation, and sustain this state permanently.

But biology is designed to defend energy stores. Appetite increases when weight drops. Metabolism adapts. This is homeostasis, not failure.

Behaviour was never designed to fight survival biology for a lifetime.

2. Compete with automaticity using conscious effort

Much of eating behaviour is driven by automatic processes:

• biological signals

• learned patterns

• stress responses

• environmental cues

The system assumed that knowledge and motivation would be enough to override these forces.

That’s like asking someone to consciously control their breathing all day, and blaming them when they can’t.

3. Carry responsibility for outcomes it doesn’t control

When weight didn’t change, or returned, behaviour was blamed.

People were asked to interpret predictable biological responses as personal failure, to absorb shame as motivation, and to try again harder.

Behaviour was never designed to be a moral container for physiology.

4. Deliver a socially valued body, not health

This matters.

The system wasn’t really asking behaviour to support metabolic health or psychological wellbeing. It was asking behaviour to produce a thinner body, one that aligns with a narrow cultural ideal and signals discipline, worth, and success.

That’s not a health task.

That’s a social one.

5. Do all of this repeatedly, across a lifetime

Weight management was never framed as a one-off challenge. It was framed as a permanent obligation.

Behaviour was asked to be endlessly resilient to failure, relapse, and biological pushback.

No human system works like that.

What GLP-1s are revealing, not solving

When GLP-1s are introduced, behaviour appears to improve, not because people suddenly become more disciplined, but because the biological terrain changes.

When they are stopped, appetite returns and weight often follows. This is not surprising. It is biology reasserting itself.

The failure here is not the medication.

And it is not the person.

The failure is the expectation that behaviour should have been able to do biology’s job all along.

Seen through this lens, the question what could I have done? begins to look less like accountability and more like misplaced responsibility.

What this means for behavioural science

This doesn’t mean behavioural science is redundant.

But it does mean its role has often been overstated, and sometimes misapplied.

Behavioural science is powerful when it helps us:

• design environments that work with automaticity

• reduce shame and moral judgement

• support people through biological change

• prevent panic-driven restriction and escalation

It is not designed to permanently override biology in pursuit of a socially prescribed body (and I’m not suggesting behavioural scientists think this, but, in the case of weight and health, there is a suggestion of it).

GLP-1s don’t undermine behavioural science.

They clarify its limits, and, in doing so, point us toward a more honest and humane understanding of health.

Sitting with the right discomfort

Letting go of the belief that we can always change behaviour is unsettling.

But it may be the first step toward designing health systems and narratives that stop asking people to do the impossible.

Sometimes the most important thing we can do is stop asking behaviour to carry responsibility for outcomes it was never meant to control.

So what can we do?

For those of us who struggle to let go of the need to do something, to support, intervene, or affect change, this isn’t a call to passivity. But it is a call to change what we think our role is.

What we can do today is stop asking behaviour to do work it was never designed to do. We can stop interpreting predictable biological responses as personal or professional failure. We can design environments, services, and conversations that work with automaticity rather than against it. We can reduce shame, soften moral judgement, and help people trust their bodies instead of escalating control when biology reasserts itself.

For those who find it easier to sit with this reframing when it’s grounded in real-world practice, here are a few examples of what this can look like in action.

In healthcare practice:

This might mean changing the goal in the room, explicitly naming health rather than weight as the outcome, and treating weight change as descriptive rather than prescriptive. It can mean normalising appetite changes and weight regain as biological responses rather than warning signs, and using psychological support to contain distress, reduce panic-driven restriction, and protect identity, rather than to enforce control or compliance.

For individuals navigating their own health

It can look like changing the question from what did I do wrong? to what is my body responding to? and resisting the urge to escalate control when hunger, appetite, or weight change return. It may also mean seeking support that respects biology, opting out of moralising language, and choosing care that prioritises wellbeing over appearance.

At a system or commissioning level:

Action looks like redefining success: funding and evaluating services based on metabolic health, quality of life, psychological safety, and sustainability over time, not kilograms or stones lost. It means designing care that supports people through biological transitions, including stopping medication, and embedding non-stigmatising language and weight-neutral principles as a standard rather than an aspiration.

Sometimes the most meaningful form of action isn’t adding another intervention, it is adapting existing ones and removing the assumptions that quietly cause harm.

What interests me isn’t weight loss itself. It’s what GLP-1 outcomes are quietly forcing us to confront about health, behaviour, and biology.

Weight-management services have largely been commissioned on the strength of their wraparound care, shorthand for behaviour change support. The implicit assumption has long been that, with the right education, motivation, and psychological support, people will ultimately be able to regulate their weight.

GLP-1s are exposing an uncomfortable truth for a field that has spent decades believing that the right behaviours, sufficiently supported will always win.

They won’t.

Biology sets the parameters

Biology is a dominant organising principle. It sets the parameters within which behaviour and systems operate.

Behaviour matters. Systems matter. But they operate within biological constraints, not independently of them. GLP-1s are forcing us to confront this reality because they alter biological signals, appetite regulation, satiety, reward processing, not just behavioural responses. They don’t increase willpower or motivation. They change the terrain altogether.

This is deeply uncomfortable for a field that has often implied, sometimes explicitly, sometimes quietly, that behaviour will always prevail if we just try hard enough.

What GLP-1s are exposing

GLP-1 outcomes are revealing several things we have been reluctant to name:

• how tightly body weight is biologically defended

• how little voluntary control most people ever had over body size

• how misleading it was to treat weight as a reliable proxy for health

This isn’t new science. What’s new is that it’s becoming much harder to ignore. Revealing, not solving GLP-1s are not solving the problem of health. They are revealing how we’ve misunderstood it.

They are showing us that:

• Weight is not a disease: It is a biologically regulated characteristic.

• Bodies defend weight differently: They always have. GLP-1s don’t create this, they expose it.

• Our culture confuses thinness with health: Which is why these drugs are celebrated when bodies shrink, yet scrutinised when health improves without weight loss.

• We have misused medicine: By treating weight as the target rather than health as the outcome. That is not a failure of pharmacology, it’s a failure of framing.

Medicines were developed to treat health conditions. Yet we have repurposed them to shrink bodies, because smaller bodies are more socially palatable.

That should give us pause.

So how do we adapt if the goal is genuinely better health?

If GLP-1s are teaching us anything useful, it’s that health cannot be reduced to a single lever, behavioural or biological.

Here are some necessary shifts.

1. Redefine success: If weight remains the primary outcome, we will continue to misuse every tool we have.

Success should be defined by:

• metabolic health

• functional ability

• psychological wellbeing

• sustainability over time

If weight changes, that is descriptive, not prescriptive.

2. Stop asking behaviour change to do biology’s job

Behavioural science is powerful when used well.

It is well suited to:

• supporting health-protective behaviours

• improving quality of life

• reducing shame and distress

• helping people live well within their biology

It is not designed to override homeostatic systems indefinitely.

3. Use pharmacology as support, not a moral shortcut

If a medication safely supports appetite regulation or metabolic health, the ethical question is not should we allow this? but: What health outcome are we trying to achieve, and for whom?

Used responsibly, pharmacology can:

• reduce blame

• increase compassion

• free behaviour change to focus on wellbeing rather than control

4. Design care around people, not ideologies

A genuinely person-centred approach accepts that:

• some people will benefit from pharmacological support

• some won’t want it

• some won’t need it

The failure lies in insisting on a single pathway for everyone.

What gets in the way?

This shift isn’t simple, and the barriers are real:

• persistent weight stigma

• funding and commissioning models tied to weight outcomes

• professional identity threat

• behavioural overconfidence, the belief that behaviour should always be enough

These are not individual failures.

They are systemic ones.

A final thought

GLP-1s don’t undermine behavioural science.

They clarify it.

They remind us that health lives at the intersection of biology, behaviour, and systems, and that pretending otherwise has cost people years of shame, failed interventions, and misplaced blame.

If we are serious about health, we must stop asking people to fight their biology, and start designing care that works with it.

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But I’d like to offer a different reading, one grounded in biology, behavioural science, and a growing body of critical weight scholarship.

I want to frame this conversation around three simple pillars:

Pillar One: We all knew this was coming. This is biology, and biology is doing its job.

Let’s be honest: no one working seriously in this space is surprised by today’s BBC article titled: People who come off slimming jabs regain weight four times faster than dieters.

The review shows that when WMMs are stopped, appetite increases, weight returns, and cardiometabolic markers trend back towards baseline. This is being framed as a problem. But from a biological perspective, it is exactly what we would expect. These medications work by altering appetite signalling, insulin sensitivity, and metabolic processes. Remove the pharmacological support, and the body responds by restoring energy balance.

That is not failure. That is homeostasis.

In fact, this review is a quiet success story: Biology is responding as designed, pharmacology is effective while present and, the body is protecting itself when support is withdrawn

So rather than panic, perhaps the correct response is:

Well done, biology. And well done, pharmacology.

The mistake comes in how we interpret what happens next.

Pillar Two:. Weight regain is treated as the problem, but what if weight wasn’t the outcome at all?

The review assumes that cardiometabolic benefits are contingent on sustained weight loss, and that rapid weight regain represents clinical failure.

But this assumption deserves challenge.

What if we simply… removed weight from the equation? We could do that. Genuinely. We’d all have to agree to go together, collaboratively, as a system, but it is entirely possible.

Imagine a system where:

• Success is measured in glycaemic control, cardiovascular risk, liver health, renal outcomes, sleep quality, and quality of life

• Weight becomes background data, not the headline

• Programmes are designed for health gain, not body shrinkage

Weight management teams wouldn’t disappear; they’d evolve. (The real threat immediately dissipates!)

They’d have better jobs, delivering better outcomes, with less harm.

So what’s stopping us?

Let’s be honest:

• Diet culture

• Appearance-based values

• Long-standing ideals about thinness and success

• And yes, money

Weight remains a powerful cultural currency. But we should be brave enough to ask whether that serves health, or undermines it?

Pillar Three: Behaviour cannot override biology, and our weight-centric paradigm is holding innovation back

This is the uncomfortable part, especially for those of us trained in behaviour change.

Behavioural science is powerful, but it has limits. It cannot permanently override appetite biology. It cannot out-train homeostatic mechanisms, and it should never be asked to.

At the same time, we also need to say something we are often reluctant to admit: Weight management, as currently practiced, is not working. We continue to operate within a weight-centric health paradigm that:

• Uses weight as a proxy for health

• Reinforces stigma

• Fuels cycles of loss and regain

• Increases psychological distress

• And, for many, paradoxically increases adiposity over time

Let me be clear: denying that adiposity can contribute to clinical harm would be irresponsible.

But continuing to pursue weight loss as the primary outcome, when the evidence shows it is unstable, harmful for many, and biologically resisted, is equally problematic.

This is why innovation feels so hard.

Not because we lack tools.

But because we are stuck measuring the wrong thing.

A moment for rethink, and an invitation

As I move more deeply into clinical health and diabetes innovation, I want to be open about my position.

I believe that these medications are likely long-term metabolic supports, not short-term weight fixes

A weight-neutral approach, or better still, one that is not organised around weight at all, would align more closely with what we know about biology, behaviour, and mental health.

Shifting weight away from its role as the primary outcome has the potential to reduce stigma, support psychological safety, and improve care.

I welcome challenge.

I welcome critique.

But I welcome it in conversation, openly, respectfully, and directly. If you disagree, I’m genuinely interested in listening and reflecting. Progress comes from honest dialogue with people, not conversations about them.

I also recognise that questioning a weight-centred paradigm can feel uncomfortable. For some, it may feel like a threat to established roles, identities, or ways of working. I understand that, change is rarely easy.

But this shift is not about removing expertise or undermining professions. It is about evolving how that expertise is used. If our shared goal is to improve health outcomes, then moving beyond a singular focus on weight may not diminish our impact, it may deepen it.

This is not an individual position.

It’s an invitation.

And it’s something we can only do together.

How do you feel about this? Does it land comfortably? Or, does it land hot? I’m keen to know.

I actually admire this impulse. I’m often inspired by the challenges people set themselves, it’s deeply human. Wanting more, trying something new, stretching ourselves. That’s what keeps life interesting.

But a small reminder, from a psychologist’s perspective:

As the new year approaches, two things are worth holding gently in mind.

First:

It is perfectly valid to look around, feel inspired and still decide that 2026 is a year of staying calm and still.

You might choose to just be.

To let the year roll in and see how you get on.

That, in itself, is an aim. And a meaningful one.

Second:

Every January, a disproportionate amount of energy ends up focused on the same familiar themes:

More exercise, less weight, ‘new year, new you.’

As Matt Haig has said, you’re not an iPhone - you don’t need replacing.

You are already enough.

The only changes worth making are the ones you feel drawn to.

The ones that make the day pass a little more easily.

The ones you actually have the capacity, and the kindness, to make.

If I could grant some wishes for 2026, they would be:

1. That the unhelpful noise around weight loss, and the current obsession with GLP-1 drugs, was finally regulated.

2. That medications designed for health were no longer marketed, endlessly, through the lens of weight and body size.

3. I would ban talk of appearance and body size, full stop.

4. I would quietly retire ‘clean eating,’ ‘keto,’ and any other unsustainable rules dressed up as virtue.

5. And I would gently ask all parents, mums and dads, to stop dieting and restricting around their children. Because whether we intend it or not, that behaviour sends a message. That bodies must shrink or change shape to be worthy. We can set children free simply by erasing that conversation altogether.

If you want to take the pressure off this January, you could try:

1. Choosing one thing to stop, rather than something to start

2. Setting intentions around how you want your days to feel, not how you want your body to look

3. Unfollowing accounts that make you feel inadequate, rushed or ‘behind’

4. Letting food, movement and rest be practical supports, not moral projects

5. Giving yourself permission to arrive into 2026 as you are, not as a ‘before’

You don’t need a new version of yourself this year.

You just need a little more space to live in the one you already are.