Know What Your Doctor is Really Thinking #3: Dear GP, Please refer this overweight lady to the dietician. (Dear Colleague, No - and here’s why)

You’re back to see me with a letter in your hand - the one from the knee clinic. You want to know why, after twenty years of pain, an MRI confirming the joint is genuinely wrecked, and a specialist agreeing you need a replacement, the answer is: not yet, go and see the dietician first.

Thank goodness you bought the letter with you, because the NHS is utterly dreadful when it comes to communication. But now you’re here, paper in hand, let’s have a read:

On the face of it, not unreasonable. There’s a problem, the solution is hampered by your weight, refer to the dietician. Clean logic. Except I already know, before you’ve said a word, that you’ve done this before. To be clear - the surgeon is right: weight loss will not only lower your anaesthetic risk considerably, but will also improve your chances of a good outcome from the joint replacement. So they aren’t being deliberately obstructive - they perhaps just aren’t equipped to deal with what has to happen before you go under the knife.

I don’t need to ask whether you’ve tried to lose weight. I need to ask what you’ve already tried, because your answer will tell me what the letter doesn’t:

• Which diets, and for how long - Weight Watchers, Slimming World, low carb, no carb, intermittent fasting, whatever came after that

• Whether you understand the physiology already - some patients arrive knowing more about obesity medicine than the orthopaedic consultant does

• Has anything changed significantly for you in the last few years - hormones, work, sleep, family, other illnesses, stress, finances

I’m asking these not to catch you out, but because if you’ve already run the standard playbook and it hasn’t worked, sending you to run it again isn’t a plan. It’s a delay dressed up as a management plan.

There’s a version of this where I write “Weight loss required, Refer dietician” and move on to the next patient. That’s the easy out. In reality, I suspect you are well aware of the nutritional differences between a Terry’s Chocolate Orange and a citrus fruit from the fields of Seville. You are probably well-versed on the benefits of protein with every meal and the sugary down-sides of bowl of ice-cream eaten in bed while watching the latest episode of Bridgerton. A dietician is very, very rarely the answer in this scenario.

What I’m really trying not to miss is any underlying faulty biology that could be exacerbating your weight struggles, and then - once we’ve excluded that (I’m specifically thinking about undiagnosed type 2 diabetes and thyroid dysfunction) we need to have a proper think about the underlying physiology of obesity.

• Cortisol running high from years of unmanaged stress driving up insulin resistance, worsening inflammation and increasing your appetite for simple carbs

• Leptin resistance and ghrelin surges all working to tell you you’re hungry - even though you’ve already eaten more calories than your body can use

• GLP-1 signalling that isn’t as effective as it was when you were 20

This is biology working to keep your weight firmly where it is, and sadly not helping you to get it to where the orthopaedic chap wants it to be!

Not in the way the letter implies. I’m not sending you off to relearn nutrition you already know. What I’d actually want is:

• Some simple labs to check TFTs (thyroid function) and HbA1c (diabetes)

• Consideration of medical therapy alongside an all too-familiar discussion around lifestyle. Years of trying and failing often pushes us to give up on the boring, but essential parts of this very tricky puzzle.

What I won’t do is send an expert patient to a beginner’s nutrition appointment. Referring you to see the dietician at this stage is like booking Richard Branson in to see the small business manager at your local bank.

Obesity, in most cases, isn’t a knowledge problem. It’s a physiological one - one that’s been actively working against you for years, and that no amount of willpower alone was ever going to out-argue. It’s not you, it’s science.

I don’t wait twelve months for you to go round in circles again before asking if it worked.

• Referral for proper obesity-medicine input, not a repeat dietician appointment. This might be for consideration of medical therapy, or in some cases input from the bariatric team. Bariatrics used to be a dirty word, but honestly it can be a game changer for the right patients. Waiting a lifetime for a problem that isn’t going to fix itself is a life wasted.

• Encouragement to get back to the good eating habits you already know how to do.

• A plan for regular strength training - building muscle is not only one of the few effective levers in the battle of the bulge (by reducing insulin resistance and boosting metabolism), but it will also help prepare you for surgery - prehab is the new rehab!

• Ongoing input from the orthopaedic team in parallel, not sequentially

• Regular check-ins. Weight loss, regardless of your route, is not an easy journey. Life gets in the way, your lose focus of motivation, get scared about the options offered to you - these are all things you GP is there to talk through.

I want to know how you’re actually feeling holding that letter - because for a lot of people, “refer to the dietician” reads as you did this to yourself, go and fix it. That’s not what it says, but it’s often how it reads. If that’s sitting with you, say so. It gives me chance to tell you otherwise.

You’re not an expert patient because you failed at losing weight repeatedly. You’re an expert patient because you’ve been running the experiment on your own body for twenty years, and the results are data that reflect biology - not evidence that you didn’t try hard enough.

If GLP-1s are something you’re embarking on or curious about - in this Clinic episode, I talk about what to expect at the start of a GLP-1 journey. Check it out.

* The content of these emails/posts/publications/audio files is intended as general health and wellness information, not as individual medical advice. Please consult your own doctor for advice that is specific to you and your needs.