The Fat Doctor Podcast

Charlie's Story

• Dr Asher Larmie • Season 5 • Episode 11

Share episode

 In this episode, I dive into Charlie's story, who develops Idiopathic Intracranial Hypertension (IIH) in their early thrities. Charlie's journey reveals the terrible reality of weight stigma in healthcare - from delayed diagnosis to being blamed for their condition, and ultimately being prescribed weight loss instead of effective treatment. I also get pretty fired up discussing how the medical establishment continues to prescribe weight loss for IIH based on a single terrible study with just 25 participants who were essentially starved on 425 calories a day! 

 If you'd like to learn more about IIH and weight-inclusive approaches to healthcare, head to noweigh.org for my free resources. My IIH Masterclass which is available now to all Masterclass members (£40/month). I also referenced my upcoming book and No Weigh program where I cover the evidence that everything you've been told about weight loss is a lie. And don't forget to grab a free ticket to my Fat Joy Celebration happening on Friday, March 21st at 5pm UK time (1pm Eastern, 10am Pacific) - we'll have a virtual potluck, dancing, and celebration of fat community! 

Got a question for the next podcast? Let me know!

Connect With Me

Find me on Instagram, YouTube, and LinkedIn.

 It is Wednesday the 19th of March 2025. This is season five of the Fat Doctor Podcast and I'm your host, Dr. Asher Larmie. You have no idea how long it takes me to get my head around those three simple facts when I start recording. But welcome to episode 11. I'm going to be talking about Charlie today. Charlie is another amalgamation of my many, many patients whom I have created to give you a little bit of a flavour of what it's like when you have a condition that is always, always, always blamed on your weight. So without further ado, let's just get into it. Charlie is a 32-year-old school teacher, primary school, elementary school, whichever way you want to describe it. And I have to say I've had a lot of patients over the years who are teachers and there is no doubt that they are some of the most hardest working people on the planet. So needless to say, a bit of a stressful job. And Charlie being the good person that they are, tries to remain active and generally healthy because, you know, that's what we're supposed to do. A little bit on the heavy side, let's be real - bit fat, but probably wouldn't use that word. Swims twice a week, watches what they eat, of course. Charlie really hadn't had to deal with doctors until a little while ago when they began to experience these headaches first thing in the morning and they were worse when they laid down. And occasionally have these visual disturbances as well like, best way to describe it was like a bit of double vision and maybe some kind of sparkly vision in the peripheries. A few flashing floaty bits, but not really like anything really obvious, but wasn't quite right. And at first Charlie attributed all of these symptoms to work stress and screen time because that's what we're told is very bad for our health and gives us headaches, which is true, by the way. Focusing too long on a small screen can absolutely give you headaches. And stress can cause headaches as well. They're not the only reasons we get headaches though. So whilst I understand why Charlie blamed those headaches on these simple things to begin with, it's not the only reason you can be getting headaches. And so eventually Charlie does what we all do. Took Charlie a while and that's because Charlie is fat and Charlie knows just how badly doctors treat their fat patients, even though they've never been to a doctor before. Not really, not as an adult, not really had to. But they know, they've heard, they've heard. Doctors aren't a fan and oh my gosh, of course they're going to blame my weight. So Charlie's put it off for as long as possible but eventually it's just like, well, probably ought to see a doctor about this. And so they go. And they see their GP because they're in the UK, folks, all right they're in the UK. So who do you see when you have a headache? You see your GP. I know it's different in different parts of the world. You can get in to see a specialist, maybe you have a primary care practitioner who will refer you. Maybe you don't even see a doctor, maybe see a nurse practitioner. But in the UK, unless you have some really weird and wonderful symptoms, your headache's getting managed by your GP. Very rarely are you getting referred to a neurologist. So go see the GP. GP listens vaguely, doesn't really spend much time looking up from their computer, does a lot of note taking. And then asks a few questions. And with very little effort on their part, diagnosis migraine. And on top of that, the GP finds a way, finds a way, folks, to bring weight into the conversation, which is hard when it comes to migraine because really, the two are not linked, but this GP finds a way, as they often do, they'll use any excuse you're sitting in front of them to mention your weight. Now, you might be thinking, why? Why do GPs do that? Well, in the UK, when a GP has their computer screen up with your notes on it, there's the top bits just got your name and your details. And then depending on which program you use there two, maybe three programs that the UK uses, all their GPs use. And so there'll be lots of information about you dotting around the screen and probably in the top right or left hand corner there will be something it might look like a post-it note, it might look like a little reminder saying these are all the things you need to do with this patient. So if the patient's diabetic, for example, it might say patient is due diabetic review. It might say you need to check their blood pressure. You need to measure their weight. And so weight is often one of the things. And that's because in order for GPs to make their money they have something called the Quality and Outcomes Framework, the QWF. QOF and basically they have all these rules they have to follow, all these boxes they have to take, all these jobs they have to do in order to earn the money that they need in order for the practice to survive and to thrive. This is not like additional money, this is like bog standard your income, the NHS will only pay you if you achieve this stuff. So we get rather fixated on that box on our screen. You see, it's quite loud and it's quite large and it's quite in our face and it's warning us. You have two months left until you have to finish this, that, and the other. And so that is one of the main reasons that GPs will be fixated on your weight. You see, there'll be a reminder mentioning your weight. And it could be because you have a BMI over 30 and in the UK, if you have a BMI over 30, you are in and on what we call the obesity register, which is literally a register of fat people. If you have a BMI of 30, you're on the register. You didn't even know you were. You didn't opt into the register. You're just on it. And so they might want to weigh you because of that. Or it might be that you have, I don't know, high blood pressure or your kidney function has been funny. It can be all sorts of reasons why your computer notes are flagging up that we need to monitor your weight. So a GP doesn't need a reason to mention your weight. They'll find a way around it if there's a reason, if there's a financial reason, primarily because we work for money and just like everybody else. I'm not excusing it, by the way, I'm just saying that it's the system that's kind of fucked when it's sitting there reminding you, do this, do that, do this it's very hard to focus on anything else. And that's deliberate, that's intentional. So that was a bit of a tangent we went on, but going back GP says it's just migraines, reduce your stress. You know, eat better, not much information. It's just migraines. Take painkillers when you need to. And there weren't an examination or tests or anything like that. It was a very simple kind of consultation and Charlie leaves feeling like, well, that was a waste of time. And so they do what everyone else in their situation does, who's just been scolded by their GP for being fat but hasn't actually been giving any real information. They turn to the internet and to Dr. Google. I'm not judging you for doing that. I mean, what else are you supposed to do if your doctor's not offering you good advice? Where else are you supposed to go? So researched it. And to be fair to Charlie typed in headache worse in the morning, worse when lying down, double vision and immediately out popped Idiopathic Intracranial Hypertension, IIH. And Charlie's like, what's that? Never heard of it. Starts reading about it, says it's quite common in certain groups. Oh, I meet all of those criteria. Hang on a second. This could be me. I think I've cracked it. So Charlie goes back to a different doctor this time. And says, I think I might have idiopathic intracranial hypertension. To which the doctor's like, you're probably wrong because a doctor's never going to admit when you've cracked it and they haven't. But they're like, you know what, fair enough. You meet the criteria. I'm going to refer you to an ophthalmologist who will look in the back of your eyes. And that's what we need to do when we're making a diagnosis. First things first. Have a look at the back of the eyes. And so referred to the eye clinic, Charlie goes to the eye clinic, waits for three hours, finally seen, drops in the back of the eyes. They look at the optic disc. Oh dear, they're swollen. Oh, that's not a good sign. That's a serious problem. Let's quickly refer you to neurology. So then has to go sit and wait in the emergency department for a few hours, finally get seen by a neurologist. Who was like, oh, we can probably do this as an outpatient. And then after all that, just sends them home and then brings them back and then they have to wait another few hours and eventually eventually what happens is they get a lumbar puncture. Which is the best way really to diagnose idiopathic intracranial hypertension. So for those who don't know, the lumbar puncture is when we take a needle essentially and stick it into your spine, into your spinal cord through the back. We don't go all the way into the nerve. That would be a disaster but we go into the canal which the nerve passes through and that canal is surrounded by something called cerebrospinal fluid or CSF liquid that basically bathes the canal. And in idiopathic intracranial hypertension, the pressure, the CSF pressure is high. So when we do a lumbar puncture, we measure the pressure and if it's really high, if it's higher than expected, then that is a diagnosis. So yeah, lo and behold, Charlie has idiopathic intracranial hypertension. Turns out Dr. Google was correct. And you'd think, all right. Asher, we're getting somewhere. Okay, there was a little bit of weight stigma at the beginning, but we finally have a diagnosis. This is great. This is not great. This is not great at all because this is a condition that is always blamed on weight. Just always blamed on weight. I have never met anyone who got an IIH diagnosis and their doctor went, oh, no, it's nothing to do with your weight. That's never happened in the history of ever. Maybe it has, but I've certainly never met this person, this elusive person. So I promise you. But also after the lumbar puncture, which by the way, not a pleasant experience, and after having to wait hours, probably days to get the diagnosis, maybe weeks, maybe months, who knows. It depends on how fast they're being. Eventually, eventually, you're sat in a doctor's office. Poor Charlie. Face to face with a neurologist, now neurologist, very serious people, right? Like they've done a lot of work to get to where they are. I'm not saying all doctors think they're God, but if you're going to find a God complex in a doctor, you're going to find one in a neurologist. And so looks over at Charlie and says, well, this is all because of your weight. If you weren't fat, this wouldn't have happened. That's nice. Just to be sat there, having gone through this all, I've been quite worried. Also, you know, like, this is not a sort of a laid back kind of situation where they just did a blood test. No, this was a lumbar puncture. This was people getting really worked up about the fact that, oh, you've got swollen optic discs, that can be very serious and we have to do this and that and an MRI. You know, they've had all these tests and they know it's no joke. It's not something that they should just, you know, they can just relax about. So to be told then after all of this palaver, it's all your fault. If only you weren't fat, this would never have happened. Is really problematic. It's harmful, isn't it? It's harmful to be blamed for a medical condition. Poor Charlie. I mean, I'm just talking about poor Charlie, like, you know, oh, poor Charlie. Yeah, I mean, that's bad. But also what happens if you're being blamed for, you know, if your weight is the only thing that caused it, well, guess what? What's the treatment? Weight loss. What's the other treatment? There is no other treatment. It's weight loss. Are you saying that weight loss is my only option? That is correct. Lose some weight. And that's what Charlie's told. Instead of being treated. Gets referred to a weight management program. And you might be thinking, all right, Asher, if there's no other treatment, what are you going to do? Of course there's other treatment. They just, they don't give it. Instead, they refer to a weight management program. And this is not a one-off situation, folks. This is what happens to pretty much everybody who is diagnosed with idiopathic intracranial hypertension. Unless, for whatever reason, that person is thin, in which case it's different. But if they're fat… It's weight loss. That's the solution. And so based on the doctor's advice and neurologist's advice, it's a very serious condition. You've had to have a lumbar puncture, an MRI. There's swelling, there's a raised cerebrospinal fluid. Charlie attempts some calorie restrictions, some extreme calorie restriction as advised. In fact. Everything Charlie's read and the people at the weight management program have said you could consider going down even to 800 calories a day. And Charlie doesn't go that far, but 1200, 1200 is the target. That's nothing. That's how much a toddler needs, probably less than a toddler needs on a daily basis. So what happens during this time? Not much happens with the headaches, if I'm honest. Not much happens with the vision either. Charlie is feeling good because they're losing weight and everyone's noticing and giving them a pat on the back and saying, well done, you're doing a really good job. Congratulations for taking control of your health. So they're feeling a bit better in themselves. But it's really not impacted their headaches or their vision. They are starting to be more forgetful and have memory lapses, for want of a better word, because they're hungry, because they're not getting enough energy. It's harder to focus, harder to concentrate. Are getting weak and dizzy sometimes just because of the rapid calorie restriction, energy restriction. They're not getting enough energy. Their body needs probably somewhere like 2,800 to 3000 calories a day, according to the calculation of how much the body requires just without expending any extra energy, just your basal metabolic rate. But they're only getting 1200 so maybe they're having half, maybe they're having less than half of what they need so that's no good. And unsurprisingly, eventually their mental health begins to deteriorate because it's not really helping their headaches or their vision, but they are feeling crappier and crappier. And after a while, especially when the weight loss slows down, which is the hardest part of the diet. That's not great. It's tapping into old disordered eating patterns. It's tapping into all of that shame and guilt that they're carrying around. There's no bueno, right? Oh gosh, that was the most English version of no good ever. Sorry about that. No good at all, folks. No good at all. So Charlie hits a crisis point. And one of the things they notice is eventually their headaches and their vision gets worse. And that's when they know that there's a serious problem. Because instead of getting better, it gets worse. It's a particularly stressful time of the year. They have what we call here in the UK an Ofsted inspection. That's basically the people who get to decide whether a school is good or bad and can stay open or has to close. They come and do inspections every so often. That was a very basic version of what Ofsted is, by the way. But yeah, stressful times. If you're a teacher, and I know a lot of teachers, I know a stressful time. So really stressful time at work. They've just had this inspection. You know, and so they're not having a great time of it. They're starving themselves, which isn't helping. They've noticed that their headaches are getting significantly worse. So bad one day their vision's an absolute mess they're nauseous they can barely open their eyes and just need to lie down. It feels absolutely horrendous, but lying down makes it worse. They just sit up in a dark room feeling absolutely horrendous. And so eventually go to the emergency room, don't know what to do, panic, can't get an appointment with the GP because of course they can't, the UK. So go to the doctor and eventually find their way back to the neurologist who says you haven't been following medical advice, I told you to lose weight. You haven't been doing it. And of course you're feeling worse. It's your fault. And Charlie's like, no, no, no, I've been on a diet. And the doctor's like, really? Because it doesn't look like you've done much. Maybe you're down a few pounds, but you've not tried hard enough. You just, you clearly don't care about your own health. And Charlie's like, no, no, no, I've been doing everything in my power. I am desperate. I am not getting better. And there's a lot of back and forth and it's a really, really painful experience. Charlie ends up crying halfway through the consultation, which they really did not want to do. Nobody wants to cry in front of their doctor, especially if it's because the doctor's being a big fat meanie. So yeah, it's quite horrendous. Charlie's not going to forget this consultation for a long time that has been burned, etched into their memory. And maybe on this occasion and probably not on this occasion, but maybe on the next occasion, eventually the doctor says, well, there is a medication we could try. There is a medication we can try, folks. It's called acetazolamide. It's not perfect by any stretch of the imagination, but it is a treatment for idiopathic intracranial hypertension. Why were they not prescribed this in the beginning, I wonder. It's an odd one, isn't it? Like if there is a treatment why not in the beginning? Anyway, horrendous, absolutely horrendous. And that is basically the management of idiopathic intracranial hypertension. And now I want you to imagine for a moment that Charlie connects with a weight inclusive neurologist. There must be one out there. I haven't met them yet, but they must exist. I'm not sure they're in the UK. It's probably one in the States. There's an organization that I think I've told you now several times that I'm on the board for this organization called the Association of Weight and Size Inclusive Medicine. I'm going to find out if there's a neurologist on there. And if there is a neurologist on there, I'm going to say, how do you treat idiopathic intracranial hypertension? I'm really curious. Anyway, in this fictitious world, in this world that having created this character, we're going to pretend for a moment. I mean, just make believe. But there is a weight inclusive neurologist. He sits down with Charlie and on the first consult says, hey. Idiopathic intracranial hypertension, the clue is in the name, idiopathic. Idiopathic means there's no known cause. So how are we blaming it on weight? If there's no known cause if weight was the cause, then it would be called weight induced intracranial hypertension. It's not idiopathic because we don't know what causes it. There is very little, if any, evidence for weight loss as treatment. And so this doctor, thankfully, rather than focusing on weight loss, because there's no evidence that it works, focuses on medical interventions, you know medicine. That's what we've been taught to do is practice medicine and in many cases prescribe medicine. And so this doctor has done the research, obviously, because they're neurologists, they've done the research, and they've looked through the evidence, the guidelines and the papers and stuff with a critical lens, looking at it through a kind of way inclusive lens, thinking well, is this really true? Is this fair? Is this right? And of course, no, the answer is no. So they've acknowledged, this doctor acknowledges the harm caused by previous weight-centric care and develops a management plan. A symptom plan that focuses on medication monitoring and quality of life. Can you imagine? And I said, well, Charlie's symptoms stabilize. And they begin to rebuild their relationship with food and with movements and with healthcare professionals. And it's not easy. It's not easy at all. But thankfully their vision is preserved and they maybe they get the occasional headache, but they're manageable. And life gets much better for Charlie because they finally got the weight inclusive care that they need. And in my make-believe world, of course. But I just wanted to highlight a few things that came out of this experience and it's absolutely relatable, I think, for a lot of people who'd be listening to this. The first thing is medical gaslighting when we say this is happening and the doctor goes, no, it's not. We say, I'm getting headaches and they're like, well. I'm in pain. Is it really pain or are you a hypochondriac? If you say, I have been trying to lose weight and they're like, have you? Have you seen you? Have you looked in the mirror? You're not trying to lose weight. And that's gaslighting. When you're not believed and when the doctor tries to sort of convince you that you're wrong. That what you're seeing is not factually correct. They make you doubt yourself and it's really harmful. And of course, there is the delayed diagnosis. Hello, if you're too busy gaslighting a patient and not actually bothered to listen to them or to examine them because of course the first time around when Charlie presented to the first doctor, if they had looked in the back of Charlie's eyes, they might have noticed the swollen optic disc. So actually not that easy to do without the proper equipment. But we do have a little fundoscope it's a little like it's a stick with a light on the end of it. It's a bit more fancy than that. And they're not cheap, you know, and we buy them for ourselves and we take really good care of them and they're in these little boxes that look very professional. And then you put it up to your eye. You have to be watching me on YouTube to really get this. And then you sort of you have to close the other eye and then you come up real close and it's very uncomfortable because you're right in the person's face. You have to make sure that you don't have bad breath or that you hold your breath and you go right up and you have a look in the eye and you go. And then down and slide to… But it looked like this and you're looking at the back of the eye. And so you can see it. So that would have been a really good way to pick it up earlier on. But you'll notice that neither the GPs did that they just, you know, first one dismissed it in the second one sent them off to the eye clinic. So, you know, that's not helpful. And that's delayed diagnosis. And we're lucky because Charlie didn't have any serious symptoms. But when we delay the diagnosis, sometimes we miss things and we can do long-term harm. What if Charlie's vision had been impaired for life? What if they'd lost some vision? That would have been a disaster. And then, of course, there is like the kind of disconnect between what the evidence says, which is there's really no evidence that weight loss helps. Versus what doctors assume, I'm not going to say believe, assume, which is that if you lose weight, it will absolutely cure your IIH. You're going to wonder, how is there such a disconnect? Why is the evidence saying one thing? And the reality, you know, the doctor's assumptions the other. Well, there's a lot of reasons. Number one, there's no access to the evidence. The doctors haven't actually bothered to read the evidence. They've read the guidelines. The guidelines are supposed to have taken all of the evidence and made some recommendations. Now, to be fair with IIH, it's actually quite hard to find guidelines. It's quite a rare condition. It's not one that has much investment in it. And that's because it really only affects females and fat females at that. And we know that these are chronically under-researched, underfunded groups of people. So there's not much evidence so therefore there's not much in terms of guidelines that there are some quite recently in the last few years, and I've taken a look at those. I've spent a lot of time reading about and researching this. They've even done a masterclass on idiopathic intracranial hypertension. In fact, you won't be surprised to find out that that's this month's masterclass. So if you're a masterclass member, you now have access to that masterclass. If you're not a member and you're like, hey, how do I become a member of the masterclass membership? That's not good, is it? That's not a good… I might need to work on that. But if you want to become a member, there's very simple. Just go to my website and you can just join for £40 a month, you get access to every single one of my masterclasses. And I think there's either 11 or 12 now. And on top of that, you also get weight inclusive Wednesdays, which is once a month where we all join together and we have a really lovely confidential virtual interaction, virtual Zoom call, live call. It's not recorded, so you can say what you want and not have to worry about that being preserved for eternity. We also have an Ask Me Anything situation. So if you can't make the live call, you can also ask questions and get answers to those questions even if you can't make it to anything life. I like to call that asynchronous coaching or asynchronous consulting, I might call it that instead. Yeah so that's like, you know, asynchronous meaning that we can do it at different times and we can still communicate with each other. So yeah, get all of that for £40 a month folks what are you waiting for? So just putting that out there. But anyway, part of it is that the research isn't out there or if their research is out there it's not been read. And part of it is just our own bias you know because we believe that being fat is bad and losing weight is good and that applies to everybody. And we just, you know, it's a very simplistic one size fits all no pun intended sort of piece of medical advice that we was willing to give to anyone when in doubt, well, lose some weight. We know that that's like you know, it's kind of like whenever anyone asks me, what causes my condition, I know I can say genetics. Like with absolute certainty. It doesn't matter what it is. Well, there's definitely a genetic component. Because there almost certainly is. And if there isn't, are you going to prove it? How are you going to prove there's no genetic? So I could just say it. Yeah. There's probably some genetic component and then there's probably some environmental component as well. That's a very good way to blag my way through a lot of things because it's true every single time. And I think doctors think that about weight. I just went and dropped. I was losing weight, not work. You know like take it to, I don't know, take a couple of Tylenols and come back in 48 hours if it doesn't get better. That's a very classic kind of line that we've learned. It makes life a lot easier just to just, yeah, lose some weight done. Out you go, off you go, we're done. I no longer have to contribute to those consultations. I have to think about medication, prescriptions, and so I just say. Lose some weight, off you go. So yeah, of course, when we tell our patients to do this, and I talked about this regularly, the biggest risk factor for weight gain is in fact intentional weight loss. And by that, what I mean is when you lose weight, you will inevitably almost always regain that weight and then up to two thirds of people actually end up being heavier. And we call this weight cycling repeated attempts at weight loss followed by weight restoration. And sometimes even weight gain. Now, weight cycling has been shown to be harmful. And a lot of the processes that we believe may be partly responsible for idiopathic intracranial hypertension, remembering it is idiopathic, so don't actually know what causes it. But there are certain things that we think, oh, yeah, this definitely has is playing a role. And of course these are links to weight cycling independently. So weight cycling is harmful, not just for idiopathic intracranial hypertension, but just in life in general. And then there's the psychological impact people. I cannot stress this enough. If you're being blamed for your condition, we talked about this last week, if you're being blamed for your condition. If you're being told you are responsible for being sick. It is your fault. I blame you. I am able to wash my hands of this situation simply by blaming you and telling you to go fix yourself. You cause a great deal of trauma. And I sort of alluded to the fact that, yeah, Charlie cries in the consultation. Or if Charlie manages to hold it together and leaves the office, gets into their car. And then starts balling and it can take weeks, sometimes months to get over these consultations. You know, they stick in our head. They come up at the most inopportune times. I don't know if you have this. But I will be merrily walking along one day minding my own business and all of a sudden, boom, I'll get a flashback to a situation that happened like five years ago when a doctor said something really horrible to me. And by flashback, folks, I'm not talking about like a clinical flashback here. I'm just talking, you know, the flashing back to the time. I don't want to confuse people. This is not post-traumatic stress although it is traumatic and it did happen a long time ago. So I'm not saying it's PTSD, post-traumatic stress disorder. But actually, this trauma does linger, doesn't it? And it accumulates over time. One is bad, two is worse, three is even worse, and so on and so forth. So if you've had like 10 of these in your lifetime like you have that's caused a scar. A scar, a big giant scar. I think I talked about this a few weeks ago when I was talking about a bag of shit where you just keep adding more shit to the bag and then it just gets bigger and bigger and you're just carrying around this giant sack of shit. And that's what medical trauma is like. So of course, there's the psychological impacts. And that has real life consequences. That has real kind of it causes physiological and psychological harm. So yeah, I just wanted to point all of those things out, folks. For a neurologist this is, this is the standard, oh, it's just idiopathic intracranial hypertension. It's just, it's not something serious. It's IIH and that one I can just breeze right through, blame on the patient's weight, send them on their way and never have to worry about them again. That's how a neurologist feels about this condition. But for Charlie, it's life-changing. Not only because of the headaches and the blurred vision, but because of the trauma that they now have to carry around with them for the rest of their lives. And it's not okay. And it's not okay. And I'm going to move on to the next section of this podcast, which is everything you've been told about weight loss is a lie. That comes from my No Weight program and my No Way book, which is "No Way: Everything You've Been Told About Weight Loss is a Lie." That's the title. You see how that works. And as you all know, I'm writing a book. I'm in the process. I'm doing chapter five right now. This piece of research comes from chapter four. Which is available if you're part of the No Way program you can head on to and read all about this and read all about idiopathic intracranial hypertension. But I thought I'd follow on from Charlie's story with a piece of evidence that I just think really sums up for me, a lot of what happens within the medical establishment. So this is Sinclair et al. It's al. Low energy diet and intracranial pressure in women with idiopathic intracranial hypertension, prospective cohort study. I actually like the fact that they were just very direct with this. All right. Low energy diet in IIH. What's the prospective cohort study. It was released, when was it? July 2010. So as I said twice and I will say again, as a prospective cohort study that means it, retrospective means we're looking back we get all these people with IIH diagnoses and we look back, but in this case it's prospective. We've got these people with IIH and then they're on a low energy diet and then we follow them in the future. And it's not a randomized control trial because we're not like there were a randomized controlled trial, there has to be at least two to arms to the study and controlled conditions in order to remove the bias. This is not the case. They just took a bunch of fat people with IIH and just put them on a low energy diet and watch them. So there's a lot of bias already introduced into this study just because we don't have two arms. We don't have cases and controls that we can compare with. 25 women. There were women, they were called women. I mean, I'm assuming that means that they're female, but they call them women, so I will call them women. 25 women in this study, only 25. And only 20 completed the study, which is, you know, 20% dropout rate is not very impressive, is it? But there you go. 25 women, 20 completed study with idiopathic intracranial hypertension and a BMI of greater than 25. They weren't all that fat. I just want to point that out. There were sort of small fats, not like they didn't include anyone with a BMI of over 40 or anything like that. But anyway, 25 of them fat women there were three month stages. So there was the baseline no intervention and then three months and then they follow a diet for three months. And I'm going to shock you all here when I say it but it is true 425 calories a day. So in the past when I've worked with people with eating disorders that's, that's anorexia nervosa kind of, you know, possibly needs admitting and feeding, even possibly needs admitting and feeding against their will with a 425 kilocalorie per day diet that is dangerously low. Dangerously, dangerously low. But this was a treatment, 425 calories. I can't get my head around the fact that the ethics committee like granted permission to do this study that was allowed, that we could starve people for three months. It's not like three days. Three days, okay, this is three months sustained starvation. That's got to cause a lot of damage to the body. But anyway, so baseline in three months of starvation and then they're followed up and then another three months later they're followed up again so from baseline to the end of the study was six months. This wasn't very long. And I talked about this before, but really if we want to have any idea of whether or not an intervention has worked, it needs to be at least ideally, when it comes to weight loss, two years, at least two years, one year, anything less than one year is no point in looking at but one to two years, I'm still not convinced. Over two years, better. Over five years, much, much better. But six months, a lot can happen in six months, especially if you starve them, give them 425 calories a day, because that's not sustainable, of course. So that's highly dangerous. So very few people, high dropout rate, ridiculously low calorie intake and only followed up for three months after the diet ended. So you will not be surprised to hear that the mean weight loss was 15.7 kilograms. Which is like 40 pounds, something like that. I don't know. I'm just guesstimating in my head. That does not surprise me. Because you starved them. And so what did they find? Well, they found a 20% reduction in intracranial pressure. 20% reduction in the pressure that you measure with the lumbar puncture. 10% reduction in headache severity. 10% reduction. So instead of like you know 10 out of 10, we dropped a 9 out of 10. And so on and so forth. They found less swelling at the back of the eyes, but I mean that's less important than visual symptoms of which there were no real improvements in the visual symptoms. There was less swelling at the back of the eyes. There were fewer women, fewer participants reported blood vision and double vision. But as I said, there's only a few people to start with. So it wasn't particularly significant. Visual function remains stable. Only five participants showing a slight improvement in that, so exactly five out of the 20. Out of the 25, sorry, out of the original people they were studied. So three months, so this was after the diet and then three months later, everything remained the same. Like the headaches reduction and the reduction the swelling and the disc and everything remained the same after three months. But we don't know what happened after three months after that. That was it. It stopped then. So what do you think? I can't do a show of hands because it's a podcast but if we were here all together and we had a show of hands raise your hands if you think this is a good study. And by good, I mean high quality. One that we can confidently rely on and say, yeah, that's given me enough information to be able to make a recommendation for weight loss. Raise your hands. No, none of you? No. Not convinced. Yeah, I'm not either. Because it's a really shit study, isn't it? Really, really shit. Like, can't believe this made it into a, it's a general shit. Like, really? That's the best you can do, folks. And you know what? That is the best they can do. This is the only study in the history of studies that shows an improvement in headache severity or visual symptoms with weight loss in idiopathic intracranial hypertension. In fact, every other study, the bigger studies, the more long-term studies, have all shown absolutely no improvement with weight loss. It's only this one that shows some improvement. And just to repeat, just so you remember, it's a 10% reduction in headache severity. They starved people on a 425 calories a day for three months, which I'm pretty sure causes headaches if nothing else. And as a result, they got a 10% reduction in headaches severity. That's it. That's as far as they got, folks. That's shit. That's absolute fucking shit. And that is the only study out there. That's what we're, that is where our recommendation to lose weight comes from folks. Everybody's ever been diagnosed with IIH and you've been told you need to lose weight based on this fucking study. How outrageous is that? How outrageous is that? Everything you've been told about weight loss is actually a lie. And that's not hyperbole. It's the truth. We're going to move on to Ask Me Anything. The portion of this podcast, the section of this podcast where you get to ask me a question and I will do my best to answer it. I have had a couple of questions come in, thankfully, because for a while none of you cared. None of you were asking me. I was like, folks, don't you have a question you want to ask me? I jest. I know you've all been exceptionally busy. You can ask your questions at the bottom of the YouTube videos. In my Instagram, there's usually at least one post that invites you to ask questions a week or you can email me contact at fatdoctor.co.uk and ask me a question. And this question was, my doctor has told me I need to lose weight because my cholesterol is high and I'm at risk of a heart attack if I don't. Is this true? So it's impossible to answer the question without asking for further clarification, but I will explain what I would do in this situation. So you've had a cholesterol test. That we know you've had a lipid test. And there are various things that we look at. The first is the total cholesterol. The second is the HDL cholesterol, high density lipoproteins. This is the quote unquote good cholesterol. So we want that to be higher. And we want the LDL, the low density lipoproteins, to be lower. So it's not just the total cholesterol, but it's actually the you know, how high is the high and how low is the low? We also look at triglycerides, which is not cholesterol. It's a different type of lipid, a different type of fat in the blood. And that's what we look at. To be honest, cholesterol is the important one when it comes to heart disease. Triglycerides less so. And we're able to take your cholesterol levels and your blood pressure levels and calculate your risk. So, you know, you've been told that you're at high risk of heart attack. Be specific. Give me a number. I want the number. If you live in the UK, we use the Q-Risk 3 school. If you live in Europe, there's a different school calculator. I forget what it's called. And in the States, again, a different school calculator. And if you head over to nowway.org. There is, in the kind of free resources that talks about cholesterol and talks about cardiac risk. There is a link to all of these calculators and you can if you know what your cholesterol levels than your blood pressure is. You can actually go and calculate it yourself rather than relying on your doctor and just go and use it online calculator, anyone can use it. I obviously, because I live in the UK and practice in the UK, use the QRISC-3 calculator. It's the only risk calculator that actually doesn't require weight, but you can add weight in, whereas all of the other ones don't actually even look at weight. But then it gives you a number, literally. Ask you for your age and where you live and all sorts of other questions. And then it spews out a number. And this is not an absolute prediction. We're not psychic. We can't hold our hands over a crystal ball and tell you exactly what your risk is. But if you had 100 versions of you with the exact same risk factors, X many would go on to develop a heart attack or a stroke in the next 10 years. That's the calculation that we're working out. And if it's less than 10%, we would say that's low risk. If it's over 20%, we'd say that was high risk. And if it's between 10 and 20%, it's moderate risk. Depending on where you live and what the guidelines are, we would absolutely treat high risk. So anybody over 20%, we would recommend treatment. Between 10 and 20 is more of a kind of grey area. I think certainly as time has progressed, we're becoming more proactive about treatment. There's definitely a conversation to be had there. Under 10% probably no point in this. There's no real evidence that there's any benefit to treating at that stage. Now, one of the biggest risk factors for heart disease is age. So as you get older, the calculation will change by definition. The second biggest risk factor, not biggest necessarily, but one of the other biggest is if you're male or female. You're much, much higher risk if you're male or if you're female. But there are all sorts of other things like your medical history and, you know, if you have a family history and do you have diabetes and do you have high blood pressure and all sorts of things. So, you know, like I said, you need a personalized calculation. So to the person who asked me this question. Am I at risk of a heart attack? Well, all of us are technically at risk of a heart attack. A heart attack, strokes, cardiovascular disease are the biggest cause of death in the UK and are very common, very, very common. The older you get, the more likely you are to get one. There are certain things that put you at high risk. If you're diabetic, if you have high blood pressure and if you have high cholesterol. So theoretically, you are at higher risk, but we're actually able to calculate that risk so rather than just being very vague about it, it would be more useful if your doctor could give you a number. Now, in terms of treating it. There really is only one option here. They can tell you all about diet and lifestyle and I can assure you that there's very little evidence that's going to help at all. Weight loss isn't going to help. And that I can show you using the QRIS 3 calculator but also just diet, you know, there's no evidence. Looking at the evidence, does weight loss help? No, not really. Does just changing my diet, like going on a low fat diet, or not really. In fact I was looking through the National Institute of Clinical Excellence, the NICE guidelines not that long ago on lipids and cholesterol. You know, the evidence was overwhelmingly crap. Once again, shit. Poor quality no real benefit. Most of the evidence was pre-1990s. So really not helpful in today's modern age. We don't tend to give much weight, pardon the pun, to any evidence pre-1990s. So because a lot has changed since then. But yeah, there's no evidence really that changing your diet, modifying your diet in any way or losing weight is going to improve your risk of heart disease. So that's not going to work. However, what does work is statins and I can confidently say that the evidence I overwhelmingly suggest roughly a 25% decrease in risk. If you stop taking a statin or lipid lowering drugs, but really it's statins, the other ones are not as effective, if you start taking one today. You will reduce your risk by 25%. It doesn't matter who you are. It doesn't matter how old you are, what your cholesterol is. It doesn't matter. It's all independent, actually. Nothing to do with your cholesterol level, per se. It's all to do with the fact that statins reduce your risk of heart disease. And they do so by a factor of about 25%. Now, if your risk is 4% and I give you a cholesterol lowering tablet, I reduce your risk to 3%, which is not very impressive, is it? But if your risk was 20%, I've reduced your risk to 15%. And if your risk is 40%, I have reduced your risk to 30%. Now that's significant. Right? So it very much depends on who you are, whether or not we need to do anything about are you at risk of a heart attack? I don't know, but it's easy to calculate. Should we do something about it? Possibly. And the thing we should do is start a cholesterol lowering tablet. If you want now there are pros and cons, there are benefits and risks and you need to discuss that with your own medical professional. However, what I will say is now the evidence for weight loss is slim to nil. In fact, since we know that weight loss almost certainly results in weight restoration and even weight gain over the long term and repeated cycles have been shown actually to increase your cholesterol also certain types of diets, especially high protein diets, low carb, high protein diets they've actually been shown to increase your cholesterol levels anyway even in the short term, not even in the long term. So we have to be very careful about recommending weight loss for anything, but certainly for cardiac risk and high cholesterol because we might actually in the long term be causing more harm than good. I mean, I mean, we will. In the long term, we'll be causing more harm than good almost certainly. So I hope that was helpful. I'll drop a link to the Q-Risk calculator in my show notes as well as the link to my link to the section on the no way homepage that's specifically about cardiac risk and cholesterol. What else is there to say? Well. What date is it that this is coming out? Is it, oh, no. Yeah, no, I said it was the 19th, so I have to get, I mean, I'm recording ahead of time. So on the 21st, in case you haven't heard already, I hope you've heard already. I'm having like a fat joy celebration in honor of spring and the spring equinox and of course if you live in the southern hemisphere that's okay because just as important as going from winter to spring is going from summer to autumn two very important equinoxes. And I'm going to be celebrating with fat people because I, it came about because I was listening to an astrology podcast as I do. And also as part of a couple of tarot readings I did for myself where I felt a real need to create just a space for celebration. Food. There will be a virtual potluck, people, where I encourage you to bring food and tell me about your food and tell me about the recipe and even share the recipe if you're being generous. Especially if it's a food that means something to you if it like reminds you of home or if it's very comforting or if it's a recipe that was passed down from generation to generation. So there'll be food, there'll be dancing, there'll be music, there'll be celebrating, and it's free. It's completely free. I just wanted to do this thing for the community. I hope there's still tickets left, but I don't know because I haven't released it yet. So it's on the 21st, which is Friday. Friday the 21st of March at 5 p.m. UK time, which is and now this is really difficult to calculate because it's not even the standard time difference because American people, you've already put your clocks forward and Europe hasn't yet. So that would be Eastern time 1 p.m. Pacific time, 10 a.m. So 10 a.m. Pacific time, 1 p.m. Eastern time, 5 p.m. GMT. UK time. And so, yeah, that's when we're doing it and you just need to register for a ticket and then we're going to have some fun. All right. Next week, I have a guest. I'm going to tell you that guest is. I'm always very wary of telling people who the guest is just in case it doesn't happen. But next week I will have a guest. And it'll be awesome. And we will be preparing for April which is coming up not too long in the future. April is Autism Awareness Month, peeps. And so I'm going to talk a little bit about being autistic. But having autistic children and about how autism and neurodivergence impacts or intersects with fat justice and with weight stigma and weight inclusivity very important to consider all of the intersections. So that's what we'll be doing. Thanks very much for joining me and I will see you next week.