Doctors Don’t Get To Be Everybody

Everybody knowsI am super excited about being a blogger for Weight Stigma Awareness Week, which starts today.  You can get all the information here!   You can also follow the action (and join in) on Twitter using #WSAW2014

For many fat people a history of absolutely terrible experiences causes them to avoid the doctor’s office more than they would avoid the plague that might send them there. We shouldn’t have to “arm ourselves” just to go and get an annual check-up, but the truth is that many of us do. In this situation, information can truly be power.

Weight and health. “Everybody knows” that they are the same thing – that you can tell how healthy someone is by their body size. “Everybody” knows that weight loss improves health. “Everybody knows” that this is proven in study after study.

Except it’s not. “Everybody” is wrong. This is something that happens a lot. If we went with what “everybody knows” we would still believe that the sun revolves around the Earth, that heroin is a non-addictive substitute for morphine and that Lysol makes a great douche.  And let me just add…yikes.

Doctors are steeped in the biases of the societies where they live just like we all are, but by choosing to become healthcare practitioners, I argue that they create an obligation to examine and overcome those prejudices and to provide care that is evidence based, driven by informed consent, blame free, shame free, future oriented and compassionate. Let’s break these down one by one as they pertain to fat patients

Evidence Based, Informed Consent

There isn’t a single study that exists where more than a tiny fraction of people were able to maintain weight loss for more than a few years. Even among those “success stories” the amount of weight loss was very often five pounds or less. So if a doctor suggests that you should lose and maintain a more than 5 pounds and to maintain that loss for more than a couple of years they are asking you to do something that, based on every piece of research that exists, is nearly impossible.

From the perspective of a healthcare professional making recommendations about health, there are no studies that would lead us to believe that maintained weight loss is even remotely likely for most people. Therefore, recommending weight loss simply does not meet the criteria for evidence-based medicine. If a doctor wants to prescribe weight loss, she or he must therefore meet the requirements of informed consent – that is, the doctor has an obligation to tell the patient that while most people lose weight in the short term, the most likely long term outcome of any weight loss attempt is weight regain, that a majority gain back more than they lost and that there is no study showing that even if the patient is in the tiny minority that succeeds there is no study that demonstrates health improvement, and that studies in fact suggest that weight loss is not associated with improved health.

In order to fully inform the patient, the doctor should at that point let them know that studies that take behavior into account show that changes in behavior are shown to lead to improved health outcomes whether or not they lead to a change in size.

To put it succinctly – knowing that health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed in any circumstances and that each of us gets to choose how highly we prioritize our health and what path we want to take to get there, and that those choices can be limited by circumstances beyond our control including access, socioeconomic status, discrimination, and the availability of true, unbiased information – healthy behaviors give us a much better chance at improved health than does weight loss if that’s something that we’re interested in.

Blame Free, Shame Free, Future Oriented

There should be absolutely no shame in having a health condition.  None. Ever. It does not matter why someone has a health issue, it matters what happens moving forward.  We can never change the past so after a diagnosis there’s no point in even wondering if it’s the patient’s fault and it certainly doesn’t help to make them feel ashamed.

I don’t believe that body size constitutes a disease diagnosis.Even if a doctor believes that being fat is a disease or even that being fat is a bad thing and being thin is a good thing, creating shame around weight has actually been correlated with weight gain so, again, that doctor would not be practicing evidence based medicine if she or he were trying to shame patients as a path to weight loss or health (not to mention the other issues with weight loss and evidence that we already discussed.)

People who are diagnosed with a health condition should be given true information, all of their options, have all of those options available and affordable for them, and be given compassionate care based on their values, culture, and choices. In order for them to be in the best place to make those choices they need to feel empowered and not shamed, blamed, or guilty.

The only kind of healthcare that makes sense is blame free, shame free, and future oriented.

Compassionate

To me this is the catch all category. Even if a doctor believes that people’s fat is their fault, even if doctors believe that they should encourage patients to diet despite the lack of evidence for and the mountain of evidence against the practice, even if doctors are steeped in a fat phobic society, they still have an obligation to first do no harm. As such, doctors are required to, if not examine and eradicate their prejudice against fat people, at least keep it to themselves and provide the same level of care and service that they give to patients against whom they don’t harbor bigotry. (If you’re looking for an example of precisely what not to do, this doctor can help you out)

I don’t know if we’ll ever stop having debacles because we put “everybody knows” before the actual evidence, but when it comes to healthcare, doctors have to do a lot better than “everybody.”

For thoughts on how to talk to your doctor about these things, check out this post

Here is the research that supports this post:

Research about the failure rate of dieting:

Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J: Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer (link goes to article)

http://www.ncbi.nlm.nih.gov/sites/entrez/17469900 (link goes to study)

“You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back.  We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people…In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.”

http://www.academia.edu/4796404/Tomiyama_A._J._Ahlstrom_B._and_Mann_T._2013_._Long-term_effects_of_dieting_Is_weight_loss_related_to_health_Social_and_Personality_Psychology_Compass_7_12_861-877._doi_10.1111_spc3.12076

We believe the ultimate goal of diets is to improve people’s long-term health, rather than to reduce their weight. Our review of randomized controlled trials of the effects of dieting on health finds very little evidence of success in achieving this goal. If diets do not lead to long-term weight loss or long-term health benefits, it is difficult to justify encouraging individuals to endure them

Miller, WC:  How Effective are Traditional Dietary and Exercise Interventions for Weight Loss

“Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr. The paucity of data provided by the weight-loss industry has been inadequate or inconclusive. Those who challenge the use of diet and exercise solely for weight control purposes base their position on the absence of weight-loss effectiveness data and on the presence of harmful effects of restrictive dieting. Any intervention strategy for the obese should be one that would promote the development of a healthy lifestyle. The outcome parameters used to evaluate the success of such an intervention should be specific to chronic disease risk and symptomatologies and not limited to medically ambiguous variables like body weight or body composition.”

Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel

A panel of experts convened by the National Institutes of Health determined that “In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years.”

Bacon L, Aphramor L:  Weight Science, Evaluating the Evidence for a Paradigm Shift

“Consider the Women’s Health Initiative, the largest and longest randomized, controlled dietary intervention clinical trial, designed to test the current recommendations. More than 20,000 women maintained a low-fat diet, reportedly reducing their calorie intake by an average of 360 calories per day and significantly increasing their activity. After almost eight years on this diet, there was almost no change in weight from starting point (a loss of 0.1 kg), and average waist circumference, which is a measure of abdominal fat, had increased (0.3 cm)”

Field et. al Relationship Between Dieting and Weight Change among preadolescents and adolescents

“Findings from this study suggest that dieting, and particularly unhealthful weight control, is either causing weight gain, disordered eating or eating disorders; serving as an early marker for the development of these later problems or is associated with some other unknown variable … that is leading to these problems.  None of the behaviors being used by adolescents (in 1999) for weight-control purposes predicted weight loss[in 2006]…Of greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors, including significant weight gain…Our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain”

Studies about healthy habits leading to healthier bodies

Matheson, et al:  Healthy, Lifestyle Habits and Mortality in Overweight and Obese Individuals

“Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”

Steven Blair – Cooper Institute

“We’ve studied this from many perspectives in women and in men, and we get the same answer: It’s not the obesity, it’s the fitness.”

Glenn Gaesser – Obesity, Health, and Metabolic Fitness

“no measure of body weight or body fat was related to the degree of coronary vessel disease. The obesity-heart disease link is just not well supported by the scientific and medical literature…Body weight, and even body fat for that matter, do not tell us nearly as much about our health as lifestyle factors, such as exercise and the foods we eat…total cholesterol levels returned to their original levels–despite absolutely no change in body weight–requiring the researchers to conclude that the fat content of the diet, not weight change, was responsible for the changes in cholesterol levels.”

Paffenbarger et. al. Physical Mortality:  All Cause Mortality, and Longevity of College Alumni

“With or without consideration of …extremes or gains in body weight…alumni mortality rates were significantly lower among the physically active.”

Wei et. al. Relationship Between Low Cardiorespiratory Fitness and Mortality in Normal-Weight, Overweight, and Obese Men

Research about doctors perception of fat patients

Rebecca M. Puhl and Chelsea A. Heuer The Stigma of Obesity –  A Review and Update

“In a study of over 620 primary care physicians, >50% viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the sample further characterized obese patients as weak-willed, sloppy, and lazy.”

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Published in: on September 22, 2014 at 6:38 am  Comments (26)  

26 CommentsLeave a comment

  1. I was fat shamed a lot by doctors and health professionals. One doctor I visited because I suffered a mild depression and wanted to intervene before it gets worse didn’t even listen to me and just told me to avoid junk food (he didn’t even bother to ask me about my eating habits) and exercise more (he didn’t even bother to ask if I exercise and was totally surprised when I told him that I do) and literally pushed me out of his office before I could even mention that I was concerned about my high body temperature of late and that I wanted him to check if I have an infection.
    I was fat shamed by my therapist, who wanted me to participate in a group for people with eating disorders after she insisted that I must have one. And after she told me that she thinks I dress too “sexy” for my size.
    And the worst of all: A few years ago I was having an abortion. The decision was the hardest I ever had to make, and I was feeling horrible aside from the chronic depression I suffer. The anesthetist not only fat shamed me but was downright cruel and abusive, so I had a nervous breakdown right before the procedure. When I climbed into the chair she even asked me if I was even able to lift my legs and put them into the holdings. WTF? I was given a short general anesthesia for the procedure and I remember waking up crying. This happened 6 years ago and I just cannot get over it, but I don’t know what to do. I never even talked about this with anyone.

    • I am so sorry you had to go through all that. If at all possible, dump the doctors and therapists who treat you badly. Report them to their licensing/governing boards. Rate them poorly on Angie’s List, if you are a member.

      But please don’t let them get into your head. They are the ones who have done shameful things, not you. You deserve to be treated with respect and compassion, just like everyone else.

      • Thank you! I just wish I had known this blog back then and had had the support of all you lovely people, I think I would have reacted completely different. Every once in a while I think about writing a letter to these people and maybe send it to them, maybe not. Just to get it out of my head.

        • Write those letters!

          Let ‘em know that their horrific treatment caused you great emotional pain and adversely affected your life today. Get specific too. No need to be impolite but do tell them exactly what they said and did and exactly how it affected you. Make sure they understand this was six years ago and it still colors your thoughts today. Call it a learning moment for them.

          Remember it’s them- not you- that did something wrong here. Maybe they will see the error in their ways and resolve to be kinder to their patients from now on.

    • I was going to comment last night, but held back. I think an abortion would be the worst time in your life since you made a decision that has life altering consequences (for you and for the child) and it’s probably the point in your life when you feel the worst about doing it. Being fat shamed on top of that was inappropriate. It was not the correct time for the anesthetist to do that (nor was any time appropraite) and it make you feel even worser than worst.

      I would advice you to write, as the other person has.

      • Mich, just so you know, not all women feel bad about their abortions. My abortions were some of the best decisions I ever made, the worst part of it were the horribly mean people outside trying to stop me from doing what I knew was best for me.

        Klara, I’m so sorry that happened to you. You are strong and you know what is best for you. As others said, write those letters!

  2. At the moment I have the weight that society sees as ideal for me. How did I do that? Well, I lost a lot of weight by being quite ill the first half of this year – and if I hadn’t had some weight before getting ill, it would have been much harder for my body to support me through this time, I think. Now I am healthy and fine again, thankfully, and of course am gaining weight again – I’ve had the same weight for 20 years now, was happy and healthy and fit with this weight, and my body wants to go back there, now that everything is ok again.
    But of course “everybody knows” that when you see a thin person, you see a healthy person😉 – I love your posts about that

    • Some years ago Mr. Twistie also lost a lot of weight (about thirty pounds, or so) and I remember a few people telling him how great he looked and asking how he did it.

      Funny thing, not one of them thought having a triple bypass sounded like a very fun way of losing weight. And I was relieved when he started regaining his normal weight, looking less ashen, and being able to move more comfortably.

      Oh, and the last time I lost a significant amount of weight was about five years ago when I came down with pertussis. One of the side effects I’d never heard of with that one is that it completely throws off your senses of smell and taste. It wasn’t that I wasn’t hungry; it was that everything I normally eat smelled so horrible to me that I would get the dry heaves just from the smell.

      For more than two weeks, the only foods I was able to tolerate were cottage cheese and the blandest apple sauce Mr. Twistie could find, I can’t tell you the thrill the day I could smell garlic again without wanting to heave!

      But hey, the important thing is that I lost weight, right?

      (epic eyeroll)

      • Isn’t pertussis whooping cough? I didn’t know it could do all that.

        There is a vaccine DTaP that I’ve been trying to get (diptheria, tetanus, and pertussis).

        • Yep, pertussis is whooping cough. I made it into my late forties without ever having met anyone who had had it… and then I came down with it. I hadn’t heard that it was so much on the rise, so it never occurred to me that I might have it. I tried to tough it out on my own for days before Mr. Twistie insisted we see a doctor. No insurance made me VERY reluctant to go.

          Get the vaccine. Trust me, you don’t want the disease. Not only is it wildly unpleasant, it has the potential to kill you.

          On the upside, nobody at the ER fat shamed me.

    • I have been heavy, as have all the women on both sides of my family, for as long as I can remember. I remember that when I had a cocaine addition and lost weight everyone was like “Oooo wow you look great!, What are you doing?” In my head I would say “OH I’m slowly killing my body by starving myself because of a highly dangerous, toxic, and addictive substance that is ruining my life”

      But of course, because I was losing weight, I must be healthier!

      I hate society.

  3. The point of being a scientist is that you have to hold yourself to a higher standard than ‘everybody knows.’ Doctors are supposed to deal in facts, not fairy tales.

  4. I always love your doctor posts, Ragen. It amazes me how often fat bias is used to justify so many health conditions…without even bothering to look further (or how often doctors resort to “In the future, you’ll have…”).

    My first big fat-shaming experience came when I had to go for an annual exam to get birth control. This is uncommon outside of the states — really, you only need someone to take your blood pressure and check your medical history. In America, getting your genitals examined while someone talks about how fat you are is usually a requirement.

    I had lost 50 pounds since my previous visit. During my previous visit, my blood pressure had been normal. No one warned me that a side effect of taking birth controls with estrogen could be high blood pressure. So, when I went in and my blood pressure had gone from its usual 110/70 to 140/90, they heaped on the fat shame like no tomorrow. I was told that they couldn’t possibly prescribe me that pill again because my blood pressure was so out of control. They even wrote my BMI down — in red! — and circled it. The NP proceeded to use her PEN to point things out to me on this paper that she was going to give me, as though I couldn’t read.

    I went onto the mini pill instead. And — heeheehee! — within 2 weeks, my blood pressure was back to normal.

    I’m also pregnant and around the time I was 30 weeks, a midwife I had never seen before told me that my file included a note that my weight was preventing the midwives from getting an accurate fundal height measurement and I would have to start getting monthly ultrasounds. This was news to me, as every midwife I had seen previously told me, “Your uterus is super obvious!” (I’ve also been in the normal range every time) I’m guessing they hadn’t expected that a woman my size might, you know, not have a whole lot of abdominal fat or something.

    I called the midwife out on it. I had to question this woman several times, and then she told me, “Yeah, we’re screening by BMI.” Ok, so you essentially lied to me when you first brought this up.

    My next appointment, I saw yet another midwife and explained everything that had happened. She told me that there was no record like that in my file, that my fundal height measurements were normal and very obvious, etc.

    I was so happy — and surprised — that she took down the name of the midwife I had seen previously and told me that she would put our conversation on file.

    My insurance usually only covers one ultrasound per pregnancy until there is a medical reason. What if I had just said, “OK, let’s schedule these ultrasounds!” That puts me at a higher risk of a c-section (because fat women always have BIG babies, obviously!) and, because there really WASN’T medical approval for it, I likely would have been punched with some surprise bills.

  5. I am a fat man who suffers from depression (probably due to my abusive father) I have knee and hip problems (from being forced into sports by my father-and being explicitly targeted on every field for being the fat gay kid) I have T2 diabetes because I am genetically predisposed to (dad, mom, all four grandparents, probably great grandparents all had it), I have high blood pressure from being stressed out my entire life, it appears I have ED because I have made a very conscious choice to be asexual and my hair is falling out (genetics of course).

    Every time I go to the doctor I am reminded that I have all the above ailments because I am fat. Funny I don’t remember the doctor and nurses being there when I was being screamed at by my father being as “queer as three dollar bill,” funny I don’t remember them being there when an entire opposing football team (and probably some on my own team) tackled me at the knees while screaming “faggot.” Funny they don’t ask about my families history when the T2 diabetes or blood pressure question is answered. And when I say that I don’t have any sexual desire or not concerned about my hair…what exactly does that have to do with me being fat?

    What is truly sick is that through state funded medical schools we pay for these people to learn this shame. Oh sure they can quote the laws of thermodynamics and calories consumption (which incidentally have NOTHING to do with each other) but do they learn to treat me and my history with compassion?

    Love you so much Ragen, thank you for bringing these issues to light.

    (Sorry about the double post, I messed something up with my wordpress login)

    • I’m so sorry, it must be incredibly frustrating for you. Doctors are trained in a way that they don’t deal with the entire history of the patient. Much is yet to be discovered about our minds and how stress and other factors can have a major impact on our overall health.

      I’ve spent too much time doing research about depression (which started a few years ago for me).If I go to a doctor now and tell doctors that my immunity is low and my cells have been affected by depression some of them might just shrug and call me crazy.

      Not all is lost, you could still find a doctor that’s more compassionate.

      Maybe this talk is useful in some way (because someone is finally saying it: health depends on many factors):

      • What a wonderful video, thank you so much.

        I often wonder where we would be without the internet and all the wonderful people we encounter to help prop us up when we need it the most. Today was kind of a rough day…and this video was just what I needed.

        • Check out Caleb Tomas on Facebook. He writes a lot about what it’s like to experience both prejudice from being Gay and fat.

          I’m sorry for all the tough stuff you’ve been through. You are one of those everyday heroes.

    • Wow. They implied or flat-out said that being fat made you gay? Can we now expect the commercials saying, “Bring your fat gay family members to Weight Watchers – we’ll make them thin and straight”?

      It makes me wonder how they explain skinny gay people, or fat straight people.

      It also makes me wonder how they manage to walk with their heads so far up a certain orifice.

  6. This takes me back in my teen years when a doctor, a nurse and my mom were all yelling at me to lose weight. I was too embarrassed to say anything, especially since my parents had made me take Herbalife products at 13 and then when we all stopped taking it my weight just exploded (as it happens with drastic diets, you actually gain afterwards).

    It breaks my heart to hear of doctors fat shaming parents and children. Even “well meaning” NGOs that are supposed to be helping kids with diabetes have mottos such as “feed your children with love, not fat”. Don’t get me started on the theory that fat is squishing your organs.

    I know doctors aren’t gods, they are humans with many flaws just like everyone else. However, any professional has to strive to go beyond his/her own beliefs and see all sides of a problem.

    I think some of them actually keep their mouths shut even if they kind of know that weight loss isn’t sustainable. They want to be seen as obesity heroes, ready to save the day with prescribing weight loss not as obesity-ugh fat slob gross promoters.

  7. I got the last laugh when my blood pressure actually increased as I lost weight.

    The Nurse Practitioner, perplexed, prescribed more and more blood pressure pills as my weight went down. Higher doses too. Yet my blood pressure continued to rise.

    I discovered the sphygmomanometer’s calibration was way out of date (by several years). The NP insisted that made no difference to my situation. In fact, she explained that since the meter read ‘zero’ when not in use that meant it was working fine. Au contraire, that doesn’t guarantee the meter readings are accurate throughout the dynamic range (where most readings are taken). The meter needs to be properly calibrated at regular intervals to assure it functions correctly. I know; part of my job is lab equipment calibration.

    Probably be stuffed full of pills ‘til I rattled had I not put an end to this charade. And today, entirely without the BP pills, my blood pressure is completely normal. Go figure.

    • I’ve worked calibration for over 30 years. The NP’s comment that the zero reading indicated accuracy across the range is definitely a SMH moment.

      In fact, I think that warrants the double facepalm.

    • All things read “zero” when not in use, even a faulty scale.

  8. A few months ago my 19-year old son had to have a physical in order to study abroad. As soon as he was undressed the doctor started fat-shaming him. My confident and well-spoken son told him politely to stop, to which the doctor replied, “Well, it’s my job to make sure that you’re healthy for years to come.” My son was furious but needed the all-clear for his study-abroad, so he stayed for the whole physical. The doctor never once asked a single question about whether my college-age son drinks, smokes, does drugs, is depressed or anxious, is sexually active, practices safe sex, etc. – all the things that present the greatest risk to young people. Fatness was all he cared about.

    • Good for your son for speaking up for himself, even though he had to stay for the whole physical. As a college professor, I know that fat students face shaming *all the time*, from their peers as well as from doctors, etc., etc., and I just hate it. So many campuses now focus on diversity and acceptance for just about everything EXCEPT body size. It’s deeply saddening and/or infuriating (depending on what mood I’m in). Again, good for your son for being confident and comfortable with himself. I hope he has a wonderful year abroad.

  9. I have had a doctor recommend weight loss for a sinus infection. I’ve been bruised by the blood pressure cuff and have not had an accurate reading as a result. The list goes on and on. It’s insane. Thanks for posting this blog.

  10. I had my blood pressure taken today and the cuff was not the correct size, so I question the reading. My doctor now thinks I have high blood pressure, when I know for a fact I don’t!


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