What Doctors Should– and Should Not– Say to Obese Patients

Below a remarkably candid and compelling essay by Emma Lewis titled “Why there’s no point in telling me to lose weight. ” It originally appeared in the January 2015 issue of BMJ (formerly the British Medical Journal).  Hat-tip to Helen Haskell, president and founder of Mothers Against Medical Error, who sent me Lewis’ piece.

In her editorial (cross-posted below), Lewis explains why she has “opted out” of the “weight-loss game.”  She confides that she has been “fat” since she was a child. She still remembers the humiliations, which continue to this day– especially when she visits a primary care doctor.

It doesn’t matter whether she is seeing the physician because she has broken an ankle or needs contraception. Inevitably, he or she brings up her Body Mass Index (BMI.) And when a GP admonishes her that she should diet and work out, he rarely asks what she eats now, or how much she exercises.  He doesn’t listen; he lectures.

In fact, Lewis does care about her health: she exercises regularly and has switched to a whole meal vegetarian diet. For years, she has been in good health. But her BMI remains above 30.

What Many Doctors Don’t Know—And What Even the Experts Don’t Understand

What these general practitioners don’t know is what doctors and scientists who specialize in obesity have discovered:  the vast majority of overweight patients cannot shed pounds—and keep them off—even in highly controlled experimental settings where patients diet and exercise under a doctor’s supervision.  As I explain in the post below two years after starting a diet, roughly 95% will have put all of the weight back on.

And even the experts who study the obesity epidemicdon’t understand why.

When I first wrote about obesity back in 2008, I had just seen an eye-opening NPR documentary titled “Fat: What No One is Telling You” 

As the film opens we see a fetching red head, puffing away on a treadmill. She’s perspiring, but she’s smiling gamely into the camera. “It’s not an average work-out, but I wasn’t an average weight,” she explains. “I have to do above and beyond what any of you guys would have to do. I have to try twice as hard, sometimes three times as hard—just to maintain this level of . . . chubbiness.”

And she is right. She is chubby. By 21st century mainstream (and magazine) standards of beauty this young woman is probably 20 or 30 pounds overweight. Charismatic and dimpled, she also is very appealing. But there is no doubt that most physicians would urge her to slim down.

Later in the film, we learn that she exercises three hours a day.  Dedicated and determined, she eats healthy meals and sticks to a strict exercise regime. Why, then, is she “chubby?”

The questions are endless, a narrator tells the audience. “Is it her genes, her childhood, a flaw in her character, stress, sadness, a lost love, processed food, television, seductive advertising, lack of sleep, a government that subsidizes corn, sugar and beef?”

All of the above may well contribute. But taken together, they still don’t constitute an answer: we don’t know what causes obesity.

The strictly controlled long-term randomized, controlled trials that might tell us have not yet been done.  As you might imagine, it is not easy to corral human beings into such trials, make sure that they do not cheat, and persuade a control group of obese patients to stop trying to lose weight for a period of one or two years.

At this point, all we know with certainty is that obesity is an extremely complicated disease driven by genetic, metabolic, social, psychological and environmental factors.   

But while we still haven’t cracked the mysteries of  “Fat,” the evidence is mounting: counting calories and eating less does not seem to be the answer.

Indeed, as I explain in the post below, some of the newest research suggests that dieting is counter-productive because reducing the amount of food we eat sends a signal to our bodies to store even more calories as fat, and, as a result, we feel even hungrier.    Thus, over time, we regain whatever weight we shed—and many people gain more than they originally lost. This is a cruel disease.

Why there’s no point telling me to lose weight  (BMJ 2015)                             

By Emma Lewis

I am one of over 97% of people for whom dieting does not lead to sustained weight loss.

I’ve experienced health benefits from increased exercise, and from switching to a wholemeal vegetarian diet. My blood pressure’s normal, as are my fasting glucose and my lung function—as far as I can tell, my health is great. But my body mass index (BMI) has been above 30 my entire adult life.

When I worry that I might be unwell, I often try to avoid visiting a general practitioner. Almost every consultation I’ve ever had—about glandular fever, contraception, a sprained ankle—has included a conversation about my weight; and that’s inevitably the conversation that destroys any rapport or trust that might have existed between me and my doctor.

Fighting “the obesity epidemic” is supposed to be about making me—as a “severely obese” person—more healthy; but the impact of obesity rhetoric on my life has been quite the opposite.

I’ve been out dancing in some slightly inadvisable shoes. On the walk home, I step awkwardly in a gutter and hurt my ankle. The next morning, the swelling is pretty severe, so I decide I ought to get it checked out.

The doctor tells me that I should be exercising more. I say: I know that increased circulation boosts healing, but as it currently hurts to stand I’m not sure what it’s best to do for exercise. He says: he’s not talking about healing up the ankle, he means, in general.

He hasn’t asked me how much exercise I already do. He doesn’t know that just last night I danced energetically for four hours then walked several miles home.

I assume that he tells all his fat patients the same thing, without bothering to find out about their individual situations. This doesn’t exactly fill me with trust that I’m receiving responsible medical advice. I don’t visit this practice again.

I have been fat my whole life. So when healthcare professionals ask me—in the middle of a consultation about something completely unrelated—whether I know that my BMI is too high and whether I’m engaged in any weight management, I’m always a little surprised when they act like they might be the first to have ever brought it up. As if I might have made it through my 30 years without ever once noticing that I was fat and that some people think that fat is bad.

It’s just a little reminder that my GP—like many other people in the world—sees me as a fat person first, and an individual second. It makes me feel like a problem to be solved—something unpleasant that needs to be eliminated.

I recently took up weightlifting. I’m happier in myself now—my stamina has increased, as has my strength; I can cycle up hills that used to defeat me.

Unfortunately, building up enough muscle mass to squat a 100 kg barbell has tipped my BMI over from “obese” to “severely obese.” I haven’t been back to a GP since, but I’m dreading it more than ever.

When health professionals bring up my weight in a consultation, I don’t feel like they’re looking out for my health. All my health markers are fine, I’m active and happy, and I’ve spent years fighting against the low self esteem that came from an adolescence spent believing that I’d never be attractive to anyone, yet they still think that it’s important to tell me to do something that I know to be impossible.

They give me the impression that my weight is the most important thing about me—more important than, say, my penchant for body piercing and platform shoes, both of which have caused me more infection and injury than my adipose tissue has. They put me right back to where I was when I was a binging-fasting teenager: full of shame.

They tell me that my body type is a “risk factor” for all kinds of diseases, and that statistically I’m more likely to be healthy if I lose weight. I might query the science behind that supposition—citing the “obesity paradox,” which indicates that fat people have better survival rates than thin people for all sorts of diseases, but I do accept that it’s orthodox medical opinion.

Even if I did want to change my body type to be less of a “risk factor”—it’s not that easy. I’m already physically active well beyond the recommendations of the chief medical officer, and I don’t rate my chances of being one of those seemingly mythical people who manage to maintain weight loss through dietary intervention.

My childhood contained so many diets, so many humiliations in school PE (physical education). No attempts to make me lose weight have ever had any long-term effects. All they did was give me a constant sense of shame and of not being good enough. This led to unhealthy eating habits that would have been labelled “disordered” in someone with a lower BMI.

It has taken me years to unlearn those habits. And it’s only recently that I’ve really discovered the joys of physical exertion, having spent most of my life thinking of exercise as “that punishment I get given for being fat”—impact based activities like running are physically painful for someone with my body type.

I’ve opted out of the weight loss game. If that makes me a non-compliant patient, then so be it. I’m healthier and happier than I was when I hated myself. I just wish that my healthcare providers would work with me on that.

Key messages: 

1. Focus on what the patient has come to see you about today. If you only do that, you’ve done a good job. Think twice before offering unsolicited advice in the guise of “education,” particularly when your patient is consulting you about something unrelated. If your patients hear the same potted advice during every appointment, it’ll soon lose its impact; and if you insist on bringing up a subject that they find traumatic you could put them off seeking your advice in future.

2. It is appropriate to give diet or exercise advice when somebody asks you directly, but try to focus on the other benefits of eating well and getting regular exercise, rather than treating weight loss as an end in itself.8 That way your patients won’t get discouraged from healthy behaviours even when they do not result in permanent weight loss.

3. Fat people know that they are fat. You don’t need to tell us; society’s been doing that our whole lives. Many of us have been traumatized by constant reminders about weight loss culture—about how shameful you seem to find our bodies.

 Note from MM: As Emma Lewis has learned, exercise, combined with a healthy diet, is the key to giving her the energy she needs to take great pleasure in life. And, very likely, she will enjoy a long life. (A recent 12-year-study reveals that a lack of physical activity claims twice as many lives as obesity does. While obesity carries a social stigma, being inactive is more likely to shorten your life.)

Nevertheless many well-meaning GP’s are still lecturing, and in some cases, blaming and shaming, overweight patients. This is understandable.  They truly believe that if their patient just consumed less, and moved more, the pounds would melt away.

After all, our doctors also live in a culture where the notion that obesity is caused by some combination of gluttony and sloth is deeply entrenched. And in medical school, the mysteries of how and why we gain weight is rarely explored.

Why is the topic neglected?  Medical education (like the media) focuses on what doctors can do—the miracles and successes of medicine.

Perhaps a course that explains “the limits of medicine” should be required in our medical schools. It might zero in on diseases that we cannot “cure” (like obesity and Alzheimer’s), and discuss taboo topics (like death).

Until that happens, caring doctors can support patients by explaining that whether or not they conform to our culture’s current norms for what counts as attractive, how they feel is far more important than how they look.

If they eat healthy foods, avoid junk, and are active, they can be “fit” even if others perceive them as “fat.”

In the posts below (here and here )  I explain what medical science now knows—and still does not know—about obesity.

 

6 thoughts on “What Doctors Should– and Should Not– Say to Obese Patients

  1. Data from the mid 1990s already showed that obese people with good exercise performance on treadmill testing, had the same low risk of heart attack and stroke as leaner people with the same performance.
    There were just not as many of the “fit fat” group.
    The impossibility of maintaining weight loss is ubiquitous in diet studies.
    For 20 years I have routinely advised being healthy, by eating fresh fruits and vegetables primarily, sleeping adequately every night (sleep loss makes weight gain) and being physically active for at least an hour per day, better if in 2 sessions. Walking to and from work or school, at least part way, about 3 miles or 5 kilometers total, is a good start.
    I hear “30 minutes 3 times a week” advised often. It is the least amount shown to be better than complete sloth, nowhere near what our bodies were designed to do daily.
    Gotta’ respect design parameters in any system.
    Be a healthy critter, not a sick zoo critter, eating pellets and lying in a cage.

    • John–

      Yes, sleep does matter– and people rarely mention this.

      On exercise–I would suggest that for seriously overweight people 30 minutes of exercise 3 times a week requires a lot of effort. They are carrying a heavier load. More exercise can be very hard on their knees, hips, etc.

      Also, some of the best advice I have read says that we should not urge overweight people to do exercises that they don’t enjoy. If it’s too painful or boring, they’ll give up. This is one reason why dance classes are highly recommended. A 30 minute dance class, 3 times a week (of any kind–square-dancing, whatever)
      improves fitness–not to mention mood.

      Also a great many people–especially poorer people–don’t have an hour a day to exercise. They work long hours, are raising kids (without help–sometimes not even a
      second parent) cleaning their own homes (can’t afford to hire someone) cooking their own food (can’t afford to order in), etc. etc.

      You’re entirely right that there just are not enough people in the “fit fat” group. But we do know that if people are active, they are much less likely to
      die of heart attack or stroke. The problem is that our culture puts so much emphasis on whether people conform to cultural norms about how people should look,
      that if they exercise and don’t lose weight, they tend to give up.

      Glad to hear you are giving your patients different advice!

      • Thanks Maggie,
        The reason that I use walking to-from work/school as an example, is that it readily becomes part of an established routine, such as walking the kids to-from school, and does not require a painful decision each time.
        It also uses time effectively, taking time out of the sedentary-yet-stressful activity of driving, and putting it into a normal function of the human body.
        I bike commute, for instance.
        Vegetable gardening is another normal human function, which respects our real nature in a very broad way, freeing us from many of the physiological insults of the agribusiness system, nurturing us, and revealing much of our nature to us, by meeting our needs.
        I’ve got more collards, kale, mustard greens, and salads than I can eat right now, but spring and fall are much better here in Texas. In summer, I get okra and black eyed peas.

  2. John Day–

    I think walking kids to school (and also encouraging kids to walk to school on their own) is very impt. My guess is that
    inactivity is a major cause of childhood obesity. Too many
    helicopter parents driving their kids to school.

    I’m also gardener (tomatoes, raspberries, blueberries, herbs, iris and many perennials. I take great pleasure in it.
    It doesn’t feel like exercise.