gaudior

So. Not really a response to the topic at hand, but:

I've seen some of Kate Harding's writing before, in the context of "Fat Acceptance." She is kind of a maniac - I'm sorry, but no, being overweight/obese is NOT healthy, and no, doctors are not assholes for telling people it's important to lose weight, because it is.

And so when I see her writing on other topics, even ones where I agree with her, I'm kind of inclined to take what she's saying with a grain of salt.

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ashnistrike.livejournal.com

Thanks for giving me the extra impetus to go read Harding's blog--some good stuff there. With the caveat that I haven't read any of her fat acceptance stuff except what's near the front of her blog, I understand the problem as being that many doctors won't tell fat people anything except that they need to lose weight. As in, won't diagnose or treat much more severe problems, because they're too focused on one relatively minor issue that carries a big cultural stigma.

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So, here's the deal. For the vast, vast majority of people who are overweight, losing weight is the #1 thing that will help them - and they can achieve this by changing their diet and exercise regimen. It's understood that lifestyle changes (including losing weight) are some of the hardest treatments to follow through on, but they a) have no side effects (because, hello, not taking a drug/having surgery), and b) they tend to correct a lot of health issues all at the same time.

Also, Kate Harding says things which are simply factually wrong. For example, she claims there is no such thing as a "healthy size." Other than, you know, hundreds of studies linking obesity to diabetes, cardiovascular disease, obstructive sleep apnea, etc. This is misinformation that can actively damage her readers.

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hundreds of studies linking obesity to diabetes, cardiovascular disease, obstructive sleep apnea,

Fat Acceptance strikes me as really complicated. Because on the one hand, yeah, being heavy is linked to many health problems, and the American lifestyle (sedentary work and recreation + plenty of tasty, fat-and-sugar-filled foods + a generally chaotic and isolating lifestyle which makes people want easy comfort) has many factors which lead to people being fat.

But on the other hand, Americans are so fucked in the head about appearance ("You must look like an anorexic supermodel or NO-ONE WILL LOVE YOU!"), and so moralizing about disability ("You are suffering because it is YOUR OWN FAULT for not making yourself better by sheer will") and so moralizing about fat in particular ("You are disgusting and evil for being gluttonous! and weak!"). It ties into the way Americans look for perfection, and viciously deride people who aren't achieving it.

And these things have become horribly intermixed. So a lot of the time, when people say "you must lose weight for health reasons," the other set of messages are present-- either underlying the doctor saying it, or simply in what the patient hears. Sometimes doctors are quite stigmatizing, even though if you asked them, they would say they were just looking at studies. And often, when people try to lose weight, what's going through their head is the latter list of reasons ("I'm disgusting, I'm weak, I'm lazy, I'm ugly") rather than the former ("I need to do something to improve my health.") And that is toxic as hell.

So while I think that the Fat Acceptance movement does use incorrect information, and can sometimes get fanatical, the work that they're doing to try to free people from the tremendous shame they feel about weight is very, very important. I also think they wouldn't be out there spreading misinformation if everyone else would work harder on not stigmatizing fat, not equating it with laziness and slovenliness and self-hate.

For example, I feel that a doctor's role is to say things like, "Are you interested in losing weight? It is what I recommend-- it has [health benefit specific to the patient's presenting problem]" and then listen to the answer. And offer advice and assistance and support in losing weight if the person wants it, but also acknowledge that if they do not choose that path, it's not because they're a bad or stupid person. I think that would help a lot.

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occultatio.livejournal.com

Okay, now I'm running into actual philosophical disagreement with you, because (as Ada can tell you) I'm actually a fairly big proponent of acceptance of one's own limitations as the route to happiness and inner peace and all that, but there's a critical difference between accepting your limitations and accepting your flaws. And being overweight is a flaw. It is objectively a bad thing. It is not the way our bodies are meant to work: we know this because our bodies work objectively better when they are not fat. "Being fat is bad" is not a matter of opinion.

Now, I completely accept that many people today become overweight without realizing it, because our culture and lifestyle frankly encourages it. That's a good reason for saying that nobody should feel bad about having become overweight. However, once you're there, it is actively dangerous to your health and lifespan to "accept" your new status as quo. If someone unexpectedly drove a nail through your hand, you wouldn't feel bad about *having* the nail in you, but it would be insane to suggest that you "accept" having it there.

Yes, there is a social stigma about being anything greater than a size 0, but the tremendous danger of the "Fat Acceptance" idea is that it attributes all of the negative aspects of being overweight to that stigma. It makes perfect sense to "come to terms" with society's negative view of you in general, but it makes no sense at all to "come to terms" with a curable medical condition.

I could deal better with the Fat Acceptance community if their attitude was, "You know what? We'd rather live less time and less healthily in exchange for not worrying about what we eat and how much we exercise." That would at least make conceivable sense. Instead, though, this movement is actively arguing that there is no problem with being fat, and that is toxic as hell.

I guess what I'm saying is, you know what, you should feel ashamed of being overweight if it is within your power to change that. I just think you should feel ashamed of your own lack of willpower, not of the mockery of others.

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I could deal better with the Fat Acceptance community if their attitude was, "You know what? We'd rather live less time and less healthily in exchange for not worrying about what we eat and how much we exercise." That would at least make conceivable sense. Instead, though, this movement is actively arguing that there is no problem with being fat, and that is toxic as hell.

Yes, this. To me, this comes down to the concept of informed consent and the ability to make rational health choices for oneself. If you are fully aware of the consequences of your health decisions, then decide on a particular path, it would be ethically (and probably legally) wrong for a physician to force you to do something different.

However, if you have not been provided with correct information (say, because you read Kate Harding's blog), or you cannot understand or refuse to understand the consequences of your decisions (say, because you're a member of the Fat Acceptance movement and don't believe that being overweight carries significant health consequences), you just aren't capable of making an appropriate choice for yourself. At that point, it's the physician's duty to make sure you're aware of the implications of your decisions, at the very least.

I know it's difficult, with our society's stigmas, to be told by someone in authority how detrimental your weight is, even if they don't care about what you look like but rather are concerned about your health. However, I think a physician who doesn't try to make their patients aware of the consequences of overweight/obesity and encourage them to change is as morally wrong as a physician who doesn't offer chemo to their cancer patient.

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pastwatcher

So, how can a physician inform a typical overweight American patient in a way that society and media haven't already done? Given that an overweight person already almost certainly suffers from stigma, it is likely that they feel powerless to change anything about their weight, and would wish to change it even without being aware of health risks. From a doctor's point of view in wanting actively to help patients, what is a good way to make people aware of the problem without worsening the effect of stigmas on them? I would be really curious to hear your opinion, or what you have learned in medical school on the issues of communicating effective action to a patient.

The reason I am responding this way: I imagine one needs a really strong focus on positive messaging, telling the patient a concrete course of diet and exercise combined with advice as to how to happily maintain or gradually acquire such a routine (since I hear people often start out by adopting regimes they can't maintain, and give up). If I read you correctly it seems that you assume the patient should work all this out for him/herself based on concrete facts presented by a doctor with no regard to his/her feelings. Am I misrepresenting you?

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If I read you correctly it seems that you assume the patient should work all this out for him/herself based on concrete facts presented by a doctor with no regard to his/her feelings. Am I misrepresenting you?

That...isn't at all what I said. So, yes, you are misinterpreting me. I'm really not sure how you went from "inform the patient and encourage them to change" to "ignore the patient's feelings and don't help them at all." Furthermore, I would think that you know me well enough to know that that's not the kind of thing I'd advocate.

Don't get me wrong, I don't like how the media portrays overweight/obese people. But there's a big difference between telling someone "you're fat and ugly, because you can only be attractive if you're thin," and "you would feel better and be healthier if you lost weight" (notice there's nothing about appearance in the second example??). Certainly people are hypersensitized to this issue, both because it really is a huge problem in this country (70% overweight? 25+% obese??) and so it's difficult for anyone, doctors or otherwise, to discuss it with people.

BUT.

That doesn't mean that the "Fat Acceptance" movement is going about things the right way. Support for people who don't fit the perfect American image? Totally awesome. Help for people who are overweight/obese? Fantastic. Telling people that being fat is not unhealthy, and ridiculing people who are trying to lose weight? Um, not cool. Also, hurtful to people in the long run.

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Support for people who don't fit the perfect American image? Totally awesome. Help for people who are overweight/obese? Fantastic. Telling people that being fat is not unhealthy, and ridiculing people who are trying to lose weight? Um, not cool. Also, hurtful to people in the long run.

This makes sense to me. (Assuming that you mean that "help" is both "help losing weight if they want to" and "help dealing with their other problems conscientiously and supportively if they say they're not interested in losing weight right now. But I do assume you mean that.)

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pastwatcher

(I loaded this page onto my computer and read it on the train--frustrating not to be able to post my reply now it's written.)

I'm sorry for misunderstanding, and the rest of your comment makes a lot of sense. I certainly don't think you would advocate disregard of patients' feelings! But I do think there is a problem with the way doctors tend to disregard patients' feelings, and wanted to know how much you thought about that general problem. It is also true that the way in which other people's weight affects my life is primarily a problem of others' psychological state; whereas it affects yours primarily in terms of medical problems.

I think we are reacting to different aspects here, as you said to

ashnistrike below. We're agreed on media; my perception of practicing doctors isn't as bad as some of the stories below, but the communications from my doctor are nothing like as good as those I get from my dentist (who is still trying to help my teeth deal with the effects of a mediocre orthodontist and an absent-minded me). In fact, perhaps due to being thin, I have /not/ been talked to by enough doctors about nutrition; while I have made my lifestyle significantly healthier over the last two years, I still haven't had anyone analyze my (easy to describe) diet and probably should--e.g. next time I see a doctor I should ask about milk, if only I remember to do so.

My perception of the fat acceptance movement, on the other hand, is that I've seen it do the things you said are "awesome/fantastic" and figured there were only a few nutcases who did the "not cool" bit. Apparently your experience is not at all concordant with mine, and that explains the different priorities.

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I can tell you what I learned in medical school about communicating with patients. We learned the stages of change model. Basically, for someone to make a change, it doesn't work to tell them to change and then walk away. That's actually a great way to make them discouraged and not change anything at all or want to come back to see you ever again. People make changes slowly. Most of the research in this was done with smoking cessation counseling, and the phases are:

Precontemplation
Contemplation
Preparation
Action
Maintance

The idea is to figure out where the patient/client is, and go from there. You can generally help someone go one step. So if a person hasn't considered smoking cessation, you don't tell them to quit. You ask if they would think about quitting, point out some of the health risks in a non-judgemental way. If a person is thinking about quitting, you can then help them create a plan. Even then, you don't give them a pre-printed generic plan. You help them figure out a specific, personal plan.

That's what I was taught in the classroom on a few specific occasions and have rarely seen used in practice. What I was taught by observation in most cases was generic advice being handed out without a current understanding of what the patient actually is or isn't doing. And then behind the scenes, an awful lot of judgement and ridicule.

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pastwatcher

Now that you mention it, I think I may have learned something like that in high-school health class. I've never stories of doctors applying such a technique, so as you imply it would be good if they did. Thanks for your answer, and your other comments are interesting and useful.

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Comparing obesity to cancer is comparing apples to oranges, here.

A person with certain kinds of cancer is currently objectively sick. The likelihood of survival without treatment is stastically very low to nonexistant. And even then, as you say, the physician can and should offer treatment, not force treatment or insist upon treatment or refuse to stop seeing the patient if they refuse a certain kind of treatment.

A person who is overweight may or may not be currently objectively sick. The person may be at increased risk, based on population data or family history, and those issues should be addressed. But population data does not equal personal risk, and I don't treat populations in the exam room.

If there is borderline or elevated cholesterol, addressing diet with this in mind is certainly the right thing to do. If there is evidence of insulin insensitivity or PCOS, than recommending exercise and helping the patient find a feasible exercise regimen is the right thing to do. If there is arthritic knee pain which may be improved by loosing weight, addressing the weight directly may be helpful, with the caveat that the pain itself may preclude many typically suggested activities.

Further, it's been shown that, for some conditions helped by weight loss, comparatively small amounts of weight can make a large improvement in health outcomes. Such a patient may lose some weight, derive health benefits, but still be objectively overweight and continue to be the recipient of negative weight-based comments.

If physicians would talk about health related behaviors with all patients, regardless of weight, council patients based on their current exercise and eating routines rather than an assumption of what those routines are, and address patient's particular complaints directly, I think it would go a long way towards improving the tenous relationships often held between the health care community and the people it is trying to reach.

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First off,

occultatio,

tiamat360, it was good talking to you guys on the phone about this yesterday, and I think you raised good points, particularly about the many ways that weight affects health.

In response to this comment in particular:

I guess what I'm saying is, you know what, you should feel ashamed of being overweight if it is within your power to change that. I just think you should feel ashamed of your own lack of willpower, not of the mockery of others.

People (possibly mostly therapists) talk about the differences between "guilt" and "shame." They come to two different types of definitions. One definition says that guilt is when you feel bad because you know you did something wrong, whereas shame is when you feel bad because others saw you and told you you were wrong. The other definition says that guilt is what you feel when you did something bad, whereas shame is when you feel that you are bad, as a person-- that something about your very essence is wrong and disgusting and possibly evil. As you can see, these two sets of definitions have some overlap, though they are not identical.

It sounds to me like you're saying that being fat is something about which a person-- a person whose obesity is not caused by medication, hormonal problems, dietary restrictions, mobility impairment, other health problems, etc, etc, etc-- should feel guilt ("not changing my lifestyle is a specific thing which I am doing which harms me, so I should change that, and then I won't feel guilty any more") but not shame ("being overweight is a sign of my general weakness, immorality and badness, and if I didn't know that already, every single person I run into, including my doctor, is thinking it and will let me know how bad I am"). Is that right?

It is intensely challenging to learn to overcome unhealthy shame while retaining healthy guilt. People can do it, but it takes work and time and often spending a while pendulum-swinging. If you start at "I am a horrible person because I'm fat," then you may need to go all the way to the other end of the spectrum-- "There's nothing wrong with being fat, so there's nothing wrong with me!" before you reach the healthy middle ground of "There's nothing essentially wrong with me as a person, but I would feel better if I lost some weight." I think that, as

ashnistrike points out below, people use the Fat Acceptance movement for just that process, and I think that's wonderful.

I agree that it would be better if some members of the Fat Acceptance movement did not say that all medical studies are wrong and all doctors are enemies. But I think that attacking them is getting the wrong end of the stick-- the Fat Acceptance movement is tiny, and the problems with Americans' lifestyles are huge. Yes, what they're doing is problematic, but it is much, much less problematic than the way that Americans moralize and shame themselves and others about appearance, disability, and weight. I think that making fat into a moral issue is one of the things that makes it hardest for people to face it head-on and make whatever lifestyle changes they need to be healthiest.

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One issue is that health consequences related to size are determined on a population level, and then applied on a personal level.

Yes, weight is linked to hypertension, type 2 diabetes and heart disease on a population level. But that doesn't mean that every person with a certain weight/BMI is at increased personal risk, nor that every person with a "normal" weight is at minimal risk for those conditions.

And I agree with basically the therapist's approach you outline. There are many presenting problems which are unrelated to weight at all, and in those cases, there's probably no reason to bring weight up at all (yet many doctors will.) And there are presenting problems where health behaviors are likely a factor, in which case it may be beneficial to address these behaviors rather than the actual weight number itself. If someone has high cholesterol, recommending a low cholesterol diet and increased exercise will address the existing health problem without mentioning the weight directly.

As a pediatrician, I try to promote healthy eating and healthy behaviors in general to all my patients, rather than just lecture those whose charts tell me are "overweight."

As a side note, there is an awful lot of fat phobia and ridicule of fatness which takes place behind the scenes in medical circles, removed from actual discussions of actual health.

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seishonagon.livejournal.com

Also, I know a number of overweight people who, to give an actual recent example, have trouble being treated for a sinus infection. They go to the doctor, say "I think I have a sinus infection," and the doctor refuses to even examine them, or examines them but doesn't do anything about the sinus infection (so, no antibiotics prescribed), but just gives the person advice on losing weight. Someone I know nearly died because of this, because she had to get pneumonia before the doctor would actually engage with the problem that was bringing her to the doctor in the first place. This kind of thing happens to overweight people all the time. Often not in so extreme circumstances, but I've known so many people who have this problem that it can't just be a problem with people I know.

Also, while people should be encouraged to maintain a healthy lifestyle, that won't help everyone who is overweight. It will help most, and that encouragement is vital whether it will help the person lose weight or not, but it's not just about weight. There are also plenty of people who are overweight for other reasons, such as already-existing medical conditions that they don't necessarily have the ability to affect directly, or as a side-effect of other medications (I know I have gained a fair amount of weight - almost 40 pounds - since I started taking certain medications, at the same time that I've been getting more exercise and eating healthier, and blood tests show that my cholesterol level is lower than it was when I weighed less). But people assume that I'm overweight because I'm lazy, or because I eat nothing but fried food, or whatnot. And I also get a lot of assumptions that my health problems are based on my weight, rather than, say, the chronic viral infection I have.

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This sounds like part of the larger general problem of patients having trouble getting doctors to listen to them. And especially with chronic illnesses, where doctors may find the work less satisfying because they can't do anything to fix it-- saying the problem is caused by the patient's "lifestyle choices" means that it's not the doctor who's incapable of fixing this illness. Not all doctors do that, but I do think it's a serious problem when some do.

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ryenna.livejournal.com

I can personally attest to your first point. I've never liked going to see doctors but when I was getting hives over about half my body and couldn't figure out the source on my own I finally made an appointment in hopes that I could get a referral to an allergist.

Instead my full body hives (legs, arms and front and back of my torso) were dismissed as "just itchy" and that "the real problem is [my] weight" and I got a lecture on my weight and eating habits. Which the doctor didn't bother asking me about and got totally wrong. I left the office feeling like I wasn't worth treating and that clearly anything wrong with me was connected to my weight and therefore my fault and I shouldn't waste a doctor's time with it. That helps no one and from what I can tell, it's sadly common.

(The hives turned out to be caused by a polyester blanket, and I've now got a new doctor who is really awesome.)

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occultatio.livejournal.com

But that doesn't mean that every person with a certain weight/BMI is at increased personal risk

Actually, yes it does: your claim here is factually incorrect. Being overweight doesn't mean those people have those problems, but it absolutely means that they are at increased risk of getting them. That's what it means to say that "weight is linked to hypertension etc."

rather than just lecture those whose charts tell me are "overweight."

Nobody in these comments has suggested this route. There's a major difference between "informing" someone, even if it's not something they want to hear, and "lecturing" them.

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ashnistrike.livejournal.com

(Gaudior, let me know if this is getting too far off the topic of the post, and I'll bow out. I don't want to derail.)

For the vast majority of people, changing their diet and exercise will improve their health. I'm 5'1 and 100 pounds, and my doctor tells me that I need to exercise more and eat more salad. My doctor also bothered to look at my cholesterol values and general health before telling me that, but it's pretty good advice for anyone regardless of BMI.

Gaudior, below, pretty much covers my opinion of the fat acceptance movement. Short version: I think they oversimplify, and for much the same reason that DARE gets kids to try drugs. Massively overstate the danger of anything, and it's inevitable that some people will understate it. I've also seen a lot of friends, listening to the fat acceptance movement, get over their guilt about body size enough to actually do something about their health.

I've got a couple of stories that illustrate my problem with the emphasis on body size. First, I have one friend who's been massively overweight for the entire time I've known her. For most of her life, she had stomach troubles, which her doctors chalked up to her weight. They all told her to diet and didn't bother inquiring further. Two years ago, a doctor actually did some tests, identified a gall bladder disorder, a couple of dietary sensitivities, and the massive stress of her job. She got gall bladder surgery, a specific diet tailored to her actual body, and meditation lessons. All of this helped her health in general--not to mention started her being able to lose weight for the first time--a lot more than just being told that she lacked willpower.

Another friend, maybe 50-75 pounds overweight, got married last year and started to think about having kids. Her doctor immediately told her that she shouldn't even try till she'd lost an amount of weight that can't be lost in any healthy way in less than a year or two. She's 40, so this may not have been the most helpful advice in the world.

The issue is not that doctors tell people that being fat is unhealthy. The issue is that many doctors refuse to tell people anything else.

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"The issue is that many doctors refuse to tell people anything else"

I would agree with this, and add that many doctors bring up weight whether it is relevant to the patient's current health concern or not. They bring up weight as a moral issue rather than a health issue when it is relevant. The result is that many patients then avoid seeking health care for any reason because they understandibly don't want to be the recipients of these messages.

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They bring up weight as a moral issue rather than a health issue when it is relevant. The result is that many patients then avoid seeking health care for any reason because they understandibly don't want to be the recipients of these messages.

This! Very, very this!

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I've also seen a lot of friends, listening to the fat acceptance movement, get over their guilt about body size enough to actually do something about their health

Okay. So, right now my thought is that we have encountered two vastly different aspects (proponents?) of the "Fat Acceptance" movement. Because, this? Sounds like a great thing.

But what I've encountered is 1) people who claim that being fat is in no way detrimental to one's health (this includes Kate Harding), and 2) people who ostracize others in the movement if they decide to lose weight. And neither of those things, to me, is acceptable, even if the idea of support groups for people who are overweight/obese is a great one.

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ashnistrike.livejournal.com

Okay. So, right now my thought is that we have encountered two vastly different aspects (proponents?) of the "Fat Acceptance" movement.

That's quite possible. I've never encountered or been part of a movement that didn't have a few very loud idiots. And I'm glad you're not objecting to the existence of the whole movement, which was my original interpretation.

I'm sorry that you've had to deal with (2). That's horrible. One of these days, humans will learn how to accept that people can choose differently from them without seeing that choice as a criticism.

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I also think it's worth noticing that changing lifestyles is a lot of work, and while it's a good idea, it may not be a person's priority at the moment.

The last time I went to my doctor, he asked about lifestyle and exercise (I don't, really), and then he showed me how my weight had been increasing over the past five years, and talked a bit about metabolism and aging. And then he said that since I was about to quit both my jobs and move across the country, now might not be the right time for me to make huge lifestyle changes, but this was something it was useful for me to be aware of. And I said thank you, and have been thinking more about diet and exercise, and once I finish doing a huge home repair project (hauling 500 bricks totally counts as an exercise program, I am just saying), will start actually doing push-ups and sit-ups and stair-climbing and things that I haven't done for years cuz they annoy me. I'm glad my doctor talked to me about this, but I'm really glad he talked to me about it in a way which was respectful, not pushy, and acknowledged that he was asking me to do something which is not easy. I think that's really, really, really important.

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