When I was in college, I volunteered one afternoon each week in the ER at Yale-New Haven Hospital.  One of the stories making the rounds at the time was about two residents who were trying to do a spinal tap on an elderly, Black, obese woman.  The residents had trouble successfully drawing cerebrospinal fluid from the patient.  They then started to make cruel quips about the woman, thinking that she couldn’t hear them.  They were very wrong and she let the attending doctor know what these guys said about her.  The attending then proceeded to rip the young docs a new one.

What was going on here?  In short, the residents were treating the woman as “less than.”  Her age almost definitely played a role and her race and gender probably did too.  But I’m wondering if her weight figured into it as well.  Even while the number of overweight and obese Americans explodes, our society often discriminates against those whose body mass index (BMI) is beyond what’s considered healthy.  And that bias spills into how doctors treat their obese patients.

The result is not only that doctors fat shame their very overweight patients, making them feel bad about their weight, but they also sometimes mistakenly ascribe symptoms to patients’ elevated weight, causing serious conditions to be overlooked.  Underlying this mistreatment is a disdain stemming from many physicians’ belief that being overweight is a condition patients could avoid if they wanted to.  In my career I’ve interviewed many doctors about how they treat Type 2 diabetes.  I’ve often heard doctors voice their frustration, sometimes tinged with disdain, with patients that return visit after visit at the same high weight while their blood sugar levels drift perilously upwards.  Yes, T2 diabetes is a disease where patient behavior directly affects the speed at which the disease progresses.  Since physicians feel like their warnings about weight gain fall on deaf ears, their frustration is understandable.  I simply want to beseech doctors to consider that there’s often a lot more at play than a lack of willpower.

The person behind the patient

Danielle Ofri, an internist at New York’s Bellevue Hospital and author of several books on healthcare that often focus on the patient-doctor relationship, relates the story of a 350-pound woman, Ms. Vincent, who saw her for a general physical in her book What Patients Say, What Doctors Hear.  Dr. Ofri writes, “My job is to be nonjudgmental but the reflexive discomfort I was experiencing was impossible to deny, and I was upset at my unease.”  She attributes her discomfort in part to her emotional feeling that obesity is self-induced “despite mountains of scientific evidence” that genetic and other factors besides a lack of willpower drive weight gain.

Dr. Ofri’s discomfort lessened the more she talked with Ms. Vincent about the challenges in her life and how stress and depression caused her to eat more – stress and depression that had arisen against a backdrop of “obesity, emotional abuse, and neglect” in her family.  Ms. Vincent’s humiliation when she walked into a gym and her inability to find a job due to her weight only added to her stress, leading to yet more eating.  Ms. Vincent couldn’t break out of this endless stress→eating→stress cycle despite her acute awareness of how miserable her obesity was making her.

Dr. Ofri makes the bold suggestion that fat shaming is as harmful and insidious as racism.  Dr. Ofri’s experience treating overweight patients has led her to challenge her emotional, irrational bias against obese patients by getting to know them as complete people rather than just as patients with high body mass indexes.  Similarly, Black musician Daryl Davis was able to get Ku Klux Klan members to renounce their membership in the Klan by offering these former racists a chance to get to know Daryl as a complete person rather than just as a member of a race they had reviled.

One could argue that our society tolerates fat shaming more than racism.  Why can Bill Maher call for a return to fat shaming on his HBO show and not be fired while if he called for the reinstatement of Jim Crow, he’d be fired in an instant (as he should be)?

Stress eating

The role stress plays in causing Ms. Vincent to overeat got me thinking that maybe the increasing amount of stress in our society has played as large a role in increasing the percentage of the population that’s overweight as commonly cited factors such as the omnipresence of high fructose corn syrup in our food, crash diets, the bargain prices of many highly processed foods, lack of time to prepare home-cooked meals, and supersized portions.  We are a stressed out society, especially during the past year of isolation and loss.  Deaths of despair from drugs and suicide have skyrocketed.  Maybe deaths that stem in part from obesity should also be called deaths of despair.

I know stress eating’s a real thing because I do it.  My vice is absent-mindedly eating pretzels, cookies, and dry cereal while watching TV with the result that I can afford to lose a few pounds and my triglycerides are higher than they should be.  And my wife rightfully complains about stray Cheerios left on the couch and the floor.  Should I have more willpower?  I suppose, and sometimes willpower works for a while before I slip back into my carb addiction.  Stress does more than just cause us to overeat.  It stimulates the release of the hormone cortisol, which also causes the pounds to pile on.

How to improve obese patients’ health

We’re not going to dial back our society’s high stress levels overnight but there are a few things we can do now to improve the physical and mental well-being of overweight and obese people:

• Increase healthcare provider empathy for overweight people. Teach doctors to recognize their biases against obese patients using the same techniques that make them aware of their biases against women and minorities. (See my blog post about physicians’ bias against female patients.)
• Empower overweight patients to call out fat shaming by their healthcare providers. There are some great resources out there, such as this one, that advise patients on how they can help doctors and nurses recognize and challenge their anti-fat biases.
• The rest of us also need to examine our prejudices against overweight people. Take a critical look at the reflexive disdain we might have when we see a 300-pound person eating a large hot fudge sundae.  Think about the various reasons they might have for eating the sundae besides a blithe lack of awareness that it’s unhealthy.
• Healthcare providers should not discuss weight goals with patients. The CDC says HCPs should be very sparing in how much they talk about patients’ body mass index since a BMI discussion is stigmatizing and counter-productive.  That does not mean that doctors and nurses shouldn’t discuss the need for patients to get to a healthier weight but the CDC and others say the focus should be more on the process of eating healthier food and doing more physical activity rather than on getting to a specific weight goal.  Star actor Bryan Cranston said he became a star by changing his focus from goal to process, shifting to the attitude about auditions that, “I wasn’t there to get a job.  I was there to do a job.”
• Avoid fad diets that don’t work.
• Try to disrupt the mood-food-weight gain cycle. The Mayo Clinic has these suggestions.

I will leave you with James Corden’s rejoinder to Bill Maher’s douchey call for fat shaming to make a comeback (as if it ever left): “Fat-shaming is just bullying.  And bullying only makes the problem worse.  I don’t think stuff like this is going to solve the obesity epidemic.”