Memo to medical doctors

Many of you may be familiar with Sally Squires’ Lean Plate Club at the Washington Post. Squire describes the community as a “virtual” club – not a diet – with the primary focus of promoting healthy eating and increased fitness. The expectation, of course, is still that weight loss will naturally follow.

In a column reprinted today in The Oregonian, Squires recounts meeting a physician at a conference who expressed great anger at a patient who had lost 18 pounds only to regain the weight. His story inspired Squires to ask readers via her e-mail newsletter for their opinions on how doctors ought to approach weight loss with their patients. Some of the submissions are worth reprinting here:

Lean Plate Club member from South Portland, Maine, commenting in the chat about the doctor who lost his temper, said this was “exactly why so many overweight people avoid going to their physicians. Doesn’t this doctor realize that most people regain the weight they lose? They need support, not recriminations. The doctor’s temper tantrum didn’t do anything except make him feel better. He wasn’t helping his patient at all. Shame on him.”

“I dread seeing my primary-care physician because I have heart disease and I am 60 pounds overweight,” wrote a Fairfax, Va., member. “Every visit is about how I must lose weight or else I will have a heart attack or stroke. I lost 25 pounds in one year only to quickly gain almost all of it back. I am now trying to quickly lose it again before I must visit my doctor and have him find out that I have regained instead of losing more weight.”

“Very few people respond well to being yelled at or scolded,” a Lean Plate Club member from Pasadena, Calif., noted. “They also do not respond well to being demeaned or put down. Providers also need to remember that the patients’ behavior is not a reflection on them and that it isn’t personal. Lastly, providers need to, at all times, stay professional with their patients.”

And my personal favorite:

“My aunt’s doctor told her to lose 25 pounds, and she informed him that he needed to lose at least 50. Neither has lost weight, and now he doesn’t mention her weight, which is not a favorable medical practice for an internist dealing with older patients. So, docs, get skinny and talk about the weight.”

How do you feel doctors should approach issues of weight with patients? Should weight even be an issue? What are your thoughts?

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14 Comments

  1. DivaJean

     /  February 12, 2008

    Doctors should take the approach of addressing the weight issue if the patient directs them to it. I understand the focus towards health and wellness- I myself am a nurse case manager, but I would never direct my patients towards “weight loss” as a goal- due to the soaring failure rate. I instead help them look at what about being overweight bothers them- what is making them not feel healthy. Sometimes it is food and diet related- if so, we talk about making healthier choices- fresher foods cooked in more authentic manners than deep frying. If there is some weight loss that happens from this- fine. If not, we look at how they feel from eating better. Other times, patients may feel the need to increase activity. We direct it towards starting slowly and increasing a little every day.

    As a fat person myself, I abhor it when the physician “brings it up” at my appointment. It is usually never by my primary- just when I have to see whoever due to an urgent illness (sinus infection, flu, etc). Weight is not appropriate to discuss when I am there to address something specially *not* weight related. Should I start dieting when I’ve got a fever of 103 and can barely move from fever ache? Yeah- thought so, doc! My primary physician (and one of the coolest things about her!) leads me into questions about how I feel about my overall health. We talk about activity levels, energy, and my ability to keep up with my 4 little ones. I am not sure, but I could nearly bet you its flagged somewhere in my chart to NEVER ever discuss bariatric surgery- it happened once and only once- and was ugly.

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  2. Lou

     /  February 12, 2008

    I have advance heart disease at 35, I don’t go to my cardiologist anymore after the last visit where he berated me for a good 30 minutes about my weight I am 5 foot 3inch and 180lbs, he told me I was a bad father and husband for neglecting my health. I don’t smoke, don’t drink, running 3-4 miles 5 days a week. I have a strong family history of heart disease, but no other risk factors for heart disease.

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  3. Heh – maybe if all those doctors tried to “get skinny” themselves, they’d figure out that it doesn’t work.

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  4. What DivaJean said – essentially a Health at Every Size approach. It’s entirely possible to discuss eating a balanced diet and getting some exercise without making it into a weight loss lecture.

    What I’d really like to see is doctors having good ‘bedside manner’ training. Lack of tact and inability to consider the ‘big picture’ are big failings of so many of the doctors with whom I’ve personally had problems. Even if the doctor believes that fat is inherently unhealthy and that weight loss should be the prescription, there’s no need to make hurtful or snide remarks to the patient, and no need to berate them if they disagree and ‘refuse treatment’.

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  5. Chartreuse

     /  February 13, 2008

    I’m a medical student and plan to practice one day with a Health at Every Size approach. That is, I will promote fitness and healthy eating independent of weight. Everybody should be encouraged to have healthy habits, no matter what they are weight — it’s not healthy to be thin and sedentary any more than it is to be fat and sedentary.

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  6. DivaJean

     /  February 13, 2008

    Chartreuse- and any other medical students/physicians: look into Motivational Interviewing Skills. I recently took a course on improving this skill- it basically brings it all back to asking open ended questions of your patients and allowing them to define their own areas of health concern. Instead of asking, “What are your medications?” using a phrase like “Tell me about your medications” opens it up to explore other concerns, like cost factor of prescriptions, adherance to the regime, etc. Working on improving my skills of interviewing and letting the patient lead have become an invaluable tool to me.

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  7. Lillian Mitchell

     /  February 13, 2008

    I was insulted that my doctor ignored that I gained back the weight that I lost and said something to the fact that I weighed nearly the same as I did when I first started seeing him. I felt like he was applauding me for getting fat. I weighed 154 at my first visit with him over 5 years ago and I weight 155 at my visit in Sept. I weighed less the previous year.

    Information about diet is confusing. The stuff about ‘set point’ and if you can lose weight or not. Does one try to lose a few pounds or is it not worth the effort? The message is clearer for people that have more than ten to thirty pounds to lose. Diets don’t work. With people near the ‘normal’ weight range the message isn’t as clear. “Thinner” people have an easier time gaining and losing weight. That’s part of the reason that many people have the misconception that losing weight is the solution. Our ‘metabolisms’ are different. Many quote ‘overweight’ people look thin and rather fit like myself.

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  8. I think doctors, etc. should only bring up weight loss if the patient asks about it, or has serious health issues such as high blood pressure, diabetes or high cholesterol that may be alleviated by losing weight. But, even then the family history MUST be taken into consideration (example: my 92-year-old grandmother weighs 95 pounds (if that) and has her whole life exercised and watched what she ate, but she STILL has to take medication for high blood pressure and high cholesterol whereas I am 219lbs (and admit to not always making the wisest food choices), yet my numbers – including diabetes – are perfectly normal). They should instead encourage their patients to eat healthy and be as active as they can be. Yelling, lecturing, and scolding does NOT inspire the patient to want to lose weight and/or live a healthier lifestyle. The sooner doctors figure this out, the better off we’ll all be!

    Reply
  9. Bree

     /  February 14, 2008

    I think there needs to be sensitivity training for future doctors and doctors already practicing. They need to be educated in how to treat overweight (and underweight) patients in a manner that does not involve yelling, scolding, and talking down to them simply because they are not a weight they think is ideal. They also need to to learn to stop listening to the media and their own industry when it comes to “fat kills” and “fat leads to every health problem” under the sun. They also need to stop thinking that people who suddenly drop weight are doing good. Most of the time, sudden weight loss is due to a severe illness or dangerous diets. I

    Doctors also need to rationalize that maybe their fat or underweight patients are living a healthy lifestyle and aren’t eating crap or not nourishing themselves, that they are meant to be this size. In short, doctors need to treat the person and NOT the size!

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  10. queendom

     /  February 18, 2008

    HAES would be ideal in my opinion but if a doctor does not feel completely comfortable with that he or she should at least take into a account the respective patient’s weight (loss) history.
    I personally have been somewhat fat all my life – and I (or earlier on my parents) have gotten weight loss lectures from doctors for pretty much all this time. Like many other fat people I have gone on countless diets – leaving out the “minor” weight loss attempts inbetween I did lose 50-90 pounds at least for times in my life. I also have binge eating disorder which has worsened (again) after my last major weight loss 1 1/2 years ago. If a doctor seriously thinks that after this history a weight loss diet is the right thing for me than he or she should at least give me some good reasons as well as explain to me what makes their proposed diet different from the ones I have tried before. However, I have never seen a doctor who has actually done that.
    In fact, doctors usually seem unwilling to engage in an honest discussion about my situation. Most of them seem to think that I bring up my previous weight loss attempts and my eating disorder just in order to find “excuses”, often commenting along the lines that they understand how hard it is for me to lose weight. This is probably meant sympathetic – but it is also extremely triggering. It usually leaves me with feeling even more shame than usual about not being able to just “stop” bingeing, and it invariably leads to plans for yet another diet.
    All of this is made worse by the fact that every single doctor I have encountered in my life has congratulated me whenever he or she observed me losing weight (they never seem to believe me when I tell them I have done so and they have not actually observed it themselves but that’s a different rant). Nobody has ever questions how I did it, not even when I was losing weight at a very rapid rate or when my periods stopped. If I would be a stronger person, maybe I could ignore this and just tell myself that their praise (or scorn) does not matter. I try to do that. But honestly, at this point in my life I am not very successful at it.
    So the bottom line is: If you are a doctor and you think it is your duty to bring up weight or weight loss when discussing a specific problem at least listen to your patient, take him or her seriously. If you don’t want people to become defensive when you bring up weight don’t make it a moral issue and mention alternative actions they can take to improve their health, then leave it to the patient to decide which actions are feasible for him or her. And specifically if you have a patient that has an eating disorder, no matter what kind, never ever praise that patient for having lost weight.

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  11. I don’t have a problem with a doctor discussing that due to the way my skeleton is articulated, combined with my activity levels and my body weight, I have a knee problem, and that non-drug, non-surgical options include strengthening the knee by exercise and losing weight because less total weight on the joint is going to mean it will hurt less. That’s not a problem at all.

    It is a problem when I visit a doctor for the inner ear disorder I have and she wants to talk about my weight. You can talk about my sodium intake (fluid retention in ears is a bad thing), but the size of my ass is not related to whether or not I can stand up with my eyes shut without holding onto something.

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  12. Jackie

     /  March 21, 2008

    So docs get skinny and talk about weight? Was that some attempt at suggesting doctors need to be thin before they talk about weight or something? I mean, if we want size acceptance, then that should mean doctors don’t need to be thin or something. Maybe I’m reading into it wrong.

    I suffer from what I call “I-think-I’m-fat-and-therfore-sick-itis” It’s like hypochondria, except you think I’m fat and thefore I’m unhealthy, and belive you aren’t healthy until proven otherwise. I thought surely between my weight and salt intake, I do love salt, I must have had high blood pressure and therfore couldn’t go on the rollercoasters on my family’s planned trip to Disneyworld. Turns out my blood pressure’s fine.

    Now I have to contend with I-don’t-think-people-will-belive-I’m-healthy-cause-I’m-fat syndrome. As in, I’m somewhat paranoid if I try to go on a coaster, I’m going to have to prove I’m healthy. I’m pretty sure this is all just a nerosies of mine, given how involved I am with fat acceptance. Like you know how they say when a doctor starts medical school, they may get hypochondria from assuming that the diseases they’re learning about pertain to them. I have fat-hate-ochondria. I think that I’m going to be confronted with someone assuming I cannot ride something like a roller coaster just based on looking at me.

    Yes I have anxiety issues, and yes I’m taking my medicine for them.O_o lol

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  13. Was that some attempt at suggesting doctors need to be thin before they talk about weight or something?

    I think what the commenter meant was that doctors who are overweight probably personally realize how difficult it is to lose weight. Therefore, they probably shouldn’t be giving their patients flippant and casual advice to just diet and exercise in order to lose weight and make assumptions as to why the person is fat. If it were as easy as calories in/calories burned, why wouldn’t the doctor then be thin, also?

    Reply
  14. Meri

     /  April 15, 2008

    I have a new ob/gyn, and I really loved her approach. At my first annual with her, she talked to me while i was still dressed, asking me a series of questions, which started with “do you exercise regularly?” No assumptions that fat=lazy or out of shape, which was so refreshing. At the end of the questions (do you smoke, do you have any concerns you want me to address, etc) she just asked me very matter of factly if I had any concerns about my weight or if it was something I felt needed addressing (I am very large) and I said no, not at this visit, and then she moved on. It was all very matter of fact, and there was never assumptions or stereotypes about being fat – and I had control over whether we talked about it.

    Reply

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