This week, the National Institute for Health and Care Excellence (NICE) in the UK issued directive about how doctors should go about managing and advising their overweight patients. Among other things, it recommends as ‘respectful and non-blaming’ approach, and avoiding use of the word ‘obese’.
I actually broadly agree with NICE’s recommendations. I have all too often either witnessed or had relayed to me examples of doctors who appear to exhibit highly judgemental attitudes towards their overweight patients. Some years ago I was at a medical meeting where I was talking to a doctor who had developed a special interest in cognitive behavioural therapy (CBT). He told me that he’d found CBT to be quite useful with “the fatties.” This, to me, is not generally a term that would generally come out of a genuinely compassionate person.
I think a lot of the judgement expressed by doctors is rooted in a belief that weight control is simply the product of the balance of calories going into and being expended by the body, and that all individuals need to do is show a bit of determination and self-restraint and ‘eat less or exercise more’. However, the fact that this approach works so rarely might perhaps cause us to wonder if we have the wrong idea.
This was a central theme of my last book Escape the Diet Trap. In it, I explored why exercise (as is commonly advised) is rarely effective for weight loss. I also listed 10 reasons why taking conventional advice to eat fewer calories in the form of a ‘low-fat’ diet dooms most people to weight loss failure. A fundamental issue is that such a diet will tend to ensure that we run relatively high levels of the insulin – the chief fat-storage hormone.
I was at lunch today with a friend from medical school who wants to lose weight. He isa smart and thoughtful person (I’m not saying that because he’s a doctor), but as we chatted it became clear to me that his approach to weight loss was, as is the case for many, set up for failure: he believes low-fat foods such as pasta, bread, plain cereal and skimmed milk will be his salvation. He also tries periods of semi-starvation that make him so hungry he could eat his own fist.
He asked for my advice and I gave it to him: hunger usually jeopardises weight loss success and the diet he eats although ‘healthy’ from a conventional perspective is likely the reason for the fact that he is about 20 kg overweight. I talked him through the principles of effective weight loss, including the fact that portion control and conscious caloric restriction is rarely necessary. I may have imagined this, but as we talked it was almost like a huge weight was lifted from his shoulders. It seemed he really got what the fundamental problem is likely to be and, importantly, how he might navigate to a healthier weight and state of health with ease.
My old friend is not alone, of course. He is one of countless individuals who have unwittingly eaten themselves into a state of overweight or obesity despite their best efforts and ‘doing the right thing’. So, when I see an overweight individual first reaction is not generally one of judgement. I am utterly open to the idea that the reason this person may be carrying much more fat than is healthy for them may not be due to lack of self-control, ill discipline or some tragic flaw in the character. They may, quite simply, just be acting on faulty information.
When I got home from lunch, I came across this piece in The Spectator magazine written by doctor and journalist Max Pemberton. In the piece, Dr Pemberton takes issue with NICE’s recommendations, essentially saying that we doctors should not pussyfoot around our obese patients. At one point, he writes:
There’s something comforting about blaming obesity on genes. It enables people to relinquish responsibility for their weight, which can be seen as outside their control. It’s nothing new, either. Years ago, fat people blamed their ‘glands’. When I started medical school, I patiently waited for us to be taught about these magical ‘glands’ that made people fat. I’m still waiting. Even when people have problems with an underactive thyroid, which can slow the metabolism and result in weight gain, this can be treated with thyroid replacement tablets and the metabolism returns to normal. As a rule, however, fat people have one thing in common: they eat more than they need to.
I think Dr Pemberton is misinformed regarding the thyroid. I have seen many individuals with low thyroid function have their thyroid hormone levels returned to normal with medication but see little or no change in weight (despite other symptoms of low thyroid function resolving nicely).
It seems Dr Pemberton would have us believe these people are still wilfully stuffing their faces. I am not so cynical, though. I have looked into the eyes of many people who have literally cried when talking to me about their struggles with weight control despite being on ‘adequate’ thyroid hormone replacement. Often, these people are paying out of their own pockets to see me. Are all these people investing time and money just to come and lie to my face about how much they’re eating? I very much doubt it.
But (what I assume) is Dr Pemberton’s lack of experience and knowledge gap regarding hypothyroidism is not what bothers me about his piece. It’s the overwhelming attitude he appears to have that overweight individuals can only have themselves to blame. Again, as I alluded to earlier on in the piece, I believe some people are overweight through no real fault of their own. These people, I think, need education more than ‘tough talk’ and the withering attitude the people whose job it is to care for them.
I believe we can tell a lot about Dr Pemberton’s attitude to overweight individuals through his use of one specific word in this sentence in reference to the East Midlands Ambulance Service:
It has, hitherto, been struggling along with just one ambulance for fatties (a ‘bariatric’ vehicle)…
Did you spot it?
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