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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The anti-obesity messages seem to be coming through on a daily basis, but as someone who comes into regular contact with overweight clients I can assure you they’re at their wits end.
One client has been on every diet imaginable from Atkins to Lighter Life. She’s lost 8 stone and piled it all back on over and over again. She’s now at the stage where her metabolism has literally shut down.
Her last resort is bariatric surgery which she’s having done in the New Year. She’ll then be left with a serious amount of lose skin which is equally sole destroying. Fortunately for her she can afford skin tucks but for most people they’re dragging around excess skin for the rest of their life.
This is a new phenomenon brought to us by none other than the food industry who’s powerful lobbyists will never allow the government or medical authorities to endanger their sick profit-making.
Their food scientists are equally guilty by successfully designing addictive food (see Oreos), but until we put immense pressure on these greedy companies we’ll continue seeing the obesity levels soar.
Why on Earth should doctors (or anybody) avoid the word ‘obese’? It is a specific descriptor, not unlike ‘diabetic’ or ‘arthritic’. Anyone with compassion and concern can say it without sounding judgmental or condescending, while a term that is theoretically less emotionally charged such as ‘heavy’ or ‘overweight’ is not only less accurate but can sound just as nasty coming from a jerk.
I myself hovered on the overweight/obese cusp (according to BMI charts) for many years and just tipped into obese a couple of years ago upon starting a stress inducing new job. How heavy I am does not change because of the words anyone uses to describe me.
I work in a hospital on a rehab and palliative care ward. To be honest most doctors are blunt and they seem to be oblivious to that. Empathy doesn’t seem come naturally to a lot of doctors.
Where I work we always carefully monitor the dietary intake for people that are below a ‘good’ weight. But nothing is done for people that are overweight and their weight issues not only affect their health, but often they are in hospital because they cannot care for themselves due to their weight, for example doing simple things such as, putting on their own shoes, getting out of bed, sitting up unaided can be impossible. And they stay with us for prolonged periods, until they can go back home with care packages or until a place opens up in a care home.
What a refreshing and heart-warming read. I must get a copy of Escape the Diet trap.
Vict
“Why on Earth should doctors (or anybody) avoid the word ‘obese’? It is a specific descriptor, not unlike ‘diabetic’ or ‘arthritic’.”
Because for some (maybe many) people, the word ‘obese’ can feel loaded with judgement and stigma (in the way that ‘arthritic’ and ‘diabetic’ are not).
Also, as you allude to, the definition of obese is based on the body mass index. The problem is, this measurement tells us absolutely nothing about how much fat someone is carrying.
I would imagine that whatever you call a person carrying a few extra pounds around their middle, it doesn’t so much matter when you’ve then gone onto explain to them that it isn’t their fault!
For the vast majority of people who follow the popular eating guidelines propagated today, becoming fat is an inevitable consequence. Their body has simply responded to the fat driving hormone insulin, by becoming fat!
Reply to Simon….. et all
I can Highly recommend a Tasmanian Doctor by the name of Gary Fettke at http://www.nofructose.com who is currently tackling the Food Services provided in hospitals to sick people – ‘making them sicker’ … read his stuff he is a real pioneer down here and has my full support….. also read this article about who owns you…..
http://justmeint1health.wordpress.com/2013/10/02/who-owns-what-in-this-world-of-spider-web-controls/
Your comments resonate with my own thoughts on this matter. I had a trip vi ambulance to ER last week… when the AMBO learned I was a Type 2 Diabetic… he took a second look at me and said ‘wow you are not obese…. you must be doing something right……’ a backhanded compliment? or just plain rude in reverse……
Clare in Tassie
In my experience the reason most people struggle with obesity is because they are given bad advice based on the old calorie in/calorie out mantra. We now know that obesity is a complex disorder involving the interplay between genes, epigenetics, diet composition and many other factors. Even though excessive calories can contribute to obesity, they are clearly not the cause of obesity.
When a patient is given bad advice about a medical problem the physician giving the advice should shoulder the blame, not the patient.
Please do not let us forget that we should all fundamentaly take some responsibility for our health and well being, including what we eat. The medical profession cannot be responsible for people’s choices and people do choose to eat incorrectly, despite information being available if you look for it.
I realised diets don’t work years ago. I also know that generally doctors are not best placed to advise on this. I have read escape the diet trap as a result of an article in the readers digest. It all made perfect sense to me. So I went looking for more information on how exactly to put into effect your principles. I found books by Dr Charles Clark and Maureen Clark, which whilst not an exact match, the principles remain the same. The recipes are easy, quick and delicious. I lost weight as you described, with no hunger or the terrible mood swings a drop in insulin brings. All my aches and pains in knees and joints have gone and I no longer get breathless walking upstairs. Am I old or severely obese. No, just 52, a couple of stone overweight, but determined that the information is out there if you look.
Around 15 people have bought and read the books after seeing my weight loss and mood changes How many have actually tried or stuck to this plan? One!!!! Whilst I appreciate SOME people as desperate to lose weight, please remember, you can take a horse to water but you can’t make it drink.
You can blame the government, food industry, doctors or Uncle Tom Cobbley N all, but as my Dad always says, “If I told you to jump off the roof, would you do it?”
Your articles are a breath of fresh air, it’s information like this we need, you provide it. What we do with it to change our lives is up to each individual.
Lucy, I strongly urge you to get John’s book. I don’t think I’m overstating the case when I say it saved my life.
As for Dr Pemberton, he obviously isn’t aware of leptin resistance & that large amounts of abdominal fat can act as a “gland” to the detriment of your metabolic status.
Sadly, most GPs are using Government dietary recommendations. I suspect few would put their heads above the parapet & suggest low carb dietary changes rather than reach for the prescription pad.
My experience was that I ate excess calories during my fattening phase every time I had major weight gain, but the rest of the time I’m lucky to hit 2000 calories, much less “excess.” I would be willing to bet money I don’t have that that’s the case for most overweight people. And that it’s the fattening process that drives the overeating, not vice versa–the same way a spurt of growing taller drives overeating in children, though we don’t call it overeating then.
It’s still tissue growth. It just happens to be growth of storage tissue.
Otherwise I have many days where I am probably lucky to hit 2000 calories. And these days more of them are fat than carb, so while I can gradually gain if I’m hitting the “safe starches” too hard (for me, though still low by Standard American Diet parameters), I don’t exactly balloon out.
All these cute little ideas about why people are fat fail to take into account that even fat people settle in at a given set point and, usually, are not constantly gaining.
And personally I see no point in a doctor calling me “obese.” It’s enough to say something like “let’s work on some weight loss” or “how is your weight loss coming along” or “would you like some help with a weight loss program” IF remarking on such is necessary to begin with. If my labs are good and my weight’s stable then it becomes less of an issue, as weight is more of a risk factor than a direct cause of anything, and “risk factor” only means it’s sometimes associated with health problems. Associated with = found alongside of. Not as loaded as it sounds. Slenderness is also associated with chronic disease, believe it or not. There are skinny type 2s out there. Many, I would imagine, undiagnosed thanks to the obsessive focus on fat people. Ranks up there with vegetarians and joggers who get heart attacks and cancer. That always surprises people for some reason.
And I don’t need to be “approached” about my weight if I’m in for a broken leg. That seems to be the trend now, barely noticing other health issues in favor of fat-shaming. It’s no wonder fat people have more health problems when they dread going to the doctor.
And if pointing out that people were fat really helped anything, no one would be fat. Amazes me how slender people keep thinking this will work and that furthermore it has never been tried. Maybe they don’t have to think about it very much since they aren’t the targets.
Also, I have a scale, I have a mirror, I’m of sound mind and I’m over 21. Know what I mean?
Thank you for this. Wish more doctors would read it. And laypeople too.
” She’s now at the stage where her metabolism has literally shut down ” – so she’s dead, Jim ??
Shalom,
Nutrition must become part of our school education, if we are to have a healthy nation.
From educating little Johnny on the contents of his lunchbox, to educating his parents on what food is for!
Basically, we have lost the run of our selves, because of multinationals in the food industry pushing all kinds of products in supermarkets.
Unless people are educated on why & how much food the body needs to work efficiently, they will suffer from ignorance & will eat more than they need!
There is a lot of “comfort eating” going on today, because people are emotionally upset with life’s problems.
People who had it hard when they were young, can over compensate now that they have the means to purchase what they like.
The first thing I do in the morning is have a large glass of cold filtered water from the fridge. Then I have a large spoon of coconut oil & that gets rid of any hunger pangs.
I grind my coffee beans & make a large mug of coffee & pour coconut milk into it, giving it a lovely taste.
If I didn’t want to eat, I might have some nuts to nibble.
And when I do eat, I will have my one main meal of High Fat/Protein, Low Carb.
Its all about educating oneself & the Internet is a great tool for doing that!
You Tube shows you how to cook so many different meals, that no one needs to be ignorant of what is good for them.
I tell doctors to shove their statins & learn how to solve the problem.
Its all about GLUCOSE!
ALL FOOD BREAKS DOWN TO GLUCOSE; SOME A LOT QUICKER THAN OTHERS.
And its teaching their patients what happens in their body, when they eat certain kinds of food.
Doctors need to be educated on nutrition, because food is a better medicine that drugs.
But they are constrained by time & so its easier to write a prescription, then it is to explain why the patient has a problem. And others are just happy to have too many patients clogging up their waiting rooms. Curing patients is a thing of the past. They have become pimps for the drug companies & get rewarded with golf outings & some other perks.
It hurts to see educated people prostitute themselves to these legal drug pushers.
What I have learned from studying the antics of drug companies, the FDA & doctors, has shattered my faith in man. I put them on par with pedophile clergy, who destroy the lives of those who put their trust in them.
Thus ends my sermon & I’m off to bed!
It is very well for Larry Silverstein to say “shove their statins” BUT I am told that once started on statins , it is dangerous to stop them!
Does anybody know if this is true?
What mechanism goes into play for this to be so?
Please someone tell me.
Thank you
Thyroid is so important to weight and in the UK our doctor’s understand the hypothyroid condition so badly and treat it so inadequately with synthetic drugs instead of natural desiccated thyroid, that patients are lost in a misery of ill health and overweight.
We desperately need better educated thyroid doctors and access to natural desiccated thyroid. We need doctors to stop relying on the TSH test which is not the right test to work out what’s going on with the thyroid, and to stop using lab ranges to pronounce “normal!” to sick people.
We need this help urgently and we need it to be right. The NHS is so wrong that we feel hopeless. Synthetic T4 only treatment may improve some of the symptoms for a while, but it does not restore full health.