I am super excited about being a blogger for Weight Stigma Awareness Week, which starts today. You can get all the information here! You can also follow the action (and join in) on Twitter using #WSAW2014
For many fat people a history of absolutely terrible experiences causes them to avoid the doctor’s office more than they would avoid the plague that might send them there. We shouldn’t have to “arm ourselves” just to go and get an annual check-up, but the truth is that many of us do. In this situation, information can truly be power.
Weight and health. “Everybody knows” that they are the same thing – that you can tell how healthy someone is by their body size. “Everybody” knows that weight loss improves health. “Everybody knows” that this is proven in study after study.
Except it’s not. “Everybody” is wrong. This is something that happens a lot. If we went with what “everybody knows” we would still believe that the sun revolves around the Earth, that heroin is a non-addictive substitute for morphine and that Lysol makes a great douche. And let me just add…yikes.
Doctors are steeped in the biases of the societies where they live just like we all are, but by choosing to become healthcare practitioners, I argue that they create an obligation to examine and overcome those prejudices and to provide care that is evidence based, driven by informed consent, blame free, shame free, future oriented and compassionate. Let’s break these down one by one as they pertain to fat patients
Evidence Based, Informed Consent
There isn’t a single study that exists where more than a tiny fraction of people were able to maintain weight loss for more than a few years. Even among those “success stories” the amount of weight loss was very often five pounds or less. So if a doctor suggests that you should lose and maintain a more than 5 pounds and to maintain that loss for more than a couple of years they are asking you to do something that, based on every piece of research that exists, is nearly impossible.
From the perspective of a healthcare professional making recommendations about health, there are no studies that would lead us to believe that maintained weight loss is even remotely likely for most people. Therefore, recommending weight loss simply does not meet the criteria for evidence-based medicine. If a doctor wants to prescribe weight loss, she or he must therefore meet the requirements of informed consent – that is, the doctor has an obligation to tell the patient that while most people lose weight in the short term, the most likely long term outcome of any weight loss attempt is weight regain, that a majority gain back more than they lost and that there is no study showing that even if the patient is in the tiny minority that succeeds there is no study that demonstrates health improvement, and that studies in fact suggest that weight loss is not associated with improved health.
In order to fully inform the patient, the doctor should at that point let them know that studies that take behavior into account show that changes in behavior are shown to lead to improved health outcomes whether or not they lead to a change in size.
To put it succinctly – knowing that health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed in any circumstances and that each of us gets to choose how highly we prioritize our health and what path we want to take to get there, and that those choices can be limited by circumstances beyond our control including access, socioeconomic status, discrimination, and the availability of true, unbiased information – healthy behaviors give us a much better chance at improved health than does weight loss if that’s something that we’re interested in.
Blame Free, Shame Free, Future Oriented
There should be absolutely no shame in having a health condition. None. Ever. It does not matter why someone has a health issue, it matters what happens moving forward. We can never change the past so after a diagnosis there’s no point in even wondering if it’s the patient’s fault and it certainly doesn’t help to make them feel ashamed.
I don’t believe that body size constitutes a disease diagnosis.Even if a doctor believes that being fat is a disease or even that being fat is a bad thing and being thin is a good thing, creating shame around weight has actually been correlated with weight gain so, again, that doctor would not be practicing evidence based medicine if she or he were trying to shame patients as a path to weight loss or health (not to mention the other issues with weight loss and evidence that we already discussed.)
People who are diagnosed with a health condition should be given true information, all of their options, have all of those options available and affordable for them, and be given compassionate care based on their values, culture, and choices. In order for them to be in the best place to make those choices they need to feel empowered and not shamed, blamed, or guilty.
The only kind of healthcare that makes sense is blame free, shame free, and future oriented.
Compassionate
To me this is the catch all category. Even if a doctor believes that people’s fat is their fault, even if doctors believe that they should encourage patients to diet despite the lack of evidence for and the mountain of evidence against the practice, even if doctors are steeped in a fat phobic society, they still have an obligation to first do no harm. As such, doctors are required to, if not examine and eradicate their prejudice against fat people, at least keep it to themselves and provide the same level of care and service that they give to patients against whom they don’t harbor bigotry. (If you’re looking for an example of precisely what not to do, this doctor can help you out)
I don’t know if we’ll ever stop having debacles because we put “everybody knows” before the actual evidence, but when it comes to healthcare, doctors have to do a lot better than “everybody.”
For thoughts on how to talk to your doctor about these things, check out this post
Here is the research that supports this post:
Research about the failure rate of dieting:
Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J: Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer (link goes to article)
http://www.ncbi.nlm.nih.gov/sites/entrez/17469900 (link goes to study)
“You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back. We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people…In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.”
We believe the ultimate goal of diets is to improve people’s long-term health, rather than to reduce their weight. Our review of randomized controlled trials of the effects of dieting on health finds very little evidence of success in achieving this goal. If diets do not lead to long-term weight loss or long-term health benefits, it is difficult to justify encouraging individuals to endure them
Miller, WC: How Effective are Traditional Dietary and Exercise Interventions for Weight Loss
“Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr. The paucity of data provided by the weight-loss industry has been inadequate or inconclusive. Those who challenge the use of diet and exercise solely for weight control purposes base their position on the absence of weight-loss effectiveness data and on the presence of harmful effects of restrictive dieting. Any intervention strategy for the obese should be one that would promote the development of a healthy lifestyle. The outcome parameters used to evaluate the success of such an intervention should be specific to chronic disease risk and symptomatologies and not limited to medically ambiguous variables like body weight or body composition.”
Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel
A panel of experts convened by the National Institutes of Health determined that “In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years.”
Bacon L, Aphramor L: Weight Science, Evaluating the Evidence for a Paradigm Shift
“Consider the Women’s Health Initiative, the largest and longest randomized, controlled dietary intervention clinical trial, designed to test the current recommendations. More than 20,000 women maintained a low-fat diet, reportedly reducing their calorie intake by an average of 360 calories per day and significantly increasing their activity. After almost eight years on this diet, there was almost no change in weight from starting point (a loss of 0.1 kg), and average waist circumference, which is a measure of abdominal fat, had increased (0.3 cm)”
Field et. al Relationship Between Dieting and Weight Change among preadolescents and adolescents
“Findings from this study suggest that dieting, and particularly unhealthful weight control, is either causing weight gain, disordered eating or eating disorders; serving as an early marker for the development of these later problems or is associated with some other unknown variable … that is leading to these problems. None of the behaviors being used by adolescents (in 1999) for weight-control purposes predicted weight loss[in 2006]…Of greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors, including significant weight gain…Our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain”
Studies about healthy habits leading to healthier bodies
Matheson, et al: Healthy, Lifestyle Habits and Mortality in Overweight and Obese Individuals
“Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”
Steven Blair – Cooper Institute
“We’ve studied this from many perspectives in women and in men, and we get the same answer: It’s not the obesity, it’s the fitness.”
Glenn Gaesser – Obesity, Health, and Metabolic Fitness
“no measure of body weight or body fat was related to the degree of coronary vessel disease. The obesity-heart disease link is just not well supported by the scientific and medical literature…Body weight, and even body fat for that matter, do not tell us nearly as much about our health as lifestyle factors, such as exercise and the foods we eat…total cholesterol levels returned to their original levels–despite absolutely no change in body weight–requiring the researchers to conclude that the fat content of the diet, not weight change, was responsible for the changes in cholesterol levels.”
Paffenbarger et. al. Physical Mortality: All Cause Mortality, and Longevity of College Alumni
“With or without consideration of …extremes or gains in body weight…alumni mortality rates were significantly lower among the physically active.”
Research about doctors perception of fat patients
Rebecca M. Puhl and Chelsea A. Heuer The Stigma of Obesity – A Review and Update
“In a study of over 620 primary care physicians, >50% viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the sample further characterized obese patients as weak-willed, sloppy, and lazy.”
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