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I saw a gentleman in my office for his sciatica. He was having severe pain radiating from his lower back, down to his calf.
I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight. I know that this would just get better if I lost the weight.” He hung his head down as he spoke and fought off tears.
He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs. Besides, he was in significant pain, and a lecture about his weight was not in my agenda. I wanted to make sure he did not need surgery, and make him stop hurting.
This whole episode really bothered me. He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him. He was living in shame. Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character. After all, losing weight is as simple as exercise and dietary restraint, right?
Perhaps I am too easy on people, but I don’t like to lecture people on things they already know. I don’t like to say the obvious: “You need to lose weight.” Obese people are rarely under the impression that it is perfectly fine that they are overweight. They rarely are surprised to hear a person saying that their weight is at the root of many of their problems. Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.
The fear/disdain of obesity has reached into areas where it should not be. I regularly have to tell mothers of chubby babies that it is perfectly fine for their child to be that way. Children under three generally regulate their eating to what they need. I do not believe a baby can become obese on breast milk or formula. Now, if they are giving the child french fries and burgers, that is a different matter.
Instead of patronizing obese patients with a lecture, I try sympathizing with them. Just because something is simple doesn’t make it easy. How do you quit smoking? You just stop smoking. We should just pull out of Iraq. There should be peace in the middle east. People should stop hurting each other and start being nice. All of these are good ideas, but the devil is in the details. Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.
Don’t get me wrong, I don’t deny the health risk of obesity. I do my best to work on weight loss with my patients. But the idea that their personal worth lies on their BMI is extremely damaging. There are a lot of screwed-up skinny people out there; just look at super-models. It is a lot easier to lose weight when you actually like yourself and want to do something about your health. Our culture of accusation and shame simply makes obese people hate themselves. If you hate yourself, why should you want to take care of your body?
Is obesity a problem? Sure it is. But we need to get off of our self-righteous pulpits. Obese people should not be made into a group of outcasts. The “them” mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others.
It sounds a lot like Junior High.
If we really want to help with obesity, we need to grow up.
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Someone sent me to read this post… As someone with severe back pain, degenerating discs and lumbar vetebrae, made worse by not having any health care for the first 5 years after the initial injury, I wish I could find more doctors like you (and my last doctor before I had to move out of town), people who treat *the patient* and not the symptoms. I have multiple health issues, some exacerbated by my weight, certainly, but the piles of doctors who have felt the need to ignore the serious issues because they can’t see past my size aren’t doing anyone a favor.
As for the whole ‘obesity problem’ stuff — I encourage you to read junkfoodscience.blogspot.com, the journal of a nurse who looks at obesity (and other medical) “studies” and pulls many apart to find that what gets published in peer-reviewed journals… well, it says something about the peers.
Kate Meyers. I made a clinical diagnosis of Cushings in a patient after 3 minutes oftalking to him and looking at his meds and his belly and his neck. It was gratifying. I hope you’re proud of me.
Happy
Below is part of a story about Michael. It’s a true story. Suzy discovered the support group after Michael’s surgery.
“My name is Susan and I am writing this bio for my husband Michael.
He had a lot of health issues that were misdiagnosed and unanswered for several years. He developed osteoparosis, diabetes, high blood pressure and other problems over night it seems. He also had several features of cushings such as the moon face and buffalo hump.
He was finally diagnosed with Cushings about three months ago. November 2007 [when] he went into the hospital with backpain and he was unable to stand. Within days of being admitted I was told he had a compression fracture that paralyzed him from the waist down.
He had transphenoidal pituitary surgery June 23. The tumor was approximately 20 cm [probalbly mm instead of cm] which had doubled in size since November. Only part of it was removed because it was in the nerve center of brain and “wrapped” around carotid artery. Neurosurgeon was able to remove more than thought, but he might need another surgery or radiation treatment.”
To continue the story, Michael is still fighting for his life. He is on a ventilator, and it had to be turned back up to 100% last night because when his PICC line was removed, a blood clot shot straight to one of his lungs. The other lung is in threat of collapse.
In addition, Michael’s doctors did not realize he could go into AI with a dramatic drop in cortisol, and assumed since his levels were at 20 ug/dL, he didn’t need supplemental hormones. They also did not realize that after surgery the pituitary is traumatized and other hormones may not be produced.
This is a true story, happening right now, and Micheal’s wife is fighting for his life. There are some folks who have run to their aid and for support but they could use all the prayers they can get.
Happy, not only am I proud of you, you’re my hero! I’m guessing since you mentioned reviewing your patient’s meds that s/he had steroid-induced Cushing’s Syndrome and not Cushing’s Disease, like moi.
Dr. Rob, thank you for allowing we Cushing’s folk to hijack your comments thread. It was just really nice to hear from a fellow Cushie that there was a blogging doctor who has compassion for people struggling with obesity – regardless of the cause — and I had to pop over here to comment.
It’s even more heartening to see other physicians chiming in with nods to your patient approach.
I’ve never expected doctors to be gods, and not all ailments can be cured. But it sure was nice when my former, rural primary care physician called me up after my first pit surgery to check on me…and to apologize for trying to push gastric bypass oni me and for not recognizing the signs of an endocrine disorder. I told him how much his call meant and that he could make it up to me by reading up on Cushing’s and referring patients with hallmark symptoms to an endocrinologist. He said he would, and I believe he will look differently at his obese patients because of my case.
Just goes to show that we all live and learn, sometimes in unexpected ways….
Kate
I agree that shaming patients is not the way to treat obesity. But I believe that some (not all) obesity is caused by compulsive overeating. Many of us believe that compulsive eating is not a moral failing but rather a disease, not unlike alcoholism: some foods (usually those with a high glycemic impact) can, in some people, trigger a compulsion to eat to the point of self-injury, despite the best intentions to eat healthfully and a strong desire to achieve a healthy weight. (Obviously the analogy to alcoholism is not perfect. I am not contending that junk food is associated wtih crime or automobile accidents in the way drug and alcohol abuse are.)
I can report from experience that many people who suffer from this response to high glycemic impact foods do not understand what is happening to them. We don’t know why we keep eating, even after we’re full. We don’t know why others are able to stop after a few potato chips or one cookie. We don’t know what’s wrong with us and are ready to assume that we are simply weak.
Some of us can recover if we simply go on a low glycemic impact diet — South Beach, Atkins, Sugar Busters, etc. Removing the trigger is enough to break the cycle.
Some of us may need more help, however. Without the sedative effect of high GI foods, some folks may need support groups such as Overeaters Anonymous, Weight Watchers, etc. Personally, I don’t think it matters much what the support group is, so long as the person recognizes the existence of the compulsion and gets help. (Even people who don’t fit the “sugar addict” profile may enjoy greater success in their efforts to modify their lifestyle with the assistance of a support group.)
Without resorting to shaming anyone, you might be able to help some patients by letting them know, in a nonjudgmental way, that high glycemic impact foods can, in some people, trigger a compulsion to continue to eat high glycemic impact foods past the point of satiety, and that while this is not a quesiton of willpower or moral strength, a support group can help break that cycle.
Victoria, I sometimes make references to over-eating and alcoholism only for one reason. I mention it because compulsive eating and alcoholism aims to do one thing: help a person escape their problems by temporarily numbing the pain. If we think about it, all obsessions and addictions work this way. Some of these addictions are more self-destructive than others. Some of these addictions hurt our surrounding loved ones as well. But at the end of the day, the purpose of the addiction is the same.
The Health Behavior News Service just published a feature, “Larger Patients: In Search of Fewer Lectures, Better Health Care.” Two large patients talked about “fat-obsessed” and “fat-distracted” doctors who could not see past their weight, whether they came in for a headache or sprained wrist.
A Wisconsin doctor, who has been named a “Fat-Friendly” doctor, discussed his approach with heavier patients. He used the words consideration and respect.
You can read our article at http://www.cfah.org
Dr. Rob, you made the news: http://well.blogs.nytimes.com/2008/07/09/should-doctors-lecture-patients-about-their-weight/?hp
Just wanted to make sure you saw it.
Skimmmed over the responses and it seems like there are a lot of folks that have Cushing’s disease or syndrome as a cause of obesity. I assure you that by far the MAJORITY of patients I see who are obese, have that condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
Would I be doing my job if I didn’t point out someone needs to eat smaller portions, cut out snacks and exercise more in an attempt to lose weight.
I admit that I do not give a detailed nutritional analysis, but that’s why they make nutritionists!! I have recommended patients see a nutritionist if it appears that they have really tried the “Dr. Gebhard diet and exercise plan”(see above) for detailed advice on diet.
I assure you that it is the SIGNIFICANT MINORITY of patients who EVER try to eat less and exercise more to lose weight, at least in my practice. Sure they’ll try for a few days a week, but then quit. Did the weight go on in a few days or a week??
Walking the dog is not exercise!!
It seems like the majority of respondents to the NY times article feel that it would be more PC to look compassionately in the obese patient’s eyes and tell them how sorry you feel for them.
Would that really help??
Dr. Rob, After ruling out things like Cushings, beyond sympathizing with, not shaming overweight patients, what else do you do to motivate them to lose weight? How successful have you been and how do you measure success?
Paul, you bring up a good point. I think most of us can agree with eating right and exercising and realize that it is basic. Polite reminders can’t hurt and nutritionists are awesome!
Back in 2003, I saw a doctor because I had a really, really bad case of boils and my PCP tested my sugars right away to see if I had diabetes. To make a long story short, I had diabetes type 2 and at that time, my PCP told me that if I were to lose 50 pounds, I won’t need medication any longer! Was I offended? Hells no. I felt he was just doing his job. I would agree that some patients might be a little too thin-skinned? I don’t know. Let’s just say that context and the manner in which the doctor speaks in can make all the difference in the world!
I can always tell which doctors genuinely care about me and the ones that don’t or have an agenda. You know you’ve found a great doctor when you feel comfortable being honest with him/her.
Dr. Gebhard:
Why, pray tell, does walking the dog not count as exercise?
Surely the point is to encourage people to move and be active? For someone who is very overweight and sedentary, exercise needs to be doable, at least to start with. They’re not going to start out doing windsprints, for God’s sake.
Walking the dog is a great activity that can easily be incorporated into the daily routine. As people gain stamina and conditioning, they can lengthen the walk by another block, then another… you get the picture. Pretty soon they’re exercising consistently and maybe even enjoying it and benefiting from it. And it’s good for the dog as well.
I’m sorry, but I don’t think you’re doing anyone any favors by proclaiming what “counts” and what doesn’t. Any activity is better than none. There’s really no room here for elitism. If walking the dog is what gets some people moving, then they should walk the dog.
Zee, I’ll clarify. Walking the dog is not sufficient exercise to lose weight for anyone!!! If someone is obese and they tell me they are “walking the dog” for exercise and they wonder why they are not losing weight, I am simply going to point out that most of the dogs I see being walked, spend alot of time, sniffing, scratching, pooping or peeing and do not get their masters heart rates going!! I do see one guy in my neighborhood walking, rather rollerblading, a beautiful Doberman, and that is certainly exercise. Getting your heart beat into the aerobic range is what it takes to burn fat and most dogs don’t get their master’s heart beats going that fast! Certainly, I am not going to tell someone who is doing nothing, to go out and run a marathon for starters, but you are kidding yourself, if weight loss is a goal, that walking the dog is going to accomplish that goal! The BARE MINIMUM for exercise that ALL people should strive for is walking an hour a day on most days if not everyday. Those are recommendations from national panels, not from me. Again, if a patient is doing nada, I’m going to tell them to start with what they can(i.e. five minutes, ten minutes, etc.. and build up to that hour). I’ll point out what their aerobic range should be. I’ll get a stress test if I think they need it, before they start exercising. I’ll give them whatever advice I think they need, or point them to someone who has the information if I don’t, but I will NEVER say walking the dog is sufficient exercise for someone who states that is what they are doing and they can’t lose weight.
I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing's] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s?
Regards,
Robin
“I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing's] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.”
Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s? Also, Cushing’s is never secondary to lack of exercise and high caloric intake. It’s due to high cortisol from a tumor or it is iatrogenic.
Regards,
Robin
(Apologies for the repeat. I forgot to mark the quotation as such.)
Did I say that Cushing’s was “secondary to lack of exercise and high caloric intake”? I believe that other posters had already gone over the anatomy and physiology in reasonable enough fashion to describe a condition that is caused by a pituitary or adrenal problem. That problem also has fairly classic findings that if present should then prompt a workup(moon facies, abdominal striae, elevated sugar, electrolyte abnormalities). In the appropriate patient, where the clinical findings were consistent with that disease or syndrome, yes, I check the appropriate lab work or refer to an endocrinologist. I assure you that there is not an epidemic of Cushing’s syndrome out there that is responsible for this nation’s obesity problem!! I think that perhaps you should go back and re-read my initial post. In the first sentence, the linkage between Cushing’s disease and my second sentence is separated by a period: therefore, the second sentence does not expound upon the first. You’re linking [Cushing's], your brackets to my second thought is an erroneous connection and I would appreciate a correction! “…..MAJORITY of the patients I see who are obese, have that condtion…..”. Isn’t the subject of the second sentence patients who are obese, not patients with Cushing’s?? I’m no English major, but you are misquoting me, hopefully without malicious intent!
No malicious intent at all. That was how I understood what you wrote and I appreciate the clarification.
I don’t deny there is a problem with obesity that is not Cushing’s related. However, I will not admit that it is not endocrine related. There is not enough evidence either way. Fat is an endocrine organ (full article may be found on Medscape) and that is just now being studied.
Secondly, may I encourage you to read the research on subclinical/episodic/mild/cyclic Cushing’s? You may be surprised how devastating it is and how the “classic” findings really aren’t classic at all. There are all sorts of presentations. Many folks with this disease do not have all those symptoms. Others do, plus more.
In the European Journal of Endocrinology (2007) 157 725–731, Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing’s syndrome you can find the following:
“The features of endogenous hypercortisolism (especially, when mild) are protean and coincide with many common clinical conditions like the dysmetabolic syndrome (1, 2). Screening studies in high-risk populations have discovered unsuspected CS in as many as 2–5% of patients with diabetes mellitus (3–7) and suggest that mild CS is more common than previously appreciated.”
In Cyclical Cushing’s syndrome: an update (Neuroendocrinology; Current Opinion in Endocrinology, Diabetes & Obesity. 14(4):317-322, August 2007.
Mullan, Karen R; Atkinson, A Brew; Sheridan, Brian ) the full text article says, “Cyclical Cushing’s syndrome is a pattern of hypercortisolism in which the biochemistry of cortisol production fluctuates rhythmically. This syndrome is often associated with fluctuating symptoms and signs. This type of case was initially thought to be rare. It has, however, recently been recognized as occurring much more frequently. The phenomenon is important because it can, if not recognized, lead to errors in diagnosis and differential diagnosis of the syndrome and in assessment of therapeutic outcomes. All of these can have very serious clinical consequences.”
There is much, much, much more research to validate the above. It is my hope and prayer physicians everywhere will become familiar with it.
Again, I did not mean to misquote you. And again, I apologize.
(I hope my html is correct. I was not able to preview it. )
ok, so this is unfair. i am typing this on my cellphone in northern Michigan. thanks to all commenters and new visitors.
Regarding causes of obesity, I don’t think the majority is from anything other than overeating and lack of enough exercise. Cushings is not common. The purpose of this post was to say that piling on the guilt is counter-productive. I would not say I am really successful at getting people to lose’ but I doubt I am less than those who use “tough love.” But my patients don’t avoid coming in so I have more chances to help. I just don’t think pushing guilt serves a purpose. Don’t avoid reality by denying the risks of obesity, but don’t overdo it.
That is the best I can do on this phone. I feel guilty doing even this on my vacation, but you don’t get in the NY Times every day.
Dr. Rob, I appreciate that you are on the good side, but I don’t know (and I doubt anyone really does) that the majority of obesity is caused by overeating and lack of exercise. How may people are hypothyroid — I think the percentage of women over age 40 who are hypo is relatively significant. How many women have PCOS — certainly not the majority of overweight women, but probably a decent percentage. What percentage of people have depression? Statistics seem to indicate a non-nominal percentage. How many people have difficult personal circumstances that take up all of the time that might be devoted to better eating habits and more time to take care of themselves. How many have joint problems or other mobility issues? What percentage of the population have medical abnormalities that cause obesity that we haven’t figured out. “Too much food and too little exercise” is reductionist and gets docs off the hook for digging a little deeper to do the real problem solving. It’s like a marriage counselor advising a couple whose marriage is in trouble that it appears that they don’t get along. Figuring out why is the real challenge. I don’t think people mind doctors addressing weight as long as it is treated as a real medical problem that the doctor is providing real medical treatment for.
In addition, for those with an extra 20 lbs, “food and exercise” at some level probably is the issue. But study after study shows that (short of another diagnosable illness) the only long-term effective treatment for morbid obesity is surgery, and that surgery causes real changes in the metabolic system. It gives one pause that perhaps diet and exercise alone are not the culprit in morbid obesity.
Long ago, people thought epileptics were possessed and were ostracized. We now know that devil possession has nothing to do with it. I bet that in 100 years, we will find that for some significant percentage of the severely obese, we will find that they are similarly afflicted with disease, not lacking in moral character or willpower.
My friend just had her stomach re-sectioned and I have to say that I don’t understand why that surgery is even offered to people. It makes their life, moving forward, more isolating. Obviously losing weight would be hard for her but this body mutilation done in a medical setting. She’ll lose weight because she will eat less. Isn’t eating differently the key here?
I spent a couple of years at 200 pounds at 5’5″ and I know fat. My weight gain was the result of an extremely stressful year when my father couldn’t work and we ate beans and reconstituted milk – both purchased in huge sacks and served 3 times a day. My hunger became a needy companion, always wanting to know that it would/could be fed. 50 years later, I keep snacks in my purse just in case.
It took years to learn that a diet should be a successful relationship with nutrition.
I think a lot of American food attitudes are terrible. We want fast, huge, sweet, salty and often rather than savoring our meals. We shovel in food in cars and at the sink. We really need to develop a healthy food culture and then eating wouldn’t be about emotional needs but a celebration of variety of tastes.
Rather than lecturing people about obesity we may have to talk with each other about why we eat what we eat. There are zillions of edible plants but corporate mono culture has obliterated many fruits and vegetables. Our government supports this with our $$. Corn is subsidized and so high fructose corn syrup shows up everywhere. I feel there are few things for me to purchase in the grocery store because I will not eat HFCS and I want organic vegetation.
It makes little sense to take substances labeled as toxic (poisonous fertilizer? An oxymoron!) spread this on our land and then eat the things grown in the mix of dirt and poison. Soil should be respected as a living organism and should be nurtured with organic material. Organic foods taste better and are more satisfying. It’s all related.
I’m pleased to have stumbled my way into a smaller size and more attentive eating habits. Someone stopped me in a hall once and held up an organic salad dressing and told me how the key to eating less is taste. It was a simple conversation. The revelation of her discovery. She changed my life because everything hurt when I carried an extra 70 pounds every minute of the day. It wasn’t about guilt or flaws in me. It was about what she learned.
ok, I’ve been following this post for eleven days now. I have read all the comments, even all the comments in the New York Times…oh, the tedium. I have seen very little in the way of viable solutions. These next comments will be made in defense of people who cannot afford health care. Surgery is out of the question. “Diet” is not feasible for those whose primary food intake consists of beans, rice and other starchy staples. “Exercise” is not feasible because this part of the population does not have the nutritional sustenance to allow for metabolic stimulation and often suffer from bronchitis or other upper respiratory infections or arthritic flare-ups when attempting to do even the minimal amount of exercise. Before you jump on me and say that I’m only making yet another excuse, I do have a solution. It would require a major amount of time and work but is feasible. How about everyone in the medical community banding together to get this problem under control, without the attitude that has normally been presented to us. How about working with local hotels, even YMCA’s, any place in your town that has a pool to start a daily water aerobics class. I would suggest making sure the places are easily accessible (like on a direct bus line) and have heated pools. They could start at 9 am daily as most of their paying clients don’t usually start using the pool until around eleven. This would allow plenty of time for the class. I believe there are even grants offered through NIH that could fund these programs if your area needs it. For example, PAR-06-103, if you would like to make a real project out of it and let others benefit from your example. I truly believe that water aerobics is the answer for most extremely overweight people and believe that it should be offered as freely or as a condition to a welfare check, food stamps or Medicaid. Ok, that’s my two cents…
Prin, they already have Water Aerobics programs at most YMCA’s thats why you have to get there at 0530 to do any real swimming. I admit they’re not free so you might have something there. I agree with you on the Surgery, Gastric Banding is pretty benign but you should see some of the horror show complications from gastric bypasses. Its like lobotomies were in the 40′s. Seems to me it’d be easier to get the small order of fries and run 10 extra windsprints, but what do I know?
That’s just it…the patients I’m talking about can not do 10 wind sprints and probably haven’t been able to afford fast food in awhile. I have often wondered what it would be like if history (a patients past) were not considered. If each patient were treated as if the day they presented were the first day of their lives. Just forget about what all they did wrong in the past and treat how they present on the day of the visit. I know this is not possible because of insurance coding and other things but I just wonder how treatment would change.
I know some slender people that cannot do wind sprints or handle the impact of jogging. I am fat and my exercise of preference is walking an hour a day or swimming an hour a day. That is low impact. It is quite the unrealistic to expect a fat person to do wind sprints. (!!) Frank, I hope you were just being hammy and not serious!!
Also, too much exercise (going beyond one’s physical limits) is not healthy either. Basically, if possible, we should all work everything into MODERATION. The over-doing of anything is no good, and you don’t have to be a doctor to know this. It’s just common sense.
Yea! I have (temporary) access to a wireless.
Do I think most obesity is endocrine related? Sort of. I think the main reason for obesity in our society is the easy access to unhealthy food. Alcoholism is rampant in Russia. Do I think that is because of genetics? Maybe a little; but most is due to the availability of Vodka. Once obese, however, I do think the endocrine effects of adipose tissue kicks in and causes it to become very difficult to lose weight (this is really the first time in the history of human kind that the major push is to lose weight, rather than gain). Our bodies are very good at adding, but bad at removing weight. There are studies with Leptin done recently that suggest the addition of this substrate may fix this problem. Let’s hope.
I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.
Even for those for whom the problem is not physiologic, the problem of compulsive eating (for comfort) is a really big deal. It should not be underestimated how hard it is to kick an addiction for something you cannot live without. I fight this battle personally.
Bottom line: very complex problem and only beginning to understand it. We should not patronize anyone, which is what many doctors do in this situation. I want it to be easy for people, regardless of their size or lifestyle, to come into my office and seek whatever help they need. Lecturing and guilt-tripping is a sure-fire way to undermine that.
Thanks for this post. As someone who has been fat all her life and who is mortified of doctor’s appointments this was a really good read for me.
As for why people are/ become fat: As said elsewhere, the reasons are complex and they differ from person to person. Personally, I am one of the fat people who do overeat – to a degree that I personally call it an eating disorder (and just as a note, not every fat person overeats and I am pretty sure that even if I stopped overeating for good I still would not lose enough weight to get me into the “normal” range of BMI). Still, I have a real problem with how many people, including most doctors that I have met, stereotype me.
Yes, I have a very problematic relationship with food, but this relationship is more complex than simple overeating. I have cycled between weight loss and weight regain for many years. I basically feel guilty for eating at all, and whenever someone (and particularly a doctor or another health care provider) tells me I need to lose weight my first reaction is to plan not to eat for a few days at all (and yes, I have done that, as hard as it seems to imagine). True, this is hardly people intend with their comments, and I can choose not to react on my first impulse, but the fact remains that these comments can be very destructive for a number of people.
Frankly, I am pissed off that I have gotten the advice to lose weight by a doctor when I went to see him for an ear infection. I am pissed off that when I saw a cardiologist in the middle of my last big weight loss because I had developed high blood pressure he told me to lose weight and when I said that I had lost already over 40 pounds (which was at the time over 15% of my total body weight) he told me to just keep it up and lose some more – irrespective of the fact that I had lost the first 40 pounds very quickly and that it had not helped my blood pressure whatsoever. I am also pissed off that I have not seen one doctor who really listened when I told him or her about the effects that making me feel bad about my weight has on my already shaky relationship with my body and with food. And I am extremely pissed off that when it was discovered that I have gallstones that became (mildly) symptomatic after a weight loss my doctor told me how great my weight loss was for my gallbladder and that when I actually developed amenorrhea while I was in six months medically supervised weight loss program as a teen nobody cared – after all I had lost weight and that was a good thing, right?
I really believe that most doctors have the best interest of their patients in mind. And I understand that there is limited time that a doctor can spend with each patient – and to listen to my weight/ weigth loss history and why I don’t want to go on another conscious weight loss attempt right now needs time, particularly since I get so anxious when I step into a doctor’s office that my tongue gets completely tied and I change from a reasonably intelligent woman with a life science and a psychology degree into someone that can barely string two words together. Still, it would be nice that if I do manage to mention some of the things I described above as a response to getting bludgered with weight loss advice the respective doctor would show some sign that he or she actually listened instead of saying something along the lines of “I know this is a weak spot for you”. (You bet it is a “weak spot”, but honestly, that really doesn’t describe the issue well, and it certainly does not solve it.)
I am interested in taking responsibility for my health. But if you really want to be of assistence to me in that matter than you have to take seriously what I tell you. You also have to take serious that issues like shame and fear of getting stared at or even insulted keep many fat people from gyms, swimmingpools, dance and exercise classes or even public biking paths (and that fear is justified, believe me). And you have to understand that even if I decide not to make another weight loss attempt you can still help me to build a more healthy life, even in terms of exercise and food. Those issues are hardly only important for health because they have an influence on weight.
Jeez Sannanina, BLA BLA BLA, seriously, do you ever read other peoples comments? You’ve got Cushing’s Baby, waddle your fat ass to the Endocrinologist and get a check up. Never Understood Women, isn’t Amennorhea a Good Thing? That’d be enough to keep me doin Crunches, Nome Sayin? And don’t feel guilty about children starving in Darfur while you inhale that King Size bag of Doritos, they’ll make more.
Frank Drackman – my comment was probably longer than it should have been, it is one of my weaknesses that I am not very concise when I talk about personal experiences. I wanted to offer an example of one fat patient and her experiences with doctors and why she tends to distrust them and if I failed at that that’s due to my own shortcomings.
But you have no, no right whatsover to judge if I am concerned about starving children in Darfur or the pain and suffering of other people in this world or not. I have worked as a freaking full-time volunteer for two years, one of them with a developmental aid agency. I have been a vegetarian since I was fifteen, in part because of the negative effect that meat overconsumption has on the environment and on food availability for people in poorer countries. I don’t own a car, so I use public transport or walk and bike in order to go place. (Yes, imagine that, a fat person who rides a bike!) And I don’t like Doritos.
I try not to be judgmental of others, usually I go by the assumption that most people at least mean well. But you really should consider that it is not a very smart thing to assume things about others if you have very little information about them.
“I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.”
Dr. Rob, I appreciate that you do look further, but those of us who’ve lived through endocrine hell know that a case of Cushing’s, or other endocrine disease, can slip past really good physicians if they believe that it’s so rare that “nobody gets it”, as some of us have been told. An excess of cortisol (very similar to the steroids many people have to take for arthritis or asthma) actually makes a person extremely hungry. High cortisol also wreaks havoc on blood sugar levels and that can make a person hungry, too. So if you tell someone with this kind of hunger that their weight is their own fault for eating so much, chances are they will believe you. We feel guilty enough about our appearance and are already blaming ourselves before even seeing a doctor. To further your endocrine education, I hope you will check out http://survivethejourney.blogspot.com. Robin has a great post about her hunger resulting from high cortisol that might really illuminate the subject for you.
Oh, and Drackman, yes most people do lose weight after surgery. I easily lost 50 pounds post-surgery, with little effort. I’ve not lost all that I gained, but am earnestly working on losing the rest. I’ve been thin and I’ve been fat, and I prefer thin. Thin people don’t get insulted by doctors as often, for one thing.
An unreal thing I heard today from the author of “Why are you so fat” (his blog): He says that pituitary surgery is … and I quote, “the easy way out of dieting and exercise” (!!)
Oh dear. Well, thankfully he’s not a doctor. He just pretends to be one.
Oh my! I hope he isn’t a doctor!
Pituitary surgery might be considered the easy way out of disability and death, but it’s a rather elaborate and extremely dangerous way to lose weight!
I know this is topic is about obesity, but I feel the need the stick up for all the Cushing’s patients out there!!!!
Cushing’s is NOT as rare as some doctors that may think. I belong to a supprt group of other Cushing’s patients that has 4,855 other members and I know there are many more out there. Many that don’t sign up for this support group. I know this because when myself or one of the other memebers goes to the specilists we see, there are many other “Cushies” in the waiting rooms, who do not know about the support group. Unfortunitly the word is not out there enough yet, and we have to travel to see these Cushing’s specialists. The doctor I see that specializes in only Cushing’s will flat out tell you “Cushing’s is not nearly as rare as once thought.”
So please, when looking at a obese person please don’t pass judgement on them, they may have a real dease, that if not treated is deadly, just like cancer.
I would like to thank you for your wonderful article, and commend you on such an enlightened perspective. If you will indulge me, I will add my experience and point of view. I believe that judging any degree of healthful habits based on weight is prone to great inaccuracy. I lost over 50 pound over a period of 4 years, despite 3 pregnancies. During this time, I developed a very pronounced and life threatening arrhythmia. I was also hypokalemic, however the only person to recognize and devise treatment for this was my pregnancy caregiver. My point in this brief history is to illustrate that weight loss can be a concern, and yet in our “thin” obsessed culture, no one thinks twice to mention or ask about it. It is often overlooked or even commended. Had I GAINED 50 lbs, I feel more than certain it would have been mentioned, likely with condescension. However, as it was not, I went years without realizing a potentially life-threatening issue was developing. I was thrilled to lose the weight, though I felt increasing fatigue, etc… Yet the weight loss required no effort on my part. My current DR believes it’s quite possible that I had Addisons, then went into spontaneous remission. I was active before the weight loss, and was active during….and am currently quite active though I now have lab verified hypercortisolism, and have regained some weight, despite a healthy diet, exercise (what I can tolerate, due to extreme muscle wasting and bone catabolism) and relaxation/meditation.
I am happy to “do the time” with regard to exercise. I am disciplined with regard to cooking as well as how I eat and feed my family. I am seeing an endocrinologist, but not for a quick fix. I don’t relish the idea of pituitary or adrenal surgery. Though, if I have to have it, the very LAST reason will be for weight loss. Primarily, and I believe you will find this is true for many of not most overweight patients, weight is not the biggest issue. I felt as tired and unwell when I was thin as I do now that I am heavier. Quality of life, the ability to care for and enjoy our loved ones, living with joy and vibrance, these are the things that we miss and wish to restore to our lives. And to attain that, we need compassionate DRs who are willing to listen to us, believe us, and work with us to remove the obstacles to good health or at least do no harm.
I reckon that this could be said about other (non-obesity related) diseases as well.
I honestly don’t think that the fat stigma will ever go away. Has education ever worked in the past? And this goes for all other people who appear as if they cannot defend themselves including those with AIDS etc. With that said, since we cannot change the ignorant playground bullies out there, we must change our mindset… somehow. So, lose weight? Regarding someone’s looks, there are some things that we can change and some things that we cannot. People so thin-skinned to take someone’s life style and looks so personally just may have worse problems than we (obese people) do. Think about it.
Doctors and other medical personnel are not immune from the problem of stating the obvious. I have a couple of examples that are not obesity related. My husband who had polio at the age of 5 (he is now 60) saw a physician’s assistant for a back spasm. The PA looked at his clearly curved back and said ‘Have you considered a lift?’ My husband just waved his built-up left shoe.
I have ichthyosis which makes my skin extremely dry and scaly. As an adolescent, I was very self-conscious about this. Almost every visit with a doctor for any reason started with the doctor sayin ‘Do you know you have extremely dry skin? Have you tried xxx?’ I finally saw a doctor in my late 20s who said ‘Well, you probably know more about this than I do.’
Obesity certainly is a complex condition, and in any individual, it is hard to tell without workup (and often times *with* workup) what the underlying causes may be — Cushing’s, other metabolic/endocrine cause, intestinal bacteria, differing metabolic “set point”, lack of exercise, overeating, etc..
However, it *IS* true that we as a nation are getting more and more obese, at an almost ridiculous rate:
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
It would be hard to believe that our increasing obesity as a nation over the last 20 years can be attributed to much other than changing diets/lifestyle habits.
What does this mean in an individual obese person’s case? Very little. It could still be caused by any number of factors, and even if the obesity *IS* primarily due to overeating/sedentary lifestyle, it still means a long, difficult battle with physical/mental/emotional components.
Epigenetics could promote obesity in next generation :
“There is an obesity epidemic in the United States and it’s increasingly recognized as a worldwide phenomenon,” said Dr. Robert A. Waterland, assistant professor of pediatrics – nutrition at BCM and lead author of the study that appears in the International Journal of Obesity. “Why is everyone getting heavier and heavier? One hypothesis is that maternal obesity before and during pregnancy affects the establishment of body weight regulatory mechanisms in her baby. Maternal obesity could promote obesity in the next generation.”
This not new news. Can genes explain rising obesity?
Contrary to conventional wisdom, the obesity epidemic is not restricted to people in Western countries who eat bad diets and are not very active.
In developing countries, it is estimated that over 115 million people suffer from obesity-related problems.
Experts believe that in many of these people these problems are not due to lifestyle but a condition called metabolic syndrome…There are many uncertainties about metabolic syndrome but one thing is certain – it cannot be explained entirely by genetics or lifestyle factors.
… Professor Mark Hanson, Director of Developmental Origins of Health and Disease Division and professor of cardiovascular science at the University of Southampton believes the answer lies in the study of epigenetics.
A student newspaper caught wind of it recently, though. Yes, you can tell it’s a student, but the sources are excellent. Well worth reading.
“This tells us that nutrition in utero is largely responsible for our epigenetic
programming and that under nutrition in one generation could explain the rise in
obesity, heart disease and diabetes in the next! It’s a far cry from the popular
cultural view that lifestyle changes are the be all and end all determinants of
good, or poor health – that everything boils down to personal decision
making…”
Again, I hope my coding is readable. Apologies ahead of time if it isn’t.
This was a very interesting post. It reminded me of a radio program I heard several years ago on the CBC by Kelley Jo Burke. It was called Fat Girls Sweet. In it she mentions that any health issue she needs to go to the doctor about is dismissed by the doctor as being a result of her weight. She rants, justly, that her sore throat will not just go away if she loses weight.
You can listen to it here:
http://www.cbc.ca/ideas/features/fat/index.html
Hey Dr. Rob,
don’t you think that last comment of Drackman’s is personal?
And I challenge ANYONE who has had lapbanding to describe it as “non-invasive” and easily tolerated or some such nonsense. Throwing up for WEEKS is common as dirt, plateauing after 40-50 pounds is NORMAL, not being able to attend a normal meal is terribly mentally debilitating.
As a fat man who neither eats fast food nor makes Doritos a regular part of his diet, I can only say that I pay as much attention to the naturally skinny MD lecturing me about weight as I do the 20-something hygenist who lectures me about flossing. And I can probably walk you into the ground, because at 51 I can still knock off 12-minute miles for approximately forever (I walk at least 15 miles/week. It hasn’t done a damn thing for my weight, but my dog enjoys it. So THIS to the doc up-thread: come walk with me, and then come back and talk about walking the dog, you small-minded idiot.)
Sometimes those types of things are worth leaving up due to the fact that they so obviously indict the one saying it. There are a very small number of people who agree with or sympathize with his opinion. Leaving it up there simply lets more people draw opinions on him based on the statements he made.
The whole point of this, however, was to avoid making moral judgments of another person based either on their weight or anything else. Another recent post on the NY times blog states that the psychological damage is equal to those who bully and those who are bullied. We need to step beyond that kind of stuff and start acting like adults.
Gee John, for someone who is so concerned about comments being “personal”, you don’t seem to mind making personal attacks yourself(“…THIS to the doc up-thread….etc..”, you know what you wrote. To quote myself, since you didn’t, “Walking the dog is not sufficient exercise to lose weight for anyone”. Since you are a self-described “fat man”, I guess I’m right about those 12 minute miles while you’re out walking Lassie!
When I speak to my patients about losing weight (or smoking cessation, quitting drugs, safe sex practices, e.t.c.), I find it best to be honest and up front with them, but in a way that doesn’t make them feel like I think they’re losers. Patients can tell when the physician cares about them and when the physician is judging them. I find that one of the ways I can communicate to the patients that I care for them is to spend extra time with them during those visits. I don’t just recommend weight loss and leave. Obesity is an epidemic in our country that needs to be tackled by physicians, but it has to be done with compassion, kindness and honesty. Great post Dr. Rob.
Gee Paul, where did I say I was concerned about comments being personal? That was Rob. RFC, please. I was pointing out an inconsistency, which was explained to me.
And the point, sorry that it whipped by you, is that even fast walking, and being relatively fit, don’t translate into weight loss. Out here in the real world, very little does, sanctimonious MDs nonwithstanding.
But you go right ahead and nag and bitch at your patients, and see if compliance goes up or down.
Sanctimonious or not, stop acting like Jr. High students. Discussion and disagreement is one thing, but nobody enjoys watching these kind of comments. The point of the post was to encourage a mature approach to treating people. Clearly the name calling can happen from both sides. This point is well proven and any more sticking your tongue out won’t accomplish anything. For anyone else who is subscribed to these comments, I ask you to stop.
OK, Sorry for the snark, Dr. Rob.
But the reality of weight loss is that even with Weight watchers, and a lot more exercise than usually called for, I AM NOT LOSING WEIGHT. I am not alone in this.
And when I go to my doctor, that’s all I hear about, never mind the ringing in my ears that I went for.
So, I stop going. THAT’S the point.
I’ve read everything I can get my hands on about weight loss, the original papers when possible. And the one thing that is clear is that we don’t know why people gain weight, we don’t know why they can’t lose it and we don’t know why they can’t keep it off.
But we do know that a sympathetic ear in the Dr.’s office is more likely to be listened to than “tough love” (meaning yelling and folding arms and being tough.) It is entirely possible to be committed to telling your patients what they need to hear without making them feel like they are losers for not losing. At least then you have them coming into your office, so that you can monitor them for other health issues.
Thank you. As a former obese person, I can only say that we KNOW we are fat. When we see the doctor for an injury or illness, we want help for that – not a lecture about something we must live with every day. Lectures will not motivate us to lose weight. Motivation comes only – only – from within. So God bless you for being a doctor who understands and truly cares.
Thanks for the blog! On the other hand, I do cringe when I read of stories about how the government is getting involved with our weight. My son, when he was in kindergarden, was so drilled on what to eat and what not to eat that he wouldn’t eat. Later changing schools, I waved a note from his physicians to the school administrators that he could have anything he wanted to eat. He is nine now, and getting enough food down him is a battle. He is 4′ tall, and weights 54 lbs.
I too have Cushings. I build hospitals for a living. At the first of my diagnostic journey, ten years ago, I was pretty intimidated by the road that lay ahead (picture dirt road ending at the grand canyon). It took a long time to find a doctor who would listen and put the puzzle together. As more physicians were added, the roads became rockier. In time though, inroads were made, bridges built, and alot of “gravel” was hauled off (some relationships just didn’t work.) In looking at my journey, I think the biggest difference is that I had one doctor who was very encouraging. He turned my thinking about the weight issue to me being healthy. He encouraged me to excercise and take care of my health as best as possible in the face of a potential debilitaing illness. Where all of the other doctors had written me off as a nut, or someone who just wanted attention, he was an example of patience, of steadiness, of calm decision making. He helped calm me during some pretty rough storms. Gradually, I added other doctors that had similar approaches to my care team. It made a difference in how I saw myself (esteem), how I decided to approach my illness (diligence), helped me develop postive relationships with co-workers and family members, and helped me drastically improve the relationship with God and my church.
I still build hospitals. I still have cushings too. I am at 201lbs, 5’4, with a BMI of 44. The first surgery was not successful. Now, I am on a cortisol inhibitor. I hope to be able to stay on it for about 3 more years, until the current hospital is complete. I started nutrisystem 4 months ago, not to lose weight, although I did lose 8 lbs. Remarkably, my labs were the best they had been in 2 years! My doctors marvel at how well I am doing (under the breath of paddling through uncharted waters)
Point is… encouragement and caring can make a big difference. The positive effects can have a wider reach that what might be otherwise considered. Some of it is circular too…I renovated the same O.R. that my surgeon operates in 3 times a week.
Kudos to you Kristina, you are a real inspiration for others suffering from Cushings.
Best wishes always.
Right on! Its not until we stop feeling guilty about our weight that we can actually lose it! Thank you so much for you insight and understanding!
As someone who has lost a lot of weight and continues with the journey to lose another 15 to 20 pounds, I can affirm that the stock exercise advice of 30 minutes a day is insufficient for weight loss unless it’s accompanied by fairly strict food intake.
Now, by strict food intake, I don’t mean under 1000 calories, I mean high nutrient, reduced calorie foods: fruits, veggies, lean protein, etc.
The mindset that got me where I am and will get me where I am going is that I will do what it takes. If I reach a state of stasis, then something has to change. If I am honest with myself and know that my diet is all it should be (and it never is, honestly) then it’s time to change the exercise or increase it.
This is something I am doing for me. I never take the attitude of “I’ve done enough, if that doesn’t lose the weight, then I’m not doing any more”…because that’s the attitude that will defeat me and my purpose.
Always reach for more. More time, more heartbeats per minute, more sweat, more pounds on the barbell. The more you do, the more you CAN do. Think of your time spent exercising NOT as putting in the minimum, but pursuing a new personal best, a world record for YOU. You will always come out a winner.
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