A Weight-Skeptical Approach to the Care of Patients with Obesity

[rev ronin]

https://medicine.uw.edu/grand-rounds/2022/hagan

Discuss?

[mgriffiths]

I'm in the process of watching, so I do reserve the right to edit as I watch more, but approximately 5min in and this phrase is HIGHLY concerning to me:

• Weight Inclusivity: to reject the pathologizing of specific weight and respect the diversity of body shape and sizes.

The research is pretty clear, as body weight increases beyond a certain point morbidity and mortality increases.  Furthermore, where fat is deposited matters as well.  Research has shown that truncal obesity is far more concerning than fat deposits in other areas of the body.  Does that mean we assume every abnormal lab result, patient symptom, etc. is the result of their weight? Does that mean we attack patients and harp on their weight every visit and make everything about their weight?  Of course not...and it may not even be appropriate to discuss weight until a solid relationship is formed and other more acute problems are addressed.  But, to ignore weight as a factor of someone's health is not helping them.

Using myself as an example, I'm a mid-30s male who by most standards would be considered in "good shape."  I exercise hard 4-5+ days per week, but definitely enjoy eating a bit too much.  As a result I weigh anywhere from 230-240lbs on any given day with a BMI of approximately 31-32.  I am significantly stronger with significantly more muscle mass than the majority of the population due to being a previous college wrestler and football player, and continue to compete in powerlifting.  Do I carry the same risk factors as someone who does not exercise regularly but has my same BMI?  Of course not.  Would I statistically be healthier if I weighed 225lbs or even 205lbs?  Absolutely.  But, dropping my weight to 205lbs still leaves me in the "overweight" BMI category, with a 27, but my body fat would likely be at or below 10%.  This is where BMI breaks down and the individualizing of medicine must occur.  For me to drop to and sustain 190lbs or below, which brings my BMI to 25, would require a massive loss of muscle mass.  Would doing so improve my health?  The research I've read isn't in full agreement, but I argue a strong "no."

So, should my PCP discuss my weight at my next visit?  Absolutely.  Is it the most important factor for my longterm health?  Arguably yes, and therefore it would be good for my PCP to give me a bit of a push while my overall health is still good, instead of waiting until I potentially develop diabetes, hypertension, hyperlipidemia, etc.

[rev ronin]

Do watch all of it. He is not totally drinking HAES Kool-aid, but nor is he willing to stick with approaches proven to not work.

Also, correlation is not causation. One of the things he briefly touches on is weight stigma: if we make weight the focus of every visit and "lose weight and come back" the first line intervention for everything, some number of people are going to give up on going to the doctor, and hence skip preventative care, with attendant consequences.

[rev ronin]

Oh, also, I found it easy to follow along with at 1.5 speed.

[wilso2ar]

I'm surprised this did not get more comments.  I watched the video and was impressed with the presentation.  I was also surprised by the morbidity and mortality with traditional metabolic disease when comparing obese vs. "normal weight" when taking fitness levels into account. 

working in chronic pain I see weight stigma a lot.  I try to focus on getting them more active and not to use weight as a measure of success.  obese people know they are obese. They have likely tried numerous options to try and lose weight and were not successful. They do not need need me to point this out to them.  I'm not saying I don't mention it at all, but I think they would have a much better quality of life if they focused time and money on physical activity instead of what the scale says. 

[CAAdmission]

An interesting piece, to some extent seeking to normalize obesity (or at least overweight). Perhaps that is the next phase of human evolution. Most folks in my circle have recognized that BMI is often a low value number. Much better to consider body fat percentages and the location of that fat. It also makes sense that it is probably better to be a little overweight but stable rather than doing crash fluctuations through trendy diets. 

Any time I hear a study mention "implicit bias" tests, my interest level drops 25%. The evidence behind these is very questionable. 

People just need to own being fat. I'm fat. It's 100% my fault, tied to my caloric intake and my activity (or lack thereof). It doesn't make me a bad person, and if I had more willpower I could lose weight. Probably almost anyone could, and could be healthier for doing so. 

 

[rev ronin]

3 hours ago, CAAdmission said:

An interesting piece, to some extent seeking to normalize obesity (or at least overweight). Perhaps that is the next phase of human evolution. Most folks in my circle have recognized that BMI is often a low value number. Much better to consider body fat percentages and the location of that fat. It also makes sense that it is probably better to be a little overweight but stable rather than doing crash fluctuations through trendy diets. 

Any time I hear a study mention "implicit bias" tests, my interest level drops 25%. The evidence behind these is very questionable. 

People just need to own being fat. I'm fat. It's 100% my fault, tied to my caloric intake and my activity (or lack thereof). It doesn't make me a bad person, and if I had more willpower I could lose weight. Probably almost anyone could, and could be healthier for doing so.

I'm not sure "normalizing obesity" is the best way to express it. I'd say "harmonize the hysteria with the evidence" instead. We're getting more and more evidence that it's not weight per se that is the problem, but sedentary lifestyle. People have been hearing weight, weight, weight for so long that it's almost a matter of religious dogma that higher weight is unhealthy and that losing weight is healthy.

Yes, implicit bias is mostly a crock, but what this is talking about is explicit bias.  For example, in a weight-watchers funded study (Puhl RM, Lessard LM, Himmelstein MS, Foster GD. The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries. PLOS ONE. 2021;16(6):e0251566. doi:10.1371/journal.pone.0251566) found that patient-perceived weight stigma, not raw BMI, was associated with healthcare avoidance to the p <0.001 level. Now, there's a bunch of limitations with the study--it polled weight watchers customers, had a dismal response rate, was funded by industry, cross-sectional, etc.--but it still paints a pretty compelling picture that when you survey the patients themselves, they think their doctors dismiss them because of their weight.  At the VERY least, that's a patient communication or cultural competency problem.

Finally, you're statistically likely to be wrong about your ability to lose weight. Much like the alcoholic may believe "I can quit any time I want to," the belief is likely entirely sincere but unconnected to reality.  The evidence is the vast majority of people (95%, IIRC) will regain lost weight by three years, with most of them regaining the weight within one year.  Why are you likely to be special or different?  Fact is, humans have hormonal regulation of weight that will push back against any effort to lose weight or stay at a lower weight. Finally, and I'm not accusing you of supporting this, why do we as a medical culture have a "just lose weight" approach to obesity, when abstinence-based approaches to sex and recreational pharmaceuticals are derided as unrealistic?

[EMEDPA]

3 minutes ago, rev ronin said:

 

Finally, you're statistically likely to be wrong about your ability to lose weight. Much like the alcoholic may believe "I can quit any time I want to," the belief is likely entirely sincere but unconnected to reality.  The evidence is the vast majority of people (95%, IIRC) will regain lost weight by three years, with most of them regaining the weight within one year.  Why are you likely to be special or different?  Fact is, humans have hormonal regulation of weight that will push back against any effort to lose weight or stay at a lower weight. Finally, and I'm not accusing you of supporting this, why do we as a medical culture have a "just lose weight" approach to obesity, when abstinence-based approaches to sex and recreational pharmaceuticals are derided as unrealistic?

I would counter that folks who regain the weight within three years have made a decision that being a bit overweight is a better life choice for them than eating small portions and jogging. It doesn't "happen" to them, they let their original goals take on less importance. Yes, a lot of people are mild to moderately obese. They need to know that it carries a price and that price is earlier cardiovascular disease, cancer, and joint problems. Skinny people generally don't end up with knee or hip replacements aside from in the case of trauma.  There are not a lot of spry, morbidly obese folks running around in their 90s for a reason. Healthy 95 year olds look like Dick Van Dyke, not Lizzo. Remember the somewhere over the rainbow singer? "Kamakawiwoʻole suffered from obesity throughout his life,^[19] at one point weighing 757 pounds (343 kg) while standing 6 feet 2 inches (1.88 m) tall.^[11] He endured several hospitalizations because of his weight.^[11] With chronic medical problems including respiratory and cardiac issues, he died at the age of 38 in the Queen's Medical Center at 12:18 am on June 26, 1997, from respiratory failure.^[11]

Morbidly obese. Dead at 38. Fat is not healthy. A bit chubby is fine, but as medical providers we can't tell someone who is 350 lbs that they are healthy. 

I know lots of folks who have had gastric bypass. None of them are happy with the decision 5 years out. They either regain the weight or are on such a restricted diet, requiring tiny meals and supplements, that they wish they had never done it. American culture embraces the "pill for everything solution"; cholesterol too high? take a statin. BMI of 40, take phentermine, back hurts? Take aleve. I know that lifestyle modification isn't easy, but eating better and learning to lift properly is better than a lifetime addiction to rx meds( yes, I know some folks have to take a statin despite ideal diet and exercise, but this is not the vast majority of statin users). 

[CAAdmission]

25 minutes ago, rev ronin said:

We're getting more and more evidence that it's not weight per se that is the problem, but sedentary lifestyle. People have been hearing weight, weight, weight for so long that it's almost a matter of religious dogma that higher weight is unhealthy and that losing weight is healthy.

I've never doubted that, and I'd hope most people of average intelligence would understand a difference between a 300 lb linebacker and a 300 lb fat slob. I'm with you on the importance of addressing fat over weight. Sadly, I'm both fat and I also have a poor overall level of fitness. 

 

28 minutes ago, rev ronin said:

they think their doctors dismiss them because of their weight. 

Thanks, I'll have to read that. Do they fear being dismissed or fear being nagged? If a patient is not physically fit and you don't discuss it as part of a health maintenance visit, that's malpractice. I guess a lot of people wouldn't want to hear it over and over, much like people don't want to be nagged about smoking. 

If people are embarrassed about being fat, that's life. Sports Illustrated can have all the fat models they want in the swimsuit edition but non-fat people are going to still get preferentially selected out for copulatory activity after the prom. 

 

33 minutes ago, rev ronin said:

Finally, you're statistically likely to be wrong about your ability to lose weight.

Not about the ability. Anyone has the ability to lose weight. They can blame a slow metabolism, or gland problems, or whatever, but people do not photosynthesize fat. I was a high school and college athlete. If I increased my activity level to even half of what it was then, and took a lot of meat out of my diet I'd lose a lot of fat weight. 

[rev ronin]

21 minutes ago, EMEDPA said:

I would counter that folks who regain the weight within three years have made a decision that being a bit overweight is a better life choice for them than eating small portions and jogging.

That's a value-based reaction, not an evidence-based reaction. Now, values can be independently worth following regardless of evidence, but there's some serious physiological factors working against weight loss ever working.

The evidence points to almost all lost weight coming back, often with 5-10 lbs extra, within 1-3 years.  Would we tell people to stop smoking if we knew that each time they failed, they'd pick up another 1/4 pack per day of cigarette use?

Consider Oprah: smart, driven, built a media empire from scratch, and still the only female self-made billionaire in America and perhaps the world, if I'm up to date on everything.  Yet with motivation and functionally unlimited income for personal shoppers, chefs, and trainers she's had multiple public failures: not to lose weight, but to maintain a lower weight once lost. Anyone CAN lose weight, but it's the weight regain that's driven by physiology, not simply willpower failure. If Oprah can't do it, what hope do our patients have?

[rev ronin]

27 minutes ago, CAAdmission said:

Thanks, I'll have to read that. Do they fear being dismissed or fear being nagged? If a patient is not physically fit and you don't discuss it as part of a health maintenance visit, that's malpractice. I guess a lot of people wouldn't want to hear it over and over, much like people don't want to be nagged about smoking.

PM me the email you want me to send the PDF to.

The patients feel like the are perceived as less valuable by their PCPs because of their weight--they perceive reactions like disgust, dismissiveness, and low diagnostic curiosity.  There's some more to it than that, but that's the gist. Rebecca Puhl has done a lot of work on the negative health impacts of weight stigma over the past 10 years or so, and it's building a pretty compelling case that weight stigma is an independent problem not directly related to weight.

As far as ability to lose weight, I should be more precise: the ability to lose weight involves both the initial weight loss, the ability to keep the weight off, the ability to keep the weight off without significant effort, and the ability to thrive and enjoy life at that lower weight. Whether it's 10 lbs or 50 lbs down, if you're miserable and calorie-counting for the rest of your life, that's a horrible way to live.

One thing the Grand Rounds presentation touches on is that losing weight triggers a metabolic drop. That is, people dieting will spend less calories as their bodies try to fight back against weight loss.  It's not simply "calories in minus calories expended" when the latter number will drop without any conscious control if the former does. Our bodies do what they do regardless of our conscious will, based on genetic algorithms that are neither well understood, nor currently manipulable: think of all the effort that's gone into making a male birth control pill.

[EMEDPA]

22 minutes ago, rev ronin said:

 

Consider Oprah: smart, driven, built a media empire from scratch, and still the only female self-made billionaire in America and perhaps the world, if I'm up to date on everything.  

https://en.wikipedia.org/wiki/List_of_female_billionaires

Apparently there are several hundred. I came up with 3 fairly quickly besides Oprah: JK Rowling of Harry Potter Fame, Melissa Gates, and Jeff Bezos ex wife. 

[EMEDPA]

Re: Rich folks and weight loss. Consider if you will the case of actors who can gain or lose weight at will for roles. Apparently saying "we will give you 5 million dollars to look like a super hero" can cause a lot of lifestyle modifications. Prior to Guardians of the galaxy , Chris Pratt was known as the fat guy from Parks and Rec. A good friend of mine says " nothing tastes as good as skinny feels" and he is right. 

[rev ronin]

22 minutes ago, EMEDPA said:

https://en.wikipedia.org/wiki/List_of_female_billionaires

Apparently there are several hundred. I came up with 3 fairly quickly besides Oprah: JK Rowling of Harry Potter Fame, Melissa Gates, and Jeff Bezos ex wife. 

Ah. Of that list, only Rowling is self-made, though.

[CAAdmission]

3 hours ago, EMEDPA said:

American culture embraces the "pill for everything solution"

That's a big issue. People like quick, cheap, painless solutions. But they are rarely effective. I remember long ago seeing a magazine add for a weight loss pill that would help the taker "avoid the unhealthy strain of exercise." LOL.

 

2 hours ago, rev ronin said:

Whether it's 10 lbs or 50 lbs down, if you're miserable and calorie-counting for the rest of your life, that's a horrible way to live.

I concur. That's why I'm fat. 

 

2 hours ago, rev ronin said:

One thing the Grand Rounds presentation touches on is that losing weight triggers a metabolic drop.

You should be able to mostly counter this with a good fitness program. Build muscle which is more metabolically active than lard. 

 

2 hours ago, rev ronin said:

The evidence points to almost all lost weight coming back, often with 5-10 lbs extra, within 1-3 years.

I'd be interested to see a control group of fat people. Do they stack on another 5 pounds, too, over the same period?

 

2 hours ago, EMEDPA said:

A good friend of mine says " nothing tastes as good as skinny feels" and he is right. 

I like that. I'll write it down, but I fear your friend just needs to find a better cook!

[EMEDPA]

4 minutes ago, CAAdmission said:

I like that. I'll write it down, but I fear your friend just needs to find a better cook!

He and his wife are both great cooks. They eat well, drink in moderation, and exercise daily.

My take on diet is everything in moderation, including moderation. Kinda the 80/20 rule. Eat well most of the time, but don't skimp on thanksgiving, xmas, best friend's bday party, etc., skimp in your day to day life. Every potluck at work is not a special occasion. A buddy of mine lost 10 lbs and kept it off just by not eating from the daily potlucks at work. 

I have been doing the intermittent fasting thing recently as well as increasing exercise which I enjoy, such as running and biking. I admit it is easy for me. I come from a family of skinny folks. My mom in her 90s still weighs about what she did in her 30s. I find I can gauge my fitness pretty easily based on my resting heart rate. If it goes over 60 for more than a day or 2 I am slacking and need to treat myself better by getting some sleep and getting outdoors for some exercise. 

[rev ronin]

2 hours ago, EMEDPA said:

I admit it is easy for me. I come from a family of skinny folks. My mom in her 90s still weighs about what she did in her 30s.

I'm happy for you. But @CAAdmission and I probably have a different genetic makeup.  One of the things we've observed in the little genomic medicine on eating disorders that's been done to date is that some people are very comfortable at a negative caloric balance for the day--that would be you--and others of us are quite uncomfortable going to bed hungry--that would be me--such that these tendencies run in families at least as much as any other trait does.

For people who are naturally predispositioned to be OK with a negative calorie balance for the day? Losing weight works. Or, more likely, y'all never put on the weight in the first place. For my mother, the yo-yo dieting of Weight Watchers throughout the 1980s... Well, at some time before I die, I hope to have an actual estimate of the quality-adjusted life years diet and exercise will have stolen from her.  Finally, there's an explanation that makes sense: Dieting is fundamentally different from gaining weight because the body's defenses against starvation don't recognize ideal weight, just homeostasis.

Anecdotally, I suspect we'll end up seeing that most of America is in the same genetic boat I am in.

[EMEDPA]

If I don't exercise and eat whatever I want, have seconds at dinner every night, etc I gain weight just like everyone else. I put on 23 lbs right after PA school and didn't realize it until a friend I had not seen in a while said I was getting pudgy. She was right. No seconds at dinner, cutting out fast food, and regular exercise and I was back down to my high school weight inside of 6 months. I am currently a few pounds more than I was when I graduated PA school. 

It may take me less exercise to take it off and be easier for me to diet than others. I find drinking a large glass of water fools my body into thinking I have eaten for a few hrs and lets me get past most hunger issues outside of meal times. 

[CAAdmission]

8 hours ago, EMEDPA said:

I find drinking a large glass of water fools my body into thinking I have eaten for a few hrs and lets me get past most hunger issues outside of meal times. 

I find the same, but I unfortunately prefer my water to have fermented barley and hops in it. 

@rev ronin raises an interesting point about the genetics of all this. I suppose there must be a mix of nature vs nurture. If kids are obese, the parents usually are too. The hardest part is getting started. If I could take a pill and magically have 20 pounds of fat disappear, I could get rid of the next 20 pounds fairly easily. Right now when I try to jog, all I feel is flab bouncing up and down. 

[SedRate]

19 hours ago, rev ronin said:

Finally, you're statistically likely to be wrong about your ability to lose weight. Much like the alcoholic may believe "I can quit any time I want to," the belief is likely entirely sincere but unconnected to reality.  The evidence is the vast majority of people (95%, IIRC) will regain lost weight by three years, with most of them regaining the weight within one year.  Why are you likely to be special or different?  Fact is, humans have hormonal regulation of weight that will push back against any effort to lose weight or stay at a lower weight. Finally, and I'm not accusing you of supporting this, why do we as a medical culture have a "just lose weight" approach to obesity, when abstinence-based approaches to sex and recreational pharmaceuticals are derided as unrealistic?

 

19 hours ago, CAAdmission said:

Not about the ability. Anyone has the ability to lose weight. They can blame a slow metabolism, or gland problems, or whatever, but people do not photosynthesize fat. I was a high school and college athlete. If I increased my activity level to even half of what it was then, and took a lot of meat out of my diet I'd lose a lot of fat weight. 

 

13 hours ago, rev ronin said:

Dieting is fundamentally different from gaining weight because the body's defenses against starvation don't recognize ideal weight, just homeostasis.

I can't remember if I came across this article on the forum or elsewhere but "Obesity Pathogenesis: An Endocrine Society Scientific Statement" is a great read:

"Growing evidence suggests that obesity is a disorder of the energy homeostasis system, rather than simply arising from the passive accumulation of excess weight. We need to elucidate the mechanisms underlying this "upward setting" or "resetting" of the defended level of body-fat mass, whether inherited or acquired. The ongoing study of how genetic, developmental, and environmental forces affect the energy homeostasis system will help us better understand these mechanisms and are therefore a major focus of this statement."

https://pubmed.ncbi.nlm.nih.gov/28898979/

It's dense but insightful. As someone who's maintained their weight since high school and couldn't understand why it was so difficult for overweight/obese individuals to return to their ideal body size, I have a new appreciation for weight maintenance after reading this.

[mgriffiths]

So I was finally able to watch the rest of the video and here are the rest of my takeaways:

1. My above post still stands.  Many of the points I made he specifically referenced to which he agreed.

2. Weight bias harms patients - not sure I can get behind this.  As I've said before, and I will say again, overemphasizing weight loss or presenting it as the only solution can be harmful, but that doesn't mean that we are harming patients by mentioning weight loss as a meaningful treatment option for many diagnoses.

3. "How would you manage in someone without obesity?" This question ignores the fact that weight is a factor in these diagnoses.  Of course I'm not going to recommend weight loss to someone with hypertension, diabetes, hyperlipidemia, etc. who is already at a healthy weight.  But guess what, I would still have a conversation with them about making healthier dietary choices and exercise.  It is completely possible to have an extremely poor diet while maintaining a healthy weight for a wide variety of reasons.  It is also completely possible to have poor fitness while maintaining a healthy weight for a wide variety of reasons.  In the fitness community this is often referred to as "skinny-fat."  Obviously that isn't a term I would recommend using to patient, but gets the point across. 

4. One of my biggest takeaways is the ability to define "efficacy" in different ways.  The first is whether successful and maintained weight loss is efficacious for improved health, or could instead be stated as decreased morbidity and mortality?  The second definition is whether the patient is successful at weight loss.  A lot of the research Scott references seems to present that weight loss is inconsequential.  But, I don't think that is the point of the research, or is even a proper conclusion based on the research itself.  Sure, weight loss isn't necessarily the only treatment option, but it certainly can be a powerful treatment option.  The reader must be careful reading into research beyond the null hypothesis that is tested.  For one, for diabetes control...yes weight loss alone vs. exercise alone are essentially equivalent.  But what about when performed successfully and regularly together.  That's been shown time and again to be the best.  Furthermore, he does mention, but glosses over, medical weight loss (surgical and pharmaceutical) as a tool for successful and sustained weight loss for lowering risk factors, but as he mentioned longterm research isn't yet available.  The reality is to make sure we are presenting weight loss vs. exercise appropriately.  Exercise is good whether it results in weight loss or not.  A healthier diet is good whether it results in weight loss or not.  Maybe that should be the focus more than weight loss, but I don't recall him stating this very obvious option.

Finally, my response to Scott's Thoughts:

• Ask permission? - do we ask permission to discuss diabetes, hypertension, cancer, smoking, hyperlipidemia, etc?  Weight is a factor of health.  Again, do we harp on it and be the only thing we recommend?  No.  Does it need to be mentioned at every visit? Maybe.  Should a relationship likely be developed first?  Yeah.  But to not mention it because a patient doesn't want you to isn't helping them.  I'll give an example: back when I was in family medicine I had a patient who smoked and I mentioned her smoking.  She became combative and immediately responded saying something to the effect of, "I know it's bad for me, but I'm willing to accept that risk."  Ok...I shut up about it.  At her next visit she wore a shirt that said, "Smoking is bad for me."  She actually had it specially made to wear to her visit, and we made a deal...as long as she wore that shirt to her appointments with me I would take that as her statement that she understood the risk and had received smoking cessation education.  After being her provider for 2 years she forgot one time and I brought up her smoking and she was surprised I remembered and actually agreed to try Chantix for the first time.  Unfortunately there isn't a happy ending as she died of an "unexpected" stroke shortly thereafter. 
• "Your body may like the weight you are at." - what does this even mean?  It may be comfortable at said weight and therefore resist weight loss through the hormone pathways referenced at the beginning of the video, but does that mean the body actually "likes" it?  Beyond metabolic diseases what about arthritis, which can be a major factor in a patient staying/being active?
• "I think you can be healthy without losing weight." - Again, how do we define "healthy?"  I think a better statement would be, "I think you can IMPROVE your health without having to lose weight."  This wouldn't be true for everyone, generally including myself.  Yeah, my diet isn't perfect...but it's pretty good.  The #1 thing I could do to improve my health would be to lose about 10-15lbs.
• Avoid "fat, "overweight" (prefer BMI, higher weight) - I tend to internally vomit at the idea of "trigger words," but that is likely due to the over-utilization and improper use of this term by the "far-left."  Overall, I can generally get behind this idea and already do it myself.  In orthopedics, when I have a patient who needs a total knee replacement I focus less on the terms of being "obese," "fat," etc. and more so focus on the fact that the insurance company won't approve their surgery until their BMI is at or below 40.  I then explain the reasons for this.
• Supported weight management options - yeah, obviously...surgery should be the last case scenario though.

[rev ronin]

@mgriffiths Thank you for taking the time to review the entire presentation and respond at length. I respect that you've kept this on your personal to-do list and gotten back to it.

Re: 2., weight bias DOES harm patients; properly understood this isn't really a controversial statement. Medical people naturally bristle at the insinuation that we're the ones doing the harm: that's a natural reaction as well.

Understand 2 things: First, weight bias is not just a medical phenomenon, but exists throughout society, and the disdain for higher-BMI patients by medical practitioners is not something unique to medicine, but merely an outgrowth of society's "othering" of higher-BMI people. When you're passed over for a job or promotion due to weight, which happens all the time, it cuts access to the benefits of higher socioeconomic status, like the ability to live outside food deserts, get insurance, etc. That's harm.

This is a complex pathology, as studies show higher BMI people with both internalized weight stigma, as well as weight judgment against other higher weighted people. Despite the number of higher-weighted people, the acceptable messages of disdain for those carrying around more weight are staggering. The studies showing that physicians despise higher weighted patients were briefly touched on in the presentation. I've got several papers on the topic that are really sobering, the worst of all being ones that show that eating disorders medical staff have anti-fat bias... Like, it's OK to talk Anorexic folks off the ledge, but those Binge Eating Disorder folks deserve the hate they get?

Second, by the time you've seen your outpatient patient, odds are they've just been weighed, no matter what their complaint is. This is traumatizing to many, again based on how society in general has treated them because of their weight, even if our MAs handle the weighing in a maximally sensitive manner. I'm sorry, but I thought one of the principles of medicine was "don't run a test unless the result will change your course of treatment." We're so used to weights being collected, we don't get how dehumanizing being weighed is, especially to people who've been told they are less valuable as human beings because of their weight.  Your patients may not tell you, but mine tell me, especially because I ask.

3. You probably think you're right, because you're a decent human being and it would never occur to you to tell someone to lose weight for a non-weight-influenced diagnosis. That's not the reality that higher weighted patients experience. Migraines? Lose weight, and come back if that doesn't work. The manifestation of clinician disdain for higher weighted individuals is often-enough manifested as a lack of diagnostic curiosity and a dismissive prescription for the patient to make herself or himself look more socially acceptable before bothering the clinician with the same problem again.

However, I wholeheartedly agree with the idea of promoting a healthy diet and appropriate exercise without mentioning weight or BMI as a goal: weight is a terrible substitute end point.

4. I don't think the evidence shows weight loss is inconsequential, I see that it shows weight loss is substantially unsustainable, and worse, that when not sustained, leads to further weight gain. Failed interventions that make the original problems worse are problematic, and should only be recommended when the cost/benefit ratio is appropriate--never blithely or routinely.

Asking permission to raise a topic is always a good thing. It's called informed consent, shows courtesy and sensitivity, and yes, it should extend to the topics of conversation.

"The #1 thing I could do to improve my health would be to lose about 10-15lbs." I doubt that. First, there's a 95% chance that after successfully losing the weight, you'll put it back on within three years, and, in doing so, likely add a few pounds more weight, and possibly increase your risk for metabolic consequences like DM II.  If you were able to lose weight and sustain that weight loss, your body would slow your metabolism and defer maintenance to try and regain that weight, which it views as a disturbance in homeostasis.  What we don't have much of is evidence that dropping to a lower weight improves outcomes in the long term, because so few people maintain a lower weight over years to decades.

It's far better to never gain weight in the first place, because once the body tries to defend a higher "set point" we are fighting our own homeostatic efforts which understandably doesn't end well.

At any rate... it takes time to wrap our heads around this stuff. Don't feel bad if parts of you are rebelling against it. Some of what's being said is likely hyperbolic, some may be wrong, but one of my middle school experiences illustrated how much weight bias can be cultural.  My 7th grade social studies teacher was Mr. Chu; he was proud to be Chinese, but the most patriotic American possible after having escaped the communists. He had a rounded belly, probably BMI 35-40, and was very straightforward about his value system: "In China, to be a little fat meant you were rich."

Our task is to de-privilege our assumptions about weight, and test what is really true using the scientific method, and consternation as we realign assumptions is a necessary part of the process.

[mgriffiths]

Weight bias: I didn't state myself very clearly.  I agree that weight bias harms patients, just as other forms of bias can harm patients.  A provider attributing a symptom to an obese patient's weight without a thorough exam/workup is wrong and at least borders on malpractice.  That doesn't mean their knee pain isn't caused by their weight...but maybe it's Lyme disease.  You brought up the example of migraines that aren't even likely related to their weight being treated by recommending weight loss.  I would argue that is malpractice and is definitely not what I am calling for.  

The issue I'm not sure I can get behind is how it seemed he defined weight bias.  In his presentation he seems to define it as just simply bringing up a patient's weight or including weight loss as a potentially effective treatment option.  Again, this gets back to what we mean as "effective."  Just because a patient isn't successful with weight loss doesn't mean that weight loss wouldn't actually help their metabolic disorder.  Example: I also recognize that if treating hypertension and the patient fails to take their lisinopril that that could be classified as "ineffective."  But, is that because the medication doesn't work or because the patient didn't take it?  Weight loss, improved health habits (with or without weight loss), and other similar lifestyle changes can be powerful.  Of course if a patient fails to make those changes that doesn't mean we refuse further treatment options and continuously harp on their weight.  But, I just seemed to get the vibe that he is arguing we should ignore their weight as a problem.  I think that's just simply ignoring the elephant in the room...literally. (sorry...couldn't help it)

 

20 hours ago, rev ronin said:

the disdain for higher-BMI patients by medical practitioners

This is a powerful statement, and unfortunately I will admit that in both family medicine and orthopedics I dislike higher-BMI patients.  Is it because I view them as lazy?  No...the majority of my patients are lazy, regardless of their BMI.  The reason is that higher-BMI patients are more complex and will require more of my time while they are also less likely to actually get better.  The patient with a BMI of 48 coming in with knee pain (that isn't caused by something goofy like Lyme disease)?  Yeah, I don't have anything that is going to solve their knee pain.  Maybe I can buy some time with a steroid injection, but even if they don't have visible arthritis on their XR they're developing it and rapidly.  Does that mean I shouldn't examine them thoroughly?  Of course I should...but more often than not there is going to come a time when I have to tell them I don't have anything else to offer them because their BMI is beyond the cutoff to have a knee replacement and the injections aren't working.  And that's assuming they're healthy enough to be able to take NSAIDs, have injections, go to PT, etc. when they first come to me.  That doesn't mean I won't treat them.  That doesn't mean I'm going to harp on their weight.  In fact, in orthopedics I likely won't even bring it up..EXCEPT I will bring it up every...single...time when a patient tells me, "I know my knee pain isn't related to my weight."  Once I've examined them and ruled out goofy stuff, I will tell them they're wrong.  I'm not going to go along with their lie, even if they're just lying to themselves.  I see it as completely equal to the diabetic with an A1c of 10 who says it's not a big deal.  Nope...it's a big deal.  I see it as completely equal to the hypertensive patient with a BP of 160/95 who says they're fine.  Nope...you're not fine.   

To go further...what about my time and reimbursement?  Yeah, if I spend more time I get more RVUs, but medicine is moving more and more to outcome based reimbursement.  What is the expected outcome for a higher BMI patient?  Is that patient likely to be reimbursement positive, neutral, or negative for my practice under an outcome based reimbursement model?  I understand that pushing them to lose weight once they gain it may have limited success in actually occurring, but the reality is that their eating and inactivity is what put them in their position.  There has to be accountability for that.  Does that mean they should be ignored by the medical community?  Of course not.

Let's be clear...higher BMI patients require more work for pretty much everyone involved.  Let's take it outside of medical providers.  When they're in the hospital they require more of the nursing staff's time and there is a higher risk of staff injury due to the patient's weight.  Their surgeries are more difficult and come with more complications.  The list goes on and on.  Again, does that mean we mistreat them?  Does that mean we ignore them?  No.  They are humans and they are just as important and special as any other human.  I get they don't feel that way, and that often is the result of mistreatment by others.  That is wrong and unfortunate.  But, often times higher BMI is associated with mental problems like anxiety, depression, etc.  It can sometimes be a chicken or the egg situation...which came first.  But, with these mental diagnoses often patients don't interpret stimuli appropriately and have their own biases assuming they will be mistreated and therefore interpret essentially everything and everyone as mistreating them. 

20 hours ago, rev ronin said:

"The #1 thing I could do to improve my health would be to lose about 10-15lbs." I doubt that. First, there's a 95% chance that after successfully losing the weight, you'll put it back on within three years, and, in doing so, likely add a few pounds more weight, and possibly increase your risk for metabolic consequences like DM II.  If you were able to lose weight and sustain that weight loss, your body would slow your metabolism and defer maintenance to try and regain that weight, which it views as a disturbance in homeostasis.  What we don't have much of is evidence that dropping to a lower weight improves outcomes in the long term, because so few people maintain a lower weight over years to decades.

Again, I should have been more clear.  The assumption is that I lose that 10-15lbs and KEEP it off.  Absolutely yoyoing isn't healthy.  Guess what, almost 3 years ago when my annual blood work come back showing my fasting blood glucose at 103 I put in the effort to improve my diet and lose weight.  I lost from ~235lbs all the way down to 205lbs over the course of 5-6 months.  And guess what...I became the statistic as my weight slowly crept back up to ~235lbs over the course of the next year.  I've now been stable at ~235lbs again.  At my next annual blood work my fasting blood glucose was 103, but my cholesterol labs were significantly improved.  This coming winter when I have my blood work again I'm hoping that my improved diet and continued increased activity will have a further impact on improving my lab results.

Could I sustain the weight loss?  Yes...but as basically anyone who has tried, it IS hard.  I know EXACTLY what happened that allowed my weight to begin slipping, and I know the mental gymnastics I went through to "ok" the weight gain. "Oh, being 210 is ok...I'm still good."  "Oh, 220 is still ok."  "Oh, I haven't reached 230 yet, that extra piece of cake won't hurt anything."  ...until...BOOM!!!  I wake up and step on the scale weighing 236lbs.  I remember the day.  I also remember the day in middle school when a dad of one of my wrestling teammates was doing preseason weigh-ins and said, "[Mgriffiths], lay off the cupcakes."  I then grew something like 6 inches that year.  I was a bean pole and walking around like a baby giraffe.

Let's be clear, the weight loss is possible.  Is sustainable weight loss possible?  Absolutely.  It's hard...it's really hard.  It's made even harder by our society that causes constant stress and doesn't give room for self-care, especially for those who need it most.  It's made almost impossible by our food manufacturers.  Buying anything even mildly processed almost universally has a ridiculous amount of sugar added to it.  Oh, and our two favorite holidays are coming up that have lost almost complete meaning beyond gorging ourselves with food, cookies, candy, etc. and they're preceded by a holiday that basically worships candy!

The cards are against the patient and therefore understanding must be given.  Does that mean we ignore the problem?  I don't think so.  Ignoring the issue is being complicit.

[mgriffiths]

I'm going to respond to my above post...and intentionally not edit it.  Upon a reread, the above comes across to myself as callous, and I don't mean it that way.  I mean it to be real and honest.

I've lived the moderate weight gain.  I've lived the weight loss.  I've lived the re-weight gain and the frustration that comes with it.  But, I have no one to blame but myself.  I allowed my goal of weight loss to become less important than other things.  My #1 downfall is snacking late at night...which gets right to another major problem for me...sleep.  I don't get enough sleep, and late at night I love nothing more than making a ridiculous amount of popcorn (because homemade must be healthier ) that has far too much butter and salt.  Sometimes I'll try to be healthy and substitute chips, cheez-its, or something similar for the popcorn.  During my weight loss I got better sleep and didn't snack after dinner.  I actually didn't stop having the occasional donut at work, or partake in the occasional potluck, or limit my normal meal portions.  I ate until I was satisfied, like I generally always do.  But, I stopped the late night snacking.  Do you know how many calories are in a stick of butter?  

I can understand that we need to be careful recommending weight loss when we "know" it's pretty much universally not going to be successful (keyword here).  I can also understand that we need to be even more careful knowing that almost every patient who does have success with weight loss is going to add that weight back...and likely at least a few more.  Therefore the question of, "are we actually helping them by advising weight loss?," is a very valid question.

So, maybe the focus needs to shift to how to keep this cycle from continuing?  There are some working on it, but it's limited in impact from what I can tell.  But, then I ask, how do we keep from becoming a "nanny state" by controlling our food industry more tightly?  Is it actually good for the government to become intimately involved in what is being put on our plates?  Can we ban or limit added sugars?  Why does everything have to have corn syrup in it?  Why is it that obesity rates in European countries are 10+ percentage points behind the USA?

[rev ronin]

I want to commend you for your honesty and insight. I think that the people who treat higher BMI patients badly have exactly the same experiences... but lack the compassion that you're expressing.

It's hard to care for people when some are harder and you know it and everyone knows it. So often, that frustration gets misdirected at the people who are themselves victims... and that's another thorny label.

Like you, I like night eating. I don't meet the DSM criteria for night eating disorder, but that's clearly why I've gained in recent years, once I got myself on a good CPAP, because yes, poor sleep is a big weight problem.  Am I a victim? I don't think of myself as one.  Certainly, I could, but haven't, made different choices. I could be a runner like EMEDPA, only I'd suck at it, hate it more, and look funnier doing it. I blame Covid-19 for my decrease in cardiovascular fitness, but it could just be my weight and age catching up with me.

Some of our patients are victims.  I'm thinking of the lady who crossed 400 lbs that I wrote about in my JAAPA piece. To the extent that there are things that could have set her up to not end up that way... she had none of those advantages.

Yet if you had both her and me as patients (and assume for the sake of example we're the same weight, even though we're not), you'd probably react more negatively to her than to me, because she exudes helplessness and hopelessness, while I'm pretty matter of fact about my weight. We, as "Type A" people with the drive and discipline to succeed as PAs, naturally look down on people who typify "learned helplessness" as weaker.

The trick is to flip the script and see ourselves as protectors and defenders of those with learned helplessness.  I've had to learn to do that, both with my long term injured workers and my eating disorders patients. That's why I advocate for them, because what we've (royal we as in medicine as a whole, not you or I) been doing--haranguing and shaming them--hasn't worked. It's time for a different approach. That's where I started 10 years ago, despising patients with learned helplessness.

I needed an attitude adjustment, and working with the very sorts of people I was tempted to disdain cured me of my arrogance, sitting and listening to not only their problems but their habits of thinking made me thankful for my upbringing and education that taught me better ones.  Again, the option is disdain or compassion, and I intentionally choose the latter.  Now, it's absolutely frustrating when an eating disordered patient gets out of an intensive treatment program and goes right back to their disordered eating and behaviors: we can show them how to eat healthy, show them how it doesn't result in disaster, educate them on all the right nutritional information... and then none of it matters and old habits reassert themselves when we try to launch that person back into her or his own life.

A CRM class taught me you can't be mad and curious at the same time, so I intentionally cultivate my curiosity about why these patients fail... because whatever went wrong, I know the last thing they need is me being mad at them for failing. Nonjudgmentalism is hard work, but so rewarding when you see it "take" after so long without success.