Sunday, February 24, 2013

Politics and Weight: Risk Hyperbole

NJ Governor Chris Christie
The recent nonsense over whether Governor Chris Christie should be elected President "at his weight" is yet another example of size profiling (making medical judgments about a person's health and habits based only on weight) and the ridiculous risk hyperbole around obesity.

The blog, First Do No Harm, highlighted this, as have Paul Campos and others.

For those who have been in a vacuum, here's what happened.  Dr. Connie Mariano, former White House physician, made the following comments about Chris Christie on CNN:
“I like Chris Christie a lot, I want him to run, I just want him to lose weight.” 
“I’m a physician more than a Democrat or a Republican, and I worry about this man dying in office. I worry that he may have a heart attack, he may have a stroke…it’s almost like a time bomb waiting to happen unless he addresses those issues before he runs for office.
This is the metaphor doctors love when size-profiling fat people..."a time bomb waiting to happen."  As if we are walking corpses, waiting to keel over at any second at the least stress or difficulty.

It's that kind of nonsensical hyperbole around the risks of fatness that cause so much of the weight stigmatization and weight discrimination today. Yes, there are risks associated with having a high BMI, but these risks get inflated in people's minds until they think of us as about to stroke out and die at any second.

Like the countries who won't let fat folks adopt children because they think fat people won't live long enough to raise the children.  Or fat women being pressured to abort their babies because "it's just too dangerous" to carry a baby at their weight.  Or fat women being told that they will no doubt have a heart attack and die during labor.

Christie responded:
“You know, I find it fascinating that a doctor in Arizona who’s never met me, never examined me, never reviewed my medical history or records, knows nothing about my family history, could make a medical diagnosis from 2,400 miles away. She must be a genius. She should probably be the Surgeon General of the United States, I suspect, because she must be a genius. I think this is just another hack who wants 5 minutes on TV.” 
“And it’s completely irresponsible. Completely irresponsible. My children saw that last night. And she sat there on TV and said ‘I’m afraid he’s going to die in office.’ I have four children between 9 and 19. And my 12 year old son comes in last night and says, ‘Dad are you going to die?’ This is irresponsible stuff. And people who have a medical license, who have the privilege of having a medical license, should in my view conduct themselves more responsibly than that. If she wants to get on a plane to come here to New Jersey, and ask me if she wants to examine me and review my medical history, I’ll have a conversation with her about that. But until that time she should shut up.”
Bravo to Christie for fighting back, but this doctor is far from the only person questioning whether his weight should keep him from being president. Barbara Walters also asked it, and so have quite a few others.  And many others are thinking it, even as some rush to declare that no, it's not an automatic disqualifier.

So let's take a look at the question.  Is a fat man in his 50s a walking time bomb?  Is he going to keel over at any moment if he works at a stressful job?  Should weight be considered more strongly than other risk factors?

Risk Factors Viewed Unequally

It is fair to ask whether a candidate's medical history might impact their ability to do the job. However, not all risk factors seem to be considered equally when the press ask this question. The fact that weight is more of a concern for them than many other risk factors just shows the distorted sense of risk we have developed around weight.

One of those distorted risks is the prediction that a fat person is going to keel over dead at any moment.  Yet the First Do No Harm article pointed out that "a 50 year old 'morbidly obese' man with no comorbidities...who doesn't drink or smoke, and is reasonably fit is fairly unlikely to die before 62, the age Christie would be when he leaves office if he runs and wins in 2016."

Paul Campos points out that the weight critics are ignoring the fact that age is a far more potent risk factor for death in office than weight, yet we routinely consider electing older politicians to office:
In January of 2017 Christie will be 54, while the current Democratic frontrunner for her party’s presidential nomination, Hillary Clinton, will be 69. It is true that, compared to “normal weight” people such as Clinton, very obese people like Christie have, all other things being equal, an elevated mortality risk. Specifically, the most recent, detailed, and sophisticated study of the question, published last month in the Journal of the American Medical Association, found that people as heavy as Christie have a 29% increase in mortality risk, compared to otherwise similar people of normal weight. 
Now 29% may sound like a significant elevation in risk, but let’s compare it to another factor — one which has a vastly more powerful effect than body weight: age. 
All other things being equal, government actuarial tables reveal that the odds that a 69-year-old woman will die between January of 2017 and January of 2021 are 115% higher than the odds a 54-year-old man will die during that four-year time period. In other words, age poses almost exactly four times greater a mortality risk to Hillary Clinton than weight does to Chris Christie, in regard to the chances that either would die during their first presidential term.
So older age is a stronger risk factor in the next election's potential candidates than weight, yet weight is the one getting the attention. That says a lot about the media spin put on obesity.

What about other risk factors?  How much attention do those get?

Others have pointed out that President Obama smoked until recently, and that is a very significant risk factor for heart disease and stroke.  Some people gave him a hard time about the smoking, but for the most part that risk factor was overlooked.

John McCain had a history of skin cancer when he ran for president.  He also would have been one of the oldest presidents, had he been elected.  Although these issues were raised in the campaign, the public did not seem to see his age or his prior cancer as serious considerations and he came close to winning.

John Kerry had a history of prostate cancer when he ran for president.  So did Bob Dole, who was another one of our oldest candidates.  Again, although mentioned occasionally, the issue of their prior cancer seemed to gather little attention during the campaigns.

Pre-existing health conditions, history of potentially life-threatening disease, and smoking are certainly legitimate risk factors, but the fact that weight gets far more focus as a risk factor is more a reflection of our risk hyperbole around obesity than anything else.

What about the pressures of the office on someone with a significant medical risk factor or condition?

John F. Kennedy is a president who took office with significant health issues, although these were not made known until after he died.  He suffered from Addison's Disease and was under major medical treatment while in office, yet somehow managed to deal with the pressures of the office.

Lyndon Johnson was a former heavy smoker who had had a major heart attack several years before being elected vice-president in 1961.  He became president in 1963 when Kennedy was assassinated. He survived eight years as vice-president and president during extremely turbulent, war-filled, and stressful times.

And don't forget that Dick Cheney, a man with a history of already having had THREE heart attacks (plus a coronary artery bypass operation) was elected to the VP office in 2000, a heartbeat away from president. He then had another heart attack, a stent placed, angioplasty, and placement of a defibrillator, and people still elected him to a second term as VP in 2004. He managed to survive eight years of being one of the most involved vice-presidents ever, during years of terrorism and wars, despite an extremely extensive history of heart troubles.

Yes, it's incredibly stressful to be President or Vice-President, but by no means is it a death sentence, even for those with serious pre-existing conditions.

As for a fat person's ability to handle stress, don't forget that Christie has been the governor of New Jersey for quite a while ─ a position hardly free of stress ─ and has done fine so far.  As he himself pointed out, during Hurricane Sandy and its recovery efforts he was putting in incredibly long hours and was under enormous stress.  Yet he did fine.  Although no one has a crystal ball, likely he would be fine while president too.

A History of Fat Presidents

Grover Cleveland,
22nd and 24th President
Of course, Dr. Mariano completely ignores that there already HAVE been fat presidents and they didn't die in office.

If fat folks were really that much of a walking time bomb, shouldn't we have seen those fat presidents keel over right and left?

So the question becomes, who have been our fat presidents, what were their BMIs, and how did they fare in office?

Well, it's not easy to find a reliable source of presidential BMIs (and even more difficult to verify them), so you have to apply some caveats to these numbers. And Presidents' weights may have fluctuated while in office, so the BMIs reported below may have varied, higher or lower, over time. But here's what one source gives for presidential BMIs.

According to this source, our "overweight" (BMI 25-30) presidents have been:
  • Dwight Eisenhower (BMI of 25.3)
  • George Washington (25.5)
  • James Monroe (25.6)
  • Gerald Ford (25.7)
  • George W. Bush (25.9)
  • Lyndon Johnson (26.0)
  • Rutherford B. Hayes (26.0)
  • Harry Truman (26.3)
  • James Polk (26.4)
  • James Buchanan (26.9)
  • John Quincy Adams (27.2)
  • Herbert Hoover (27.7) 
  • Bill Clinton (28.3)
  • Chester Arthur (28.7)
That's fourteen presidents who were officially in what we now call the "overweight" BMI category.  Guess it wasn't all that uncommon for people to be "overweight" even in the good old days, eh? And really, this list goes to show just how silly the BMI cutoffs are, as many people would not have guessed that some of the above presidents were in the "overweight" category at all.

There are fewer "obese" (BMI 30+) presidents, it's true. Certainly, weight prejudice and looks bias played a role in politics, even in the old days, so you have to wonder whether Chris Christie's chances of being elected will be influenced by his weight ─ not so much because of his health, but because of people's biases about his weight and his looks.

However, it's too strong for Dr. Mariano to suggest that the stresses of the presidency would almost surely kill a fat person. If that were true, most of these fat presidents should have died in office:
  • Teddy Roosevelt (BMI of 30.2)
  • Zachary Taylor (30.2)
  • William McKinley (31.1)
  • Grover Cleveland (34.6)
  • William Howard Taft (42.3)
Okay, William McKinley died in office, but he was assassinated, so no relationship to his weight.  Oh, and he was assassinated in his second term, so he lived through his first term just fine.

Zachary Taylor died in office, but the cause was a severe case of gastroenteritis.  This could have come from food poisoning, cholera, a bad virus, or a bacterial infection. Again, it was not related to weight.

What about the others, you ask?

President Theodore Roosevelt and family, 1903
Teddy Roosevelt succeeded to the presidency after McKinley was assassinated.  He had a long prior history of childhood ailments (including heart issues and asthma) and malaria from his time in Cuba, but was a vigorous devotee of exercise. He thrived during nearly 8 years of the presidency, and ran for the presidency again several years later. He lost only because he split the votes from the Republicans by running on a third-party ticket.

Roosevelt was known for his high energy and voracious intelligence and is regarded by many as one of the best presidents of all time. He was rough and tough; he was shot by a would-be assassin in his third election, but went on to deliver his speech anyhow. He did die relatively young after his presidency (age 60, heart attack), but this was likely brought on by complications from the previous malaria and an extremely serious infection he had acquired on a South American trip.

Grover Cleveland, our second fattest president, was elected twice. He is the only president who was elected to two non-consecutive terms. He won in 1884, won the popular vote but narrowly lost the electoral vote in 1888, and re-won the presidency fully in 1892.

Cleveland served during a stressful time of significant labor unrest and a serious economic depression. Despite this, he survived two terms as president, with four years in between. Hardly the ticking time bomb Dr. Mariano predicts.

William Howard Taft,
Official White House Portrait
Of course, our fattest president was William Howard Taft (BMI of 42.3). Reports differ on his exact weight, but it was over 300 lbs. during his presidency.  He was a big yo-yoer and his weight went up while president, so I would guess that his BMI well exceeded 42.3 during his presidency.  Yet he survived his term just fine and lived for many years afterwards.

I'm sure a troll would point out that Taft supposedly got stuck in the bathtub at the White House, a story repeated again and again as if true, although its veracity is questionable. It's likely an urban legend, one of those stories people want to be true to confirm their own biases and so keep repeating, regardless of any actual truth to the story.

It is true that Taft had some health issues while in office, in particular high blood pressure and severe sleep apnea, neither of which had effective medical treatments then.  And there is no doubt that Taft fell into the Class III "morbidly obese" category ─ yet he somehow managed to survive four years of presidency.

Also note that Taft had been U.S. Solicitor General, Governor General of the Philippines, and Secretary of War before he became President, and he went on to become Chief Justice of the Supreme Court a few years after his presidency, a position he held for nine years. None of these were low-stress positions, yet somehow he managed to survive many years of this high stress, all while morbidly obese with health issues.

In fact, our two fattest presidents both had good life spans, especially considering the time period in which they lived.  Grover Cleveland died at 71, and William Howard Taft died at 72. They hardly keeled over at an early age from their weight.

It's also worth noting that Taft likely would have won a second term, except that Teddy Roosevelt ran against him, splitting the votes of his party and making it possible for Democrat Woodrow Wilson to win instead.  Notice that it was Wilson, with a "healthy" BMI of 23, who was the one who had a series of strokes while in the White House, not Taft with a BMI that was almost twice as high. Obviously, BMI is not necessarily a good indicator of health.

None of this predicts how Chris Christie would do, of course. His health may well be different than these men; in fact, one concern for him would be his frequent yo-yo dieting rather than just his BMI alone. He also has asthma to consider. But the point is that BMI is not a good surrogate for health, and that several fat folks have survived the presidency just fine.

But Would We Elect a Fat Person?

The question now is not whether we can elect a fat person president.  Obviously, we can and we have in the past. The question is whether we would elect a significantly fat person president in this age of obesity risk hyperbole and weight stigma.

In one major news magazine poll, the majority of responders felt that Christie's weight should be a major issue.  The comments showed that many people still equate fatness with laziness, a weak character, low self-esteem, a lack of control, and "time bomb" health status.

For example, here are some comments (trigger warning: insert major Sanity Watchers' points!) from readers of one article about whether a fat man could get elected president:
  • Fatness is gluttony. The last thing we need right now or even in the future is a person who cannot control their appetite controlling our government spending!
  • ...The question that is important is "Why is that person over weight?" Is it a symptom of something like lack of self control, low sense self worth, or just plain laziness? Those are questions that shouldn't be ignored for fear of upsetting the gods of political correctness for these questions can tell us a lot about what kind of person we're dealing with when the cameras are off.
  • ...People perceive fat people as lazy and unmotivated. People will think that a fat president can't take care of his body. If they can't take care of their body then how are they going to be able to handle taking care of the country? 
  • A person who does not have the self control to lose weight would not be my choice for President. The President must be health conscious in order to set a good example for our already overweight populace, especially our young people.
  • The stress of the job of being President is overwhelming in itself. Add obesity to this equation and the job becomes almost physically impossible, and a massive liability to our nation.
  • It is not really a question of fat or not fat, it is a question of what the media will push as a perception of body mass as a symbol for the politics and policies of the candidate. I, for one, will get tired very quickly of the fat jokes that will flood the airwaves once a corpulent candidate is nominated. 
Sadly, I despair whether a fat person could ever get elected in this modern media age.  The Health Police are too unrelenting in their condemnation to let it go, as evidenced by Dr. Mariano lecturing Chris Christie, who isn't even a candidate yet for an election that is still four years away.  

This is one of the outcomes of public health campaigns about obesity; they reinforce all the old stereotypes about obese if the ONLY way you can be fat is if you are an out-of-control glutton, as if all fat people are lazy and unmotivated, as if obesity is always the result of low self-esteem and emotional eating as compensation, as if all you have to do to lose weight and keep it off is to put down the fork and go for a little walk.   

Sigh. No matter how many times you say that it's more complicated than that, people won't believe you, largely because they want to believe that it's your fault, that weight is completely within one's own control if you just try hard enough. They need to believe that if they personally are not fat, it is because they are virtuous and in control of their eating, not because they lucked out in the genetics department.  

The one encouraging thing in all of this is that there is some sympathetic backlash to some of these weight-related attacks on Christie. When his opponent tried to use Christie's weight against him in the last New Jersey governor's election, Christie was able to spin that against the opponent, and the opponent's weight jabs actually worked against him. And a lot of people now feel sorry for Christie after Dr. Mariano's insensitive comments.  

However, this sympathy will only last so long.  The moment that Christie does something unpopular, out will come the unrelenting fat jokes.  Out will come the editorial cartoons lampooning his weight, or using his size as a negative metaphor in a political cartoon.  Yes, Christie has been able to turn some of these jokes to his favor by making his own fat jokes about himself first (see the recent Letterman show), but this only goes so far.  If he decides to campaign for president, the mean-spirited fat jokes will start flying fast and furious, and the sympathetic bounce will quickly disappear.  

Yes, there were other fat candidates this last election, but if they had gotten very far in the polls, you know their size would have been used against them sooner or later, and you know that the fat jokes would have been everywhere.  

And we can only imagine what the reaction would have been if the candidates had been fat women. You can bet that Hillary Clinton, Michele Bachmann, Sarah Palin, Elizabeth Warren, or any other potential female candidate would never have gotten very far if they had been fat.  And of the political women who have been speculated about as presidential candidates in 2016, you'll notice that not one is fat.

If the world is ambivalent about a fat male politician, it's even less welcoming to the thought of a fat female politician.  And that's even more frustrating.

Final Thoughts

Yes, it's legitimate up to a point to raise questions about a candidate's health when they are running for office, but these health concerns have to be put into perspective.

Pre-existing medical conditions are a potential concern, but history has shown that many presidents with health conditions have done just fine in office. Just how strongly a pre-existing condition has to be considered will depend on the condition.

But history has also clearly shown that fatness alone doesn't mean you're going to keel over from the pressures of the office.  We've had fat presidents before, even very fat presidents, and they've been fine.  It's time to do away with this whole "too fat for a stressful job" idea.

While we can look closely at a candidate's health, we have to ask ourselves hard questions about our own biases when doing so.  It's very telling that in all of these media discussions, other risk factors like age, smoking, and prior significant medical conditions were considered a relatively minor concern and largely overlooked. In contrast, Christie's weight is considered a major concern by many.

Why does weight get such disproportionate attention as a risk factor? Frankly, it's more a reflection of obesity hyperbole than it is the reality of imminent risk. 

The Health Police see a fat candidate as yet another chance to beat the drum about the dangers of obeeeeesity in order to scare people into radical weight loss. The fact that some voters take this so seriously that they would automatically discard a politician only because of weight is yet another demonstration of the danger of these well-meaning but misguided public health campaigns.

I say, vote for a candidate or not based on your opinion of his/her politics and leave weight out of the picture.  If Chris Christie decides to run for president next time, then ask him pertinent questions about his health, just as all candidates should be asked those same questions.  But don't jump to conclusions about his health or what that will mean for his job based on the scale alone, don't make assumptions about his habits or his medical future based only on his weight, and stop throwing around the "time bomb" metaphor.  That is just risk hyperbole, nothing more, and it's just plain irresponsible and unfair.

*Post-Script:  Comments are welcome, but this is not the place for political debates or slurs on opposition candidates, whatever your political persuasion. Inappropriate or unkind comments about politics or weight etc. will not be published. Keep any discussion polite and limited to the intersection of weight and politics, please.

Thursday, February 7, 2013

The Repercussions of Weight Bullying

all images from
I'm concerned about the increasing trend towards Weight Bullying among some healthcare providers.

As the pressure on providers to "do something" about the Obeeeesity Epidemic increases, so does the pressure for them to participate in weight bullying at appointments.

What is "weight bullying"?  Weight bullying is the unrelenting, negative focus on a patient's weight during medical appointments to the detriment of all other issues.

It is the constant harassment to lose weight ─ not just work on healthy habits, but actually put the primary focus on losing weight ─ by whatever means necessary, even radical ones.

It is blaming the patient's weight for everything that is wrong with that patient, even when such a connection is dubious.

It is overlooking other possible causes because the care provider cannot see anything besides the patient's weight ("fat distraction," also known as "size profiling").

It is limiting access to tests and treatments, based only on a patient's weight (or willingness to pursue losing weight).  It is denying treatment until a patient acquiesces and loses weight.

Sometimes this pressure for weight bullying comes from the insurance companies that providers have to answer to, sometimes from colleagues within the profession, sometimes from research articles that contend that care providers aren't doing enough to combat the  "obesity problem," etc.

Many articles in the popular media and in the medical research claim that doctors are rarely engaging in "obesity screening" or "weight loss counseling."  Funny how that doesn't seem to jibe with the experiences of most "obese" people, who report that the harassment over their weight and pressure for weight loss is unrelenting at most appointments.

Whatever the source of the pressure, care providers need to start recognizing that weight bullying is causing more harm than good for many obese people.

The Dreaded "Weight Talk"

There was a great article about this called "Dear Doctors, Quit It With The Weight Bullying" and it's by "Jess." It can be found here.

The topic of the  post, as you might guess, is weight bullying.  Specifically, "the weight talk" and pressure to lose weight, often without regard to why you're really at the doctor in the first place, and usually without even asking about your habits first (because you're only going to lie about them, right?).

Jess pointed out that when a routine health check-up becomes an exercise in shame, it tends to have a chilling effect on future doctor visits.  

And that is one of the most ominous effects of weight bullying at the doctor's, because putting off regular appointments can result in serious conditions going overlooked or undertreated, and thereby irreparably harming a person's health.

Here is what Jess experienced.  She was at her doctor's for a regular pap smear. Here's part of what happened:
...he asked what I ate, but he didn't wait for an answer. I had to exercise more, he said, having no idea how much I was exercising. I also needed to eat less than whatever it was I was eating which I hadn't gotten a chance to tell him. 
Dear god, what cutting-edge medical research! I certainly never thought of “eat less and exercise more,” especially not when I was bulimic, which incidentally is in that file of papers you’re holding which we like to call “records.” 
“I’m not concerned about it,” I said tightly, “and if it comes up again I’m going to have to find another doctor.”

“Any other doctor would tell you the same,” he said, as though I hadn't been coming to him, just as fat as now, for several years. 
“Well, I prefer a doctor who at least waits to hear what I eat before telling me to eat less." 
He looked exasperated. “There’s no possible way you’re not eating too much.”
Even though she fought back and fired this doctor, she found herself putting off her next yearly exam because she dreaded finding a new doctor who might put her through all that again.

When fat people get bullied, not believed, or made to feel like crap at the doctor's office, they tend not to not return. 

What a surprise. Imagine not being keen to keep going back for repeated harassment and derision.

Worse yet, they often lose trust in being able to get reasonable health care from other providers, and so tend to put off a return to ANY provider, not just the fat-phobic one.

Then doctors whine about how obese people avoid the doctor, and gees, how can we get fat people to be compliant with the recommended doctor visits?  How can we get them to improve their health?  How can we get them to regularly undergo tests and see specialists as needed?


Weight Bullying Repercussions

Care providers greatly underestimate the negative impact of weight bullying.  It rebounds in so many harmful ways.

Weight bullying results in people trying over and over again to lose weight, even though research clearly shows that permanent success is very unlikely.  It results in weight cycling, which can increase the chances for gallstones, kidney cancer, further weight gain, and potentially many other issues.

Weight bullying results in fat people resorting to ever-escalating steps to try and lose weight.  When the usual recommendation of "eat less and exercise more" doesn't do enough, most dieters try to eat even less or exercise even more.  If that doesn't work, they go even further, sometimes to dangerous levels.

When that doesn't work, they try fasting, meal-replacement drinks, herbal supplements, or weight-loss drugs that have significant risks and which may do permanent harm to their systems.

When the weight loss doesn't last, many resort to surgery, maiming perfectly healthy organ systems in a desperate attempt to achieve thinness and "health," only to find other, unexpected complications instead. And still, even with stomach amputations and gut bypasses, most don't lose enough weight to achieve a "normal" BMI.  Does that really sound like a purely behavioral problem?  Or could something more be going on to cause their obesity?

With such poor results, so many negative side effects, and the extreme unlikelihood of achieving a "normal" BMI, does this sound like a goal worth pursuing?

Weight bullying also results in people (especially women) developing low self-esteem and poor body image.  Some develop eating disorders because of the shame and disapproval they have internalized.

Even when a full-on eating disorder does not occur, many people have developed harmful habits like overeating or binge-eating, and have internalized toxic attitudes about food and body image.

And, as we have seen, weight bullying discourages fat people from making regular doctor visits and makes them less likely to get tests that might help prevent/diagnose various diseases early.  In the end, this has far greater negative impact on fat people's health than choosing not to go on the latest diet.

In particular, fat people LOATHE:
  • being lectured about weight/pressured to diet when they are at the doctor's about something completely unrelated to weight
  • having every condition they experience blamed on their weight, even when it is clearly unrelated
  • being told they are liars (either to others or to themselves) when they try to share that they eat normally or are already exercising
  • being told that they just haven't tried "hard enough" or with the "right" program yet
  • having to have The Weight Discussion over and over again, every time they visit the doctor, despite previously explaining patiently why they have reservations about weight loss/dieting and why they are exercising their right to patient autonomy by declining this treatment
  • having weight loss promoted as the only treatment choice for whatever ails them, even when their condition has nothing to do with weight or there are alternative treatments to consider
  • having the risks associated with obesity exaggerated in order to scare them into losing weight ("You won't live to see 40!" "You'll never see your child grow up!"
  • not being given access to tests that people of "normal weight" would automatically receive with the same symptoms because the care provider has concluded that weight is the main issue
  • not being allowed access to needed treatment without having to lose weight first
But, but, but.....!

I know, I know.  Many doctors view it as part of their job to promote healthy behaviors, and that bringing up uncomfortable topics is part of good care. I understand that and I truly respect the difficult line that care providers walk when trying to treat all groups with respect and yet also promote better health.

However, there is a difference between promoting good nutrition/exercise and browbeating someone about their weight.

Providers need a better sense of when they cross the line between encouraging health and harassing someone about weight.  It's not that weight cannot ever be brought up, but rather that it should be a respectful and dynamic dialogue, not a one-sided lecture full of assumptions about what the fat person "must" or "must not" be doing, or pressure to lose weight no matter what extreme tactics must be used to do so.

Too many times, fat people try to share their concerns about the health downsides of yo-yo dieting, extreme restrictions, or the eating-disordered behaviors that dieting and weigh-ins can trigger, only to have their concerns completely dismissed or cut off.

Providers need to realize that many people who have opted out of the weight-loss paradigm have done so for very legitimate reasons, not out of laziness, gluttony, or lack of knowledge about the risks of obesity, but because it makes better sense for their body and their life and they feel healthier overall doing so.

Providers also need to understand that patient autonomy means respecting people's right to decline a recommended treatment (weight loss) and still receive respectful, considerate care.

Providers need to understand that repeatedly challenging a person's decision not to pursue weight loss and harassing them about their weight can result in the person avoiding  healthcare altogether until an emergency presents, and this certainly does not improve that person's health.

Furthermore, providers need to realize that promoting healthy habits doesn't have to involve weight loss or a weight discussion at all. 

Providers need to understand that promoting healthy habits can result in health improvements without significant weight loss, and that promoting weight loss as a goal at any cost often backfires and can result in extremely unhealthy behaviors.

By all means, promote more exercise and movement for patients...but don't tie it to weight loss as a goal. We know that exercise is beneficial, even when it doesn't lead to weight loss.  But if exercise is seen only as a means to weight loss, it is rarely sustained.

Exercise should be promoted as a goal in and of itself, not just as a weight loss tool.  

And don't forget to promote healthy habits for all your patients, not just the fat ones.  Don't make it about weight control, make it about lowering the risk for health complications.  Fitness is the best predictor of health, whatever a person's BMI, and may be the most efficient way to improve health for those who have difficulty losing weight.

Don't assume that a fat person never exercises, or that thin ones are exercising plenty.  The truth is that you can't tell how much a person exercises just by looking at them.

ASK THEM their habits and then advise them based on what you are told.  Find out what barriers there are to improvement of habits, and then help them strategize how to overcome those barriers.

Providers can and should encourage healthy behaviors ─ but it is more effective to do so without tying it to weight, without assumptions about what a person's habits "must" be (based only on their BMI), and without indulging in shaming and blaming.

As Deb Burgard says, "Listen to your public health messages with the ears of your fat loved one or colleague...Tease out the hate [speech] from the health speech."

Or as Ragen Chastain says, "People don't hate themselves healthy....We need to take weight out of the equation and make public health about public health and not public thinness."


I believe that most providers mean well, but they need to understand just how much weight loss pressure/weight bullying backfires in terms of a person's overall health.

Health care avoidance is a REAL issue for many people of size, and many have darn good reasons for doing so, based on past experiences.

One of the most important things that care providers can do for people of size is to build trust about the care they will receive ─ independent of weight ─ so that fat patients will not avoid the doctor and will utilize all the tools available to improve/monitor their health long-term.  

Providers, please divorce weight loss from the promotion of health.  By all means, encourage healthy habits, but don't keep tying it to weight loss.

Bringing up weight constantly, shaming patients about it, or harassing them to lose weight doesn't work. Instead, it alienates the very people it is trying to help, often discouraging them from seeking care at all.  And that certainly does not improve their health.