Thursday, May 30, 2013

Size matters.

So I recently came upon this post discussing the existence of weight-related bias in the medical profession, and was...sadly, not terribly surprised. In medical school alone, I've seen countless instances of body-shaming and downright hatefulness related to people's (usually patients') size, including a discussion of childhood obesity that somehow devolved--while led by an attending physician I otherwise greatly admire--into a youtube-comments-worthy, riffing free-for-all on the themes of "Why can't fat people just not eat fatty fat all day," "God, why are fat people so gross?" and "If they weren't so lazy and would just exercise..." Interestingly, now that I think about it, my medical school class of 125 had...5 people I can think of who might qualify as 'obese' (ie, BMI >30, which is totally arbitrary, but whatever). That's 4% of my class, as opposed to 36% of Americans as a whole. Not drawing any conclusions (cough, education and socioeconomic status, cough) just...thinking.

 It was around the time that someone suggested drawing attention to a child's obesity at every single office visit (to 'inspire them to change,' of course) that I started getting truly angry. I stuck my hand in the air.
"Don't you think," I said, "That's somewhat shaming for the kid? Don't you think it's overdoing it to mention size not just once a year at physicals but during every visit for every runny nose and earache? Don't you think these kids are already aware that they're fat? Don't you think their peers already remind them every day?"
"Well, if shame acts as a motivator..." Her voice trailed off and she smiled.
"No," I said, "Shame is an awful motivator. Shame doesn't lead to healthy changes. Ok, I hear you, more than a third of American youth are overweight or obese. But you know what? Between a quarter and a half of young women in the USA have disordered eating patterns--or outright eating disorders--that put them at much greater physical and emotional risk. And do you know what drives eating disorders? Shame."
And then I sat down and tried not to look at anyone, because I could tell my voice had gotten a little growl-y at the end and I didn't want to be known as 'the girl who flipped her shit during that obesity talk'...but it was already too late. In hindsight, I'm kind of proud of it.

College was a rough time for me, body-wise. I started college weighing 170 lbs, which for my height put me--just barely--in the 'obese' BMI category (the vagaries and vicissitudes of BMI is a topic for a whole different post). I also had some rip-roaring bulimia going on, for which I sought help at the Student Health Center. However, because of my weight, my eating disorder wasn't deemed 'serious.' It wasn't until it morphed from bulimia to anorexia, and I dropped 70 lbs in the space of a year, that I was suddenly granted the label of someone with a 'real' eating disorder. I remember very distinctly coming back to school August of my sophomore year and seeing my physician at Student Health for the first time in several months. At the time I was in the low-normal BMI range, and creeping ever-downward.
"Look," she said to me, suddenly very stern, "You're at a normal weight now. A little low, even. You can stop doing this now."
As if everything that had come before had been legitimized. As if it were OK to starve myself and purge and overexercise while I was "overweight" (because everyone knows fat people can't have 'real' eating disorders). As if an iffy weight-loss technique suddenly became pathological when I crossed that magical line of 'healthy' BMI. As if self-loathing and body hatred and abject despair over what I saw in the mirror were totally fine, even expected--as long as I was fat.

I've heard doctors mock their obese patients in private, and I've heard them rake patients over the coals for their weight face-to-face (mostly the former, thank God--for the patients' sake). Which is sad, really, for a lot of reasons--but primarily because doctors are DOCTORS--professionals with a duty to do no harm and provide the best possible care, which doesn't include shaming. Shame, as mentioned previously, is a terrible motivator. How on earth is telling someone that their body is ugly and disgusting and unacceptable supposed to motivate them to take care of it? People don't take care of things they hate.

I'm not saying physicians shouldn't discuss weight with their patients--far from it. There are certain health problems that are more common among overweight/obese folks, and losing weight can sometimes help clear them up. It would be foolish at best and malpractice at worst not to tell an overweight patient with PCOS that losing weight could help her improve her fertility. The same goes for patients with diabetes, or osteoarthritis, or high blood pressure. However, focusing on weight as the sole metric of a person's health is not only myopic, it can be counterproductive. There are numerous studies that indicate focusing on behaviors instead--increasing intake of produce and whole grains, getting more exercise, reducing stress--is more effective in improving outcomes.

Para ejemplo: a relative of mine makes occasional attempts to lose weight. He's what would be called, somewhat melodramatically, 'morbidly obese.' It all starts well--he'll begin eating more fruits and vegetables, checking his portion sizes, and getting more exercise. For a few weeks, or even months, this 'works,' in that he loses weight. He starts feeling more energetic and less depressed. Then the numbers on the scale plateau, and because that's the only thing he and his doctor focus on (rather than how his new regimen makes him feel, rather than the fact that his blood sugar and blood pressure are improving, rather than the fact that his stamina has grown by leaps and bounds), he gets discouraged and impatient...and he stops. What was an opportunity for him to feel stronger, healthier and happier gets derailed because people (himself included--it's hard not to do as 50-odd years of socialization have trained you) are only looking at the numbers.

People aren't numbers. They're people.

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