Why Do So Many Doctors Refuse to Listen to Fat Patients?

Some doctors who are otherwise perceptive have a huge mental block when it comes to fat people.

I appreciate the comments IM Doc, a doctor on the frontline of the pandemic, makes about covid-19 on the Naked Capitalism blog. To quote a comment he made on January 1 of this year:

On Dec 31 2020 231K COVID cases were logged in USA – on DEC 31 2021 – that number is 443K. Deaths on DEC 31 2020 were 3,400 and on DEC 31 2021 – were 1,181. Please remember in 2020 – we were much further into the hospitalization curve so that death number may very well increase. I certainly pray every day that is the case. But the difference between 2021 (approximately 65% of USA fully vaccinated) and 2020 (0% vaccinated) could not be more stark and concerning. As I have repeatedly taught medical students over decades – we must look at the final common outcomes to really gauge the success of an intervention. Given these numbers, and the status of the ERs all over America, I would give the vaccines a solid F as a public health measure. That said, it is clear for INDIVIDUAL risk mitigation, there is currently an advantage.

His perspective on vaccines has persuaded me. As a public health measure, vax-centric policies are a failure. The countries which have much lower covid-19 death tolls are the ones where public health authorities put a much heavier emphasis on non-pharmaceutical interventions, such as border controls/quarantines, indoor air quality, widespread testing, material support for people in self-isolation, and/or masking.

Since IM Doc has, at times, been the only doctor on duty in a hospital emergency room while the other doctors were in quarantine, I want him to save his time and energy for taking care of himself and his patients, not arguing with strangers on the internet. That’s why I haven’t challenged his fatphobia directly in comments. So instead, I’m blogging. This isn’t even about him as an individual—he’s just an example of a pattern.

When he comments about covid-19, he often makes glib remarks about how people should ‘skip the Doritos’ or that people need to diet or exercise. When other commenters challenge on him on his fatphobia, he backtracks and says things about how it’s also the fault of the food industry/food processors/advertising, somehow, that’s never what he says first. He starts with exhortations for fat people to eat less and exercise more. This is a striking contrast with his overall emphasis on showing compassion for patients.

This is a contradiction to me. Just about everybody in the United States capable of language processing has heard exhortations to eat “well” and exercise. Fat people have heard them even more often. This has been going on for decades. Meanwhile, obesity rates went up. If the vaccine-centric policies are a public health fail, then telling people to eat “well” or less and to exercise more is an even greater public health fail.

I’ve been following Shannon Ashley’s lipedema journey. For decades, doctors dismissed her health problems because they just saw that she was fat. When she told them she was on calorie-restricted diets and walking miles per day, they assumed she was lying. Because so many doctors refused to diagnose her disease, it got progressively worse, and now to treat it she has to spend over 100,000 USD (despite having health insurance). In the earlier stages of her disease, treatment would have been much easier and cheaper. She reports that she’s gotten comments from many retired doctors who, after reading her essays and see her photos, recognize that they had patients with lipedema, but since they hadn’t known about lipedema, they didn’t give good medical advice.

About a decade ago, I looked into the evidence that exercise reduces weight—and the badness of the evidence shocked me. When I discussed this with people, they were so fixated on the idea that weight is all about calories in vs. calories out and that exercise is all ‘calories out’ that, even when I showed them the evidence, it didn’t sink in. Some reasons exercise fails to cause weight loss are: people who exercise more also eat more, exercise leads to muscle increase (and thus weight gain), and more conscious exercise (such as jogging) reduces subconscious exercise (such as fiddling thumbs) so it may not lead to overall higher calorie expenditure. Some kinds of exercise may also interfere with metabolism in such a way that it causes some people’s fat tissue to grow. If you believe that exercise actually leads to long-term weight loss, PROVE IT!

The evidence that some kinds of dietary changes in some people lead to long-term weight loss is much better. However, just telling people to “eat less” or “eat better” doesn’t work. Shaming fat people is even worse, since it increases their stress levels, and increased stress often leads to weight gain (and is also unhealthy).

I haven’t even asked whether fat is bad for health. The answer, as far as I can tell, is that it’s complicated. Extreme obesity seems to be bad for health, especially during covid-19 infections, but bodies are complex and what’s healthy for a particular individual depends on a lot of factors. In some cases, being ‘overweight’ may be healthier than having a ‘normal’ weight.

But let’s say that we want to reduce obesity at the population level. Exhorting people to change their lifestyles doesn’t work. If it worked, obesity levels in the United States would be way lower now.

The only explanations for the rise of obesity at a population level which make sense to me are environmental changes. It’s not like we turned into a culture which celebrates avoiding physical activity and overeating.

Do changes in food processing over the past few decades have something to do with it? Yeah, probably. Do changes in neighborhood designs, encouraging going around in cars instead of walking, have something to do with it? Maybe a little, though considering how much the evidence for exercise in isolation causing long-term weight loss sucks, I’m skeptical. How about food deserts? Yep, probably a factor.

I suspect chemicals are also disrupting the hormonal balance which regulates our metabolisms. For example, plastic pollution (including micro-plastics) increased dramatically alongside obesity rates. Maybe plastic isn’t the culprit, but other chemicals might be. That would also help explain the rise of many other hormone-related diseases.

That a major environmental change, such as the spread of plastic, has transformed something as intimate as my hormonal-metabolism balance, and that there’s nothing I can do about it as an individual, scares me. If I believed fat people were only fat because of their own immoral ways, and that I could ensure I never share their fate by guarding my moral virtue, that would be a consolation. Perhaps that is the foundation of fatphobia.

I suspect that doctors assume that fat patients who report dieting and exercise efforts are lying because, if they believed their patients, they would have to admit that medical workers can’t do much about fat. Except perhaps surgery.

I urge you not to internalize or externalize fatphobia. Or at least, don’t externalize it, it’s not my business what your private beliefs about your own body are. Treat people of all body sizes with the same level of dignity.

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