(This is a guest post, written by a med school student, who prefers to remain anonymous. –Amp)
At least at my school, I have often felt that fat-hating is explicitly built into the pre-clinical medical curriculum. I have, thus far, only taken pre-clinical classes, so I have no idea whether the attitudes taught in 1st- and 2nd-year persist beyond this point (or even if anything taught in the first two years matters at all!)
Nevertheless, I was rather infuriated about the way fat was approached in our curriculum. At the time, I had not yet heard of fat acceptance or HAES1, and was still firmly in a dieting mindset. Still, I found the difference between how fat was treated compared to how just about anything else was treated quite remarkable. For every other potentially loaded topic, from smoking to mental illness, there was a concerted and explicit emphasis on (1) following an evidence-based approach, and (2) to treating individuals with kindness and empathy. When it comes to teaching about fat, suddenly all that is thrown out the window.
Some representative examples would be cases where a fat man is described, for comic effect, as having difficulty fitting into a waiting room chair. Or where a woman with a BMI of 23 is described as appearing overweight. Or clinical tutors who repeatedly tell us that “calories in = calories out”, and that fat people simply lack willpower. Or lecturers who tell us that 1200 kCal per day is a reasonable weight-loss diet to recommend to patients. Or descriptions of how weight-loss dieting is the most appropriate response to bullying of fat kids. Or students who make comments in class such as “fat people don’t lose weight because they are stupid”. Or numerous alarmist lectures about the “obesity epidemic”. Etc, etc, etc.
My personal favorite, though, had to be the diabetes lecture where we were given a graph showing rates of obesity and rates of type II diabetes in various countries. The rates did not match up; some countries were identified as having soaring obesity and relatively stable diabetes rates, while others had soaring diabetes and relatively stable obesity rates. The conclusion drawn in the lecture was that the data must be wrong, because, after all, we all know that obesity causes diabetes! If it wasn’t so disturbing it would be quite funny – after all, I’m pretty sure I was taught at some point that the scientific method and evidence-based medicine are not _supposed_ to be about discarding data that do not match your pet hypothesis… ;-)
Those are just my personal impressions, and I don’t know how medical students’ attitudes objectively compare to the general population. I would guess that the teaching doesn’t so much make attitudes worse but rather reinforces the anti-fat attitudes that you’d typically find in a group of affluent young people. Of course, that’s not good enough! They should be actively teaching us to treat fat people well as much as they actively teach us to treat members of any other marginalized group well.
- HAES = “Health At Every Size.” [↩]
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I have no more idea than this person of how medical student’s attitudes compare objectively to the general population (although they don’t sound that unusual), but a) these are people who have less excuse for prejudice, given their training on health matters, and b) more disturbingly, they will also go on to have more influence and be given more credence by the general population when expressing what is actually an ill-founded prejudice. So this article is incredibly disturbing.
because, after all, we all know that obesity causes diabetes
Yeah. Correlation does not equal causation, especially if the correlation is not true in all cases.
There’s SOMETHING about our current lifestyle in the US which is causing an upsurge in both obesity and diabetes. Obesity is probably contributing to the upsurge in diabetes, but it may not be the only reason.
I think there is coming a day when the medical establishment is going to have to look further into this. At least in my mom’s generation, the skinny people are following the plump people into diabetes hell. It took the skinny people five-ten years longer, but it’s still happening. And their doctors are saying things like “well, you must have been fat at one point, and that’s to blame!” then putting them on the new oral diabetes medications.
It’s unfortunate that this isn’t even shocking to hear about. I think progress could be made if the disparity is emphasized between how our new doctors are being trained to deal with smokers, versus how they are trained to deal with overweight patients. Other angles to argue are easily bogged down with the usual nonsense about “they’re just lazy” etc etc. The fact that this one condition is singled out as OK to be unpleasant and mocking about… That might be a point that finally gets across to lecturers the fact that they are passing on and reinforcing an unkind, damaging cultural preconception.
I appreciate you writing about this. Actually, it made me cry, but that’s only because I’ve already had a lousy day.
This morning I was told by my doctor that I’m not hypothyroid, I’m just “fat.” I was told that my dry skin and hair, fatigue, headaches, swollen legs, puffy neck, and inability to lose weight even on a diet and at the gym, were all probably caused by “something else.” No suggestions as to what might cause it. But I should probably start another diet.
Because I’m fat.
And they wonder why ‘overweight’ people sometimes go years between medical visits. Once again, I very much appreciate you taking this on.
A recent study done in Korea found evidence of no causal link between diabetes and obesity, but rather, between diabetes and certain pesticides.
When researchers controlled for levels of pesticide, the link between obesity and diabetes vanished. They hypothesize that because a fairly large percentage of people who have BMIs above 30 tend to eat lots of animal protein, and pesticides bioaccumulate in animal tissue, therefore they have more concentrated levels of the pesticides in their own blood streams. But according to their study, high-BMI folks who don’t have high levels of pesticide in their systems are at no greater risk of diabetes than people at lower BMIs.
They caution that further research is needed to confirm this, but it’s highly suggestive that the diabetes epidemic is related to pesticides, not obesity.
Here’s a link to an interview on the topic:
http://www.loe.org/shows/segments.htm?programID=06-P13-00050&segmentID=2
-l.
Medical students reflect the social and class biases of the population from which they are drawn, and they are drawn disproportionately from the children of affluent well-educated people. If you think your fellow med students have disdain for their fat patients, just wait until you hear about their thoughts on their poor patients, and worst of all, their fat, poor patients. Or maybe the consciousness of doctors has been raised since I dated one.
Orange – I’m so sorry that this made you upset. There are good doctors out there! I hope that you find one.
Barbara – I don’t agree entirely with respect to attitudes towards poor people. At least where I go to school, medical students are socially conscious to the point of pretentiousness. They want to save the world. They volunteer extensively in shelters, with social organizations, etc. They may think that poor people are pitiable and see them as victims, but as a group nobody would dare disagree that poor patients should be treated with respect. Fat people, on the other hand, are seen as causing their own problems and thus not as deserving the same level of respect. In my personal experience, anyways.
My husband is a Vietnam vet, who was sprayed several times with Agent Orange (a ‘jungle defolient’). As he says, anything that kills jungle just can’ t be good for you. He was diagnosed as a type II diabetic about 4 years ago. There are currently 9 diseases directly associated with Agent Orange, to the degree that the Veteran’s Administration deems them ‘presumed service connected’ if you have documented exposure to Agent Orange. 8 of the diseases are forms of leukemia. In 2002 the VA added type II diabetes as number 9. I suspect that one of the countries that has a high rate of type II diabetes and a low or stable rate of obesiety would be Vietnam.
Good post. Good comments.
Orange, I hope you find a reasonable doctor soon. And please don’t forget to report to EVERYONE why you’re leaving the old one. Doctors who don’t treat their patients well should go into labratory research, or surveys. I’ve more experience with docs who treat women badly for their reproductive choices. Good luck.
Orange: I urge you to find other doctor’s, until you find one who will listen to you. It took me 7 years until I found an MD willing to prescribe Synthroid for me. I was repeatedly told that I was “depressed” when I brought in my page-long list of classic hypothyroid symptoms (brittle and receding hair, loss of eyebrows, weight gain, lethargy, mental confusion). I kept telling them that “hell yeah, I was depressed… because of the symptoms”. duh.
But also know that being treated for hypothyroid in no means reduces your weight! It makes you feel better, but I can attest to the fact that weight gain is quite possible while being treated. :)
Good luck!
oh, when getting tested, always ask for the full thyroid panel, with all the bells and whistles. Check T4, T3, etc.
I’ve noticed that some people look at my wife with contempor disgust. What is going on in these peoples minds for them to have created such an attitude?
orange, tell your doctor you would like a copy of your medical file, because you were talking to a lawyer friend the other day about your medical issues. If that doesn’t go off like a bomb I don’t know what will.
NO doctor with half a brain rules out thyroid problems just because a patient is fat.
Medstudent- No, no, I’m glad it made me upset ! Because I need to have the strength to go do something about it. :) Thank you again.
And to everyone else: I can’t tell you how much I appreciate hearing that other people have gone through the same struggles and come out better on the other side. I will take your advice.
Orange:
Also, try to get tested when the symptoms are at their worse (if there is a worse).
My family has a history of Grave’s disease (hyperthyroidism), but with an odd presentation. The thyroid does not fail completely–it cycles. If the person is tested at the right time (while the thyroid is in a hyper state) they are diagnosed. If not, the levels may be normal, or even low (hypothyroidism). Not all doctors know that this can be an abnormal Grave’s presentation. A lot of doctors–especially GPs–operate under the idea that the thyroid rarely changes state, and that thyroid diseases are either all or nothing. This is not always true.
I think that medical professionals should treat all patients with respect and courtesy. I also do believe that medical professionals should indeed behave differently with obese patients. They should urge them (gently, but firmly) to loose weight.
I know what I speak of. I’ve been obese for years, when I went to doctors for a yearly checkup, they would just gently suggest that I should loose weight with diet and exercise. I never paid much attention, and I had no family history of heart disease, hypertension, diabetes. Then, last year, I was diagnosed with diabetes at such a checkup.
I did a lot of research after that and learned that fasting blood sugar (the criterion used for diagnosis) is practically the last indice to deterioriate. You could run high postprandial blood sugars for years and have a normal blood sugar, as I did, with final deterioration coming on over a year or so. But a lot of the damage has already been done — FBS deterioration is a fairly advanced stage of the disease.
So yes, obesity is a huge risk factor for diabetes. You can roll the dice and assume your genes will protect you (as I thought). You can deny that — its your own pancreas, heart, limbs, kidney and eyes. But any health care provider who soft pedals your risk is not doing you a favor, but the greatest disservice of your life. I wish my doctors had been more insistent (although to be honest, I would probably have ignored them anyway).
Let me respond to a few strawmen
“. Or lecturers who tell us that 1200 kCal per day is a reasonable weight-loss diet to recommend to patients”
I’m not aware of any reputable doctor/nutritionist who would suggest a caloric intake more than 500 calories below your BMR. For most adult males, that would be much higher. When I was diagnosed with diabetes, the dietitian recommended a 2300-2400 cal a day diet, saying that diet, with exercise would make me loose a pound a week, which she said was a safe weight loss. In general, very low calorie diets are the prerogative of quack doctors.
“My personal favorite, though, had to be the diabetes lecture where we were given a graph showing rates of obesity and rates of type II diabetes in various countries. The rates did not match up; some countries were identified as having soaring obesity and relatively stable diabetes rates, while others had soaring diabetes and relatively stable obesity rates. The conclusion drawn in the lecture was that the data must be wrong, because, after all, we all know that obesity causes diabetes! If it wasn’t so disturbing it would be quite funny – after all, I’m pretty sure I was taught at some point that the scientific method anevidence-based medicine are not _supposed_ to be about discarding data that do not match your pet hypothesis… ;-)”
Obesity does not cause diabetes. However, it is a very strong risk factor. The scientific evidence for that is undeniable. There is also strong evidence that diet, exercise and relative modest weight reduction can delay or prevent the onset of diabetes (see the reports of the DPP studies). It is unscientific to deny that.
Now, I don’t know what charts were being referred to here, but all epidemiologists and medical professionals know that you cannot always compare directly between different countries and indeed it is unscientific to do so. Data from developing countries is often poor and out-of-date. The average age in different countries tends to vary a lot, and older populations are more likely to have higher incidence rates of disease. Finally, ethnic stock, lifetstyle and diet tends to vary a lot (there is some evidence that the Med diet may be protective).
Furthermore it is also true that the BMI calculations and definition of “obesity” may not be completely valid for different ethnicities. Indeed, there is plenty of evidence that Asian and South Asian first generation immigrants in the US have considerably higher risks than Caucasian Americans with the same BMI (or the same blood pressure or cholestrol for that matter). All of this would be an argument for trying to use different metrics for people with different ethnic backgrounds (lower BP, lower BMI, lower LDL targets). Not for saying that such tables aren’t useful !!
The so-called diseases of affluence (diabetes, obesity, heart disease) are exploding in China and India, and yes there is evidence that obesity is increasing in these countries. There was a report just a few days back that incidence of obesity had increased in India (so equally unfortunately, had the rate of malnutrition). I would suggest reading the WHO reports on diabetes in this case.
To be blunt — this is just pure denial. There are a vast number of medical conditions and recommendations that are based on statistical data. You will almost never find a medical correlation that is true in all cases. AThere will always be people who smoke 5 packets a day and spend their nights in a radon filled basement and never get lung cancer. There are people with Type 2 diabetes who do not control their diet at all, and never suffer from kidney, heart, eye or nerve disease. But we know from strong statistical evidence that smoking vastly increases the risk of lung cancer or that diabetes vastly increases risk of a dozen types of damage to your body.
if you wanted 100 % correlation, you would never take a medication, never get vaccinated, since no medication or vaccine works for everyone. Equally, there are many drugs or diseases for which we don’t know the exact pathology. B
And while we don’t know the exact mechanism yet, there are many theories, with some evidence as to why obesity is a strong risk factor for diabetes. Obesity is a cause/symptom of insulin resistance, which is almost always required for type II diabetes. Also, the fat reserves in our body are known to release various inflammatory hormones and free fatty acids that possibly kill pancreatic insulin secreting beta-cells.
No, we don’t know for sure, but there is lots about diabetes (and indeed many diseases) that we don’t know for sure. I’m sure we will know more in the future, just as we will know more about heart disease, stroke, Alzheimers and so on.
Not all people with type 2 diabetes are obese, not all obese people get diabetes. But we do know is that obesity is a huge risk factor for diabetes.
I’m a semi-regular poster here, but not quite willing to discuss this in detail non-anonymously yet. Apologies.
During each of my two pregnancies I gained 40+ pounds, and then only lost 15. I was completely unable to lose more weight than that no matter what I did, even though when not pregnant my weight is extremely stable. My foot size grew, and my ring size grew. During pregnancy I was hungry to the point that I could not get full, no matter how much I ate (literally, at one point I was so hungry that I decided to screw watching what I ate, and went to an all-you-can eat Chinese buffet. After four full plates, I gave up. I was still as hungry as when I had gone in.) None of this set off any alarm bells in anyone.
Fast forward six years – I’ve just been diagnosed with a pituitary tumor. I’ve had it in my skull for at least nine years, and pregnancy hormones make it (and me) grow. If I weren’t related to an excellent neurologist who noticed the hand growth and forehead growth, and ran me through an MRI, I still wouldn’t know. I likely wouldn’t have found out until the tumor started squeezing my optic nerves (which it’s resting against). If I had developed diabetes (common with acromegaly), it would probably have been chalked up to my obesity, despite my generally good diet, and excellent physical condition.
If every physician I’ve ever had hadn’t viewed the weight as the primary problem, instead of a possible symptom (in the process completely disbelieving my reports), it’s possible I could have been diagnosed a decade ago. As it is, I have to feel incredibly lucky that I was diagnosed after only a decade or so, instead of when I went blind.
A note to ‘Semi-regular’. I’ve noticed a significant increase in weight due to my Acromegaly and I know a few others with the condition who have too. Feel free to browse my blog for my dieting results, treatment etc.. .(As I’m sure you’ll know, Acromegaly is pretty rare!).
Wow – thanks Jason, I’ll do that. I hadn’t run into anybody else with a pituitary adenoma yet, let alone acromegaly.
Doctors should indeed evaluate all symptoms of their patients. Unexplained weight gain or weight loss should be an alarm bell. However, weight gain or hunger during pregnancy would not normally be considered unusual.
I’ve not heard before that excess GH leads to obesity or that obesity is a symptom of acromegaly. So no, its not a symptom, nor is extreme hunger for that matter.
Unfortunately most GPs rarely deal with very rare conditions such as acromegaly so the doctors probably missed it.
Something else worth adding — statistically, the probability that obesity is due to glandular disorders is very rare. Cushing’s disease, for instance, has an incidence rate or 10 per million. Hypothyroidism is more common, but it has many other symptoms. And it rarely leads to weight gain more than 10 lbs or so.
For the vast majority of obese people, its lack of exercise and caloric excess that leads to obesity. That was the case for me !!
Yes, one generally needs a genetic predisposition to be obese. But thats irrelevant. Nature is not going to give you a pass just because you drew a gene that gave you this disposition and more than you get a pass on the harmful effects of blood pressure just because you inherited a genetic tendency to get high BP.
jon said:
Uh, given we’re talking about a medstudent talking about their own lecturers, and given I have encountered medical professionals who recommend this level of calorie intake as reasonable, I’m not sure strawman means what you think it means. Whether or not you believe doctors who advocate this are ‘quacks’ doesn’t change that there are a sizeable number of doctors who *do* advocate this, and many of them, wait for it, went to medical school. Which indicates that perhaps it’s not so unbelievable that there are lecturers in medical schools who are teaching that this is reasonable.
You’ve not heard of it before, so it’s not true? Are you really stooping to that level, considering I’m not seeing your medical credentials? Obviously the reports of people with these conditions is completely irrelevant. Not to mention that the human body has a tendency to, well, do wacky things.
Of course, what you’re missing is that there *are* conditions where obesity is a symptom. PCOS is one that hasn’t been mentioned, but many of the women I know who have it start by going to the doctor about no or infrequent periods, and got met with the dismissal that it was because they were overweight, even if they’d maintained the same size for some time and the period problem was more recent.
That such conditions are rare doesn’t make them not worth considering. If anything, if one wants to quickly get back to telling one’s patient how fat and horrible they are, they should be the first things to rule out, since the quicker you do that, the quicker you can go back to being an insulting ass.
My point, in the examples in the original post, was that the teaching about obesity in medical school is rife with unsupported facts, and that evidence-based medicine goes out the window when we are talking about the evils of being fat. Whether or not you believe that a reputable medical professional would say these things is irrelevant: they were explicitly taught, in lecture, to my medical school class. These attitudes, I believe, are part of the reasons why fat people are so marginalized by physicians.
1. I think there’s a heck of a lot we don’t know about the body. The consensus is right now that obesity is a “marker” for diabetes. We still don’t know how all this fits together with exercise habits, trans-fat, corn syrup, environment, the phase of the moon, etc., etc., and so forth.
2. Obesity can be the marker for other things as well. (And Orange, yah, hope you find a better doctor. How many instances of classic thyroidal symptoms do you have to list before they listen?)
3. Exercise with fun stuff like belly dance and hiking and eat reasonable amounts of delicious food. Life is too short to eat crap. Works for me!
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