What if the Doctor is Fat too?
I read an interesting article in the Times which contained the inner turmoil that a doctor goes through when giving the tired advice of moving more and eating less to an overweight person when the doctor himself is overweight.
How on earth, I was thinking, am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don’t follow it very well myself? How to reconcile that with her mother’s reasonable request: Don’t make her feel bad about herself? And taking it all together, how am I supposed to help stem the so-called epidemic of childhood obesity when not a week goes by that I don’t break my own resolutions? What price the not-skinny doctor?
I think the better question for him to consider is why is he compelled to provide this advice when he knows it doesn’t work. He may believe it does, but he also is keenly aware that it’s nearly impossible to do. These doctors must truly believe that thin people like myself, just have this masterful command over our energy expenditure and calorie-intake such that we can remain thin while he and his patient struggle with overweight.
“The advice we’re supposed to give in pediatric clinic, it boils down to ‘Eat less, exercise more,’ ” said Dr. Julie C. Lumeng, an assistant professor of pediatrics at the University of Michigan Medical School and an expert in childhood obesity. “This is such blasphemy, but when I deliver this advice to families, my heart’s not in it, because I just feel like so often the families are just glazing over, and when that advice is delivered to me, I glaze over, too.”
I think by this response, the doctor clearly understands the futility of this advice. If he would follow the science, he would instruct the girl and the parents to cut this 8 year-old’s sugar consumption. That would be a start. That would at least have a slightly greater than fifty percent chance of getting her back on the weight curve for her age. Dr. James Sidbury did work with children and found that he could completely reverse the urge for the sweet in 18 months. This would be hard to swallow for both the child and her parents but this would be something that actually works.
What does it mean when the doctor clearly cannot follow the doctor’s own advice? I asked that question of Dr. David Ludwig, director of the Optimal Weight for Life Program at Children’s Hospital Boston, a multispecialty program for the care of overweight children.
“This is an issue that can cut in every possible direction,” he replied. “The doctor who is herself struggling with her weight will have the advantage of personal experience from the patient’s perspective — which may increase compassion and provide other insights that a primary-care practitioner without the problem may not have.
“On the other hand,” he continued, “the patient may view a doctor who is substantially overweight or unfit as lacking the basic understanding of the problem to put those principles into effect in his own life.”
This advice should not be based solely on the doctor’s experience. It should be based on an understanding of the science of metabolic syndrome and the advice of Dr. Spock and those who came before just 50 years ago. Carbohydrates are the key to fattening and if one wants to avoid weight gain, then they must decrease carbohydrate consumption. They used to know and teach this until Ancel Keys came along with his total cholesterol nonsense. Now, doctors must stand confused in front of their patients with only their experience to rely on. Is it any wonder that the patients glaze over? I think it’s only right. If an obese person came up to me trying to tell me about the unhealthiness of my diet, I would have to laugh. I mean, really.
The drumbeat of concern about childhood obesity has grown louder in recent years, with much new research and more and more clinical trials and interventions. But in the meantime, the children of America have gotten heavier, I have diagnosed Type 2 diabetes in too many of my patients, and I haven’t done any major shrinking myself.
We’ve learned more about risk factors. For example, a 2007 study by Dr. Lumeng found that the fewer hours of sleep children got in the third grade, the more likely they were to be obese in the sixth grade, regardless of other family factors. Her current research centers on how mothers’ beliefs about obesity and diet affect their children’s risk of obesity.
But Dr. Lumeng has struggled with her own weight — she says she lost 50 pounds in the past year after a gestational diabetes scare — and she understands how hard it is to translate her own beliefs into daily practice. When she gets home from a long day at work, she told me, she knows she really ought to tell her three children to turn off the television and ride their bikes, while she is cooking broccoli and salmon for dinner.
“I know it all, I do research in this,” she went on. “But in the moment I’m exhausted, it’s been a long day at work, everyone’s sort of irritable. You can know what you need to do, but when the moment comes … .”
That’s what is has come down to. We have doctors who can only treat risk factors. They are unable to treat the patient standing in front of them because they have no idea how one becomes obese or diabetic nor do they understand how to reverse it. They’ve been told that carbohydrates cause all of these maladies but it does not fit with their religion so they cannot embrace it. It would be blasphemous to tell the young girl the truth and it could cost the doctor his hard-earned reputation.
Back in the exam room, with that 8-year-old, I took some early and unsure steps toward discussing the topic. I showed her her growth chart, on the pink (for girls) graph paper. See, I said, you’re growing — you’re getting taller, and you’re adding muscle to your body as you grow. But we need to give you time to get taller before you add more weight.
And we talked nutrition (cut back on sweet drinks, fast food, eating in front of the TV), and we talked exercise (how about tap dancing, soccer, swimming lessons?).
And finally I looked the mother in the eye and said, without planning to say it, “If this were easy, I would be thin and fit.”
Despite all of this, he does indeed give some pretty good advice. He should be more specific on the fast food, however. If the poor girl would drop the bun and the french fries, she could still enjoy a fast-food burger, but that’s another story altogether.
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on July 24, 2009 at 9:56 pm
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“If an obese person came up to me trying to tell me about the unhealthiness of my diet, I would have to laugh. I mean, really.”
Exactly. The physicians don’t know how to maintain their own health, why should anyone take their advice to heart?
“They are unable to treat the patient standing in front of them because they have no idea how one becomes obese or diabetic nor do they understand how to reverse it. They’ve been told that carbohydrates cause all of these maladies but it does not fit with their religion so they cannot embrace it.”
Medical school nutrition training amounts to garbage (lipid hypothesis) in, so what do you expect when they give nutrition advice — naturally, garbage out.