The bar in question is inside an upscale Italian restaurant in northern Wisconsin. The men are middle-aged with graying hair and glasses. But they’re both fit. They look like they might spend their spare time sailing. One wears a blue button-down shirt and jeans. The other is dressed in a polo shirt and camouflage shorts.
Button Down arrives first with a blonde woman. They grab stools, and he orders a beer. A few minutes later Camo Shorts joins the party. He clearly knows Button Down. There are some handshakes and back slaps, and then the two men start to talk shop. They’re both doctors.
I am seated next to them, and I catch snippets of their conversation. But then they start swapping stories about patients who are overweight and refuse to slim down. These patients won’t listen to their doctorly advice to cut calories no matter how many times they give it. I am a science journalist, and also very nosy. So now I am eavesdropping in earnest.
Camo Shorts outlines the oh-so-helpful five-step diet plan he gives his patients:
1. Eat less
2. Exercise more
3. Eat less
4. Exercise more
5. Repeat steps one, three, and five.
“People don’t understand,” he says. “Food is fat. I go to the gym and run two miles with weight vests on. The machine tells me I burned 645 calories. If I eat one cherry donut I’ve canceled out my workout.”
Button Down nods knowingly, and Camo Shorts continues with a story about one overweight patient who had trouble catching his breath when climbing hills and stairs. The man received a ventricular assist device, a mechanical pump that helps the heart shuttle blood to the body. The machine helped. “But that’s about $500,000 worth of medical technology,” Camo Shorts says. “I could get the same result for $3.94,” he adds. “That’s the price of a roll of duct tape. I’d tape his mouth shut so he doesn’t eat so much.” The men guffaw. I seethe.
I think what makes this story so shocking is that Button Down and Camo Shorts are doctors, the very people who are supposed to help us feel better when we’re ill. But the sentiment is all too familiar. “People tend to think [weight gain] is a totally voluntary process, and it looks like it is,” says Rudolph Leibel, a physician who studies the genetics of obesity at Columbia University. “But I think at a deeper level it isn’t. There are molecular mechanisms underlying this,” he says. I talked to Leibel in January for a piece I wrote for Nature on the heritability of obesity.
Studies conducted over the past few decades suggest that our genes influence not only our food choices and food intake, but also how much of that food we convert to fat. Here’s one study that shows just how powerful genes can be: In the mid 1980s, 12 pairs of genetically identical twin boys reported to a dormitory at Laval University in Quebec to take part in an experiment. Canadian researcher Claude Bouchard wanted to know what would happen if he consistently overfed these lean young men. So for 84 days, he asked the boys to stuff themselves. Each man consumed 1,000 calories more than he normally would have eaten.
The results were striking: All the twins gained weight—about 18 pounds on average. But while some packed on 10 pounds, others gained nearly 30. “I was expecting some variation, but not that amount,” says Bouchard, who now works at the Pennington Biomedical Research Center in Baton Rouge, Louisiana. Within pairs, however, the variability was dramatically diminished. Brothers tended to gain a similar amount, and they put on weight largely in the same spots—belly or thighs or buttocks.
Genetic variation also helps explain why it’s so tough for some people to slim down. “You’re bucking a system which is hard wired in a sense,” Leibel says. “It doesn’t mean you can’t do it. It just means it’s very difficult.” Indeed, every weight loss study ever conducted seems to come to a similar conclusion: Losing weight is relatively easy. Keeping the weight off is really effing hard.
Last year, bioethicist Daniel Callahan argued that the best strategy to fight obesity in the long term would be to stigmatize the overweight through social pressure. “When it is as common as is now the case, those who are overweight hardly notice that others are the same: it is just the way ordinary people look,” he writes. “They need, to use an old phrase, a shock of recognition.” It’s the kind of strategy I think Button Down and Camo Shorts would embrace.
But aside from being exceedingly cruel, this strategy fails to take into account the complex causes of obesity. “If stigmatizing fat people worked, it would have done so by now,” wrote Janet Tomiyama and Traci Mann in response. “Obese people are already the most openly stigmatized individuals in our society. And there’s no question that obesity is something people wish to avoid.” One survey of people who had lost at least 100 pounds through gastric bypass showed that nearly everyone would rather be deaf, blind, or lose a leg rather than gain back the weight they had lost.
I get that doctors are frustrated with patients who seem to be ignoring their orders. But how about a little compassion? How about some discussion of evidence-based weight loss strategies? How about supporting your patients rather than ridiculing them . . . yes, even when you’re just hanging out at the bar.
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Image credit: brad k! on Flickr
But are there any evidence-based weight loss strategies, short of bariatric surgery?
Not that this excuses the doctors. If they have no treatment, I think they should admit it — but that’s just me. On the whole, which is worse for patients; thinking there’s nothing that will reduce your weight or thinking that if you only had more willpower you could reduce it? As an overweight person myself, I have to say that following the physiological literature has made me less likely to even try to reduce. Am I better off for having abandoned what looks like a hopeless struggle, or worse off for having stopped trying?
Pat, there are evidence-based weight loss strategies. And they typically include lots of support, including group or individual sessions. See here. No, I don’t think we should just throw up our hands and say weight loss is impossible. But I don’t think that shaming individuals who are overweight or obese is helpful either. What pisses me off is this mentality that body weight is 100% under the individual’s control, and that anyone who becomes overweight is weak willed and lazy. That’s simply not true. And when doctors start spouting that kind of nonsense it’s just maddening.
Interesting article. I love how you find topics in unusual places!
If any of your readers are interested, I wrote a book that looks at weight loss from a mindset perspective and breaks the challenge down into small decisions that anyone can make. The title of the book is “FAT is all in your HEAD, 101 Small Decisions for Amazing Health” and the first 50 pages can be downloaded for free at http://www.FatisallinyourHead.com.
I personally think that in many of these situations (certainly my own), obesity is more a problem of the mind, of the psyche, than of the body.
(I know for a fact this is not universally true; I’ve a friend that struggled with her weight all her life, and was brought to open weeping by many doctors telling her to simply increase her exercise and decrease her diet, when she was already living on water and a treadmill, pre-puberty and after. Until the miraculous moment in her late 20s when she was diagnosed with a thyroid condition, and within months of treatment, was a whole new person, body and spirit.)
But I would suggest that obesity caused by overeating and lack of exercise are ultimately themselves symptoms of loneliness, depression, and other psychological issues best dealt with by professionals like therapists (supplemented with an instructive nutritionist and maybe an encouraging trainer at the local gym), and personal support as found in peer groups like Weight Watchers.
Perhaps doctors are frustrated because of the many horrible physical consequences of obesity and knowing that in many of these cases it was at some point preventable, like smoking or alcoholism or drug abuse. But I would no more rely on a general practitioner’s tips on weight loss and healthier living than I would ask my OBGYN about rotator cuff issues.
(It’s certainly worth mentioning, as I found my OBGYN /did/ help identify the cause of my chronic migraines, as confirmed by a visit to a neurologist, but I certainly wouldn’t take the gyno’s word as law in that circumstance.) I think a good doctor has the healthy ego balanced with a reasonably scientific outlook to see the situation, talk it out with a patient, then say, “Look, I think what you’re really struggling with here is depression. Here’s some information on healthier dieting, and here’s a referral to a shrink that partners with our practice. Give it a try, and you’ll feel better, and then you’ll learn you can lose weight, and then you’ll feel better still, and every day after.”