I saw a gentleman in my office recently.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight.  I know that this would just get better if I lost the weight.”  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don’t like to lecture people on things they already know.  I don’t like to say the obvious: “You need to lose weight.”  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

The fear/disdain of obesity has reached into areas where it should not be.  I regularly have to tell mothers of chubby babies that it is perfectly fine for their child to be that way.  Children under three generally regulate their eating to what they need.  I do not believe a baby can become obese on breast milk or formula.  Now, if they are giving the child french fries and burgers, that is a different matter.

Instead of patronizing obese patients with a lecture, I try sympathizing with them.  Just because something is simple doesn’t make it easy.  How do you quit smoking?  You just stop smoking.  We should just pull out of Iraq.  There should be peace in the middle east.  People should stop hurting each other and start being nice.  All of these are good ideas, but the devil is in the details.  Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.

Don’t get me wrong, I don’t deny the health risk of obesity.  I do my best to work on weight loss with my patients.  But the idea that their personal worth lies on their BMI is extremely damaging.  There are a lot of screwed-up skinny people out there; just look at super-models.  It is a lot easier to lose weight when you actually like yourself and want to do something about your health.  Our culture of accusation and shame simply makes obese people hate themselves.  If you hate yourself, why should you want to take care of your body?

Is obesity a problem?  Sure it is.  But we need to get off of our self-righteous pulpits.  Obese people should not be made into a group of outcasts.  The “them” mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others.

It sounds a lot like Junior High.

If we really want to help with obesity, we need to grow up.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind) where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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39 Responses for “Shame”

  1. BobbyG says:

    I think everyone concerned with actual heath “care” should read Victoria Sweet’s compelling new book “God’s Hotel. See http://www.victoriasweet.com

  2. john says:

    Great post. Counterintuitive, but excellent point.

    • rbaer says:

      At the risk of sounding like a certified (anonymous) a-hole, let me point out that this is not counterintuitive because lecturing and shaming are no longer felt to be good motivational techniques – we tell this our 2nd year med students when teaching motivational interviewing.

      Re. connection between obesity and LS spine DJD – everyone suspects it and there is at least some evidence, e.g.
      http://www.rheumatology.org/about/newsroom/2012/2012_01_03.asp

      Re. overweight toddlers/infants – I am no expert in this field but I believe that fruit juices are felt to greatly contribute to very early obesity – so maybe it would be a good idea to ask whether it is just breastmilk/formula.

      Doctors should not shame (although patients very often preemptively feel shamed and lectured when any lifestyle issue is brought up in a neutral, nonjudgmental manner), but I believe that society should set expectations. There are many things that are enforced by collective/peer pressure, and exercise and reasonable weight would be good targets.

      Otherwise, I agree that incentives may be more important, or better said, as a 1st step, the reversal of dysfunctional farming subsidies.

  3. Barry Carol says:

    I wonder how many smokers who tried unsuccessfully to quit for years were suddenly able to do so once the price of a pack of cigarettes skyrocketed in the states that sharply increased their tobacco taxes. Maybe the same approach would be effective if we raised taxes on unhealthy food though designing a tax that could be fairly applied and efficiently administered would be a considerable challenge. Incentives matter though. Perhaps higher taxes on unhealthy foods would be a useful catalyst to help significantly overweight people lose weight. However, I recognize that for many, it’s easier said than done no matter what.

  4. Great Post. The problem is most people know they have an issue but no desire or willpower to make that change. Really needs to come from the individual. Its a perplexing probelm for sure.

  5. DeterminedMD says:

    Good luck trying to rectify this problem. Check out the prices of fruits and vegetables these days? And, where are these super markets in big cities to even access healthier food choices? And, where is shame in society these days? Certainly not read on the Internet!

  6. southern doc says:

    Can anyone come up with a single good study that shows non-surgical physician intervention leads to significant, long-term weight loss?

  7. Leto L. says:

    Naowadays kids’ obesity is becoming one of the biggest problems and concerns. There are many reasons for that and one of the reasons is techologies! Look at kids in your neighbourhood, what are they doing? Are they playing any active games? Usually not, they are playing with their mobile phones, iPads, etc, but not hide-and-seek or smth. like this… This is sad and makes me think that such old games for kida are on the edge of instinction…

  8. OtherBecky says:

    Thank you for writing this. I once had a routine UTI turn into a nasty kidney infection because I didn’t want to go back to the doctor who had spent nine minutes (by the clock) haranguing me about my weight (at the overweight/obese borderline) when I went in with a sore throat, fever, swollen glands, and the information that four of my students had recently been out with strep throat. I only managed to get a strep test (positive, oddly enough) by refusing to leave until they did one.

    I’m more than half convinced that a fair percentage of the negative health outcomes correlated with being fat are due to poor medical care or unwillingness to seek treatment. This recent post at First, Do No Harm is a pretty classic example.

  9. Peter1 says:

    We could try “No Fat Zones” as that seems to be effective with smoking. :>)

    Or we could shame food manufacturers for marketing junk food to children instead of shaming the obese – naw, can’t have that, too much money to be made and too many campaign donations at stake.

    How do you tackle a problem that is a national health crisis with recent projections that close to half of Americans will be obese in 20 years. First you have to be willing to recognize it as a crisis – not happening anytime soon.

    As Barry Carol said, and as I have advocated, we need to tax sugar and fat in food. We can already read the percentages on the label so using the bar code to automatically calculate the tax is not technically difficult. We may not make anyone less fat, but we will collect money to pay for the massive cost to health care, which no system, private or public, will be able to afford.

    Ask yourself, why is sugar and fat used so much as additives to food – because industrial processed food is crap and tastes like crap without the mood altering feel good addition of sugar and fat. Processors have tapped into our DNA to sell crap.

    I’m sure that any attempt to tackle this problem will be framed as a, “liberal” plot as has global warming where it’s good divisive political strategy that not paying now will be cheaper than paying later for doing nothing.

  10. OtherBecky says:

    Peter1 — an easier solution, and one less immediately punitive to the poor, would be to stop subsidizing corn and soybeans. If corn syrup, corn oil, and soybean oil weren’t so cheap (due to subsidies), they probably wouldn’t get used nearly so much.

    The problem we have now is that the least nutritious food is also the cheapest. It is entirely possible to be both fat and malnourished. Weight is very much becoming a class issue. Being able to afford fresh produce and regular exercise is a luxury that a lot of people don’t have, in terms of both time and money. Walking may be free, but if you live in a neighborhood where it isn’t safe, you’re still not going to be able to get much exercise unless you can afford a gym membership. And if you could afford a gym membership, you’d probably be living in a safer neighborhood.

    Trying to address systemic inequities is a lot harder than just taxing sugar and fat, but at least it’s not punishing people who already have the short end of the stick.

    • Peter1 says:

      Becky, eliminating subsidies will also increase food costs – even for the poor.

      I have proposed we transfer subsidies from corn/soybeans to fresh fruits and vegetables, for which a tax will help pay for. Arriving at a proper level of tax is important but given the toxic divisive working relationship in Congress it would be used to divide constituencies rather than address a problem.

      We can’t continually fail to act because someone will be hurt.

      • MD as HELL says:

        Subsidizing the poor has resulted in rampant poor people. We should subsidize nothing at the federal level. States can do what they want. The federal “we” should not meddle in people’s lives. Offer education, but stay out of the behavior mod business. “We” have no right to do it.

        • Peter1 says:

          “stay out of the behavior mod business. “We” have no right to do it.”

          Does the corporate food industry have a right to be in the “mod business”?

        • SteveH says:

          “Subsidizing the poor has resulted in rampant poor people.”

          Yeah! That’s why the proportion of the population in poverty has gone up from 22% in 1959 to 14.3% in 2009!

          • MD as HELL says:

            Less than half the population pays taxes. The big half collect benefits.

          • SteveH says:

            “Less than half the population pays taxes. ”

            One of those memes that’s completely false. Some people don’t pay Federal income taxes while they pay plenty of other taxes, including Medicare and SS. If you think they’re lifestyle’s so great, try trading places with one of them.

  11. Ron says:

    I am a big fan of Michael Pollian’s “In Defense of Food” and it’s criticism of “nutritionism.” Yes, food subsidies are harmful, and part of the reason for rampant obesity is the same reason there is rampant alcoholism in Russia, cheap food here (never in history has less been spent of personal income on food than now in the US) and cheap vodka in Russia. The problem is systemic, not simply due to a group of bad, stupid, or ignorant people who are obese.
    Regarding infant “obesity,” the idea that a child under 1 should be put on a diet is absurd (I say as a pediatrician). People are paranoid about their babies being overweight, and I think that that is harmful.

  12. Alex says:

    Thank you for writing this. I have battled my weight for 15 years. Sometimes I win, somethimes I get pushed back. Weight gain and obesity are complex issues and there is no ‘one-size fits all’ solution. But what has never helped is shame. I have only managed to lose weight when I feel better about myself. I sometimes weigh nearly 400lbs – telling me i need to lose weight is not helpful. I work in healthcare, I understand what I am doing to myself. If obesity is a national crisis, then those who dismiss it as a problem of ‘willpower’ or some similar platitude aren’t helping, they are hindering. Understanding, support and encouragement are what is needed.

  13. Lynn in SC says:

    It has taken most of my lifetime to change our culture to reduce our rate of smoking and almost as long to increase the rate of seat belt usage. Social change is slow and hard. Weight management and good nutrition have only recently been reintroduced to the realm of the “medical.” [Remember MDs used to advertise cigarettes.]

    It’s simple but not easy…food cues are all around us. We live in an abundant food economy where the poor are obese and the wealthy are thin. It’s a complex psycho-social-economic-social problem and like our health care problem, “We have met the enemy, and it is us!”
    Shame is not a useful tool any Mother can tell you it really doesn’t work. Behavioral economics does offer some important clues.

  14. DeterminedMD says:

    Social Darwinist here to note that if solution A offered can have a realistic impact on 2/3 the population targeted, then why are people dismissing it for the 1/3 who will lose? Liberal attitudes fail this society because they allege to HAVE to save all, just like conservatives fail because they only want to benefit the few and their own. This society is going to have to contract if it will endure.

    Pay attention to who gets outraged by this comment, if they rebut. People who can change, can adapt are those intended to move forward.

    This planet can’t handle double digit billion populations of homo sapiens. Again, that damn gorilla doing the Macarana!

  15. THANKS!

    I gave up “wagging my finger at patients” a long time ago. I interact withpatients on an adult to adult level where paternalism, humiliation and shame have no role.

  16. Elias says:

    True. Accusing others and making them feel guilty is not helpful (except for the accuser, who feels he/she is better). Lecturing on things the person knows is futile too. Instead finding a way to encourage them (and participating in the effort) is not only much better, but very effective. You can get tips on keeping fit on: http://freedomnow-online.com/exercise.html

  17. tim says:

    When I eat whatever I feel like eating, I gain weight. At 20 pounds heavier than I am right now, I feel bad all over. My hips and knees hurt, and my back strains easily. I don’t like myself and I avoid the mirror.

    Of course, eating whatever you feel like eating is irresponsible. When I take responsibility for my weight, I lose weight. For me, when I stop eating at a certain calorie count, I lose weight at an utterly predictable rate. It is a mathematical exercise. I can choose a number and land there. (I do not have herculean self-control.) Close to my ideal weight (according to me), my joints and back no longer hurt. I like how I look. (BTW, when I look ideal to myself, I am still considered “borderline obese” on all the charts.)

    When I don’t think about what to eat, I get fat. When I consider and make choices, I get trim. I’m not convinced it is any more complex than that for anybody (except for people with real metabolic problems.) Show me one obese person with stories of how “diets don’t work for me”, and I’ll show you a person who gets angry when you ask them to write their food in a notebook for a week. They all work when you do them.

    The problem is that Western culture has succeeded. The goal of technology has always been to maximize pleasure and minimize work. Now, we are sedentary and awash in cheap calories, and this centuries-long process will not be reversed. Fewer and fewer people are required to stand erect for much of the day, and more and more people can afford a thousand calories per meal. (Poor people buy a thousand calories at the drive-through without hanging up their smart phone.) The recliners in the movie “Wall-E” are the literal goal of the majority of humans.

    In fact, this is all THE major goal of the Enlightenment project. To think you’ll reverse it by a “tax” is to think you’ll turn the river with a sandbag. If that’s you, you simply do not understand rivers.

    No government is going to force people to be healthier in the long run. (Also, there is no perpetual motion machine, and cold fusion does not exist.) The people themselves are the government. The river cannot dam itself. People in the aggregate will not achieve a different end than they desire as individuals.

    They will all talk like they will (for generations), because when they talk about what “we” should do, people actually mean “they”.

    Every discussion of the problem of obesity that puts “we” in place of the pronoun “I” will result in more obesity. “We” can tax this, “we” should stop shaming, “we” shouldn’t subsidize corn, etc. You cannot get people to be responsible for themselves by talking about the collective. Also, the sky is blue and the grass is green.

    In particular, the notion that poor people in America are overweight because they can’t afford to eat good food is a level of delusion I never thought I’d get to enjoy. I’m thinking of offering a cash reward for the name of one of these people. They don’t exist.

    Of course, “shame” doesn’t work — and neither does “self-esteem”, “affirmation”, or anything else THAT IS COMING FROM OUTSIDE, FROM OTHER PEOPLE.

    Decide what you want to weigh, and make a decision in the next 5 minutes to get there. Then make another one.

    All else is delusion.

  18. Peter1 says:

    “To think you’ll reverse it by a “tax” is to think you’ll turn the river with a sandbag.”

    Didn’t say that I cared about turning the river. But I do care about paying for irresponsible behavior that costs other people.

    “No government is going to force people to be healthier in the long run.”

    The nicotine delivery industry didn’t force people to be healthier, it was government action through taxes and non-smoking areas, as well as a realization that clean air is for everybody, that reduced rates of smoking. It can be done, but it takes time and the right policies.

    • rbaer says:

      What a bizarre discussion. Of course incentives play a role, the question is to what extent. Price of fuel goes up, Americans drive less all other things being about equal; subsidize solar energy in Germany, and you have a quite a bit in a rather cloudy, northern climate (don’t say it makes sense); complicated back surgery (multilevel fusion is paid better), surgeons do it way more often … there are probably 100s more examples.

      And does shame work?
      1st, As I said, physicians are there to help, to connect and to work with the patient, and to empower him/her. However, they are also obliged to tell the patient what lifestyle factor(s) contribute(s) to their morbidity and mortality. There are enough patients who claim (rightly or wrongly) after a bad health event happened to them: noone told me that. (I believe there was even some succesful litigation about a counseling deficit, and some docs always end their notes with “lifestyle counseling was provided”). As a side note, there are enough patients who get irritated and defensive when a not at all obvious lifestyle issue is briefly brought up in a nonjudgmental, informative manner.
      2nd, of course shame/societal pressure does work to some extent, at least for some if not most of us, to a varying extent. It forces us being polite, mowing our lawns, not mistreating creatures weaker than us, showing up to work even if we don’t want to, and not to use the PC inappropriately when we are there …
      I tend to show up 5 minutes too late for meetings, because I always find something to do before I take off; no one ever looked at me or even blamed me, but does shame help me being more timely? Yes, to some extent. Societal expectations are a fact of life, and a lot of them are a pain, but some of them are productive.

  19. Barry Carol says:

    I think one of the more unfortunate aspects of human nature is that most people don’t like to be told what they don’t want to hear and I’m not talking just about healthcare. For example, it seems that too many people want more benefits and services from government than they’re willing to pay for whether we’re talking about local, county, state or the federal government. They expect someone else, presumably the rich, to pay but not them.

    They think more medical care is better care and they want someone else to pay for that too. If they’re overweight, maybe there is a pill that can magically solve their problem but personal responsibility and self-discipline are foreign concepts to them. It may be harder to lose weight if you’re poor because you can’t easily afford or access healthy food and a safe place to exercise but it’s not impossible.

    If a patient needs to lose weight, telling him so in a non-judgmental way can’t do any harm and may do some good eventually. My advice to the docs: keep trying. In the meantime, financial incentives like higher taxes on unhealthy food or lower farm subsidies would also be helpful.

  20. As a scientist I’m working on primary prevention of chronic lifestyle dependent diseases.
    We do know that a healthier lifestyle prevents disease. What we don’t know is what prevents a healthier lifestyle. I have been working on the answer to this question for the past 15 years. I do not claim to have found the answer, but, surprisingly, stigmatization is at the heart of it. It is easy for us in public health to point a finger at the obese and to lay the fault for their obesity on them. But once you get into the biobehavioral origins of obesity, the picture is not so simple. For one, there are neurohormonal pathways which are strong drivers of our dietary behaviors. Tellingly they reside in the same cortical centers as the pathways of addiction. Virtually the same neurohormonal cascades which drive an addict to booze, drugs or cigarettes drive the rest of us to sweetened and fattened food. Even when we are fully aware of its detrimental effects. From the biobehavioral sciences we even know the neurohormonal equivalents of liking and wanting and the distinctions between them. It has been called incentive salience theory, first developed by Robinson and Berridge 20 years ago. More amazing than this theory is the fact that we don’t find it in the strategies and programs with which we treat obesity. Probably because it is easier to blame the obese than to think about the implications of having to modify our obesigenic environment.
    Having said that, I don’t entirely exculpate the obese. After all, there are many people who have experimented with drugs, but never became addicts. There are reformed alcoholics and ex-smokers who successfully kicked the habit. So there are ways to change. I have written in my blog about those and the obstacles we encounter on these ways (http://bit.ly/drlutz_3barriers2chronichealth).

  21. Peter1 says:

    MD as HELL says:
    May 19, 2012 at 5:20 pm

    “Yes they do”

    I guess then cigarette companies have a right to deliver an addictive drug through cigarettes but the government has no right to counter act that?

    • DeterminedMD says:

      counter it while promising health care for everyone, even those who smoke?

      Counterproductive is a nice term to describe it, dumbass is better!

      Here’s an idea: don’t allow people who smoke access to health care insurance, at least those under 30 years old!

      • Peter1 says:

        “Here’s an idea: don’t allow people who smoke access to health care insurance, at least those under 30 years old!”

        Why the cut off of 30 years – why not everyone? Got any more health problems you’d deny insurance for? I guess though that doing that would require government interference/regulation and a certain “behavior mod business” on the part of the government.

        • DeterminedMD says:

          Why should such people be allowed to access health insurance as of 2012 when it is painfully obvious smokers have much more morbidity and mortality than non smokers? And why the hell did the idiots who passed PPACA do nothing about the role of smoking in the legislation to begin with? Oh yeah, the tobacco lobby controls all, just like the insurance and pharma lobby did in their role with PPACA too!

          Sorry, smokers can’t die fast enough for me. There is no tolerance for dependency that just ruins it for all around them. Call me prejudiced, bigoted, discriminatory, I don’t care. People who choose to want to start smoking in the the past 20 years, they have no rights when it comes to care directly attributed to that habit. Sadly, no one else here has the gonads to call it what it is. Because PC and sad politeness had them removed by the end of med school!!!

          • BobbyG says:

            NO ONE should have ANY access to health care unless they pass the DMD test for Comprehensive Lifestyle Probity.

  22. DeterminedMD says:

    I believe this in the difference between the consequences of smoking versus obesity: smoking is fully a choice, and while difficult to terminate, can be done if people are willing to persevere; weight gain has many variables and some are not in control by the patient, but, there still must be effort to look for factors that can impact on some weight loss at least. I see people every day who are just not interested in change, in accepting the status quo is not appropriate, and just think there are quick fixes, or even worse, who they are is just fine and society should accept it without debate. Yeah, right.

    Dependency is a major cause to the demise of American society, and I am not talking about substance abuse. Healthy, invested, responsible societies will not tolerate pathological dependency, or it will destroy the “village”. Hence why the current message of Julia by the Obama campaign is so repugnant to me.

    As is the republican message of “fend for yourselves, we aren’t interested” is equally disturbing and needs rejected ASAP!

  23. Age Spot says:

    There is a good saying. You must live by next rule: Eat to live, not live to eat.

  24. I agree with Dr. Rick. Lecture your patients and see if they come back to visit you again. They won’t. Instead they will wait until they are really really sick and end up in the hospital. I’m pretty sure no one was taught that method in school.

  25. Jane says:

    Great post! Obesity is really a hard issue/problem for some. The answer to this kind of problem is actually in the hands of those who suffer from it. Some people just lack the will to do the right thing. Obese people could achieve their goal to become healthy and fit by having motivation to lose weight, having a proper diet and self discipline.

  26. Camilla says:

    This brings up an interesting question. What do you think of teens getting weight loss surgery? Obviously it is an issue and now teens are turning towards surgery as a way to rectify the issue. Is that a solution? Or do we intervene sooner? I really do wonder how we go about it but this doctor seems to want to help (http://primesurgicare.com/dr-seun-talks-young-adults-lapband-surgery-ny1/)

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