Shame

Shame

39
SHARE

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.

Leave a Reply

39 Comments on "Shame"


Guest
May 16, 2012

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

Member
May 16, 2012

Great post. Counterintuitive, but excellent point.

Guest
rbaer
May 16, 2012

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.

Guest
Barry Carol
May 16, 2012

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.

Guest

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.

Guest
DeterminedMD
May 16, 2012

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!

Guest
southern doc
May 16, 2012

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

Guest
May 16, 2012

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…

Guest
OtherBecky
May 16, 2012

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.

Guest
Peter1
May 17, 2012

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.

Guest
OtherBecky
May 17, 2012

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.

Guest
Peter1
May 17, 2012

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.

Guest
MD as HELL
May 18, 2012

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.

Guest
Peter1
May 18, 2012

“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”?

Guest
MD as HELL
May 19, 2012

Yes they do

Guest
SteveH
May 18, 2012

“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!

Guest
MD as HELL
May 19, 2012

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

Guest
SteveH
May 19, 2012

“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.

Guest
Ron
May 17, 2012

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.

Guest
Alex
May 17, 2012

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.

Guest
Lynn in SC
May 17, 2012

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.

Guest
DeterminedMD
May 17, 2012

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!

Guest
May 17, 2012

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.