Teaching about obesity

[liv]

So next week I have drawn the lucky ticket which means I get to facilitate a first year workshop on obesity. I have really mixed feelings about this!

On the one hand it's a really great opportunity to do what I can to influence future doctors towards treating their fat patients with respect and giving them appropriate care. The people who have put the teaching session together are very sensible and very caring and have deliberately created a session to challenge prejudices. On the other hand, well, the medical community as a whole is very anti-fat and the first years are not exactly oblivious to that. It may be that the best I can hope for is for the students to be non-judgemental in the same way they are taught to be towards patients who smoke or abuse alcohol, while they still come out believing that obesity is a bad lifestyle choice which causes all kinds of terrible diseases.

One issue is that the medical consensus is still very much that there's a huge health burden caused directly by people eating too much and not doing enough exercise and therefore getting fat. There are individual studies which challenge this consensus, certainly, and I do try to do things like draw students' attention to the large-scale, long-term population studies which show that people classed as "overweight" by BMI live longer than those classed as "normal weight". And the stacks and stacks of evidence that we simply do not have a reliable, safe way to turn fat people into thin people. But the students have to accept the orthodoxy in order to get through their exams and qualify as doctors, and indeed if I start telling them information that goes against the mainstream they are as likely to disregard everything I say as to change their minds. And that reduces my chances of convincing them of in some ways more important idea that they need to respect their fat patients, even if the students do believe that being fat increases patients' risk of diabetes, cardiovascular disease, cancer etc etc.

Another apprehension I have about teaching this session is that students are likely to say incredibly offensive things about fat people. I have to give them a free rein to say what they like in these kinds of discussions; it's not a discussion if everybody is only allowed to say what I want to hear. I can certainly check them if they start being actively abusive, by reminding them that it's their duty as doctors not to discriminate and not to create an atmosphere which could be detrimental to anybody's access to healthcare. But they can express fat-phobic opinions as long as they couch them in polite language, indeed it's incredibly normalized within the medical sphere to do so. I'm lucky that I don't take that kind of thing personally, and I'm perfectly willing to put myself on the line and say things like: look, I have a BMI of 32, are you saying I'm lazy / uneducated / ignorant / insert stereotype here? What scares me is that there will be fat students involved in the discussion, and I know there are students who have struggled with eating disorders; how can I make sure to protect those students so that they don't feel excluded or even triggered?

Only yesterday I was eating lunch in the staff room and one of the most senior academics, who is also a practising GP, told this hi-larious anecdote about how he told a patient "I see you're still a fat bastard" and the patient made a complaint against him and aren't these patients just delightfully wacky taking offence at a little thing like that? That's part of the context in which these students are being trained. Even if the official line of the medical school is very much about being non-judgemental and respectful and positive about diversity and so on.

Any suggestions or thoughts? I myself believe in health at every size, but I welcome perspectives from people who subscribe to the mainstream medical view of obesity as long as you start from the assumption that fat people are human beings worthy of respect. (And if you don't believe that, why are you even friends with me, a fat person?)

While we're on the subject, I am drawing sparkly hearts all over this lovely article by Lesley A Hall, guesting at the wonderful Body Impolitic, where Hall compares the obesity epidemic to older health panics about masturbation.

Comments

[azurelunatic]

I might be terribly tempted to lure them into a scenario of denying care to someone "until they lose weight" and then explaining exactly how many shades of screwed up that is. Though I do not know quite how to bedeck that particular garden path...

[liv]

Hmm, that's a possibility. As a teacher I'm very reluctant to use methods that involve deliberately trapping students into saying something they will hopefully then realize is an absurd consequence. Partly because it's too adversarial, I want the students to feel confident that I am on their side and that means trusting that I won't trick them. And partly because sometimes they won't in fact realize that the consequence is absurd, or they will remember the trap but not the conclusion.

Part of the discussion includes addressing the issue of whether it's appropriate to withhold treatment until patient loses weight; I do intend to lean very heavily on the side of HELL NO (unless there's a rock solid medical reason why it would be dangerous or detrimental for the specific treatment to go ahead while the patient is very fat).

[sunflowerinrain]

"they will remember the trap but not the conclusion"

Sadly, this is very likely; unless it comes as a PUNCH-line.

Why won't people believe the evidence?

There are good reasons for keeping weight in check, for some people, but they don't appear to be the reasons trotted out usually.

Hmm. Perhaps start with a few stats on effects on life and death of being UNDERweight, then the stats on fat-people-live-longer (the figures swooping in, huge font, sparklies, that kind of thing). And perhaps a reminder of why medical stats are important, evidence v. assumption, and the story of what Flo Nightingale really did.

Only then segue to what to do about it.

[liv]

Yeah, I really do want to focus them on the evidence. It's quite frightening that this same year-group had an assessment where they had to précis a piece of research with some counterintuitive findings about obesity and half of them just parrotted the conventional wisdom about weight loss while ignoring the actual data in front of their eyes. At the same time, though, a lot of the evidence is suspect or at least hard to interpret, because research is done with the aim of "curing" obesity, and so many papers have conclusions which contradict their data.

[ptc24]

My personal stratagem would be to try to specifically steer the discussion towards the issue of weight loss as a medical intervention: do weight loss attempts work, if/when they do work, do they deliver the health benefits that might be expected?

My other temptation is to partly turn this into a workshop on reading the literature, although I'm not sure how this fits into the curriculum and into the format of the workshop. Bringing in a few printed materials, especially if you can find some big-name source like the BMJ or Cochrane, might be an idea, or maybe not.

I found myself wanting to say "teach the controversy", and then wanting to take a shower... Irony has its limits.

[liv]

Yes, I definitely agree that the discussion must include mention of the poor success rate of every known weight loss intervention. This is a really problematic topic, because the students are currently in the middle of a whole module which is almost entirely about ways to help their patients improve their diets, do more exercise, stop smoking and reduce drinking. Going completely against that message would just make the students not take me seriously. I think my best bet is to explicitly separate out "improve their diets and do more exercise" from "lose weight". It's fine for the doctors to be encouraging and supporting patients to do the former, but they should be looking at the lifestyle intervention for its own sake, regardless of whether it produces weight loss (which it probably won't).

I definitely do want to encourage the students to read the literature for themselves, they know I'm always banging on about that. But they are first years, they've only had about three months of university level study, and lots of them are still trying to get their heads round basic concepts, they're not yet expected to be at a level of being able to synthesize and evaluate primary literature for themselves. As a facilitator rather than a leader I don't have the power to completely change the focus of the workshop, but I can certainly draw attention to the importance of actually looking at research evidence.

The other issue with sending them to the BMJ or similar is that a whole lot of published papers on obesity and particularly weight-loss still have conclusions that contradict their data. What fat activists like to call the "faith sentence" where people will publish a detailed study saying that dieting has a barely measurable effect on long term weight, and come to the conclusion it's very important for overweight people to restrict their calorie intake in order to lose weight and improve their health. So, especially for very inexperienced students, the literature is really confusing. I might provide an actual reference for the big recent study about BMI and survival, since that's had a fair amount of popular attention and wouldn't be a bad place to start.

[redbird]

Is there room to include that focusing on weight loss may both hurt patients and reduce patient compliance with healthy diet changes and exercise, because if you tell people "change how you eat and you will lose weight" and they don't lose weight, they'll go back to the old diet? That the person who is told "exercise more and you'll be thin" and stays fat is less likely to keep exercising than the one who is told "exercise more and you won't get worn out if you run for a bus" or "I see there's heart disease in your family. Regular exercise will help you live longer."

[elf]

Yes, this. Better diet and exercise, less smoking and drinking: Known health benefits. Less weight: entirely unclear health benefits, and harder goal.

Somehow, when medical-ish people recommend that patients "lose weight," it's never "drop from 225 to 200 lbs, which will take some of the strain off your back;" they're pushing for patients to get into the misnamed "normal" BMI range, with an attitude of "well, if you can't SUCCEED, at least maybe you could make some progress by dropping a few pounds." Which comes across a lot like "well, you're never going to be HEALTHY, but if you prove to me that you're trying hard, I'll continue to treat you. Maybe."

It's possible that medical students could be influenced just by pictures and videos of happy, healthy fat people. And possibly, pictures of seriously unhealthy thin people. Teach them to look for signs of health regardless of shape, and they'll have good progress away from fatphobia.

(Hmm, an exercise with a photo and basic medical chart of half a dozen patients of different body shapes, with a game of "spot the signs of health problems"? Throw in a few ongoing prescriptions for drugs that cause weight gain to complicate matters?)

[liv]

Good thoughts, thank you. I'm suspicious even of the "everybody should lose at least some weight" mantra; I am not convinced that the health benefits of dropping from 225 to 200 lb are always worth the effort it takes to achieve that kind of 10% reduction. And yes, the idea of making patients prove they're "trying" before they can access treatment is one of the things I want to counter as strongly as possible in this session.

The students should already be familiar with the idea that you can't tell someone's BMI by looking at them, and you can't tell someone's body fat proportion by their BMI. I'm hoping it should be a fairly short hop from there to get to: you can't tell someone's health status by their body fat proportion either.

And yes, there should be more images of happy healthy fat people just being there subliminally. It annoys me already that patients' BMI only gets mentioned in case studies if their weight is a medical problem, which I'm sure is reinforcing the association that overweight = sick. And they've had countless lectures about obesity illustrated with the usual stock images of headless fatties / huge piles of burgers and chips / cartoons of fat couch potatoes guzzling junk food etc. That's a broader issue, though, I can't fix it in this one seminar, but perhaps I can point it out and see if some of the students start noticing the subtext in the messages they're getting.

[elf]

There's the Illustrated BMI Flickr Project, which has photos of many different shapes of people, and says what their BMI label is.

I'm especially fond of the one that says Julia is "morbidly obese."

[liv]

I do love the illustrated BMI project, but most of the photos there aren't licensed for me to use them in teaching materials. But I'm sure if I poke around I can find some pictures of happy fat people that are Creative Commons or similar.

[elf]

In the US, copying for classroom use is fair use; they don't need to be licensed to use for educational purposes. I'm unsure how the UK's copyright laws deal with that, or with items that are copyrighted for some uses in another country but wouldn't be licensed in the UK if they were published there.

But yeah, at least there's the option of finding CC images.

[elf]

I'm suspicious even of the "everybody should lose at least some weight" mantra; I am not convinced that the health benefits of dropping from 225 to 200 lb are always worth the effort it takes to achieve that kind of 10% reduction.

Me too. And I suspect, so would any reasonable medical practitioner. Which is why they don't say "lose 25 lbs;" they say "you need to lose some weight" and "you should diet to get to a healthy size," without giving numbers.

They know that saying "you need to change from 225 lbs to 115 like this chart says is proper for your height" is completely useless advice, even if they believe it's true. So they hedge with nebulous terminology instead of accepting that the number itself is meaningless and they need to focus on something else.

[green_knight]

Also, 'match the eating habits and exercise regime' with real people. And while you probably don't want to put yourself into this too much, you might want to find active overweight people and thin couch potatoes ino the mix.

[liv]

That's a very cool icon! I think the students are already reasonably skeptical about judging people by their appearance, but the problem with that is that they can put far too much faith in "scientific" anthropometry techniques. And I don't want to set up a good fatty / bad fatty situation, where the students take the view that it's "ok" to be fat as long as you can justify that you have an ideal diet and do loads of high-intensity exercise. But definitely it makes sense to talk about the difference between population correlations and specific individuals, and just generally not making assumptions about people's lifestyles.

[liv]

Yes, I think this would be a really useful angle to take. Whether or not I can convince the students of the complexity of the associations between weight and health, I can try to sell the idea that patients are more likely to keep up lifestyle changes if they are focused on the direct health benefits rather than on weight loss as a proxy for improved health. That more or less amounts to HAES but in a somewhat depoliticized way. After all, if the orthodoxy is right, lots of people who exercise more and eat less will lose weight anyway, so everybody is happy, and if the evidence showing dieting rarely brings about significant weight loss is right, the patients will still be fat people who are active and eat healthily, and as a bonus won't be driven away from healthcare services because of anxiety about weight.

[tig_b]

You are welcome to use this as a discussion item.

I was refused a referral for investigations into possible gallstones by a GP last year, because I was too fat.
He wanted me to lose 5st before he'd refer me.
I was losing weight very fast anyway, as there was hardly anything I could eat.

I told him I was worried about the nutritional impact as I was vomiting if I ate more than 3-4g of fat. And in constant pain. He told me that I didn't need any fat in my diet.

Having developed a severe vitamin D deficiency as a result of the enforced diet change, I am now costing the NHS money for blood tests and supplements - having spent several months in a daze of fatigue and extra pain. Untreated this could have led to my death, as it is my teeth are transparent and I'm struggling to keep my bone healthy.

I finally managed to pay for private treatment, by an obesity/gastro specialist who told me, very firmly, that there was no medical reason for refusing treatment, and that the risks were no higher.

BTW, my large weight gain was caused by steroid treatments in my 30s - although my diet does contribute to keeping it on.

[redbird]

*sigh* I'm glad you finally found decent treatment. (What kind of incompetent refuses to investigate a possible disease because a patient is fat, when it's well known to be more common in fat people?)

[liv]

Wow. That is really, really appalling and I am so sad that you went through that. I knew some of this but I hadn't ever seen the whole story laid out or realized just how badly you suffered from fat prejudice. I really hope I can convince at least some of the students not to behave like this when they qualify!

Vitamin D and obesity

[tig_b]

This is filling the news today:
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001383

I've only skimmed the article, but I couldn't find any reference to them controlling for exposure to sunlight? (Most of the obese people I know cover themselves up.)

Re: Vitamin D and obesity

[liv]

Interesting piece of research. I think they're saying they can get away with not controlling for any confounders because of the way they're mathematically comparing whether obesity causes Vit D deficiency or Vit D deficiency causes obesity. I'm not sure I completely believe that, but that's their claim.

The way they've done this is looking at genes that predispose to obesity, which makes sense for their stats but I am not sure how much people who have a genetic tendency to put on weight are representative of all fat people. They do propose a sensible mechanism, namely that fat stores Vit D so the more of it you have, the less Vit D is available in circulation, which gives me some confidence in what they're proposing.

What they haven't shown very convincingly is whether obesity directly causes the vitamin D deficiency, or whether obesity causes altered behaviour (dieting? more covering their bodies as you suggest?) that leads to less Vit D, or whether the same genes that make people put on weight also alter vitamin D metabolism, or any number of possibilities.

[pretty_panther]

(A+ music choice! Love that song!)

Ahem. I guess the only thing I can think to add to your own comments and those of others is a reminder that sometimes treating the 'weight problem' of a patient can actually make things worse for them, and that might be a way to provoke them to think for themselves without trying to make them accept your thoughts?. Many conditions are impacted by your weight.

For example, a person needs more insulin if they are heavier. It is a fact that the pancreas releases more insulin/more injections are required if diabetic. Being heavier puts your pancreas under a lot more strain, whether someone is diabetic or not. HOWEVER, say a patient is type 1 diabetic and a size 16. Their body needs more insulin than someone who is a size 8, because it is harder for the body to break down the food and it needs more energy to move itself around. If that person then loses a lot of weight quickly, their body requires a lot less insulin and it isn't as easy as saying 'cut a unit for every 5 pounds lost'. Things become unpredictable and dangerous. The doctors lose control and don't know what to advice beyond 'cut your insulin until you stop going hypo'. The patient is left in a state of continuous hypos and rebounds into highs that are dangerous in the long run and can lead to hospital stays or just inability to function in 'normal' life in the mean time. Is the loss of a stone of weight worth that? For many, no. It is safer for them to remain 'fat' than to attempt to lose weight and cause their condition to spiral out of control. You have to treat a patient's condition, not just their appearance, is I guess what I'm trying to say. I'm sure there are many conditions like that, whose treatment can be altered upon the weight of the patient. It might be a route to take?

[liv]

Yay song, I was just the right age to appreciate it when it was popular.

Your diabetes example is a very good one. The students haven't really learnt about diabetes properly yet; they're supposed to spend the first year doing normal biology before they get on to disease in second year. But treat a patient's condition, not just their appearance is a really, really good principle. I might quote you on that!

[ceb]

I think this is what I've been failing to crystallise since you posted this. Obesity, like high blood pressure, is a risk factor, not a disease.

There's an interesting comparison between medical attitudes to the two. Blood pressure's not externally visible and though GPs might start off by saying "eat less salt" they probably don't say it in the hope that it'll work, and there's very little stigma around just prescribing some drugs to fix it. It's treated much more like a medical thing that needs fixing and much less like a failing in the patient.

(A colleague of mine is trying to work out whether high BMI per se is bad for you, which is just incredibly difficult because it's so confounded by everything.)

Maybe useful to start by getting the students to see how many reasons they can think of for being overweight, get them out of the "these people are all crap and lazy and eat too much" mindset?

[liv]

Yeah, I think that's a very useful comparison, thank you. Some students are still at this stage a bit confused about what a risk factor actually is, but having that discussion would be a good chance to reinforce their fairly new understanding of risk factors in health.

I think there can be some shaming about high blood pressure, partly because some people can lower their BP by eating less salt, and some can lower their BP by doing more exercise, which means that people with high BP are sometimes assumed to be eating badly and living lazy, sedentary lifestyles. Or else the high BP is assumed to be caused by being overweight and you're back to the same problem. But at least there are reasonably effective BP-lowering drugs, whereas with losing weight there just isn't a straightforward and classically medical solution.

It'd be really interesting to know whether BMI is an independent risk factor for diabetes, go your colleague. But in the end I don't think it matters all that much; if the increased risk with higher BMI is purely explained by the correlation with too high calorie diet and too little exercise etc, well, controlling your diet and doing more exercise are good anyway. And if it's independent, being more active and eating a diet that doesn't promote insulin resistance are still good anyway, even if they don't change BMI as much as one might hope.

Another comparison I might make is poverty. Low SES is most certainly a risk factor for diabetes and a whole bunch of other diseases too. But you don't get doctors telling patients, you're at risk of disease because you're poor, so you'd better go and make more money and move to a better area. Much less saying, well, you're poor so your life expectancy is lowered anyway, I'm not going to bother treating you for this other condition until you get richer.

[monanotlisa]

this hi-larious anecdote about how he told a patient "I see you're still a fat bastard" and the patient made a complaint against him and aren't these patients just delightfully wacky taking offence at a little thing like that?

I'm not surprised at all; medical doctors have a tendency to be callous, at least in my country and my experience. It's a disgrace. As in the example above, some also consider themselves real comedians. This is not a mere bedside manner issue in both cases: Their actions are informed by a genuine lack of understanding and acceptance.

Not that this is in any way news. I'll return if I have more of substance to say. ;)

[liv]

The weird thing is that I have every reason to think this guy is a caring, sensitive doctor, and he has a very high reputation nationwide as one of the best GPs out there. I can just imagine the "fat bastard" comment working as a joke, helping to put the patient at their ease and make the discussion of weight seem unthreatening. What surprises me is not that he called a patient a fat bastard, but that he (normally an exceptionally sensitive and insightful man) can't even begin to see why his joke misfiring might have caused real hurt.

[ephemera]

ohh - opportunity, and also risk.

I think my best bet is to explicitly separate out "improve their diets and do more exercise" from "lose weight".

I think that makes a lot of sense. Paired with encouraging them to re-examine their assumptions about the relative risks of various weight-loss methods (and their success rate) vs leaving BMI alone and focussing on behaviours and treatment.

(as someone who's fat and lucky enough to have a good doctor, but partnered to someone who won't seek medical treatment for anything because he's convinced they'll just tell him to go away and loose weight, anything that can help make the medical community even fractionally less fat-phobic has to be a good thing!)

[liv]

We are definitely definitely going to be talking about the risks that if doctors are too judgemental about weight, patients are simply going to avoid them altogether, and that is going to have obvious bad health consequences. Luckily the seminar as structured is very much set up to push that message.

What I'd really like is to move the students on from "being fat is terrible lifestyle choice but we have to be non-judgemental" to "being fat is a body shape which on its own is medically neutral". And yes, I hope we can talk about the risks and success rates of weight loss techniques, because even if being fat is horribly bad for you and causes all kinds of diseases, if you can't realistically do anything about it doctors can try to work with the reality in front of them.

[katieastrophe]

I assume by "health at every size" you acknowledge thin is just as healthy as fat, depending on the person?

(A lot of people who claim to believe in HAES wage war against people who try to lose weight for their health, which is a massive bugbear of mine since becoming healthier as a result of losing weight.)

[ptc24]

The thing in brackets...

For every many probably-good-on-balance ideas, there seem to be people who couple those ideas with absolutist rhetoric and a "them and us" mentality. This is vexing and induces a temptation in people like me to embrace an identity of one of "them" out of frustration.

(I was reading Linda Bacon's book, Health At Every Size, and there were lines in it which suggest that a more honest title would be Health At A Much Greater Range Of Sizes Than Might Normally Be Imagined. Also, it depends whether you're thinking about health as a thresholded "you are healthy if..." concept, or whether you're talking about "health" as "healthcare" or "health promotion" or things like that.)

thin is just as healthy as fat

[liv]

Oh, absolutely, that would be the every part of health at every size! If the students start claiming that thin people are all horribly unhealthy they are going to get challenged just as much as if they make health assumptions about fat people, believe me. As for any sort of moral judgement against thin people, that is getting shut down very firmly indeed. Some people are naturally thin, just as much as some people are naturally fat. And some people naturally see fairly major changes in body size when they increase their activity level and restrict their diet, just as other people naturally tend to maintain a stable body weight.

I think the thing about HAES believers waging war on people who intentionally try to lose weight is a bit like feminists hating women who shave their legs or wear make-up. I'm sure there are some examples of people who feel like that. But mostly they are fighting the pressure and expectation that everybody should be trying to lose weight, not the individuals who make that choice. It's your body after all, I don't at all think it would be in line with HAES principles if I were to try to dictate what you should do with it. I can quite easily see how a war on the weight loss industry might look very much like a war on dieters, which is likely to be very hurtful and one should be careful to avoid giving that impression.

I know some fat activists say things like, if you lose weight through dieting you're "literally a freak", but I think personally that's the wrong language to use. Being part of a minority of 5% or so doesn't make you a freak, it just makes you somewhat medically unusual. And it's really quite ridiculous to imply blame against those who do lose weight via lifestyle changes.

Re: thin is just as healthy as fat

[katieastrophe]

:) excellent! I figured you would be one of the sensible HAES ones, but I wanted to make sure!

[siderea]

Hmmm.

You have an additional challenge. Not only do you have to keep "safe space" in terms of protecting students (not just the fat ones -- consider the possibility of anorexia) from hearing wounding contempt of fat people, you also need to keep students safe from staying prejudiced, ugly things, and then being shamed in a "gotcha". Because when someone unreflectively blurts out something bigoted, and then is schooled about how what they did was in fact bigotry, and all this is in front of others, instead of taking it gracefully as correction, they will dig in their heels, intellectually, and manufacture justificatory reasons they are right to think and feel the bigoted way they have been thinking and feeling. By protecting students from exposing their own hurtful ignorance in public before better advised, you both protect them from being hurt and from marrying their prejudices as matters of principle.

I think I would be inclined to start with a discussion of prejudice against fat people, and from there structure the presentation in terms of "these are ways in which the emotional commitment to prejudice has caused faults of diagnostic logic, research methodology, and discrimination in care." All the other things you want to talk about, I think, then hang off that convenient coat rack. The underlying message of this approach is "this is how prejudice makes you/one stupid", and since med students and MDs are most typically vain about their intellects, I think it is a compelling form of argument.

[liv]

Thank you, siderea, this goes right to the centre of the concerns I have about this session, some of which I stated more clearly than others. I am definitely concerned about anorexic students as well as obviously fat ones (that's why I alluded to eating disorders; I don't want to go into any more detail in an internet discussion, even pseudonymous), and there are also the students who may see themselves as fat even if others don't, or have fat relatives and so on.

I really do appreciate your advice about not shaming students who say prejudiced things. I've really fucked up in the past when a student said something so shockingly racist that I blurted out "what on earth did you just say, that's completely ridiculous!" before I had a chance to think how damaging that was to the learning environment and hurtful to that student. I need to be very much conscious of holding a line between hurting students with body image issues of any kind, and making average weight and potentially fat phobic students feel that weight is a taboo topic which causes people to jump down your throat if you aren't strictly PC. You're quite right that the latter would likely harm those students' attitudes towards fat people.

Flattering their intellects seems like a good approach. The other things in my med student manipulation toolkit are appealing to their sense of self as being exceptionally altruistic and empathetic, and in rare cases their sense of duty and obligation to the public. And thankfully the seminar (and the course as a whole) are structured to put real emphasis on prejudice and how this can lead to wrong diagnosis and wrong treatment, so it's definitely going to be possible for me to follow your suggestion there.

[siderea]

I owe you an apology! I somehow either missed or by the time I got to drafting my comment forgot that you mentioned eating disorders. I'm terribly sorry, I'll be more attentive in the future.

I need to be very much conscious of holding a line between hurting students with body image issues of any kind, and making average weight and potentially fat phobic students feel that weight is a taboo topic which causes people to jump down your throat if you aren't strictly PC.

I think the crucial thing is that a discussion of how bad fat shaming (and esp. medicalized fat shaming) is, and all illustrative examples, has to happen before anybody in class is allowed to open their mouths. This guarantees people haven't already espoused and gotten invested in unfortunate positions that then they dig in and defend later, when it's explained why those positions suck. It's easier to change your mind in public if you don't have to admit you just changed it.

appealing to their sense of self as being exceptionally altruistic and empathetic

Does that work where you are? Cause I wouldn't try that here; US MDs at least don't seem to value empatheticness reliably. Many seem to have a badass cowboy know-it-all persona thing going on. The whole House, "I don't need to be civil cause I'm a genius" thing.

[lilacsigil]

I agree with siderea. While I think separating out "healthy eating and exercise" from "losing weight" is an excellent one, another tactic might be that no-one wants to think of themselves as prejudiced (even as most people, in some way, are). Can you appeal to their intellectual egos by talking about good evidence-based practice vs bad prejudice-based practice? For example, discuss the harmful prejudice that a thin person will be healthy as well as the prejudice that a fat person will be sick, and how important it is to use actual test results rather than assume. I've personally been told to lose weight for sinusitis, conjunctivitis, a UTI, psoriatic arthritis and cancer. My mother, on the other hand, is very thin and didn't have her bronchiectatis picked up for many years because doctors would assume she was healthy and just had a minor chest cold, despite her chronic asthma.

My cancer story is probably a bit dramatic and counter-productive for such a session but you're welcome to use it if you like. (There's more recent parts to the story than what's on that page, but the relevant weight part is all there.)

[liv]

That is a really, really shocking story and I'm sorry you experienced such appallingly damaging attempts at care from people who should have known better.

I definitely see a two-pronged approach, a mixture of talking about prejudice and leaping to unwarranted medical conclusions, with talking about promoting a healthy lifestyle without binding that too closely to weight loss. Maybe an additional strand is that even if they retain the belief that weight loss makes you "healthier", it's certainly not a panacea and there are many many conditions that are not going to be cured simply by losing weight. Or perhaps I can take the angle that people may be in worse health than they might be because of their weight, but may have an actual disease as well, and it's no good just assuming their weight is the cause of all their symptoms!

[blue_mai]

As an outsider this:
What scares me is that there will be fat students involved in the discussion, and I know there are students who have struggled with eating disorders; how can I make sure to protect those students so that they don't feel excluded or even triggered?
stands out as really important, and also something that should be made explicit to the students at the beginning. That fat issues are hugely emotionally and psychologically loaded, and you can't always tell by looking at someone whether that will be the case.

Also siderea's point about not shaming students who speak up, is a very good one.

[liv]

Thanks for chipping in. I think you're right, it may be good to set some ground rules at the start of the discussion. I think at least remind the students that they themselves are future patients as well as future doctors and that weight is a sensitive issue for many people. Also something about how their commitment and obligation not to discriminate includes not creating a horrible working environment for their colleagues. I don't think I want to explicitly mention eating disorders, because that's a major distraction and I really don't want the students to start speculating about who might be anorexic. But yes, Siderea is completely one hundred percent right, I need to make sure the students who may have some fat phobic prejudices feel safe as well.

[sea_bright]

I have many thoughts on this topic. Apologies if what's below gets a bit rambly or ranty.

If I was doing a session like this, I might be tempted to start by getting students to list some possible approaches to reducing obesity, and then respond with evidence about how (in)effective these have actually been shown to be (ideally I'd like to do this by setting them an investigative assignment which involves exploring the literature for themselves, but for various reasons it sounds as though this wouldn't be practical). The idea would be to give them a good grounding in the empirical evidence, and provide an opportunity to raise the question of _why_ conventional approaches to reducing obesity aren't widely effective. If (as I suspect is the case) the answer is that people aren't very good at sticking to diet and exercise regimes over the long term, that would provide an opportunity to discuss why _that_ is the case.

A possible analogy that occurs to me is compliance with treatment programmes for long-term medical conditions. I am guessing (or at least hoping) that if 80% of patients were failing to stick to a regime for managing something like diabetes, this would lead to the conclusion that the treatment was unreasonably demanding or unpleasant in some way. But if 80% of people following a medically recommended diet fall off the wagon, I suspect there'd be a much greater tendency to blame the patients - 'Oh, well, of course they didn't lose weight: they didn't stick to the diet!'

Something else that feels like it ought not to need stating, but my own experience suggests it sometimes does: most fat people are already aware that they are fat, and many of them are unhappy about this fact. Some of them will have spent much of their adult life trying to fight this. Consequently, the extra guilt and pressure added by medical advice to lose weight will often have at best limited impact. It's particularly unhelpful when that medical advice takes the form of information about what healthy eating looks like. I _know_ what healthy eating looks like; it's implementing it that's the difficult part. If the advice were more practical - about, for example, ways of sticking to a healthy eating regime when very busy or on a very strict budget, or overcoming a tendency to comfort eat - that might actually be some help, assuming it was coming from someone who actually sounded as though they understood the issues at stake.

Finally, a point that someone's already alluded to above: unsolicited advice about weight can sometimes have other knock-on effects. Last year, I was aware that I was putting off going to the doctor's because I was fairly sure that when I did go, I'd be nagged about my weight. Rationally, of course, I know that my health is more important than a few minutes of feeling awkward and the horrible experience of being made to weigh myself in front of another person, but... well, human beings aren't always totally rational.

I don't envy you the task in the slightest, but I'm glad for the sake of both your students and their future patients that someone like you is leading this session!

[liv]

Thank you, I really appreciate your bringing up all these points. I'm definitely planning to talk about the very poor success rates of all known weight loss schemes and put a strong emphasis on evidence.

There's actually surprisingly little direct research on why people don't stick to diets and exercise; most of the research on whether weight loss systems work basically throw out the participants who don't stick to the regime. Weight loss diets don't produce significant weight loss in the long term in 95% of cases even when people follow them strictly. That's partly because most dieters regain the weight as soon as they reach their goal and relax their strict diet, but also partly because many people just never lose more than a few kg however hard they try. Part of the problem is that when subjects don't lose weight as expected, doctors and researchers are likely to assume they must be lying about whether they stuck to the diet or not, which clouds the issue further.

The students have been learning about what sorts of support help people to make big changes in their lifestyle. That implicitly includes some of the stuff about what is unhelpful and means people don't stick to their new healthy habits. Like I think smokers take something like five attempts on average to actually give up permanently. But yes, there is a very strong tendency to blame people for not having enough willpower if they're unable to stick to increasingly strict calorie restriction and putting serious hours into exercise. I think it would be helpful if the students considered that such a regime is really too onerous, yes.

Definitely worth leaning strongly on the idea that people avoid seeing doctors at all if they think they're going to get nagged about their weight. I think the giving advice about what a healthy diet looks like relates to the fact that most of the students who are politically what I might broadly describe as liberal tend to think that the only reason people have unhealthy behaviours is because they just don't know any better. If only they as doctors could educate their patients about what a healthy lifestyle looks like, and the horrible dangers of an unhealthy lifestyle, they imagine the problem can be fixed. (The less liberal type students tend to think that unhealthy behaviours are a moral failing, which is a different problem again.)

I think part of the reason why the detailed teaching about how to support lifestyle changes isn't sinking in is again because of fat prejudice. The students are sort of subconsciously assuming that the only possible way someone could get and stay fat is by stuffing their faces all the time, and it's easy enough just not to eat so much junk food, so they don't see changing your diet as a hard problem in the way that giving up smoking or dealing with alcoholism is.

[green_knight]

The students are sort of subconsciously assuming that the only possible way someone could get and stay fat is by stuffing their faces all the time

You might want to include a list of medical reasons why people gain weight like steroid use, lymphedema... I'm sure there are other things. If a GP assumes that the patient is stuffing their face and does not investigate further, they can miss serious underlying health issues.