I recently wrote an opinion on what I believed to be sloppy journalism in the NY Times. Briefly, this article described recent research that suggested “being overweight” was actually protective. I argued that the use of BMI as a primary measure of body fat and (more importantly) overall physical health was irresponsible and not supported by research. As such, I had concerns that, just like using BMI to automatically say someone is overweight and unhealthy, it could now be used by readers to justify unhealthy eating under the guise of health. Specifically, I wrote:
My Facebook feed is already inundated with this article, and it is only a matter of time before people simply start disregarding their doctor’s advice, waiving a NY Times article in the air as they enjoy their deep fried bacon-wrapped
Twinkiesgeneric snack cake.
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In response to the above, reader Rebecca Weinberger replied on Facebook:
You don’t think BMI is an accurate measure of fat or risk (this we agree on) but you do feel comfortable saying it’s important for people to be scared of getting fat, lest they eat things you don’t want them to eat. […] That’s pretty fucked up. That leads me to believe that you’re not really interested in finding a more accurate measurement tool, but you are definitely interested in holding on to authority through scaring people.
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At first, I was of course taken aback – As a matter of principle I believe quite the opposite, and told Rebecca as much. As health care professionals, our job is to help our patients, not control them. When we run tests, the goal is to gain information to allow patients to make informed decisions. We are not Gods, and we do not know everything. One of the risks we run in today’s healthcare climate is to grasp for easy answers that insurance will cover, and avoid complicated healthcare that might simply be above our heads.
Despite all of our training, we are all guaranteed to run into a case we just don’t understand. Being continually open-minded to this possibility is essential to our work.
Lest I sound too preachy, I am as guilty as the rest of pre-judging patients. There really are those patients who come in and simply want a pill to fix everything without doing any work on their own, but we cannot let those patients cloud our view of the vast majority who simply want our help to live better lives!
When Rebecca first replied, I didn’t even catch my initial response. It wasn’t until a few hours after I read her extremely moving reply (below) that it occurred to me just how reflexive and ingrained our judgments can be. Like many in our field, I really did have an image of a fat person simply wanting to argue with me to justify the continued eating of unhealthy, harmful food. The thought was so reflexive, so quick, it didn’t even register! But it was there, and undoubtedly influences how we treat our patients.
Here is Rebecca’s complete reply. It is one of the more moving and thoughtful views into the world of a patient I have ever read, and am honored that Rebecca has allowed me to share it with you. As a final note, I believe that the insight contained within this text extends to all patients, and especially those with those more complex health issues that we would often prefer to throw under the rug and not face.
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Rebecca Weinberger (via Facebook):
I can tell you that as a fat person, and as a patient since everyone is a patient at some point, that a story that includes a fear of people eating really outlandishly unhealthy foods comes off immediately as fat-hating, because the assumption is that I eat those foods all day and that assumption is thrown at me, or people like me, all the time. And often the assumption goes along with, “Oh no, if we say being fat is ok then everyone will be lazy and ugly!” There’s even a shorthand for this in the fat-online world, which is “two whole cakes” – meaning fat people are literally accused of sitting down to eat two whole cakes a night in order to maintain their fatness. That isn’t what I eat, or what any of the fat people I know eat, but even if it was that wouldn’t be an excuse for the hatred thrown at fat people (not from you, in general). So that’s a short explanation why that sentence sounds to me like it’s about keeping people scared of being fat in order to control what they eat. But, putting that sentence aside and focusing on your response here, it sounds like we do agree. That doctors and patients need to work together to figure out what works for each patient, and that BMI is a terrible measurement tool to use. For a long time fat activists have been saying that you can’t read anyone’s health by looking at their size – there are thin people who are unhealthy and fat people who are healthy and vice versa and people move between health and unhealthiness with and without their weight changing. But when a fat person goes to the doctor (which fat people do more rarely than the rest of the population due to stigma, I can find the studies showing this if you haven’t seen them) every ailment is assumed to be about being fat, no matter how unrelated. You learn, as a fat patient, to say things like, “If you were seeing a patient who wasn’t fat, what would you think the causes of this symptom might be?” just to get the doctor out of their own obsession with fat. I don’t know if you already know this, but specifically this philosophy that skinny/=health and fat/=disease is called Health At Every Size, and it’s basically a belief that a focus on weight or BMI alone is a detriment to all of us: for skinny people it can mean assuming they are healthy when they aren’t, and for fat people it’s an assumption of being unhealthy and (when they fail to loss or keep off weight) being labeled as non-compliant, and that instead of focusing on weight or BMI, we should be focusing on movement and eating in a way that gets away from sinfulness/indulgence vs dieting/deserving for everyone.