| Daily Briefing

Why fat-shaming fails (and what works better)

Editor's note: This popular story from the Daily Briefing's archives was republished on Apr. 14, 2021.

Obesity is a serious public health threat, but too many doctors attempt to treat their obese patients using aggressive, impersonal tactics such as "fat-shaming" that simply don't work. Research suggests there is a better way to approach these conversations and help patients with obesity, Michael Hobbes writes for the Huffington Post's "Highline."

America's obesity crisis, mapped

Why obesity is a major public health threat

Obesity is a rapidly growing problem worldwide, Hobbes writes. Since 1980, 73 countries have seen obesity rates double—and no country has managed to cut its obesity rate.

In the United States, almost 80% of adults and about 33% of children are either overweight or obese, according to CDC data. In fact, more Americans have "extreme obesity" than have breast cancer, Parkinson's disease, Alzheimer's disease, or HIV put together.

Obesity has very real public health consequences, Hobbes writes. Diet is responsible for five times as many deaths as gun violence and car accidents combined. And the problem goes beyond the quantity of food we eat: About 60% of the calories Americans eat are high in sugar, low in fiber, and contain additives, all of which can throw off the biological systems that regulate energy, hunger, and satiety.

An all-too-common reaction to obesity: Fat-shaming

Despite the increasing prevalence of obesity, the medical community continues to treat obesity more as a "personal failing" than a disease, Hobbes writes.

Research shows that doctors have shorter appointments with overweight patients and express less sympathy toward them. Some doctors refuse to see overweight patients at all: A 2011 poll of OB-GYNs in Florida found 14% had barred any new patients over 200 pounds.

Many obese patients say that they find their interactions with providers frustrating or even insulting. One woman, Emily, a counselor in Washington, said she went to a gynecological surgeon to have an ovarian cyst removed. While looking at her MRI, Emily's physician pointed at her body fat and said, "Look at that skinny woman in there trying to get out."

Joy Cox, an academic from New Jersey, went to the hospital after experiencing stomach pains at the age of 16. She had a dangerously inflamed bile duct, but rather than diagnosing that condition, the doctor suggested she might feel better if she didn't eat so much fried chicken. "He managed to denigrate my fatness and my blackness in the same sentence," Cox said.

Even as doctors "fat-shame" obese patients, they often fail to provide actionable advice on dieting, according to Kimberly Gudzune, an obesity specialist at Johns Hopkins. One study that recorded 461 patient-doctor interactions found that just 13% of patients received a specific plan for diet or exercise, while just 5% received help arranging a follow-up appointment.

Fat-shaming is a "cartoonishly out of step" approach, research suggests

So why do so many doctors "fat-shame" their patients? Some believe that it truly works, Hobbes writes. In 2013, Daniel Callahan, a bioethicist, wrote a journal article arguing that obese people should face even more stigma. Callahan argued that an intense feeling of shame led him to stop smoking cigarettes—and so a similar application of shame should help obese patients.

But the notion that fat-shaming can help obese patients is "cartoonishly out of step with a generation of research into obesity and human behavior," Hobbes writes.

Jody Dushay, an endocrinologist and obesity specialist at Beth Israel Deaconess Medical Center, said the majority of her patients have lost and gained weight repeatedly before coming to her. "Telling them to try again, but in harsher terms, only sets them up to fail and then blame themselves," Hobbes writes.

And fat-shaming can drive obese patients away from the health care system, with dangerous consequences. Three different studies found that overweight women were more likely to die from breast and cervical cancer than non-overweight women, partly because they were reluctant to see a doctor and get screened.

Overweight people who are discriminated against also end up with shorter life expectancies than similarly overweight people who don't face discrimination, according to a 2015 study. "The stigma associated with [being overweight] is more harmful than actually being overweight," the study found.

If fat-shaming doesn't work, what does?

To know what treatments can help overweight patients, it's important to know what doesn't work. For example, diets typically don't work—at least not in the long run. Research dating back to 1959 has found that 95 to 98% of attempts at losing weight ultimately fail, and about 66% of dieters wind up gaining back more weight than they lost.

That's not because of personal failings on the part of dieters, Hobbes writes. Rather, research going back to 1969 has shown that losing just 3% of one's body weight can cause a 17% slowdown in metabolism, which can set off hunger hormones and ultimately lead to weight gain. "Keeping weight off means fighting your body's energy-regulation system and battling hunger all day, every day, for the rest of your life," Hobbes writes.

So rather than simply preaching in general terms the virtues of diet and exercise, providers need to attune themselves closely to each individual's psychological and medical needs, according to Stephanie Sogg, a psychologist from Mass General Weight Center.

"For something as emotional as weight, you have to listen for a long time before you give any advice," Sogg said. "Telling someone, 'Lay off the cheeseburgers' is never going to work if you don't know what those cheeseburgers are doing for them."

This personalized approach has been proven to work. In 2017, the U.S. Preventive Services Task Force (USPSTF) found that diet was not the most important factor in obesity care; what mattered more was the amount of attention and support patients received. As a result, USPSTF recommended "intensive, multicomponent behavioral counseling" for overweight patients.

But the U.S. health care system has a long way to go before that kind of intensely personal, supportive weight management care becomes the norm, Hobbes writes. For now, insurance companies typically only cover one or two sessions with a dietician for their patients.

As Chris Gallagher, a policy consultant at the Obesity Action Coalition, put it, "Health plans refuse to treat [obesity] as anything other than a personal problem" (Hobbes, "Highline," Huffington Post, 9/19).

Learn more: Help your employees promote healthy habits

Introducing the wellness spectrum

Programs aimed at promoting healthy habits among employees are likely to lead to improved employee engagement and productivity—but they're unlikely to reduce the total cost of care. To do that, you'll need to take a population health approach.

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