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Can Obese Doctors Help Obese Patients?



This week’s edition of JAMA features a most interesting essay by Nitin Kapur, a physician associated with Yale university in New Haven, CT.

Dr. Kapur describes his interactions with a Mr C., a 5-foot 7-inch patient weighing 320 lbs (BMI=50). As Dr. Kapur points out, he himself is about the same height and carries 245 lbs (BMI=38), which led him to ponder whether he could indeed be of any help to his patient.

While Mr. C. gained his considerable stature (and continued gaining weight during his interactions with Dr. Kapur) after replacing his heroin addiction with bacon double-cheeseburgers, Dr. Kapur attibuted his weight problem to his stressful life as a medical resident and the demanding nature of physicianhood.

So here, as Dr. Kapur puts it, we have the morbidly obese drug addict and the severely obese Ivy League graduate, both struggling with their weight problem.

“So”, asks Dr. Kapur, “am I a hypocrite offering help to this patient, even though I couldn’t help myself?”

As Mr. C. continues gaining weight, Dr. Kapur begins to feel responsible and wonders it if would have been better to send Mr. C. to someone unencumbered by a 40-inch waist.

Finally, one day, Dr. Kapur asks Mr. C. whether it would indeed have been more inspirational for him to have seen someone thinner.

But Mr. C. dismisses any such concerns, responding that only Dr. Kapur could have truly understood what it felt like to be fat and that he very much enjoyed the care and had no doubt that he would eventually lose the weight.

This most insightful and touching story raises an important issue: can health professionals, who themselves struggle with excess weight, really provide help to their obese patients? Or are obese health professionals perhaps the only folks who can really understand the extent to which excess weight affects their obese patients’ lives.

What do my readers think? Does the weight of the health professionals giving weight management advice matter one way or the other?

AMS
Edmonton, Alberta

Hat Tip to Tobias Pischon for bringing this essay to my attention.

22 Comments

  1. I ALWAYS feel comforted when my physicians show evidence of (or admit to) struggling with the same issues I myself am experiencing. I think the ability of a doctor to offer understanding, comfort and empathy is every bit as important as his/her ability to offer medical intervention and/or treatment — and that empathy comes from having experienced pain, hardship, suffering, discrimination and misery, I would absolutely go to an overweight bariatric surgeon. 🙂

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  2. This is such a great post and great questions.
    As an “obese” public health professional, I’ve grappeled with this quite a bit.
    The conclusion I come to is that some “normal weight” people will tune me out, and some “obese” people will, too, thinking that I can’t be of any service to them because I’m overweight.
    But since what I “preach” is that each of us has many aspects of our lives we can’t control and mostly can’t even influence, it’s best to focus on what we CAN change. This might be managing stress, or looking at what we eat and seeing, is it a reflection of how we want to be eating. I ask, are you active enough to be able to do what you want to in life? I am very active — people who are slimmer than me but sedentary might learn a thing or two from me.
    For many people, how I present myself (fat, well-dressed, well-spoken and striving for the best possible health I can get) allows them to think differently about weight, health, health behaviors, health values and health goals, and frees them up to think that they can make changes in health that aren’t necessarily tied to weight. And that it isn’t necessary to be thin in order to be professional, well-dressed, well-spoken, and that I have a huge amount of compassion and understanding for how hard life can be. This may be seen as a form of prejudice, that just because I’m fat, I would be more understanding, but in my case, it’s true that, due to a great deal of self-examination and critical examination of our societal and environmental context, I am compassionate.

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  3. Amy makes great points with her comments. I will not repeat what she says but I agree with all she says.
    I want to take this a step farther Dr Sharma. If an obese patient could learn how to eat from a former obese person or go to the gym and train with a former obese person would we not all benefit? All the fitness trainers or gym’s in the world cannot solve the obesity crisis yet, we might have the solutions right under our noses, if we would just accept the obvious. Let the former obese become the leaders in the obesity fight.
    Just a thought.
    Pierre for the Thee Quest team

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  4. A few years ago I went to see a dietician who specialized in helping athletes because I was struggling to get the weight off that I gained after retiring from varsity wrestling. The dietician I saw was overweight. She did share with me some of her own personal struggles and yes this was somewhat comforting to know she could relate, but I will admit to questioning her ability to help me reach my goals because I could see that she could not reach her own.

    It’s a very interesting post Dr. Sharma. But along the same lines – how likely is a patient who is addicted so smoking, drinking or cocaine going to seek help or try to quit based on the advice of a doctor who smokes or is an alcoholic?

    Antigone

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  5. For health professionals see this link for recommendations on how to handle comments from your clients about your weight.
    How to Discuss (Or Not) Our Size With Clients
    http://www.mollykellogg.com/archive08.html#71
    It’s from a dietitian but can apply to any health professional.

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  6. Arya, I think that any obese physician who treat an obese patient should be ready, comfortable and opened to discuss with the patient its own issue about obesity, from a medicine-morbidity point of view and its own attempts to lose weight if needed and if it is asked by the patient.

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  7. This is an interesting post. I have certainly thought about this a lot in my practice as a dietitian. I am according to BMI underweight, can eat whatever I want and gain very little. This makes me question if I can really relate to my obese patients and their struggles with diet and activity. Also I have clients come in, look at me and expect that I must be successful with my diet and must therefore be able to make them look like me, which is certainly unrealistic.

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  8. What a wonderful dialogue you are opening up Dr. Sharma! This is truly a thoughtful topic.

    As a health professional who was once fat and am no longer so, I now understand what it takes to lose weight and keep it off. It seems sometimes a full time job in itself and something I have to remember to keep on top of mind every day. I have always been very active but realized that food is by far the most important part of the equation for me since I could consume many calories in such a short amount of time that no amount of exercise would ever be able to negate.

    I have come to understand that I could not make just a few lifestyle changes. What I needed to do was accept the fact that I would have to make changes and continue them forever. I have had to accept the fact that I simply had to give up food as a large source of enjoyment in my life, especially in the quantities and also the variety that I used to eat. When I accepted this, I was able to lose my extra pounds and keep them off. Eating is no longer a social event for me because it is simply too tempting to eat either the wrong kinds of food or too much.

    My compassion has always been there for my clients but my understanding of what it really takes – to keep weight off in the long run -would never be there unless I had been there myself. I have felt the panic of backsliding when I saw the pounds creep back little by little and felt dismay at how much swimming against the stream of my hectic life and the pressures of modern living it requires to lose those pounds again.

    Any diet or eating plan or activity regimen will get you to lose weight but that is not the hard part. The hard part is keeping that weight off and not backsliding into the behaviours/reasons that got you fat in the first place. I truly believe that while an obese health care professional can offer some information about losing weight, it is just “head” stuff. It is the insights and strategies for dealing with stress or sabotagging friends, family and coworkers; the tempting nature of all social interactions; the pitfalls in the grocery stores, restaurants, cafes; the self discipline and thinking changes and that are needed. It is also about learning to think and do things from a different point of view. Holding food as some kind of “treat” is a mentality that will not lead to long term success. Someone who has not themselves been successful can never really offer help for long term success. They can offer some “tips” but that is not really what we are after. There are dozens, well actually thousands of “tips” in every magazine and news paper article out there but they do not lead to long lasting success. I believe that you cannot teach what you do not know and knowing is something deep and much more than just a bunch of information like how many calories it takes to lose a pound of body fat. To help someone else we need the wisdom that comes from experience. Keeping weight off is just the experience that is needed. Other experiences about overcoming other challenges we face in life could be helpful, but food is special because we eat everyday, many times a day whereas other behaviours like drinking or drug addictions can be completely abandoned, whereas food cannot. To help others we need to know the whole picture, not just a few pieces.

    Thanks for opening up this dialogue.

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  9. Thanks for all these insightful comments. Special thanks to Christina for the link to the health professional tips on how to deal with the providers weight if and when it comes up.

    AMS

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  10. As a member of the Association for Size Diversity and Health (ASDAH) http://www.sizediversityandhealth.org/ I have to point out the obvious here and wonder what it might be like for both the physician and patient to discover that “health comes in all sizes.” They might support each other in making lifestyle changes (that they can change) rather than focusing on weight, which results in a pathologizing feedback loop and reinforces internalized body-hatred, shame and perpetuates socially acceptable weightism and fat stigmatization.

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  11. One more thought, from the perspective of a long-time obese person. If there is one thing that someone who has been obese for a while comes to understand, it is that this is always going to be your own individual fight and no one else’s. You can be taught all about nutrition, exercise, behaviour modification, good choices, motivation, etc., and it is still going to come down to you facing and slaying your own dragon. I think many obese patients would understand that the fact that a physician hasn’t yet themselves reached that point does not mean that the physician cannot teach them about the necessary tools to get there.

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  12. Dr. Sharma- your last blog speaks volumes to my current medical practice. Thought you might find the article below of interest. I have always maintained that some of the best Endocrinologists do not have Diabetes and some of the best OB/GYN docs are men. If Obesity is to ever be embraced by our profession than having the disease does not preclude us from treating it. I know I am singing to the choir. Thanks for the essay. Looking forward to meeting you in person, All the best, Ali

    http://www.vancouversun.com/health/Torch+relay+health+graduation+Vancouver+doctor/2498519/story.html

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  13. Dr. Sharma

    Thanks for sharing this. While I am certain there are exceptions, my concern regarding morbidly obese physicians treating morbidly obese patients is that obesity is a multifaceted problem and the weight is the result of psychological issues. How the psychological issues play out in a physicians practice is what is the most important issue. I can’t see this as being a subject that can be pigeon-holed and instead would suggest the college monitor physicians with obvious psychological issues such as morbid obesity, alcoholism, etc.

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  14. James: >suggest the college monitor physicians with obvious psychological issues such as morbid obesity, alcoholism, etc.< Not sure I agree with the statement that morbid obesity is always a "psychological" issue and I don't think that the issue can be resolved through the colleges (like alcoholism, drug addiction, professional misconduct, etc.) ams

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  15. Thank you Dr, Sharma, first for kicking me out of your office when i lost 35 pounds secondly for this exciting blog. At my height of 5’7″ I weighed 264 pounds 4 years ago and was recommended that I go to Capital Health and your Obesity Clinic. My first meeting was with you 2.5 years ago, having lost the 35 pounds and keeping it off you instructed me that it was not necessary to continue meeting with you. That was good. I still carry that 229 pounds, I love to eat lots, however my diet consists of a nutritional support system in capsule form plus raw whole fruits, vegetables, grapes, berries and grains with three hand sized servings of protein at all three meals. the desire to eat is my problem.
    My daughter and I own a training facility where at the age of 67 I help as a training coach to do either sport specific. general fitness, weight loss or rehab training. At my weight and height some our clients’ first impression of me is that of, perhaps, shall I say disappointment.
    There are clients attending our gym who are obese and/or very slim. Slim is not indication of good health necessarily. Because of my age and obese presence I use it to my advantage when training people.
    I admit my addiction to GOOD food and eating to much and tell them my story of how I thought I was going to have to use a cane to move about before we opened the Gym and keeping off the 35 pounds.
    I show them how I can at 67 years of age leg press 700 pounds for 12 reps, stand on a swiss ball without any assisstance, do 80 pound dumbbell bench presses, jog at one minute intervals for 30 minutes, balance on the balance board without touching the floor for 60 seconds, they then become comfortable with my presence.
    We have also discouvered that some obese and aged people do not train well when “Arnold” or “Miss America” is near by and/or trainng.
    I must relate an experience I had with a young 60 year old obese lady that I trained. At first i had to help her get up from the floor mat while doing some core work. I showed her how hard it was for me at one time and how easy it is now to do the same thing. This particular moment i was making a shake for another client at the juice bar. Behind my back I heard my name being yelled outloud several times from across the the floor. Everybody stopped we thought she was hurt, she asked us all to watch. She laid down on the floor and got back up on her own. We all gave cheers and congratulations!!!!

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  16. Although I am at my highest weight ever–170 lb, curvy, (more curves than straight lines!!) silver-haired, 5’8” 65 yrs old and white skinned, most of my weight loss clients are aboriginal people needing help with diabetes. I am healthy and love food. However, we all laugh instead of cringing when a client admits to not trying very hard, or eating a plate of sugared donuts or cake, because I too love donuts, and can often be heard telling them that I would have loved to down such delicious treats, almost as good as a huge movie-theatre-sized bag of red Twizzlers, the ultimate non-food food that there could be. But my tastes have changed to mango or papaya as ultimates these days, and so might their’s change. Without being so like them I believe there would be little incentive to listen to me telling them that soon they will feel better, their blood sugars will lower, and they will have taken some control over their future. Big reward!!!!!

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  17. This post brings to mind something I considered a while ago. I was morbidly obese (now ‘severely’ obese) and looking for a change in employment when I saw a job opportunity within the Department of Sports and Recreation as a spokesperson regarding activities and exercise as well as undertaking community consultation. I met all the requirements for the position but my main focus was on whether I WOULD BE the ideal applicant for the job… I was overweight, not highly active and basically the alter-ego of whom I saw getting the job, so I didn’t apply. I felt that I would be tuned out regardless of my abilities in undertaking the job because I wouldn’t meet the ‘image’ you would expect in such a role… I think this would apply to many situations… like a psychiatrist with a mental health disorder… but what about alcoholics anonymous, where alcoholics pair up with reformed alcoholics (they still identify themselves as alcoholics), or male gynaecologists/obstetricians … there are situations where an intimate knowledge of the experiences others are going through are an obvious benefit, and other circumstances where we accept advice and assistance from someone that has never ans will never experience the same issues as we do.

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  18. ~As a certified personal trainer and specialist in fitness nutrition, I have to ask…if you come to me looking to lose fat and I am 30 pounds overweight (and have never experienced weight loss myself), will you want to work with me to achieve your physical goals?

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  19. When you are talking with someone who is or was (and you know that they where) obese, it is not as hard to hear. Someone else feels (felt) the same as you. They REALY understand. It helps to take some of the pressures off. The pressures that you put on yourself, because you think that the size 4 sitting across from you has no idea! They eat celery all day and like in a gym, no children and no STRESS.
    So for me to talk with someone who can truly understand how you are feeling, make the journey less of a battle and more of an achievable goal.
    And as for what our friend Kevin has said; I am taking a class from an amazing instructor who has a extra pound or two, but she is working at it. That dose not mean that she dose not know what she is doing, but she can relate to what you are going threw. Same as the medical professional. We would all be on the journey together.
    People need to understand that it is not the size 4 that is the healthiest, but the one who may have a few extra pounds, and no medical issues. High blood pressure, diabetic, and so on. When I achieve a healthy weight for me, size 10 or 16 as long as I am healthy and happy, that will be my perfect image!

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  20. This has come up with my patients. I have gone from being obese (65″ and 224#) to a weight range of 130-135# over about 18 months. The initial 50-60# were intentional, as 165# is a known sustainable weight for me, and I can run easily and so on (still overweight by numbers, but entirely functional.)

    I found that patients generally related well to me regardless of my weight when I discussed body size if it was impacting health with them, or when it was at risk of impacting health. I think I may have referred more people for sleep apnea evaluations than anyone else in the region… Even if not counseling specifically re: weight, maintaining adequate activity/exercise is universally part of health education and outreach for my patients. I’ve had several people tell me that they at least knew I was following my own advice re: “keep moving” when I was at my highest weight, and that if I was doing it, they figured they’d better do it too. My practice is in a Very Small Town (we share our one-horse with a neighboring town, so this is really a half-of-a-horse town). I actually wonder if I will now lose a little credibility in this area, or if I would lose a little credibility were I to move to a new town.

    When people have asked what has worked for me, I’ve been candid; I’ve referred to information that is evidence-based and helpful, I’m not shy about saying, “Gosh, that’s just… crap” when there’s a questionable practice promoted, etc. And I’ve been equally candid about the work involved, that it is an ongoing change in habits, that I have to be mindful, etc.
    Plus, in the small town, there’s an added phenomenon: I have 700-odd monitors who look in my grocery basket or bring my plate if I go to the diner.

    I could go on for quite some time about issues re: disclosure and boundaries, will spare you. The link from Christina addresses much of the topic very well, I think.

    Sidenote: Unfortunately, the remaining 30-odd pounds came off after a few months’ plateau at 165ish, were -not- intentional and were due to other medical causes. (Unexpected bonus of keeping a food log and weight log. Evidence that it’s really unexplained weight loss, which meant that everything was worked up very quickly.) It’s been an interesting reminder of things I “knew” but hadn’t lived. People make social comments about body size and ask what my ‘secret’ is; I suppress the snide answer that pops to mind. Since I’m still healthy looking (for someone who takes a lot of night call) and active, and was initially overweight, there has been no concern re: illness out in the social world.
    It’s given me even more empathy for my eating disordered patients and the amount of social attention that is paid to body size. Hardly news. Nevertheless, I find it unpleasant and sad that I perceived more positive direct social attention for the loss of X lbs, 30% of which was due to illness, than I did for completing my clinical training.

    Camerin: I do take a ‘health-at-many-sizes’ approach, and I always take the ‘and you bloody well deserve top notch health care at any size’ approach. I focus on outcomes other than weight alone, but, in the case of some conditions, weight has been an unavoidable clinical issue for some patients. I agree re: the feedback loops; I think there are very bad ways to work with a patient on weight, and that solution finding needs to be an orientation. However, Greta Christina’s blog had an excellent discussion of this – her blog is *very much NSFW*, but her open letter was very good and links to two prior posts. (Dr. S, I don’t know if you’d already seen her letter, apologies if it’s already been linked. Also, she is very eclectic in her writings. Please, again, did I mention that her site is not suitable for work for many workplaces?)
    http://gretachristina.typepad.com/greta_christinas_weblog/2009/08/open-letter-fat-positive.html

    Kevin: you sound like you are wondering whether your body size and weight history would raise concerns on my part were I a potential client. (GREAT link on the counseling site, by the way, Christina.) Anyway – if your knowledge base is good by my standards, if your credentials are solid, and, most importantly, if you have the interpersonal skills to work with me or a client and are not condescending or rigid in your thinking… sure, of course! I’d welcome the experience you bring. A trainer who can work well with chronically demoralized clients is, in my mind, worth a lot – I only know a handful of those trainers. Know your motivational interviewing, become a master of goal-setting, and that will make you a rockstar. Of course, those aren’t the ‘fun’ clients, initially; also, I don’t know what you’re hoping to get out of your CPT work. I do find this population rewarding as patients in the long run, though.
    The uni at the big hospital way up the road pays their director of physio a remarkably good wage because he is the best I’ve ever seen at this kind of work. He’s not whippet thin, he’s not obese, but, as he says, he could survive a good long cold-water swim better than most. But he sure does get folks off the sofa, both in PT and in personal training, and I take him seriously. He never talks down to patients, and that respect is worth everything. He’s one of the only people I routinely hear described by patients as “life-changing.”
    THAT is a skill-set worth cultivating. And with that skill-set, I don’t give a darn about 30#.

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  21. Dear Dr. Sharma and other readers,
    Thanks to Dr. Sharma for reading “Doppelganger” in last week’s JAMA and for the insightful discussion posted on his blog. One of the tensions of “Doppelganger,” is whether or not I, as an obese physician, have any business counseling my morbidly obese patient regarding weight loss. The impetus to write this story came from the realization that my weight was frequently the elephant in the room during my patient encounters with “Mr. C” my patient. I would often fixate on just counseling him about his weight without any acknowledgment of my own weight loss difficulties. Since I am a resident in internal medicine and am currently in training, discussions surrounding my own weight were also excluded from discussions with my attending physicians about my management plans for this patient. Honestly, I am still not sure if I (as an obese doctor) am the ideal person to counsel Mr. C about his weight. Because I am a resident in a clinic that caters to the underserved, we are, to some extent, stuck with each other. He is convinced that I am the best man for the job, but I am not entirely sure. What I do know is that the literature on this topic is sparse and the few studies that have been done demonstrate contradictory findings (ie. Some find that obese doctors do a disservice to their obese patients; others find that obese doctors are the best to counsel their patients). In the process of reflexively examining my encounters with him and writing and publishing “Doppelganger,” I have also become much closer to him and am hopeful, at least for the time being, that we will both be successful in our weight loss efforts. I also feel as though an acknowledgment of my own fallibilities to him have reminded both him (and me) that doctors are only human and prone to the same temptations and negative health behaviors of their patients.
    I must also point out that an interesting (and much more insightful and intelligent) article that I just came across that addresses this issue was just published in this month’s Health Affairs by Dr. Perri Klass, a physician-writer and self-described “plump pediatrician” in New York. I think that most of you all would find it very interesting:

    http://content.healthaffairs.org/cgi/reprint/29/3/554

    Nitin A. Kapur MD, MPH

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  22. This is an old post, but I have to say that as far as I’m concerned, lazy, incompetent doctors equate weight with health and fail to ask the right questions or to think critically when their patients are fat. They blame everything on weight, and they are incapable of providing proper care to fat people.

    Good doctors treat health problems rather than concentrating on weight. If they mention weight at all, its just to inform you that it’s a risk factor for certain conditions. They might follow up by asking more screening questions, discussing symptoms to look out for, or recommending testing. They’ll never tell you to lose weight as a primary means of treatment, because they’ll be aware that for the vast majority of people, there is no safe, effective way to permanently lose weight.

    Either a good doctor or a lazy, incompetent doctor could be underweight or as big as a house. I wouldn’t care. I’m always thrilled if I can find a good doctor, but they are very rare.

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