Shame

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I saw a gentleman in my office for his sciatica.  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.

217 thoughts on “Shame”

  1. My sister underwent surgery to help her. She has been heavy all of her life, and I felt for her. I saw the lengths she would go to, to weigh less. She did try on her own, but she just couldn’t do it alone. My heart broke for her, to see the cables, and staples all up and down her midsection. I realized how much pain there must be inside of her for her to have to endure that. You have great insight, Dr. Rob. You are the way a physician should be.

  2. My sister underwent surgery to help her. She has been heavy all of her life, and I felt for her. I saw the lengths she would go to, to weigh less. She did try on her own, but she just couldn’t do it alone. My heart broke for her, to see the cables, and staples all up and down her midsection. I realized how much pain there must be inside of her for her to have to endure that. You have great insight, Dr. Rob. You are the way a physician should be.

  3. Your post made me cry, but in a good way. I read many blogs and not many people are as compassionate as you (and I do not just mean about weight). I’d love to meet you in person and shake your hand.

  4. Your post made me cry, but in a good way. I read many blogs and not many people are as compassionate as you (and I do not just mean about weight). I’d love to meet you in person and shake your hand.

  5. The more I read your blog, the more I wish there were more docs out there like you. So many of them spend their time lecturing their patients in such a patronizing way that it makes you (as a patient) want to smack them off of their high horses. You, on the other hand, sound very down to earth and empathetic. One can only hope it’s not merely your blogging persona…as for junior high…I could write endless posts on my own blog about that one, and they would be as ugly as some of the things obese people tend to hear from their health care providers! Perhaps I will someday. The saddest part? A good number of people never outgrow that junior high mentality, which makes it harder for those of us who are obviously different in some way. Thanks for not being one of those people…I’m sure that helps make you a decent doc, too.

  6. The more I read your blog, the more I wish there were more docs out there like you. So many of them spend their time lecturing their patients in such a patronizing way that it makes you (as a patient) want to smack them off of their high horses. You, on the other hand, sound very down to earth and empathetic. One can only hope it’s not merely your blogging persona…as for junior high…I could write endless posts on my own blog about that one, and they would be as ugly as some of the things obese people tend to hear from their health care providers! Perhaps I will someday. The saddest part? A good number of people never outgrow that junior high mentality, which makes it harder for those of us who are obviously different in some way. Thanks for not being one of those people…I’m sure that helps make you a decent doc, too.

  7. As a family physician in a similar practice to yours, I agree wholeheartedly. My philosophy on “lecturing” patients with obvious problems that they are fully aware of is the same as that in your post. It was refreshing to see a fellow physician in primary care with a similar philosophy, and one that acknowledges the patient as a person with struggles that we can only assist with if they are ready.

  8. As a family physician in a similar practice to yours, I agree wholeheartedly. My philosophy on “lecturing” patients with obvious problems that they are fully aware of is the same as that in your post. It was refreshing to see a fellow physician in primary care with a similar philosophy, and one that acknowledges the patient as a person with struggles that we can only assist with if they are ready.

  9. BRAVO! I wish I could say I had encountered a lot of doctors with your approach but I have not. There is research showing that fat women are less likely to seek routine health care and I suspect the same is true for fat men as well. And shaming from physicians and their staff is the major factor — everything from having the scale in a semi-public area to paper gowns that tear because they do not fit to the ridiculous “Have you considered losing weight?”

  10. BRAVO! I wish I could say I had encountered a lot of doctors with your approach but I have not. There is research showing that fat women are less likely to seek routine health care and I suspect the same is true for fat men as well. And shaming from physicians and their staff is the major factor — everything from having the scale in a semi-public area to paper gowns that tear because they do not fit to the ridiculous “Have you considered losing weight?”

  11. Amen to all that you have said.If only all doctor’s were as sympathetic as you and did not add to the self loathing and disdain of their clients.

  12. Amen to all that you have said.If only all doctor’s were as sympathetic as you and did not add to the self loathing and disdain of their clients.

  13. its certainly unapt for a doctor to start with the high nose lecturing one on weight loss.
    how about recommending lapband surgery? its indicated for those who are morbidly obese and some are saying even the moderately obese. as far as i have read in the most recent journal articles, weight loss is a guarantee, the operation is safe and has few complications, and very well tolerated. totally reversible. maybe this is surgeon in me speaking. but i think providing the patient alternatives should be every doctor’s aims.

    what do you reckon?

  14. its certainly unapt for a doctor to start with the high nose lecturing one on weight loss.
    how about recommending lapband surgery? its indicated for those who are morbidly obese and some are saying even the moderately obese. as far as i have read in the most recent journal articles, weight loss is a guarantee, the operation is safe and has few complications, and very well tolerated. totally reversible. maybe this is surgeon in me speaking. but i think providing the patient alternatives should be every doctor’s aims.

    what do you reckon?

  15. Good post. As a future psychiatrist who is also committed to helping the medical field understand the physiology of physical health (not sure how that’s going to come together just yet), I applaud your thoughts.
    Weight loss and health is all about empowerment. Empowerment isn’t so far off from blame, but it’s an idea that the medical establishment does have some trouble with understanding. Much of this comes from our own lack of understanding of exercise physiology and functional anatomy. But that’s a rant for another time.

    I think you said it well by saying simple and easy are not the same thing. Weight loss is simple, but it isn’t easy. And structuring diet and exercise properly is far far more involved and complicated than most realize. It is not just eat less and workout more.

    Weight loss and physical health starts in the head. I approach it with ‘clients’ (i never charge for fitness stuff as I’m not credentialed yet), by being sympathetic, understanding, and acknowledging the genetic and developmental factors they have to work against. But in doing so, I also offer them little tidbits of knowledge that let them know just how much power they have over bodies, the power to change the way they work at the cellular level.

    Encouraging weight loss isn’t about blame, but about empowerment, whether we’re talking in the finger-waving harangue sense or in a more scholarly fashion.

  16. Good post. As a future psychiatrist who is also committed to helping the medical field understand the physiology of physical health (not sure how that’s going to come together just yet), I applaud your thoughts.
    Weight loss and health is all about empowerment. Empowerment isn’t so far off from blame, but it’s an idea that the medical establishment does have some trouble with understanding. Much of this comes from our own lack of understanding of exercise physiology and functional anatomy. But that’s a rant for another time.

    I think you said it well by saying simple and easy are not the same thing. Weight loss is simple, but it isn’t easy. And structuring diet and exercise properly is far far more involved and complicated than most realize. It is not just eat less and workout more.

    Weight loss and physical health starts in the head. I approach it with ‘clients’ (i never charge for fitness stuff as I’m not credentialed yet), by being sympathetic, understanding, and acknowledging the genetic and developmental factors they have to work against. But in doing so, I also offer them little tidbits of knowledge that let them know just how much power they have over bodies, the power to change the way they work at the cellular level.

    Encouraging weight loss isn’t about blame, but about empowerment, whether we’re talking in the finger-waving harangue sense or in a more scholarly fashion.

  17. It’s refreshing to read your post. I am a Cushing’s Disease (in remission, hopefully cured) survivor, and I mean that in every definition of the term. IN SPITE OF….
    I hear this man’s “shame”. I’ve been where he is, and it took over 25 years for my symptoms of Cushing’s Disease to be recognized by a doctor as “endocrine”.

    Love his heart….

    Robin

  18. It’s refreshing to read your post. I am a Cushing’s Disease (in remission, hopefully cured) survivor, and I mean that in every definition of the term. IN SPITE OF….
    I hear this man’s “shame”. I’ve been where he is, and it took over 25 years for my symptoms of Cushing’s Disease to be recognized by a doctor as “endocrine”.

    Love his heart….

    Robin

  19. Thank you for your very insightful post, I would love to see more on the subject of socially acceptable obesity.
    The idea that we can all eat the same and weigh the same is ridiculous in and of itsself. I have an ACTH dependent cushing’s disease and have had 2 pituitary surgies that have left me growth hormone deficient (another hormonal factor in weight gain). I still have cushing’s and very few options at this point. This may be my “forever body” and I am really lucky to have doctors who understand that.

    Being sick is one thing… being sick and loathed is heartbreaking.

  20. Thank you for your very insightful post, I would love to see more on the subject of socially acceptable obesity.
    The idea that we can all eat the same and weigh the same is ridiculous in and of itsself. I have an ACTH dependent cushing’s disease and have had 2 pituitary surgies that have left me growth hormone deficient (another hormonal factor in weight gain). I still have cushing’s and very few options at this point. This may be my “forever body” and I am really lucky to have doctors who understand that.

    Being sick is one thing… being sick and loathed is heartbreaking.

  21. Thank you. I used to go to the “teaching” hospital in my town until I just couldn’t take it anymore. I could almost swear there must be an “arrogance” or “how to be an asshole to indigent patients” course that must be passed in order to get to a higher level in medicine. I now go to a clinic and have a pa that I love and treats me with respect.

  22. Thank you. I used to go to the “teaching” hospital in my town until I just couldn’t take it anymore. I could almost swear there must be an “arrogance” or “how to be an asshole to indigent patients” course that must be passed in order to get to a higher level in medicine. I now go to a clinic and have a pa that I love and treats me with respect.

  23. So well said. Like the others, I wish more doctors had your perspective. I too am another Cushings patient who was told losing weight would make me better. Thankfully there was a doctor out there that looked past the weight and saw this horrible endocrine disorder. If doctors could see there’s more than just the weight, they just might learn something.

  24. So well said. Like the others, I wish more doctors had your perspective. I too am another Cushings patient who was told losing weight would make me better. Thankfully there was a doctor out there that looked past the weight and saw this horrible endocrine disorder. If doctors could see there’s more than just the weight, they just might learn something.

  25. Thank you for a thoughtful and poignant article. Robin (who left a post above) pointed me to your article. I am currently struggling with ACTH dependent Cushing’s. I also happen to be an RN. I know all too well of what you speak.
    My PCP, God Bless her, has known something was wrong with me for over 10 years. But she never considered Cushing’s. I will never forget the day we first discussed an evaluation I’d gotten from the first endo who suspected Cushing’s (I went to an endo thinking I was having thyroid problems). She looked at me and said sheepishly that I did look an awful lot like I had it. She apologized for not having considered it sooner herself.

    I hope many other doctors not only read your article but also read some of these comments… sometimes using binoculars to be SURE those hoofbeats aren’t zebras may not be what the HMO wants, but it means the world to a zebra like me.

  26. Thank you for a thoughtful and poignant article. Robin (who left a post above) pointed me to your article. I am currently struggling with ACTH dependent Cushing’s. I also happen to be an RN. I know all too well of what you speak.
    My PCP, God Bless her, has known something was wrong with me for over 10 years. But she never considered Cushing’s. I will never forget the day we first discussed an evaluation I’d gotten from the first endo who suspected Cushing’s (I went to an endo thinking I was having thyroid problems). She looked at me and said sheepishly that I did look an awful lot like I had it. She apologized for not having considered it sooner herself.

    I hope many other doctors not only read your article but also read some of these comments… sometimes using binoculars to be SURE those hoofbeats aren’t zebras may not be what the HMO wants, but it means the world to a zebra like me.

  27. Certainly reading all of the comments from the Cushings community has made me sit back and wonder. I do generally look for it, but It is somewhat easy to miss. I am glad to hear of a doctor apologizing to a patient – trying hard does not mean we always get things right. If you have a good enough relationship with your patients that you can apologize there is little risk of lawsuit.

  28. Certainly reading all of the comments from the Cushings community has made me sit back and wonder. I do generally look for it, but It is somewhat easy to miss. I am glad to hear of a doctor apologizing to a patient – trying hard does not mean we always get things right. If you have a good enough relationship with your patients that you can apologize there is little risk of lawsuit.

  29. It’s more than easy to miss… in my case the first tests came back showing hormones that were way out of whack but a 24-hour UFC that was WNL. The endo suggested waiting 6 months and re-testing. Now it’s some 3 years, more blood work and 24 hour UFC’s then I care to think about, imagining studies and an IPSS that took more than 8 hours to complete.
    Not only do I have a PMD that is kind, she is teaching med students.

    When you have patients that have any amount of symptoms that point to Cushing’s (osteopenia, diabetes or HBP that is resistant to treatment are some big ones besides centripital obesity and sudden weight gain) that persist in a patient that reports difficulty loosing weight and feeling that something is wrong it’s worth looking and, and even going back to later (as that first endo suggested to me).

    P.S. I like you am a distractible mind. There’s an awful lot of us in medicine.

  30. It’s more than easy to miss… in my case the first tests came back showing hormones that were way out of whack but a 24-hour UFC that was WNL. The endo suggested waiting 6 months and re-testing. Now it’s some 3 years, more blood work and 24 hour UFC’s then I care to think about, imagining studies and an IPSS that took more than 8 hours to complete.
    Not only do I have a PMD that is kind, she is teaching med students.

    When you have patients that have any amount of symptoms that point to Cushing’s (osteopenia, diabetes or HBP that is resistant to treatment are some big ones besides centripital obesity and sudden weight gain) that persist in a patient that reports difficulty loosing weight and feeling that something is wrong it’s worth looking and, and even going back to later (as that first endo suggested to me).

    P.S. I like you am a distractible mind. There’s an awful lot of us in medicine.

  31. On Weight And Shame « In This Storm

    […] July 1, 2008 · No Comments An excellent post by the good doctor HERE. […]

  32. Thank you for this touching post. I’d heard there are more doctors out there like you, but haven’t met many of them.I’m another Cushing’s survivor, hopefully cured. I also had a doctor apologize to me after my diagnosis and surgery. He was the doctor who had told me I needed a boyfriend and a sports car…..obviously I needed something. Too bad he didn’t investigate to find out what it was. He could have saved me years of pain.

  33. Thank you for this touching post. I’d heard there are more doctors out there like you, but haven’t met many of them.I’m another Cushing’s survivor, hopefully cured. I also had a doctor apologize to me after my diagnosis and surgery. He was the doctor who had told me I needed a boyfriend and a sports car…..obviously I needed something. Too bad he didn’t investigate to find out what it was. He could have saved me years of pain.

  34. Cushings IS easy to miss. I was one who was blown off by local doctors because all my numbers were normal during the DAY. I suppressed on the dex test, which in itself is not a diagnostic test of Cushings, but was for my docs. Turns out my midnight and 4am numbers were off the charts ABNORMAL. It took a doc across the country to know to test at that point in time and come to the conclusion I had cyclical cushings. I have since had pit surgery to remove the tumor and am praying I’m on my way to a cure. All we want is for doctors to be aware of this and not judge the book by the cover – or even the first few pages.
    The pituitary network says 1 in 5 people have a pituitary problem that goes undetected by the medical community. That’s a lot of “fat” people that could be dying from something other than just being fat.

  35. Cushings IS easy to miss. I was one who was blown off by local doctors because all my numbers were normal during the DAY. I suppressed on the dex test, which in itself is not a diagnostic test of Cushings, but was for my docs. Turns out my midnight and 4am numbers were off the charts ABNORMAL. It took a doc across the country to know to test at that point in time and come to the conclusion I had cyclical cushings. I have since had pit surgery to remove the tumor and am praying I’m on my way to a cure. All we want is for doctors to be aware of this and not judge the book by the cover – or even the first few pages.
    The pituitary network says 1 in 5 people have a pituitary problem that goes undetected by the medical community. That’s a lot of “fat” people that could be dying from something other than just being fat.

  36. I LOVE what you have said here. It is true. I am overweight woman. I have tried several diets, “life style changes”, and I can loose weight. I have lost the same 60-65 pounds on and off for 10 years. I am so sick and tired of hearing my weight is the root of all my health problems. I have pain in my wrist, hands, elbow and shoulder on the left side, I was actually told it is because I am to fat. No test, no MRI, no real exam. I have actually not gone for my yearly exam for 2 years just because I do not want to hear the lecture about my weight. I am going next week, but I am dreading it. This year the doctor should be a little happier because I have stopped smoking. But I am still fat, but that does not make me less of a person, it just makes people think that it is okay to treat me as less of a person.

  37. I LOVE what you have said here. It is true. I am overweight woman. I have tried several diets, “life style changes”, and I can loose weight. I have lost the same 60-65 pounds on and off for 10 years. I am so sick and tired of hearing my weight is the root of all my health problems. I have pain in my wrist, hands, elbow and shoulder on the left side, I was actually told it is because I am to fat. No test, no MRI, no real exam. I have actually not gone for my yearly exam for 2 years just because I do not want to hear the lecture about my weight. I am going next week, but I am dreading it. This year the doctor should be a little happier because I have stopped smoking. But I am still fat, but that does not make me less of a person, it just makes people think that it is okay to treat me as less of a person.

  38. This was very refreshing to read. Often doctors are so narrow minded conflating their personal morals with practicing medicine and thoroughly damage the patient in the process. When I first started seeing my current GP, I was 80lbs overweight. I wasn’t a sloth or particularly down on my appearance. I was aware of my size but I wasn’t waiting for my “thin” fantasies to manifest before having the kind of life I wanted. I was suprised at how judgmental he could be about certain things. I know he had some issues with female fatness because when I lost 90 pounds, putting me decidedly UNDERWEIGHT, he said I looked perfect, but never once reviewed the health benefits I’d gained from making my lifestyle changes.
    I switched providers and now am with someone who ideology is more in alignment with what you have written here. In absence of a shaming jerk, it’s amazing how much my health has improved with a provider who is caring, kind and competent.

  39. This was very refreshing to read. Often doctors are so narrow minded conflating their personal morals with practicing medicine and thoroughly damage the patient in the process. When I first started seeing my current GP, I was 80lbs overweight. I wasn’t a sloth or particularly down on my appearance. I was aware of my size but I wasn’t waiting for my “thin” fantasies to manifest before having the kind of life I wanted. I was suprised at how judgmental he could be about certain things. I know he had some issues with female fatness because when I lost 90 pounds, putting me decidedly UNDERWEIGHT, he said I looked perfect, but never once reviewed the health benefits I’d gained from making my lifestyle changes.
    I switched providers and now am with someone who ideology is more in alignment with what you have written here. In absence of a shaming jerk, it’s amazing how much my health has improved with a provider who is caring, kind and competent.

  40. and there you have it, a perfect example of why most overweight people suffer from depression, guilt, shame and have given up hope. No one offers a realistic solution, just scorn. I sure hope you are not a doctor…..

  41. and there you have it, a perfect example of why most overweight people suffer from depression, guilt, shame and have given up hope. No one offers a realistic solution, just scorn. I sure hope you are not a doctor…..

  42. Love the post, and now I love you. Hope you don’t mind.
    Just yesterday I picked up a man who had been admitted the night before with a life-threatening illness that has nothing (NOTHING) to do with the fact that he ways over 600 pounds. Really, really nice guy.

    So I walk in and get to know him and he says something about his weight. I stopped him. “I am in no position to lecture you about your weight, and I’m sure you’ve heard it all before. Your illness has nothing to do with being fat, and I will never mention it.” He relaxed.

    As I reviewed his chart, it seemed he was in chronic renal failure, a new diagnosis for him. So I consulted nephrology. This man, who I formerly respected so very much, changed our patient’s diet to 1200 kcal. One thousand two hundred calories per day.

    Honest to God, when I saw that my big fat stomach twisted up in a knot.

    Thanks for listening.

  43. Love the post, and now I love you. Hope you don’t mind.
    Just yesterday I picked up a man who had been admitted the night before with a life-threatening illness that has nothing (NOTHING) to do with the fact that he ways over 600 pounds. Really, really nice guy.

    So I walk in and get to know him and he says something about his weight. I stopped him. “I am in no position to lecture you about your weight, and I’m sure you’ve heard it all before. Your illness has nothing to do with being fat, and I will never mention it.” He relaxed.

    As I reviewed his chart, it seemed he was in chronic renal failure, a new diagnosis for him. So I consulted nephrology. This man, who I formerly respected so very much, changed our patient’s diet to 1200 kcal. One thousand two hundred calories per day.

    Honest to God, when I saw that my big fat stomach twisted up in a knot.

    Thanks for listening.

  44. Thank you for the honesty and compassion in your approach with obese patients. The outright gall of some physicians to blame everything on a patient’s weight astounds me, as if a patients entire well-being hinges on that one aspect. They think that losing weight is like a country song played backwards: you get your wife back, your truck back, your money back…. kcals are quantifiable. Weight is quantifiable. Emotions and motivation are not, so they are inconvenient “confounding variables” in a sterile, patient-as-data clinician’s head.
    I can’t write more without letting loose on the a$$hat nephrologist above, so I’ll just stop now and thank you again.

  45. Thank you for the honesty and compassion in your approach with obese patients. The outright gall of some physicians to blame everything on a patient’s weight astounds me, as if a patients entire well-being hinges on that one aspect. They think that losing weight is like a country song played backwards: you get your wife back, your truck back, your money back…. kcals are quantifiable. Weight is quantifiable. Emotions and motivation are not, so they are inconvenient “confounding variables” in a sterile, patient-as-data clinician’s head.
    I can’t write more without letting loose on the a$$hat nephrologist above, so I’ll just stop now and thank you again.

  46. Frank Drackman

    OK I’m gonna piss some people off here, but its Tough Love, and its what everyones really thinking while they’re nodding sympathetically. Its not your Cushings, your slow BMR, your huddled masses, you eat like pigs, and you don’t exercise. I see you guys (How can we miss you) parking in the handicapped or fire lanes, riding your scooters in the grocery store, complaining that the Family Sized bag of Doritos isn’t big enough. Yeah, I know, keep fooling yourselves, you eat like a bird. Yeah right, some huge fucking flightless bird. I go to this little Mom and Pop Pizzeria for lunch, they used to have a Noon Buffet, but had to discontinue it because of the fatties. You’d see these fat bastards take an entire pizza and think it was OK since they had a salad on top of it, and complain that the place didn’t stuff the crust with cheese like Pizza Hut does. I see 2 year old kids who’s BMI doesn’t fit on the page.. So go ahead, have another slice of Cheese Cake, get your 2 am fasting (who am I kidding) random ACTH/Melatonin levels checked. Why run some windsprints when you can get your intestines bypassed.

  47. Frank Drackman

    OK I’m gonna piss some people off here, but its Tough Love, and its what everyones really thinking while they’re nodding sympathetically. Its not your Cushings, your slow BMR, your huddled masses, you eat like pigs, and you don’t exercise. I see you guys (How can we miss you) parking in the handicapped or fire lanes, riding your scooters in the grocery store, complaining that the Family Sized bag of Doritos isn’t big enough. Yeah, I know, keep fooling yourselves, you eat like a bird. Yeah right, some huge fucking flightless bird. I go to this little Mom and Pop Pizzeria for lunch, they used to have a Noon Buffet, but had to discontinue it because of the fatties. You’d see these fat bastards take an entire pizza and think it was OK since they had a salad on top of it, and complain that the place didn’t stuff the crust with cheese like Pizza Hut does. I see 2 year old kids who’s BMI doesn’t fit on the page.. So go ahead, have another slice of Cheese Cake, get your 2 am fasting (who am I kidding) random ACTH/Melatonin levels checked. Why run some windsprints when you can get your intestines bypassed.

  48. Frank: First let me ask if you have problems with what I wrote about in the post itself. The point is not that people don’t overeat – I do that myself (although not morbidly obese), the point is that guilt-mongering seems to be the way many doctors try to get their message across to “help” their patients. This is not only ineffective, it keeps people away from care altogether.Second, be careful about the comments on Cushings if you don’t have knowledge in that area. Medically, a cortisol excess is hard to diagnose and it makes people become significantly overweight. Those people who responded to this post referring to that were all sent here via a link for Cushing’s support. They all have Cushing’s and were made to feel their obesity was “their fault” when it was REALLY something wrong with their body.
    Finally, I do think that tough love has its place. You need to address the issue, and at times be more stern with people. But the point of this is not to make them feel bad (which seems to be the tone of your comment), it is to help them deal with their own weaknesses. It is wrong to be enabling to problems like this, but the tone that you take in your response is juvenile – hardly something that a physician should employ when dealing with a person in medical need.
    I won’t edit your comment simply to show others the Junior-High mentality at work.

  49. Frank: First let me ask if you have problems with what I wrote about in the post itself. The point is not that people don’t overeat – I do that myself (although not morbidly obese), the point is that guilt-mongering seems to be the way many doctors try to get their message across to “help” their patients. This is not only ineffective, it keeps people away from care altogether.Second, be careful about the comments on Cushings if you don’t have knowledge in that area. Medically, a cortisol excess is hard to diagnose and it makes people become significantly overweight. Those people who responded to this post referring to that were all sent here via a link for Cushing’s support. They all have Cushing’s and were made to feel their obesity was “their fault” when it was REALLY something wrong with their body.
    Finally, I do think that tough love has its place. You need to address the issue, and at times be more stern with people. But the point of this is not to make them feel bad (which seems to be the tone of your comment), it is to help them deal with their own weaknesses. It is wrong to be enabling to problems like this, but the tone that you take in your response is juvenile – hardly something that a physician should employ when dealing with a person in medical need.
    I won’t edit your comment simply to show others the Junior-High mentality at work.

  50. Drackman,That was your definition of tough love? It was downright deliberate stereotyping. And I’d be willing to bet you’ve never been overweight a day in your life, & you were probably one of those who taunted the obese kids in school. Oh I’m sorry, I didn’t mean to be so judgemental. I’m clinically morbidly obese but I don’t do ANY of those that you mentioned in your post. I’m not going to go on & on about how I became fat–everyone who is overweight has their reasons, medical or not. But my docs thankfully, have Dr. Rob’s attitude, & not yours, which unfortunately was just like my family’s. Instead of being a positive impact, they were only negative. Yes, you are going to see many who perpetuate the stereotype, so why not tell us something we don’t already know? TY Dr. Rob for allowing his post. BTW Drackman, I DO exercise. Everyday. The weight gain didn’t happen overnight, so neither will the weight loss.

  51. Drackman,That was your definition of tough love? It was downright deliberate stereotyping. And I’d be willing to bet you’ve never been overweight a day in your life, & you were probably one of those who taunted the obese kids in school. Oh I’m sorry, I didn’t mean to be so judgemental. I’m clinically morbidly obese but I don’t do ANY of those that you mentioned in your post. I’m not going to go on & on about how I became fat–everyone who is overweight has their reasons, medical or not. But my docs thankfully, have Dr. Rob’s attitude, & not yours, which unfortunately was just like my family’s. Instead of being a positive impact, they were only negative. Yes, you are going to see many who perpetuate the stereotype, so why not tell us something we don’t already know? TY Dr. Rob for allowing his post. BTW Drackman, I DO exercise. Everyday. The weight gain didn’t happen overnight, so neither will the weight loss.

  52. Hey Rob, no real problems with your post, except your questioning the link between obesity and back problems. Might not be any Randomized Double Blinded Clinical Trials linking them, just some plain old Kentucky Windage. Even if they’re not related, just think of the poor OR personel who have to lift these fatties onto the Operating table, My disks hurt just thinking about it. Theres also the Global Warming problem, every extra 10 pounds of fat puts an additional 8760 L of CO2 into the atmosphere per year. And yes, I’ve never diagnosed a case of Cushings Disease in 20 years, to tell the truth, I try and steer all the fatties to endocrinologists, I don’t need the wear and tear on my carpet and their constant requests for Adipex prescriptions. Just curious, if you take out the Adenoma, do patients lose weight? Feel free to flame away at my Blog “Frankie’s Hideout”

  53. Hey Rob, no real problems with your post, except your questioning the link between obesity and back problems. Might not be any Randomized Double Blinded Clinical Trials linking them, just some plain old Kentucky Windage. Even if they’re not related, just think of the poor OR personel who have to lift these fatties onto the Operating table, My disks hurt just thinking about it. Theres also the Global Warming problem, every extra 10 pounds of fat puts an additional 8760 L of CO2 into the atmosphere per year. And yes, I’ve never diagnosed a case of Cushings Disease in 20 years, to tell the truth, I try and steer all the fatties to endocrinologists, I don’t need the wear and tear on my carpet and their constant requests for Adipex prescriptions. Just curious, if you take out the Adenoma, do patients lose weight? Feel free to flame away at my Blog “Frankie’s Hideout”

  54. k, Rob, now this is just plain weird…I just checked my hotmail account and I’m getting email notifications for this article to that address. I have it set to go to the gmail one for follow-up comment notifications. The notifications are going to both addresses…weird, huh?

  55. k, Rob, now this is just plain weird…I just checked my hotmail account and I’m getting email notifications for this article to that address. I have it set to go to the gmail one for follow-up comment notifications. The notifications are going to both addresses…weird, huh?

  56. Frank: I don’t flame much – just not my style. Your points are valid, but would probably be better heard without using inflammatory words like “fatty.” I presume a reaction is what you are trying to get.Regarding the disc problems and obesity – true on the surgery part, but I have not read nor experienced an increased incidence in obese people.
    The patient’s readiness to lay anything down at the foot of his weight was what caught me. I really did not plan on going there. I figure if I can get them in my office more frequently, it is easier to work with them to actually lose weight. It is important to have as many opportunities to work on the root of the problem (whether physical or psychological), and I find guilt-tripping is superfluous in most cases, as many of the morbidly obese people are buried in self-hatred.

  57. Frank: I don’t flame much – just not my style. Your points are valid, but would probably be better heard without using inflammatory words like “fatty.” I presume a reaction is what you are trying to get.Regarding the disc problems and obesity – true on the surgery part, but I have not read nor experienced an increased incidence in obese people.
    The patient’s readiness to lay anything down at the foot of his weight was what caught me. I really did not plan on going there. I figure if I can get them in my office more frequently, it is easier to work with them to actually lose weight. It is important to have as many opportunities to work on the root of the problem (whether physical or psychological), and I find guilt-tripping is superfluous in most cases, as many of the morbidly obese people are buried in self-hatred.

  58. “Just curious, if you take out the Adenoma, do patients lose weight? Feel free to flame away at my Blog “Frankie’s Hideout””
    Dearheart, do you need blog pings that badly?

    Ok…seriously….

    Yes, we lose weight once the root of our excess cortisol is removed and IF that is the only thing that was wrong and is still wrong. However, many of us have such damaged endocrine systems (hey…don’t they teach this in med school????) that we also need other hormone replacements, including thyroid and growth hormone. For example:

    I had the pituitary adenoma for over 20 years…way over…. and looking back at old MR’s and other information, we pieced together enough to figure out I probably was growth hormone deficient early in my teens or sooner. Since my TSH was so low, no endo or other doc locally figured out I was actually thyroid deficient and I was close to myxedema by the time my current endo realized I had central thyroidism. So, that had to be addressed, also. Furthermore, the muscle and bone damage is so excrutiating for many by the time they are diagnosed, exercise is not only difficult, but can be dangerous and damaging. And I could go on and on….

    The drift here is….it ain’t as easy as you say it is! (Said in my best hillbillyonics…) Now, if YOU want to do some larnin’, come to my blog. 😉 (Sorry, couldn’t resist.) Seriously, if a hillbilly can learn this, you can.

    What DO they teach in medical school????? (Sorry, Dr. Rob….but he should know this stuff if he’s a doctor.)

  59. “Just curious, if you take out the Adenoma, do patients lose weight? Feel free to flame away at my Blog “Frankie’s Hideout””
    Dearheart, do you need blog pings that badly?

    Ok…seriously….

    Yes, we lose weight once the root of our excess cortisol is removed and IF that is the only thing that was wrong and is still wrong. However, many of us have such damaged endocrine systems (hey…don’t they teach this in med school????) that we also need other hormone replacements, including thyroid and growth hormone. For example:

    I had the pituitary adenoma for over 20 years…way over…. and looking back at old MR’s and other information, we pieced together enough to figure out I probably was growth hormone deficient early in my teens or sooner. Since my TSH was so low, no endo or other doc locally figured out I was actually thyroid deficient and I was close to myxedema by the time my current endo realized I had central thyroidism. So, that had to be addressed, also. Furthermore, the muscle and bone damage is so excrutiating for many by the time they are diagnosed, exercise is not only difficult, but can be dangerous and damaging. And I could go on and on….

    The drift here is….it ain’t as easy as you say it is! (Said in my best hillbillyonics…) Now, if YOU want to do some larnin’, come to my blog. 😉 (Sorry, couldn’t resist.) Seriously, if a hillbilly can learn this, you can.

    What DO they teach in medical school????? (Sorry, Dr. Rob….but he should know this stuff if he’s a doctor.)

  60. Sorry for the typos and misspellings above… way too sleepy to be typing…but just couldn’t help myself.
    (excruciating, hypothyroidism instead of thyroidism, etc…)

  61. Sorry for the typos and misspellings above… way too sleepy to be typing…but just couldn’t help myself.
    (excruciating, hypothyroidism instead of thyroidism, etc…)

  62. SurgeXperiences 201: Better « monash medical student

    […] Cushing’s, hop on over to Musings of a Distractible Mind where family doctor Dr Rob discusses the shame that some obese patients feel when they visit him. Picking up a patient with Cushing’s and having that as an explanation to […]

  63. Kick ass, we’ve heard from Troll, M.D.! I didn’t choose to keep it in my comment above, but I did type briefly a sentence about how someone will come along and piss on the parade, probably anonymously. The fact that 20-something-odd comments without even a “Well, many obese people really are unrealistic about the calories they consume…” was just cruisin’ for a bruisin’. The fact that the scale tipped with a (if you believe him) real doctor writing such vitriolic statements, well, that just made my holiday weekend.
    You see, I’m not offended in the least. Why? Because the grizzled Dr. Dreckman just showed all readers exactly what the problem is. This is a doctor’s POV? This is someone in whom a patient will place their trust? Dr. Dreckman’s age is unknown, but in any case represents all that was wrong with the old-school, “doctor knows best,” “tough love” approach, as if patients are Marine grunts needing to drop and do 50.

    Frankie, I welcome your next comment, if for no other reason than to prove exactly what Dr. Rob was trying to point out in the first place for all to see. Personally, I see my doughboy rolls and man boobs in the mirror and don’t have any delusions about how the laws of thermodynamics don’t apply to my corpus. Whatever struggles I may have about weight management, whatever poor decisions I may make about food–none of the colorfully and hatefully described behaviors you wrote apply to me. “Fallibility” does not mean “failure,” any more than “fat” does. While I can get my intestines bypassed if I wanted to, I’m afraid your doing so would deprive your brain of its nourishing fecal matter.

  64. Kick ass, we’ve heard from Troll, M.D.! I didn’t choose to keep it in my comment above, but I did type briefly a sentence about how someone will come along and piss on the parade, probably anonymously. The fact that 20-something-odd comments without even a “Well, many obese people really are unrealistic about the calories they consume…” was just cruisin’ for a bruisin’. The fact that the scale tipped with a (if you believe him) real doctor writing such vitriolic statements, well, that just made my holiday weekend.
    You see, I’m not offended in the least. Why? Because the grizzled Dr. Dreckman just showed all readers exactly what the problem is. This is a doctor’s POV? This is someone in whom a patient will place their trust? Dr. Dreckman’s age is unknown, but in any case represents all that was wrong with the old-school, “doctor knows best,” “tough love” approach, as if patients are Marine grunts needing to drop and do 50.

    Frankie, I welcome your next comment, if for no other reason than to prove exactly what Dr. Rob was trying to point out in the first place for all to see. Personally, I see my doughboy rolls and man boobs in the mirror and don’t have any delusions about how the laws of thermodynamics don’t apply to my corpus. Whatever struggles I may have about weight management, whatever poor decisions I may make about food–none of the colorfully and hatefully described behaviors you wrote apply to me. “Fallibility” does not mean “failure,” any more than “fat” does. While I can get my intestines bypassed if I wanted to, I’m afraid your doing so would deprive your brain of its nourishing fecal matter.

  65. I doubt Drackman freak is even a doctor. Atleast I sure as heck hope he isn’t..Back on June 25th or 26th he posted on his blog about esophageal cancer and his lack of knowledge made me about throw up when I read what he wrote. He wrote that when having an esophagectomy the colon is always used to replace the esophagus (not true, usually its the stomach thats used) then he went on to make jokes about those patients having really bad morning breathe from having the colon used……Hell, I’m just a patient and I can tell him more about EC than he could ever imagine.
    But he certainly proved your point Dr. Rob, about how overweight people are so discriminated against. He is just an internet troll.

  66. I doubt Drackman freak is even a doctor. Atleast I sure as heck hope he isn’t..Back on June 25th or 26th he posted on his blog about esophageal cancer and his lack of knowledge made me about throw up when I read what he wrote. He wrote that when having an esophagectomy the colon is always used to replace the esophagus (not true, usually its the stomach thats used) then he went on to make jokes about those patients having really bad morning breathe from having the colon used……Hell, I’m just a patient and I can tell him more about EC than he could ever imagine.
    But he certainly proved your point Dr. Rob, about how overweight people are so discriminated against. He is just an internet troll.

  67. I also want to say one thing about about weight gain. Over a year ago (clsoe to two now) my grand daughter, 9 years old, began to gain way to much weight. Three times my son and DIL took her to her Dr. office ( It may have been Dr. Drackman, not sure) to ask for blood work to try and find the cause of this weight gain. The Docs attitude was that she was just overeating and had all of a sudden became a very lazy child. On the last visit this Dr. finally gave him to my sons wishes and ordered blood work, telling my son that HE was just putting his daughter through the pain of needle sticks for no good reason.
    A few days later they get the call from the Dr. telling them they have to take her to an endocrinologist, out of town, to a childrens hospital because her thyroid is not working. End result is she has Hashimoto’s and her thyroid was completely destroyed. Her synthroid has now been raised 4 times. She immediately stopped gaining weight, and now she has begun to lose weight.

    This attitude that some Drs. have about weight gain, and their refusal to deal with it at all is dangerous. especially when it comes to children.

  68. I also want to say one thing about about weight gain. Over a year ago (clsoe to two now) my grand daughter, 9 years old, began to gain way to much weight. Three times my son and DIL took her to her Dr. office ( It may have been Dr. Drackman, not sure) to ask for blood work to try and find the cause of this weight gain. The Docs attitude was that she was just overeating and had all of a sudden became a very lazy child. On the last visit this Dr. finally gave him to my sons wishes and ordered blood work, telling my son that HE was just putting his daughter through the pain of needle sticks for no good reason.
    A few days later they get the call from the Dr. telling them they have to take her to an endocrinologist, out of town, to a childrens hospital because her thyroid is not working. End result is she has Hashimoto’s and her thyroid was completely destroyed. Her synthroid has now been raised 4 times. She immediately stopped gaining weight, and now she has begun to lose weight.

    This attitude that some Drs. have about weight gain, and their refusal to deal with it at all is dangerous. especially when it comes to children.

  69. Frank Drackman,
    Could you please do everyone who visits this nice blog a favor? It’s ok for you to spew this stuff on your OWN blog, but why come to someone else’s blog and bash the “fatties” there, too? I know it’s hard to restrain yourself, but at least keep the venom contained on your OWN spot in the blogosphere! I’m also a regular reader over at MDOD, so I’ve seen the kind of things you write. Truth be told, I just have to hope you’re not this self-righteous and full of attitude as an actual physician. If you are, I worry for your patients. (Not that you care, I know, but I’m just making a point!)

    And for Enrico, I totally LOVE your description of “deprive your brain of its nourishing fecal matter”! Thanks for making this “fatty” laugh!

  70. Frank Drackman,
    Could you please do everyone who visits this nice blog a favor? It’s ok for you to spew this stuff on your OWN blog, but why come to someone else’s blog and bash the “fatties” there, too? I know it’s hard to restrain yourself, but at least keep the venom contained on your OWN spot in the blogosphere! I’m also a regular reader over at MDOD, so I’ve seen the kind of things you write. Truth be told, I just have to hope you’re not this self-righteous and full of attitude as an actual physician. If you are, I worry for your patients. (Not that you care, I know, but I’m just making a point!)

    And for Enrico, I totally LOVE your description of “deprive your brain of its nourishing fecal matter”! Thanks for making this “fatty” laugh!

  71. Dr. Rob…
    Your kind words touch my heart.

    I am a parent of two girls who both lost their adrenal glands to Cushing’s.
    My youngest was 4 at diagnosis- though she was born with the disease (took that long for docs to get over the over fed, prader willi, munchausen by proxy speculations)

    My other Cushie girl is 17. She gained 60 lbs in 8 months. The pain and humiliation she has felt over the past two years is indescribable. She can’t walk down our street to the park without some skank yelling “fat ass!” out the car window.

    My heart is broken, sick and dark. I have little respect for the medical profession…you have restored some with your story.

    Thank You

  72. Dr. Rob…
    Your kind words touch my heart.

    I am a parent of two girls who both lost their adrenal glands to Cushing’s.
    My youngest was 4 at diagnosis- though she was born with the disease (took that long for docs to get over the over fed, prader willi, munchausen by proxy speculations)

    My other Cushie girl is 17. She gained 60 lbs in 8 months. The pain and humiliation she has felt over the past two years is indescribable. She can’t walk down our street to the park without some skank yelling “fat ass!” out the car window.

    My heart is broken, sick and dark. I have little respect for the medical profession…you have restored some with your story.

    Thank You

  73. To all who read this (I write JUST BEFORE I LEAVE ON VACATION), please don’t post anything that is aimed at a person. I took down a comment that was specifically aimed at a person’s character. Dr. D’s comments, while hurtful to some, are said in a general fashion, and that is not going to be taken down. I know there is some anger, but character assassination is not for this blog. Since I am going to be out for a week, I hope that I come back to a good discussion/debate, not libel.
    PLEASE.

  74. To all who read this (I write JUST BEFORE I LEAVE ON VACATION), please don’t post anything that is aimed at a person. I took down a comment that was specifically aimed at a person’s character. Dr. D’s comments, while hurtful to some, are said in a general fashion, and that is not going to be taken down. I know there is some anger, but character assassination is not for this blog. Since I am going to be out for a week, I hope that I come back to a good discussion/debate, not libel.
    PLEASE.

  75. Hey Med-Rec-Gal thanks for the Shout Out, but this isn’t Russia you know, Is this Russia? This isn’t Russia. No Hard Feelings I hope, and I put your Blog at the top of my Links List. Chow, Frank.

  76. Hey Med-Rec-Gal thanks for the Shout Out, but this isn’t Russia you know, Is this Russia? This isn’t Russia. No Hard Feelings I hope, and I put your Blog at the top of my Links List. Chow, Frank.

  77. i think we should be focusing on the solutions rather than reacting to a provocative comment.. no one is talking about how to deal and manage these patients. as i have above (http://distractible.org/2008/06/29/shame/#comment-1588)
    if a morbidly obese patient presents, obviously the first thing to do will be to rule out underlying disease like Cushing’s that can explain the weight gain. This may not be easy, but should be done first.

    If nothing underlying is causing the weight gain, then perhaps we should look at traditional things like diet and exercise. modifiable lifestyle factors, they call it. these should be monitored over time. a couple of years at least. engage a nutritionist’s help. engage a sports instructor if it helps. dispense lifestyle advice. warn of comorbidities.

    only as a last resort should surgery be recommended. lap band surgery is proven to help those who are morbidly obese to lose weight and reduce risk of comorbidities. it is proven guys. no debate over this. so lets focus on what CAN be done for the patients then to start the blaming finger. next we know, we should blame FDA for not banning trans-fats in the entire USA, or commercial food chains like MacDonalds’. Come on, get real.

  78. i think we should be focusing on the solutions rather than reacting to a provocative comment.. no one is talking about how to deal and manage these patients. as i have above (http://distractible.org/2008/06/29/shame/#comment-1588)
    if a morbidly obese patient presents, obviously the first thing to do will be to rule out underlying disease like Cushing’s that can explain the weight gain. This may not be easy, but should be done first.

    If nothing underlying is causing the weight gain, then perhaps we should look at traditional things like diet and exercise. modifiable lifestyle factors, they call it. these should be monitored over time. a couple of years at least. engage a nutritionist’s help. engage a sports instructor if it helps. dispense lifestyle advice. warn of comorbidities.

    only as a last resort should surgery be recommended. lap band surgery is proven to help those who are morbidly obese to lose weight and reduce risk of comorbidities. it is proven guys. no debate over this. so lets focus on what CAN be done for the patients then to start the blaming finger. next we know, we should blame FDA for not banning trans-fats in the entire USA, or commercial food chains like MacDonalds’. Come on, get real.

  79. I was never a “fatty” before. Not super slim but definitely not morbidly obese that is on the front of every medical file in big red letters.I never saw any reason to go to the doctor except to have babies. That is until I gained 50 pounds in a little over a month after having my 6th. Not cool
    I gained 100 pounds
    I lost 70 but have gained back 35, since I have adrenal rest tissue I don’t know when it is over reacting again, or if now it is the lack of every other hormone
    I wish every doctor thought like you do, or at least listened when I tell them I was never like this before…….

  80. I was never a “fatty” before. Not super slim but definitely not morbidly obese that is on the front of every medical file in big red letters.I never saw any reason to go to the doctor except to have babies. That is until I gained 50 pounds in a little over a month after having my 6th. Not cool
    I gained 100 pounds
    I lost 70 but have gained back 35, since I have adrenal rest tissue I don’t know when it is over reacting again, or if now it is the lack of every other hormone
    I wish every doctor thought like you do, or at least listened when I tell them I was never like this before…….

  81. This thread is really interesting. As someone who spent my first 22 years as a healthy-sized, pretty girl and avid runner, it was shocking to gain 50 pounds in 2 months with no change to my eating habits and while continuing to run 5 miles a day, 5 days a week.
    When I started to grow a black beard on my fair Scottish chin, and my clock-work menses stopped for a year, and I gained 110 lbs in a single year, it was embarassing. I moved away from my hometown because people no longer recognized me.

    Despite taking a pitiful array of photographs (which showed a shocking metamorphasis from 5’7″ 140 lb athlete to 300 lb morbidly obese, red-faced bearded lady) to every single doctor I’ve ever seen in my adult life, it took 17 years before a young D.O. got it right and sent me to an endocrinologist, who tested me for Cushing’s Disease. That wise doctor did not dismiss me when I got a normal UFC — he heard hoofbeats and saw that I was a zebra, not a common horse. He recommended I find a specialist in cyclical Cushing’s, and though I traveled 3,000 miles from coast to coast to do so, it was a decision, which saved my life.

    Two pitutitary surgieres (the second a complete hypophysectomy) — and positive pathology — later, I am facing down a bilateral adrenalectomy and radiation because my tumor has extended into my cavernous sinus approaching the left carotid artery. I am 41 years old, never got to have a family, had a treatable disease, which was overlooked for my entire adult life, and now I am in a fight for my life.

    It didn’t have to be that way. If just one doctor out of at least 20 I saw over those two decades had just….listened, just looked into my swollen face and seen disease instead of lack of willpower, had put some weight on those photos I dragged around in a tattered envelope, hoping someday, somehow, there would be a doctor who would understand there was something terribly wrong beyond my wide girth and tearful explanation (“You just need to eat less, exercise more and take these antidepressants)…..I might have enjoyed a return to health, running a marathon, having babies, not worrying whether I will survive these next lines of treatment, which were unnecessarily delayed by the biased eyes of the doctors in whom I entrusted my life.

    My story is not uncommon. The average length of time between onset of symptoms and Dx for someone with episodic Cushing’s is 10 years. It was nearly twice that for me. Some endocrinologists don’t even believe it exists or that it is too rare to pursue with expensive and possibly unnecessary testing. Yet more and more recent peer-reviewed journal articles are talking about Cyclical Cushing’s — even opining that between 2-4% of folks with Type II Diabetes actually have mild or episodic Cushing’s.

    I hope the tide is turning. I hope those of us who believed (because we were told) we were fat and depressed but later found we had a physiological cause to our obesity will continue to talk openly about our experiences so that others in our situation might recognize themselves and advocate earlier for appropriate testing.

    But most of all, I hope that there will be more doctors like my current team of physicians and like you, Jeff and Dr. Rob, who “get it” and don’t look past us because of our weight, who have inquisitive minds and seek to treat systems rather than symptoms.

    I believe it can happen, one doctor at a time.

    If you would like to see my story (or an obese person wanting to learn more about Cushing’s), please take 5 minutes and watch a clip of a National Geographic special called “Science of Obesity,” which may be viewed on YouTube here: http://www.youtube.com/watch?v=vxSAhLyKVqw

    You may recognize one of your own patients – or yourself – in this clip, and save more than a waistline in the process.

    Warm regards to all,
    Kate

  82. This thread is really interesting. As someone who spent my first 22 years as a healthy-sized, pretty girl and avid runner, it was shocking to gain 50 pounds in 2 months with no change to my eating habits and while continuing to run 5 miles a day, 5 days a week.
    When I started to grow a black beard on my fair Scottish chin, and my clock-work menses stopped for a year, and I gained 110 lbs in a single year, it was embarassing. I moved away from my hometown because people no longer recognized me.

    Despite taking a pitiful array of photographs (which showed a shocking metamorphasis from 5’7″ 140 lb athlete to 300 lb morbidly obese, red-faced bearded lady) to every single doctor I’ve ever seen in my adult life, it took 17 years before a young D.O. got it right and sent me to an endocrinologist, who tested me for Cushing’s Disease. That wise doctor did not dismiss me when I got a normal UFC — he heard hoofbeats and saw that I was a zebra, not a common horse. He recommended I find a specialist in cyclical Cushing’s, and though I traveled 3,000 miles from coast to coast to do so, it was a decision, which saved my life.

    Two pitutitary surgieres (the second a complete hypophysectomy) — and positive pathology — later, I am facing down a bilateral adrenalectomy and radiation because my tumor has extended into my cavernous sinus approaching the left carotid artery. I am 41 years old, never got to have a family, had a treatable disease, which was overlooked for my entire adult life, and now I am in a fight for my life.

    It didn’t have to be that way. If just one doctor out of at least 20 I saw over those two decades had just….listened, just looked into my swollen face and seen disease instead of lack of willpower, had put some weight on those photos I dragged around in a tattered envelope, hoping someday, somehow, there would be a doctor who would understand there was something terribly wrong beyond my wide girth and tearful explanation (“You just need to eat less, exercise more and take these antidepressants)…..I might have enjoyed a return to health, running a marathon, having babies, not worrying whether I will survive these next lines of treatment, which were unnecessarily delayed by the biased eyes of the doctors in whom I entrusted my life.

    My story is not uncommon. The average length of time between onset of symptoms and Dx for someone with episodic Cushing’s is 10 years. It was nearly twice that for me. Some endocrinologists don’t even believe it exists or that it is too rare to pursue with expensive and possibly unnecessary testing. Yet more and more recent peer-reviewed journal articles are talking about Cyclical Cushing’s — even opining that between 2-4% of folks with Type II Diabetes actually have mild or episodic Cushing’s.

    I hope the tide is turning. I hope those of us who believed (because we were told) we were fat and depressed but later found we had a physiological cause to our obesity will continue to talk openly about our experiences so that others in our situation might recognize themselves and advocate earlier for appropriate testing.

    But most of all, I hope that there will be more doctors like my current team of physicians and like you, Jeff and Dr. Rob, who “get it” and don’t look past us because of our weight, who have inquisitive minds and seek to treat systems rather than symptoms.

    I believe it can happen, one doctor at a time.

    If you would like to see my story (or an obese person wanting to learn more about Cushing’s), please take 5 minutes and watch a clip of a National Geographic special called “Science of Obesity,” which may be viewed on YouTube here: http://www.youtube.com/watch?v=vxSAhLyKVqw

    You may recognize one of your own patients – or yourself – in this clip, and save more than a waistline in the process.

    Warm regards to all,
    Kate

  83. Rob, Bet you didn’t know this post would be quite so active. You – are a class act. You never disappoint me.
    What a great thing for all of you that have suffered the effects of Cushing’s, to speak out. It’s good the medical community gets a reminder now and then. When day after day you see the same things, it’s hard when you are tired, and under the gun to think for a moment about the zebra that is before you. That’s why every patient looks for that one doctor that will “really” listen. The way our health care system is set up, it makes it hard on them to “take the time” to really look AND listen. We need to band (with the good doctors) to see that things change.

  84. Rob, Bet you didn’t know this post would be quite so active. You – are a class act. You never disappoint me.
    What a great thing for all of you that have suffered the effects of Cushing’s, to speak out. It’s good the medical community gets a reminder now and then. When day after day you see the same things, it’s hard when you are tired, and under the gun to think for a moment about the zebra that is before you. That’s why every patient looks for that one doctor that will “really” listen. The way our health care system is set up, it makes it hard on them to “take the time” to really look AND listen. We need to band (with the good doctors) to see that things change.

  85. There are other blogs out there like, “Why are you so Fat” and “What Fat People Don’t Like” hiding behind the “tough love” veneer simultaneously putting down fat people in the cruelest of ways. I reckon people use the “tough love” card figuring it impresses others of their ilk and giving themselves a carte blanche to say whatever they want. And they can, of course. (Spare the ‘lough love’ bit because we don’t believe you “care” about us, eh?) The fact of the matter is, their hate for the obese is irrational as any stereotype is. I often hear, “A stereotype exists for a reason”. There’s another tired cliche for yah (in an effort to silence any kind of dissent)! 🙂
    In any event, defining individuals by “their stereotype” is hardly something to be impressed by in a public forum. Can we really place high stock on these individuals? Judging people by the group rather than the individual is invariably evident of ignorance, insecurity, feeling worthless themselves, and anger triggered by something in their past. Yes, we all have stereotypes of some sort and conveniently group individuals into one convenient and cozy category, don’t we? Depending on how we feel about ourselves and our own life, depends of the severity of our hate and ways of distributing it publicly/privately. I admit to my own. But there is a different between a person who makes it public and those who keep it to themselves.

    But these angry people still need an outlet for their frustrations, don’t they? Nobody’s stopping them. And nobody really should as this is what free speech is all about. However, it’s hard to respect them and take them too seriously.

    No. Fat haters don’t like it when there is a medical or a psychological reason for our obesity. Why? Because it’s harms their own addiction: hating fat people. They don’t want anything to get in the way of this. That’s why they don’t believe in “biochemical evidence” even if it’s right in front of their faces.

    And I’m sure you all realize this, (this is not directed at Dr. Rob, obviously) but isn’t so much easier to be a doctor and dismiss every fat patient that comes to your office? Hardly any paper work, no tests, no work – it’s easy: Just exercise and diet. Gosh, I’d love to have that job. 😉 Talk about lazy.

    Oh, and those that DO believe in glandular reasons for obesity say that it’s only 10% of the fat community. The other 90% are twinkie-indulging liars – they say. These people are all looking for “proof” that it is any more than 10%. So, you give them a link, two links, or even more, and they still don’t believe you. Why? Again, it hurts their “cause”.

    I wrote about the many reasons that people become obese here as most level-headed people realize that fat people DON’T choose to be fat. Even those with no medical “excuse” are addicted to comfort food as most people are addicted to something UNHEALTHY even if it means just being mean to people that don’t measure up to their elitist standards.

    And for those that think the obesity epidemic only exists in the US, think again. The Australians have usurped us. I am saying this because I am also tired of the Anti-Americans calling the “obesity surge” an American phenomenon. Nonetheless, Americans are blamed for the surge in all countries where the obese reside. That’s interesting because how are WE dictating to other country’s people how they should eat and live? Talk about personal responsibility….

    Anyway, thanks for allowing me to share here.

  86. There are other blogs out there like, “Why are you so Fat” and “What Fat People Don’t Like” hiding behind the “tough love” veneer simultaneously putting down fat people in the cruelest of ways. I reckon people use the “tough love” card figuring it impresses others of their ilk and giving themselves a carte blanche to say whatever they want. And they can, of course. (Spare the ‘lough love’ bit because we don’t believe you “care” about us, eh?) The fact of the matter is, their hate for the obese is irrational as any stereotype is. I often hear, “A stereotype exists for a reason”. There’s another tired cliche for yah (in an effort to silence any kind of dissent)! 🙂
    In any event, defining individuals by “their stereotype” is hardly something to be impressed by in a public forum. Can we really place high stock on these individuals? Judging people by the group rather than the individual is invariably evident of ignorance, insecurity, feeling worthless themselves, and anger triggered by something in their past. Yes, we all have stereotypes of some sort and conveniently group individuals into one convenient and cozy category, don’t we? Depending on how we feel about ourselves and our own life, depends of the severity of our hate and ways of distributing it publicly/privately. I admit to my own. But there is a different between a person who makes it public and those who keep it to themselves.

    But these angry people still need an outlet for their frustrations, don’t they? Nobody’s stopping them. And nobody really should as this is what free speech is all about. However, it’s hard to respect them and take them too seriously.

    No. Fat haters don’t like it when there is a medical or a psychological reason for our obesity. Why? Because it’s harms their own addiction: hating fat people. They don’t want anything to get in the way of this. That’s why they don’t believe in “biochemical evidence” even if it’s right in front of their faces.

    And I’m sure you all realize this, (this is not directed at Dr. Rob, obviously) but isn’t so much easier to be a doctor and dismiss every fat patient that comes to your office? Hardly any paper work, no tests, no work – it’s easy: Just exercise and diet. Gosh, I’d love to have that job. 😉 Talk about lazy.

    Oh, and those that DO believe in glandular reasons for obesity say that it’s only 10% of the fat community. The other 90% are twinkie-indulging liars – they say. These people are all looking for “proof” that it is any more than 10%. So, you give them a link, two links, or even more, and they still don’t believe you. Why? Again, it hurts their “cause”.

    I wrote about the many reasons that people become obese here as most level-headed people realize that fat people DON’T choose to be fat. Even those with no medical “excuse” are addicted to comfort food as most people are addicted to something UNHEALTHY even if it means just being mean to people that don’t measure up to their elitist standards.

    And for those that think the obesity epidemic only exists in the US, think again. The Australians have usurped us. I am saying this because I am also tired of the Anti-Americans calling the “obesity surge” an American phenomenon. Nonetheless, Americans are blamed for the surge in all countries where the obese reside. That’s interesting because how are WE dictating to other country’s people how they should eat and live? Talk about personal responsibility….

    Anyway, thanks for allowing me to share here.

  87. Fat America…
    UPDATE (as of June 20th, 2008): Breaking News
    Australia has officially become the Fattest
    Nation on Earth!
    AUSTRALIA has become the fattest nation in the world, with more than 9 million adults now rated as obese or overweight, according to an alarm…

  88. Someone sent me to read this post… As someone with severe back pain, degenerating discs and lumbar vetebrae, made worse by not having any health care for the first 5 years after the initial injury, I wish I could find more doctors like you (and my last doctor before I had to move out of town), people who treat *the patient* and not the symptoms. I have multiple health issues, some exacerbated by my weight, certainly, but the piles of doctors who have felt the need to ignore the serious issues because they can’t see past my size aren’t doing anyone a favor.
    As for the whole ‘obesity problem’ stuff — I encourage you to read junkfoodscience.blogspot.com, the journal of a nurse who looks at obesity (and other medical) “studies” and pulls many apart to find that what gets published in peer-reviewed journals… well, it says something about the peers.

  89. Someone sent me to read this post… As someone with severe back pain, degenerating discs and lumbar vetebrae, made worse by not having any health care for the first 5 years after the initial injury, I wish I could find more doctors like you (and my last doctor before I had to move out of town), people who treat *the patient* and not the symptoms. I have multiple health issues, some exacerbated by my weight, certainly, but the piles of doctors who have felt the need to ignore the serious issues because they can’t see past my size aren’t doing anyone a favor.
    As for the whole ‘obesity problem’ stuff — I encourage you to read junkfoodscience.blogspot.com, the journal of a nurse who looks at obesity (and other medical) “studies” and pulls many apart to find that what gets published in peer-reviewed journals… well, it says something about the peers.

  90. Kate Meyers. I made a clinical diagnosis of Cushings in a patient after 3 minutes oftalking to him and looking at his meds and his belly and his neck. It was gratifying. I hope you’re proud of me.
    Happy

  91. Kate Meyers. I made a clinical diagnosis of Cushings in a patient after 3 minutes oftalking to him and looking at his meds and his belly and his neck. It was gratifying. I hope you’re proud of me.
    Happy

  92. Below is part of a story about Michael. It’s a true story. Suzy discovered the support group after Michael’s surgery.
    “My name is Susan and I am writing this bio for my husband Michael.

    He had a lot of health issues that were misdiagnosed and unanswered for several years. He developed osteoparosis, diabetes, high blood pressure and other problems over night it seems. He also had several features of cushings such as the moon face and buffalo hump.

    He was finally diagnosed with Cushings about three months ago. November 2007 [when] he went into the hospital with backpain and he was unable to stand. Within days of being admitted I was told he had a compression fracture that paralyzed him from the waist down.

    He had transphenoidal pituitary surgery June 23. The tumor was approximately 20 cm [probalbly mm instead of cm] which had doubled in size since November. Only part of it was removed because it was in the nerve center of brain and “wrapped” around carotid artery. Neurosurgeon was able to remove more than thought, but he might need another surgery or radiation treatment.”

    To continue the story, Michael is still fighting for his life. He is on a ventilator, and it had to be turned back up to 100% last night because when his PICC line was removed, a blood clot shot straight to one of his lungs. The other lung is in threat of collapse.

    In addition, Michael’s doctors did not realize he could go into AI with a dramatic drop in cortisol, and assumed since his levels were at 20 ug/dL, he didn’t need supplemental hormones. They also did not realize that after surgery the pituitary is traumatized and other hormones may not be produced.

    This is a true story, happening right now, and Micheal’s wife is fighting for his life. There are some folks who have run to their aid and for support but they could use all the prayers they can get.

  93. Below is part of a story about Michael. It’s a true story. Suzy discovered the support group after Michael’s surgery.
    “My name is Susan and I am writing this bio for my husband Michael.

    He had a lot of health issues that were misdiagnosed and unanswered for several years. He developed osteoparosis, diabetes, high blood pressure and other problems over night it seems. He also had several features of cushings such as the moon face and buffalo hump.

    He was finally diagnosed with Cushings about three months ago. November 2007 [when] he went into the hospital with backpain and he was unable to stand. Within days of being admitted I was told he had a compression fracture that paralyzed him from the waist down.

    He had transphenoidal pituitary surgery June 23. The tumor was approximately 20 cm [probalbly mm instead of cm] which had doubled in size since November. Only part of it was removed because it was in the nerve center of brain and “wrapped” around carotid artery. Neurosurgeon was able to remove more than thought, but he might need another surgery or radiation treatment.”

    To continue the story, Michael is still fighting for his life. He is on a ventilator, and it had to be turned back up to 100% last night because when his PICC line was removed, a blood clot shot straight to one of his lungs. The other lung is in threat of collapse.

    In addition, Michael’s doctors did not realize he could go into AI with a dramatic drop in cortisol, and assumed since his levels were at 20 ug/dL, he didn’t need supplemental hormones. They also did not realize that after surgery the pituitary is traumatized and other hormones may not be produced.

    This is a true story, happening right now, and Micheal’s wife is fighting for his life. There are some folks who have run to their aid and for support but they could use all the prayers they can get.

  94. Happy, not only am I proud of you, you’re my hero! I’m guessing since you mentioned reviewing your patient’s meds that s/he had steroid-induced Cushing’s Syndrome and not Cushing’s Disease, like moi.
    Dr. Rob, thank you for allowing we Cushing’s folk to hijack your comments thread. It was just really nice to hear from a fellow Cushie that there was a blogging doctor who has compassion for people struggling with obesity – regardless of the cause — and I had to pop over here to comment.

    It’s even more heartening to see other physicians chiming in with nods to your patient approach.

    I’ve never expected doctors to be gods, and not all ailments can be cured. But it sure was nice when my former, rural primary care physician called me up after my first pit surgery to check on me…and to apologize for trying to push gastric bypass oni me and for not recognizing the signs of an endocrine disorder. I told him how much his call meant and that he could make it up to me by reading up on Cushing’s and referring patients with hallmark symptoms to an endocrinologist. He said he would, and I believe he will look differently at his obese patients because of my case.

    Just goes to show that we all live and learn, sometimes in unexpected ways….

    Kate

  95. Happy, not only am I proud of you, you’re my hero! I’m guessing since you mentioned reviewing your patient’s meds that s/he had steroid-induced Cushing’s Syndrome and not Cushing’s Disease, like moi.
    Dr. Rob, thank you for allowing we Cushing’s folk to hijack your comments thread. It was just really nice to hear from a fellow Cushie that there was a blogging doctor who has compassion for people struggling with obesity – regardless of the cause — and I had to pop over here to comment.

    It’s even more heartening to see other physicians chiming in with nods to your patient approach.

    I’ve never expected doctors to be gods, and not all ailments can be cured. But it sure was nice when my former, rural primary care physician called me up after my first pit surgery to check on me…and to apologize for trying to push gastric bypass oni me and for not recognizing the signs of an endocrine disorder. I told him how much his call meant and that he could make it up to me by reading up on Cushing’s and referring patients with hallmark symptoms to an endocrinologist. He said he would, and I believe he will look differently at his obese patients because of my case.

    Just goes to show that we all live and learn, sometimes in unexpected ways….

    Kate

  96. I agree that shaming patients is not the way to treat obesity. But I believe that some (not all) obesity is caused by compulsive overeating. Many of us believe that compulsive eating is not a moral failing but rather a disease, not unlike alcoholism: some foods (usually those with a high glycemic impact) can, in some people, trigger a compulsion to eat to the point of self-injury, despite the best intentions to eat healthfully and a strong desire to achieve a healthy weight. (Obviously the analogy to alcoholism is not perfect. I am not contending that junk food is associated wtih crime or automobile accidents in the way drug and alcohol abuse are.)
    I can report from experience that many people who suffer from this response to high glycemic impact foods do not understand what is happening to them. We don’t know why we keep eating, even after we’re full. We don’t know why others are able to stop after a few potato chips or one cookie. We don’t know what’s wrong with us and are ready to assume that we are simply weak.

    Some of us can recover if we simply go on a low glycemic impact diet — South Beach, Atkins, Sugar Busters, etc. Removing the trigger is enough to break the cycle.

    Some of us may need more help, however. Without the sedative effect of high GI foods, some folks may need support groups such as Overeaters Anonymous, Weight Watchers, etc. Personally, I don’t think it matters much what the support group is, so long as the person recognizes the existence of the compulsion and gets help. (Even people who don’t fit the “sugar addict” profile may enjoy greater success in their efforts to modify their lifestyle with the assistance of a support group.)

    Without resorting to shaming anyone, you might be able to help some patients by letting them know, in a nonjudgmental way, that high glycemic impact foods can, in some people, trigger a compulsion to continue to eat high glycemic impact foods past the point of satiety, and that while this is not a quesiton of willpower or moral strength, a support group can help break that cycle.

  97. I agree that shaming patients is not the way to treat obesity. But I believe that some (not all) obesity is caused by compulsive overeating. Many of us believe that compulsive eating is not a moral failing but rather a disease, not unlike alcoholism: some foods (usually those with a high glycemic impact) can, in some people, trigger a compulsion to eat to the point of self-injury, despite the best intentions to eat healthfully and a strong desire to achieve a healthy weight. (Obviously the analogy to alcoholism is not perfect. I am not contending that junk food is associated wtih crime or automobile accidents in the way drug and alcohol abuse are.)
    I can report from experience that many people who suffer from this response to high glycemic impact foods do not understand what is happening to them. We don’t know why we keep eating, even after we’re full. We don’t know why others are able to stop after a few potato chips or one cookie. We don’t know what’s wrong with us and are ready to assume that we are simply weak.

    Some of us can recover if we simply go on a low glycemic impact diet — South Beach, Atkins, Sugar Busters, etc. Removing the trigger is enough to break the cycle.

    Some of us may need more help, however. Without the sedative effect of high GI foods, some folks may need support groups such as Overeaters Anonymous, Weight Watchers, etc. Personally, I don’t think it matters much what the support group is, so long as the person recognizes the existence of the compulsion and gets help. (Even people who don’t fit the “sugar addict” profile may enjoy greater success in their efforts to modify their lifestyle with the assistance of a support group.)

    Without resorting to shaming anyone, you might be able to help some patients by letting them know, in a nonjudgmental way, that high glycemic impact foods can, in some people, trigger a compulsion to continue to eat high glycemic impact foods past the point of satiety, and that while this is not a quesiton of willpower or moral strength, a support group can help break that cycle.

  98. Victoria, I sometimes make references to over-eating and alcoholism only for one reason. I mention it because compulsive eating and alcoholism aims to do one thing: help a person escape their problems by temporarily numbing the pain. If we think about it, all obsessions and addictions work this way. Some of these addictions are more self-destructive than others. Some of these addictions hurt our surrounding loved ones as well. But at the end of the day, the purpose of the addiction is the same.

  99. Victoria, I sometimes make references to over-eating and alcoholism only for one reason. I mention it because compulsive eating and alcoholism aims to do one thing: help a person escape their problems by temporarily numbing the pain. If we think about it, all obsessions and addictions work this way. Some of these addictions are more self-destructive than others. Some of these addictions hurt our surrounding loved ones as well. But at the end of the day, the purpose of the addiction is the same.

  100. The Health Behavior News Service just published a feature, “Larger Patients: In Search of Fewer Lectures, Better Health Care.” Two large patients talked about “fat-obsessed” and “fat-distracted” doctors who could not see past their weight, whether they came in for a headache or sprained wrist.
    A Wisconsin doctor, who has been named a “Fat-Friendly” doctor, discussed his approach with heavier patients. He used the words consideration and respect.

    You can read our article at http://www.cfah.org

  101. The Health Behavior News Service just published a feature, “Larger Patients: In Search of Fewer Lectures, Better Health Care.” Two large patients talked about “fat-obsessed” and “fat-distracted” doctors who could not see past their weight, whether they came in for a headache or sprained wrist.
    A Wisconsin doctor, who has been named a “Fat-Friendly” doctor, discussed his approach with heavier patients. He used the words consideration and respect.

    You can read our article at http://www.cfah.org

  102. Skimmmed over the responses and it seems like there are a lot of folks that have Cushing’s disease or syndrome as a cause of obesity. I assure you that by far the MAJORITY of patients I see who are obese, have that condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
    Would I be doing my job if I didn’t point out someone needs to eat smaller portions, cut out snacks and exercise more in an attempt to lose weight.

    I admit that I do not give a detailed nutritional analysis, but that’s why they make nutritionists!! I have recommended patients see a nutritionist if it appears that they have really tried the “Dr. Gebhard diet and exercise plan”(see above) for detailed advice on diet.

    I assure you that it is the SIGNIFICANT MINORITY of patients who EVER try to eat less and exercise more to lose weight, at least in my practice. Sure they’ll try for a few days a week, but then quit. Did the weight go on in a few days or a week??

    Walking the dog is not exercise!!

    It seems like the majority of respondents to the NY times article feel that it would be more PC to look compassionately in the obese patient’s eyes and tell them how sorry you feel for them.

    Would that really help??

  103. Skimmmed over the responses and it seems like there are a lot of folks that have Cushing’s disease or syndrome as a cause of obesity. I assure you that by far the MAJORITY of patients I see who are obese, have that condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
    Would I be doing my job if I didn’t point out someone needs to eat smaller portions, cut out snacks and exercise more in an attempt to lose weight.

    I admit that I do not give a detailed nutritional analysis, but that’s why they make nutritionists!! I have recommended patients see a nutritionist if it appears that they have really tried the “Dr. Gebhard diet and exercise plan”(see above) for detailed advice on diet.

    I assure you that it is the SIGNIFICANT MINORITY of patients who EVER try to eat less and exercise more to lose weight, at least in my practice. Sure they’ll try for a few days a week, but then quit. Did the weight go on in a few days or a week??

    Walking the dog is not exercise!!

    It seems like the majority of respondents to the NY times article feel that it would be more PC to look compassionately in the obese patient’s eyes and tell them how sorry you feel for them.

    Would that really help??

  104. Dr. Rob, After ruling out things like Cushings, beyond sympathizing with, not shaming overweight patients, what else do you do to motivate them to lose weight? How successful have you been and how do you measure success?

  105. Dr. Rob, After ruling out things like Cushings, beyond sympathizing with, not shaming overweight patients, what else do you do to motivate them to lose weight? How successful have you been and how do you measure success?

  106. Paul, you bring up a good point. I think most of us can agree with eating right and exercising and realize that it is basic. Polite reminders can’t hurt and nutritionists are awesome!
    Back in 2003, I saw a doctor because I had a really, really bad case of boils and my PCP tested my sugars right away to see if I had diabetes. To make a long story short, I had diabetes type 2 and at that time, my PCP told me that if I were to lose 50 pounds, I won’t need medication any longer! Was I offended? Hells no. I felt he was just doing his job. I would agree that some patients might be a little too thin-skinned? I don’t know. Let’s just say that context and the manner in which the doctor speaks in can make all the difference in the world!

    I can always tell which doctors genuinely care about me and the ones that don’t or have an agenda. You know you’ve found a great doctor when you feel comfortable being honest with him/her.

  107. Paul, you bring up a good point. I think most of us can agree with eating right and exercising and realize that it is basic. Polite reminders can’t hurt and nutritionists are awesome!
    Back in 2003, I saw a doctor because I had a really, really bad case of boils and my PCP tested my sugars right away to see if I had diabetes. To make a long story short, I had diabetes type 2 and at that time, my PCP told me that if I were to lose 50 pounds, I won’t need medication any longer! Was I offended? Hells no. I felt he was just doing his job. I would agree that some patients might be a little too thin-skinned? I don’t know. Let’s just say that context and the manner in which the doctor speaks in can make all the difference in the world!

    I can always tell which doctors genuinely care about me and the ones that don’t or have an agenda. You know you’ve found a great doctor when you feel comfortable being honest with him/her.

  108. Dr. Gebhard:
    Why, pray tell, does walking the dog not count as exercise?

    Surely the point is to encourage people to move and be active? For someone who is very overweight and sedentary, exercise needs to be doable, at least to start with. They’re not going to start out doing windsprints, for God’s sake.

    Walking the dog is a great activity that can easily be incorporated into the daily routine. As people gain stamina and conditioning, they can lengthen the walk by another block, then another… you get the picture. Pretty soon they’re exercising consistently and maybe even enjoying it and benefiting from it. And it’s good for the dog as well.

    I’m sorry, but I don’t think you’re doing anyone any favors by proclaiming what “counts” and what doesn’t. Any activity is better than none. There’s really no room here for elitism. If walking the dog is what gets some people moving, then they should walk the dog.

  109. Dr. Gebhard:
    Why, pray tell, does walking the dog not count as exercise?

    Surely the point is to encourage people to move and be active? For someone who is very overweight and sedentary, exercise needs to be doable, at least to start with. They’re not going to start out doing windsprints, for God’s sake.

    Walking the dog is a great activity that can easily be incorporated into the daily routine. As people gain stamina and conditioning, they can lengthen the walk by another block, then another… you get the picture. Pretty soon they’re exercising consistently and maybe even enjoying it and benefiting from it. And it’s good for the dog as well.

    I’m sorry, but I don’t think you’re doing anyone any favors by proclaiming what “counts” and what doesn’t. Any activity is better than none. There’s really no room here for elitism. If walking the dog is what gets some people moving, then they should walk the dog.

  110. Zee, I’ll clarify. Walking the dog is not sufficient exercise to lose weight for anyone!!! If someone is obese and they tell me they are “walking the dog” for exercise and they wonder why they are not losing weight, I am simply going to point out that most of the dogs I see being walked, spend alot of time, sniffing, scratching, pooping or peeing and do not get their masters heart rates going!! I do see one guy in my neighborhood walking, rather rollerblading, a beautiful Doberman, and that is certainly exercise. Getting your heart beat into the aerobic range is what it takes to burn fat and most dogs don’t get their master’s heart beats going that fast! Certainly, I am not going to tell someone who is doing nothing, to go out and run a marathon for starters, but you are kidding yourself, if weight loss is a goal, that walking the dog is going to accomplish that goal! The BARE MINIMUM for exercise that ALL people should strive for is walking an hour a day on most days if not everyday. Those are recommendations from national panels, not from me. Again, if a patient is doing nada, I’m going to tell them to start with what they can(i.e. five minutes, ten minutes, etc.. and build up to that hour). I’ll point out what their aerobic range should be. I’ll get a stress test if I think they need it, before they start exercising. I’ll give them whatever advice I think they need, or point them to someone who has the information if I don’t, but I will NEVER say walking the dog is sufficient exercise for someone who states that is what they are doing and they can’t lose weight.

  111. Zee, I’ll clarify. Walking the dog is not sufficient exercise to lose weight for anyone!!! If someone is obese and they tell me they are “walking the dog” for exercise and they wonder why they are not losing weight, I am simply going to point out that most of the dogs I see being walked, spend alot of time, sniffing, scratching, pooping or peeing and do not get their masters heart rates going!! I do see one guy in my neighborhood walking, rather rollerblading, a beautiful Doberman, and that is certainly exercise. Getting your heart beat into the aerobic range is what it takes to burn fat and most dogs don’t get their master’s heart beats going that fast! Certainly, I am not going to tell someone who is doing nothing, to go out and run a marathon for starters, but you are kidding yourself, if weight loss is a goal, that walking the dog is going to accomplish that goal! The BARE MINIMUM for exercise that ALL people should strive for is walking an hour a day on most days if not everyday. Those are recommendations from national panels, not from me. Again, if a patient is doing nada, I’m going to tell them to start with what they can(i.e. five minutes, ten minutes, etc.. and build up to that hour). I’ll point out what their aerobic range should be. I’ll get a stress test if I think they need it, before they start exercising. I’ll give them whatever advice I think they need, or point them to someone who has the information if I don’t, but I will NEVER say walking the dog is sufficient exercise for someone who states that is what they are doing and they can’t lose weight.

  112. I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing’s] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
    Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s?

    Regards,
    Robin

  113. I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing’s] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.
    Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s?

    Regards,
    Robin

  114. “I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing’s] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.”
    Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s? Also, Cushing’s is never secondary to lack of exercise and high caloric intake. It’s due to high cortisol from a tumor or it is iatrogenic.

    Regards,
    Robin

    (Apologies for the repeat. I forgot to mark the quotation as such.)

  115. “I assure you that by far the MAJORITY of patients I see who are obese, have that [Cushing’s] condition secondary to lack of exercise and excessive calorie intake, now or at some point in their lives.”
    Dr. Gebhard, may I respectfully ask how you know that? Did you check them for Cushing’s? Also, Cushing’s is never secondary to lack of exercise and high caloric intake. It’s due to high cortisol from a tumor or it is iatrogenic.

    Regards,
    Robin

    (Apologies for the repeat. I forgot to mark the quotation as such.)

  116. Did I say that Cushing’s was “secondary to lack of exercise and high caloric intake”? I believe that other posters had already gone over the anatomy and physiology in reasonable enough fashion to describe a condition that is caused by a pituitary or adrenal problem. That problem also has fairly classic findings that if present should then prompt a workup(moon facies, abdominal striae, elevated sugar, electrolyte abnormalities). In the appropriate patient, where the clinical findings were consistent with that disease or syndrome, yes, I check the appropriate lab work or refer to an endocrinologist. I assure you that there is not an epidemic of Cushing’s syndrome out there that is responsible for this nation’s obesity problem!! I think that perhaps you should go back and re-read my initial post. In the first sentence, the linkage between Cushing’s disease and my second sentence is separated by a period: therefore, the second sentence does not expound upon the first. You’re linking [Cushing’s], your brackets to my second thought is an erroneous connection and I would appreciate a correction! “…..MAJORITY of the patients I see who are obese, have that condtion…..”. Isn’t the subject of the second sentence patients who are obese, not patients with Cushing’s?? I’m no English major, but you are misquoting me, hopefully without malicious intent!

  117. Did I say that Cushing’s was “secondary to lack of exercise and high caloric intake”? I believe that other posters had already gone over the anatomy and physiology in reasonable enough fashion to describe a condition that is caused by a pituitary or adrenal problem. That problem also has fairly classic findings that if present should then prompt a workup(moon facies, abdominal striae, elevated sugar, electrolyte abnormalities). In the appropriate patient, where the clinical findings were consistent with that disease or syndrome, yes, I check the appropriate lab work or refer to an endocrinologist. I assure you that there is not an epidemic of Cushing’s syndrome out there that is responsible for this nation’s obesity problem!! I think that perhaps you should go back and re-read my initial post. In the first sentence, the linkage between Cushing’s disease and my second sentence is separated by a period: therefore, the second sentence does not expound upon the first. You’re linking [Cushing’s], your brackets to my second thought is an erroneous connection and I would appreciate a correction! “…..MAJORITY of the patients I see who are obese, have that condtion…..”. Isn’t the subject of the second sentence patients who are obese, not patients with Cushing’s?? I’m no English major, but you are misquoting me, hopefully without malicious intent!

  118. No malicious intent at all. That was how I understood what you wrote and I appreciate the clarification.
    I don’t deny there is a problem with obesity that is not Cushing’s related. However, I will not admit that it is not endocrine related. There is not enough evidence either way. Fat is an endocrine organ (full article may be found on Medscape) and that is just now being studied.

    Secondly, may I encourage you to read the research on subclinical/episodic/mild/cyclic Cushing’s? You may be surprised how devastating it is and how the “classic” findings really aren’t classic at all. There are all sorts of presentations. Many folks with this disease do not have all those symptoms. Others do, plus more.

    In the European Journal of Endocrinology (2007) 157 725–731, Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing’s syndrome you can find the following:

    “The features of endogenous hypercortisolism (especially, when mild) are protean and coincide with many common clinical conditions like the dysmetabolic syndrome (1, 2). Screening studies in high-risk populations have discovered unsuspected CS in as many as 2–5% of patients with diabetes mellitus (3–7) and suggest that mild CS is more common than previously appreciated.”

    In Cyclical Cushing’s syndrome: an update (Neuroendocrinology; Current Opinion in Endocrinology, Diabetes & Obesity. 14(4):317-322, August 2007.
    Mullan, Karen R; Atkinson, A Brew; Sheridan, Brian ) the full text article says, “Cyclical Cushing’s syndrome is a pattern of hypercortisolism in which the biochemistry of cortisol production fluctuates rhythmically. This syndrome is often associated with fluctuating symptoms and signs. This type of case was initially thought to be rare. It has, however, recently been recognized as occurring much more frequently. The phenomenon is important because it can, if not recognized, lead to errors in diagnosis and differential diagnosis of the syndrome and in assessment of therapeutic outcomes. All of these can have very serious clinical consequences.”

    There is much, much, much more research to validate the above. It is my hope and prayer physicians everywhere will become familiar with it.

    Again, I did not mean to misquote you. And again, I apologize.

    (I hope my html is correct. I was not able to preview it. )

  119. No malicious intent at all. That was how I understood what you wrote and I appreciate the clarification.
    I don’t deny there is a problem with obesity that is not Cushing’s related. However, I will not admit that it is not endocrine related. There is not enough evidence either way. Fat is an endocrine organ (full article may be found on Medscape) and that is just now being studied.

    Secondly, may I encourage you to read the research on subclinical/episodic/mild/cyclic Cushing’s? You may be surprised how devastating it is and how the “classic” findings really aren’t classic at all. There are all sorts of presentations. Many folks with this disease do not have all those symptoms. Others do, plus more.

    In the European Journal of Endocrinology (2007) 157 725–731, Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing’s syndrome you can find the following:

    “The features of endogenous hypercortisolism (especially, when mild) are protean and coincide with many common clinical conditions like the dysmetabolic syndrome (1, 2). Screening studies in high-risk populations have discovered unsuspected CS in as many as 2–5% of patients with diabetes mellitus (3–7) and suggest that mild CS is more common than previously appreciated.”

    In Cyclical Cushing’s syndrome: an update (Neuroendocrinology; Current Opinion in Endocrinology, Diabetes & Obesity. 14(4):317-322, August 2007.
    Mullan, Karen R; Atkinson, A Brew; Sheridan, Brian ) the full text article says, “Cyclical Cushing’s syndrome is a pattern of hypercortisolism in which the biochemistry of cortisol production fluctuates rhythmically. This syndrome is often associated with fluctuating symptoms and signs. This type of case was initially thought to be rare. It has, however, recently been recognized as occurring much more frequently. The phenomenon is important because it can, if not recognized, lead to errors in diagnosis and differential diagnosis of the syndrome and in assessment of therapeutic outcomes. All of these can have very serious clinical consequences.”

    There is much, much, much more research to validate the above. It is my hope and prayer physicians everywhere will become familiar with it.

    Again, I did not mean to misquote you. And again, I apologize.

    (I hope my html is correct. I was not able to preview it. )

  120. ok, so this is unfair. i am typing this on my cellphone in northern Michigan. thanks to all commenters and new visitors.
    Regarding causes of obesity, I don’t think the majority is from anything other than overeating and lack of enough exercise. Cushings is not common. The purpose of this post was to say that piling on the guilt is counter-productive. I would not say I am really successful at getting people to lose’ but I doubt I am less than those who use “tough love.” But my patients don’t avoid coming in so I have more chances to help. I just don’t think pushing guilt serves a purpose. Don’t avoid reality by denying the risks of obesity, but don’t overdo it.

    That is the best I can do on this phone. I feel guilty doing even this on my vacation, but you don’t get in the NY Times every day.

  121. ok, so this is unfair. i am typing this on my cellphone in northern Michigan. thanks to all commenters and new visitors.
    Regarding causes of obesity, I don’t think the majority is from anything other than overeating and lack of enough exercise. Cushings is not common. The purpose of this post was to say that piling on the guilt is counter-productive. I would not say I am really successful at getting people to lose’ but I doubt I am less than those who use “tough love.” But my patients don’t avoid coming in so I have more chances to help. I just don’t think pushing guilt serves a purpose. Don’t avoid reality by denying the risks of obesity, but don’t overdo it.

    That is the best I can do on this phone. I feel guilty doing even this on my vacation, but you don’t get in the NY Times every day.

  122. Dr. Rob, I appreciate that you are on the good side, but I don’t know (and I doubt anyone really does) that the majority of obesity is caused by overeating and lack of exercise. How may people are hypothyroid — I think the percentage of women over age 40 who are hypo is relatively significant. How many women have PCOS — certainly not the majority of overweight women, but probably a decent percentage. What percentage of people have depression? Statistics seem to indicate a non-nominal percentage. How many people have difficult personal circumstances that take up all of the time that might be devoted to better eating habits and more time to take care of themselves. How many have joint problems or other mobility issues? What percentage of the population have medical abnormalities that cause obesity that we haven’t figured out. “Too much food and too little exercise” is reductionist and gets docs off the hook for digging a little deeper to do the real problem solving. It’s like a marriage counselor advising a couple whose marriage is in trouble that it appears that they don’t get along. Figuring out why is the real challenge. I don’t think people mind doctors addressing weight as long as it is treated as a real medical problem that the doctor is providing real medical treatment for.
    In addition, for those with an extra 20 lbs, “food and exercise” at some level probably is the issue. But study after study shows that (short of another diagnosable illness) the only long-term effective treatment for morbid obesity is surgery, and that surgery causes real changes in the metabolic system. It gives one pause that perhaps diet and exercise alone are not the culprit in morbid obesity.

    Long ago, people thought epileptics were possessed and were ostracized. We now know that devil possession has nothing to do with it. I bet that in 100 years, we will find that for some significant percentage of the severely obese, we will find that they are similarly afflicted with disease, not lacking in moral character or willpower.

  123. Dr. Rob, I appreciate that you are on the good side, but I don’t know (and I doubt anyone really does) that the majority of obesity is caused by overeating and lack of exercise. How may people are hypothyroid — I think the percentage of women over age 40 who are hypo is relatively significant. How many women have PCOS — certainly not the majority of overweight women, but probably a decent percentage. What percentage of people have depression? Statistics seem to indicate a non-nominal percentage. How many people have difficult personal circumstances that take up all of the time that might be devoted to better eating habits and more time to take care of themselves. How many have joint problems or other mobility issues? What percentage of the population have medical abnormalities that cause obesity that we haven’t figured out. “Too much food and too little exercise” is reductionist and gets docs off the hook for digging a little deeper to do the real problem solving. It’s like a marriage counselor advising a couple whose marriage is in trouble that it appears that they don’t get along. Figuring out why is the real challenge. I don’t think people mind doctors addressing weight as long as it is treated as a real medical problem that the doctor is providing real medical treatment for.
    In addition, for those with an extra 20 lbs, “food and exercise” at some level probably is the issue. But study after study shows that (short of another diagnosable illness) the only long-term effective treatment for morbid obesity is surgery, and that surgery causes real changes in the metabolic system. It gives one pause that perhaps diet and exercise alone are not the culprit in morbid obesity.

    Long ago, people thought epileptics were possessed and were ostracized. We now know that devil possession has nothing to do with it. I bet that in 100 years, we will find that for some significant percentage of the severely obese, we will find that they are similarly afflicted with disease, not lacking in moral character or willpower.

  124. […] health effects. Dr Rob at Musings of a Distractible Mind has written a highly popular post “Shame” on a patient who held his head in shame, thinking Dr Rob his family doctor was going to lecture him […]

  125. My friend just had her stomach re-sectioned and I have to say that I don’t understand why that surgery is even offered to people. It makes their life, moving forward, more isolating. Obviously losing weight would be hard for her but this body mutilation done in a medical setting. She’ll lose weight because she will eat less. Isn’t eating differently the key here?
    I spent a couple of years at 200 pounds at 5’5″ and I know fat. My weight gain was the result of an extremely stressful year when my father couldn’t work and we ate beans and reconstituted milk – both purchased in huge sacks and served 3 times a day. My hunger became a needy companion, always wanting to know that it would/could be fed. 50 years later, I keep snacks in my purse just in case.

    It took years to learn that a diet should be a successful relationship with nutrition.

    I think a lot of American food attitudes are terrible. We want fast, huge, sweet, salty and often rather than savoring our meals. We shovel in food in cars and at the sink. We really need to develop a healthy food culture and then eating wouldn’t be about emotional needs but a celebration of variety of tastes.

    Rather than lecturing people about obesity we may have to talk with each other about why we eat what we eat. There are zillions of edible plants but corporate mono culture has obliterated many fruits and vegetables. Our government supports this with our $$. Corn is subsidized and so high fructose corn syrup shows up everywhere. I feel there are few things for me to purchase in the grocery store because I will not eat HFCS and I want organic vegetation.

    It makes little sense to take substances labeled as toxic (poisonous fertilizer? An oxymoron!) spread this on our land and then eat the things grown in the mix of dirt and poison. Soil should be respected as a living organism and should be nurtured with organic material. Organic foods taste better and are more satisfying. It’s all related.

    I’m pleased to have stumbled my way into a smaller size and more attentive eating habits. Someone stopped me in a hall once and held up an organic salad dressing and told me how the key to eating less is taste. It was a simple conversation. The revelation of her discovery. She changed my life because everything hurt when I carried an extra 70 pounds every minute of the day. It wasn’t about guilt or flaws in me. It was about what she learned.

  126. My friend just had her stomach re-sectioned and I have to say that I don’t understand why that surgery is even offered to people. It makes their life, moving forward, more isolating. Obviously losing weight would be hard for her but this body mutilation done in a medical setting. She’ll lose weight because she will eat less. Isn’t eating differently the key here?
    I spent a couple of years at 200 pounds at 5’5″ and I know fat. My weight gain was the result of an extremely stressful year when my father couldn’t work and we ate beans and reconstituted milk – both purchased in huge sacks and served 3 times a day. My hunger became a needy companion, always wanting to know that it would/could be fed. 50 years later, I keep snacks in my purse just in case.

    It took years to learn that a diet should be a successful relationship with nutrition.

    I think a lot of American food attitudes are terrible. We want fast, huge, sweet, salty and often rather than savoring our meals. We shovel in food in cars and at the sink. We really need to develop a healthy food culture and then eating wouldn’t be about emotional needs but a celebration of variety of tastes.

    Rather than lecturing people about obesity we may have to talk with each other about why we eat what we eat. There are zillions of edible plants but corporate mono culture has obliterated many fruits and vegetables. Our government supports this with our $$. Corn is subsidized and so high fructose corn syrup shows up everywhere. I feel there are few things for me to purchase in the grocery store because I will not eat HFCS and I want organic vegetation.

    It makes little sense to take substances labeled as toxic (poisonous fertilizer? An oxymoron!) spread this on our land and then eat the things grown in the mix of dirt and poison. Soil should be respected as a living organism and should be nurtured with organic material. Organic foods taste better and are more satisfying. It’s all related.

    I’m pleased to have stumbled my way into a smaller size and more attentive eating habits. Someone stopped me in a hall once and held up an organic salad dressing and told me how the key to eating less is taste. It was a simple conversation. The revelation of her discovery. She changed my life because everything hurt when I carried an extra 70 pounds every minute of the day. It wasn’t about guilt or flaws in me. It was about what she learned.

  127. ok, I’ve been following this post for eleven days now. I have read all the comments, even all the comments in the New York Times…oh, the tedium. I have seen very little in the way of viable solutions. These next comments will be made in defense of people who cannot afford health care. Surgery is out of the question. “Diet” is not feasible for those whose primary food intake consists of beans, rice and other starchy staples. “Exercise” is not feasible because this part of the population does not have the nutritional sustenance to allow for metabolic stimulation and often suffer from bronchitis or other upper respiratory infections or arthritic flare-ups when attempting to do even the minimal amount of exercise. Before you jump on me and say that I’m only making yet another excuse, I do have a solution. It would require a major amount of time and work but is feasible. How about everyone in the medical community banding together to get this problem under control, without the attitude that has normally been presented to us. How about working with local hotels, even YMCA’s, any place in your town that has a pool to start a daily water aerobics class. I would suggest making sure the places are easily accessible (like on a direct bus line) and have heated pools. They could start at 9 am daily as most of their paying clients don’t usually start using the pool until around eleven. This would allow plenty of time for the class. I believe there are even grants offered through NIH that could fund these programs if your area needs it. For example, PAR-06-103, if you would like to make a real project out of it and let others benefit from your example. I truly believe that water aerobics is the answer for most extremely overweight people and believe that it should be offered as freely or as a condition to a welfare check, food stamps or Medicaid. Ok, that’s my two cents…

  128. ok, I’ve been following this post for eleven days now. I have read all the comments, even all the comments in the New York Times…oh, the tedium. I have seen very little in the way of viable solutions. These next comments will be made in defense of people who cannot afford health care. Surgery is out of the question. “Diet” is not feasible for those whose primary food intake consists of beans, rice and other starchy staples. “Exercise” is not feasible because this part of the population does not have the nutritional sustenance to allow for metabolic stimulation and often suffer from bronchitis or other upper respiratory infections or arthritic flare-ups when attempting to do even the minimal amount of exercise. Before you jump on me and say that I’m only making yet another excuse, I do have a solution. It would require a major amount of time and work but is feasible. How about everyone in the medical community banding together to get this problem under control, without the attitude that has normally been presented to us. How about working with local hotels, even YMCA’s, any place in your town that has a pool to start a daily water aerobics class. I would suggest making sure the places are easily accessible (like on a direct bus line) and have heated pools. They could start at 9 am daily as most of their paying clients don’t usually start using the pool until around eleven. This would allow plenty of time for the class. I believe there are even grants offered through NIH that could fund these programs if your area needs it. For example, PAR-06-103, if you would like to make a real project out of it and let others benefit from your example. I truly believe that water aerobics is the answer for most extremely overweight people and believe that it should be offered as freely or as a condition to a welfare check, food stamps or Medicaid. Ok, that’s my two cents…

  129. Prin, they already have Water Aerobics programs at most YMCA’s thats why you have to get there at 0530 to do any real swimming. I admit they’re not free so you might have something there. I agree with you on the Surgery, Gastric Banding is pretty benign but you should see some of the horror show complications from gastric bypasses. Its like lobotomies were in the 40’s. Seems to me it’d be easier to get the small order of fries and run 10 extra windsprints, but what do I know?

  130. Prin, they already have Water Aerobics programs at most YMCA’s thats why you have to get there at 0530 to do any real swimming. I admit they’re not free so you might have something there. I agree with you on the Surgery, Gastric Banding is pretty benign but you should see some of the horror show complications from gastric bypasses. Its like lobotomies were in the 40’s. Seems to me it’d be easier to get the small order of fries and run 10 extra windsprints, but what do I know?

  131. That’s just it…the patients I’m talking about can not do 10 wind sprints and probably haven’t been able to afford fast food in awhile. I have often wondered what it would be like if history (a patients past) were not considered. If each patient were treated as if the day they presented were the first day of their lives. Just forget about what all they did wrong in the past and treat how they present on the day of the visit. I know this is not possible because of insurance coding and other things but I just wonder how treatment would change.

  132. That’s just it…the patients I’m talking about can not do 10 wind sprints and probably haven’t been able to afford fast food in awhile. I have often wondered what it would be like if history (a patients past) were not considered. If each patient were treated as if the day they presented were the first day of their lives. Just forget about what all they did wrong in the past and treat how they present on the day of the visit. I know this is not possible because of insurance coding and other things but I just wonder how treatment would change.

  133. I know some slender people that cannot do wind sprints or handle the impact of jogging. I am fat and my exercise of preference is walking an hour a day or swimming an hour a day. That is low impact. It is quite the unrealistic to expect a fat person to do wind sprints. (!!) Frank, I hope you were just being hammy and not serious!!
    Also, too much exercise (going beyond one’s physical limits) is not healthy either. Basically, if possible, we should all work everything into MODERATION. The over-doing of anything is no good, and you don’t have to be a doctor to know this. It’s just common sense.

  134. I know some slender people that cannot do wind sprints or handle the impact of jogging. I am fat and my exercise of preference is walking an hour a day or swimming an hour a day. That is low impact. It is quite the unrealistic to expect a fat person to do wind sprints. (!!) Frank, I hope you were just being hammy and not serious!!
    Also, too much exercise (going beyond one’s physical limits) is not healthy either. Basically, if possible, we should all work everything into MODERATION. The over-doing of anything is no good, and you don’t have to be a doctor to know this. It’s just common sense.

  135. Yea! I have (temporary) access to a wireless.
    Do I think most obesity is endocrine related? Sort of. I think the main reason for obesity in our society is the easy access to unhealthy food. Alcoholism is rampant in Russia. Do I think that is because of genetics? Maybe a little; but most is due to the availability of Vodka. Once obese, however, I do think the endocrine effects of adipose tissue kicks in and causes it to become very difficult to lose weight (this is really the first time in the history of human kind that the major push is to lose weight, rather than gain). Our bodies are very good at adding, but bad at removing weight. There are studies with Leptin done recently that suggest the addition of this substrate may fix this problem. Let’s hope.

    I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.

    Even for those for whom the problem is not physiologic, the problem of compulsive eating (for comfort) is a really big deal. It should not be underestimated how hard it is to kick an addiction for something you cannot live without. I fight this battle personally.

    Bottom line: very complex problem and only beginning to understand it. We should not patronize anyone, which is what many doctors do in this situation. I want it to be easy for people, regardless of their size or lifestyle, to come into my office and seek whatever help they need. Lecturing and guilt-tripping is a sure-fire way to undermine that.

  136. Yea! I have (temporary) access to a wireless.
    Do I think most obesity is endocrine related? Sort of. I think the main reason for obesity in our society is the easy access to unhealthy food. Alcoholism is rampant in Russia. Do I think that is because of genetics? Maybe a little; but most is due to the availability of Vodka. Once obese, however, I do think the endocrine effects of adipose tissue kicks in and causes it to become very difficult to lose weight (this is really the first time in the history of human kind that the major push is to lose weight, rather than gain). Our bodies are very good at adding, but bad at removing weight. There are studies with Leptin done recently that suggest the addition of this substrate may fix this problem. Let’s hope.

    I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.

    Even for those for whom the problem is not physiologic, the problem of compulsive eating (for comfort) is a really big deal. It should not be underestimated how hard it is to kick an addiction for something you cannot live without. I fight this battle personally.

    Bottom line: very complex problem and only beginning to understand it. We should not patronize anyone, which is what many doctors do in this situation. I want it to be easy for people, regardless of their size or lifestyle, to come into my office and seek whatever help they need. Lecturing and guilt-tripping is a sure-fire way to undermine that.

  137. Thanks for this post. As someone who has been fat all her life and who is mortified of doctor’s appointments this was a really good read for me.
    As for why people are/ become fat: As said elsewhere, the reasons are complex and they differ from person to person. Personally, I am one of the fat people who do overeat – to a degree that I personally call it an eating disorder (and just as a note, not every fat person overeats and I am pretty sure that even if I stopped overeating for good I still would not lose enough weight to get me into the “normal” range of BMI). Still, I have a real problem with how many people, including most doctors that I have met, stereotype me.

    Yes, I have a very problematic relationship with food, but this relationship is more complex than simple overeating. I have cycled between weight loss and weight regain for many years. I basically feel guilty for eating at all, and whenever someone (and particularly a doctor or another health care provider) tells me I need to lose weight my first reaction is to plan not to eat for a few days at all (and yes, I have done that, as hard as it seems to imagine). True, this is hardly people intend with their comments, and I can choose not to react on my first impulse, but the fact remains that these comments can be very destructive for a number of people.

    Frankly, I am pissed off that I have gotten the advice to lose weight by a doctor when I went to see him for an ear infection. I am pissed off that when I saw a cardiologist in the middle of my last big weight loss because I had developed high blood pressure he told me to lose weight and when I said that I had lost already over 40 pounds (which was at the time over 15% of my total body weight) he told me to just keep it up and lose some more – irrespective of the fact that I had lost the first 40 pounds very quickly and that it had not helped my blood pressure whatsoever. I am also pissed off that I have not seen one doctor who really listened when I told him or her about the effects that making me feel bad about my weight has on my already shaky relationship with my body and with food. And I am extremely pissed off that when it was discovered that I have gallstones that became (mildly) symptomatic after a weight loss my doctor told me how great my weight loss was for my gallbladder and that when I actually developed amenorrhea while I was in six months medically supervised weight loss program as a teen nobody cared – after all I had lost weight and that was a good thing, right?

    I really believe that most doctors have the best interest of their patients in mind. And I understand that there is limited time that a doctor can spend with each patient – and to listen to my weight/ weigth loss history and why I don’t want to go on another conscious weight loss attempt right now needs time, particularly since I get so anxious when I step into a doctor’s office that my tongue gets completely tied and I change from a reasonably intelligent woman with a life science and a psychology degree into someone that can barely string two words together. Still, it would be nice that if I do manage to mention some of the things I described above as a response to getting bludgered with weight loss advice the respective doctor would show some sign that he or she actually listened instead of saying something along the lines of “I know this is a weak spot for you”. (You bet it is a “weak spot”, but honestly, that really doesn’t describe the issue well, and it certainly does not solve it.)

    I am interested in taking responsibility for my health. But if you really want to be of assistence to me in that matter than you have to take seriously what I tell you. You also have to take serious that issues like shame and fear of getting stared at or even insulted keep many fat people from gyms, swimmingpools, dance and exercise classes or even public biking paths (and that fear is justified, believe me). And you have to understand that even if I decide not to make another weight loss attempt you can still help me to build a more healthy life, even in terms of exercise and food. Those issues are hardly only important for health because they have an influence on weight.

  138. Thanks for this post. As someone who has been fat all her life and who is mortified of doctor’s appointments this was a really good read for me.
    As for why people are/ become fat: As said elsewhere, the reasons are complex and they differ from person to person. Personally, I am one of the fat people who do overeat – to a degree that I personally call it an eating disorder (and just as a note, not every fat person overeats and I am pretty sure that even if I stopped overeating for good I still would not lose enough weight to get me into the “normal” range of BMI). Still, I have a real problem with how many people, including most doctors that I have met, stereotype me.

    Yes, I have a very problematic relationship with food, but this relationship is more complex than simple overeating. I have cycled between weight loss and weight regain for many years. I basically feel guilty for eating at all, and whenever someone (and particularly a doctor or another health care provider) tells me I need to lose weight my first reaction is to plan not to eat for a few days at all (and yes, I have done that, as hard as it seems to imagine). True, this is hardly people intend with their comments, and I can choose not to react on my first impulse, but the fact remains that these comments can be very destructive for a number of people.

    Frankly, I am pissed off that I have gotten the advice to lose weight by a doctor when I went to see him for an ear infection. I am pissed off that when I saw a cardiologist in the middle of my last big weight loss because I had developed high blood pressure he told me to lose weight and when I said that I had lost already over 40 pounds (which was at the time over 15% of my total body weight) he told me to just keep it up and lose some more – irrespective of the fact that I had lost the first 40 pounds very quickly and that it had not helped my blood pressure whatsoever. I am also pissed off that I have not seen one doctor who really listened when I told him or her about the effects that making me feel bad about my weight has on my already shaky relationship with my body and with food. And I am extremely pissed off that when it was discovered that I have gallstones that became (mildly) symptomatic after a weight loss my doctor told me how great my weight loss was for my gallbladder and that when I actually developed amenorrhea while I was in six months medically supervised weight loss program as a teen nobody cared – after all I had lost weight and that was a good thing, right?

    I really believe that most doctors have the best interest of their patients in mind. And I understand that there is limited time that a doctor can spend with each patient – and to listen to my weight/ weigth loss history and why I don’t want to go on another conscious weight loss attempt right now needs time, particularly since I get so anxious when I step into a doctor’s office that my tongue gets completely tied and I change from a reasonably intelligent woman with a life science and a psychology degree into someone that can barely string two words together. Still, it would be nice that if I do manage to mention some of the things I described above as a response to getting bludgered with weight loss advice the respective doctor would show some sign that he or she actually listened instead of saying something along the lines of “I know this is a weak spot for you”. (You bet it is a “weak spot”, but honestly, that really doesn’t describe the issue well, and it certainly does not solve it.)

    I am interested in taking responsibility for my health. But if you really want to be of assistence to me in that matter than you have to take seriously what I tell you. You also have to take serious that issues like shame and fear of getting stared at or even insulted keep many fat people from gyms, swimmingpools, dance and exercise classes or even public biking paths (and that fear is justified, believe me). And you have to understand that even if I decide not to make another weight loss attempt you can still help me to build a more healthy life, even in terms of exercise and food. Those issues are hardly only important for health because they have an influence on weight.

  139. Jeez Sannanina, BLA BLA BLA, seriously, do you ever read other peoples comments? You’ve got Cushing’s Baby, waddle your fat ass to the Endocrinologist and get a check up. Never Understood Women, isn’t Amennorhea a Good Thing? That’d be enough to keep me doin Crunches, Nome Sayin? And don’t feel guilty about children starving in Darfur while you inhale that King Size bag of Doritos, they’ll make more.

  140. Jeez Sannanina, BLA BLA BLA, seriously, do you ever read other peoples comments? You’ve got Cushing’s Baby, waddle your fat ass to the Endocrinologist and get a check up. Never Understood Women, isn’t Amennorhea a Good Thing? That’d be enough to keep me doin Crunches, Nome Sayin? And don’t feel guilty about children starving in Darfur while you inhale that King Size bag of Doritos, they’ll make more.

  141. Frank Drackman – my comment was probably longer than it should have been, it is one of my weaknesses that I am not very concise when I talk about personal experiences. I wanted to offer an example of one fat patient and her experiences with doctors and why she tends to distrust them and if I failed at that that’s due to my own shortcomings.
    But you have no, no right whatsover to judge if I am concerned about starving children in Darfur or the pain and suffering of other people in this world or not. I have worked as a freaking full-time volunteer for two years, one of them with a developmental aid agency. I have been a vegetarian since I was fifteen, in part because of the negative effect that meat overconsumption has on the environment and on food availability for people in poorer countries. I don’t own a car, so I use public transport or walk and bike in order to go place. (Yes, imagine that, a fat person who rides a bike!) And I don’t like Doritos.

    I try not to be judgmental of others, usually I go by the assumption that most people at least mean well. But you really should consider that it is not a very smart thing to assume things about others if you have very little information about them.

  142. Frank Drackman – my comment was probably longer than it should have been, it is one of my weaknesses that I am not very concise when I talk about personal experiences. I wanted to offer an example of one fat patient and her experiences with doctors and why she tends to distrust them and if I failed at that that’s due to my own shortcomings.
    But you have no, no right whatsover to judge if I am concerned about starving children in Darfur or the pain and suffering of other people in this world or not. I have worked as a freaking full-time volunteer for two years, one of them with a developmental aid agency. I have been a vegetarian since I was fifteen, in part because of the negative effect that meat overconsumption has on the environment and on food availability for people in poorer countries. I don’t own a car, so I use public transport or walk and bike in order to go place. (Yes, imagine that, a fat person who rides a bike!) And I don’t like Doritos.

    I try not to be judgmental of others, usually I go by the assumption that most people at least mean well. But you really should consider that it is not a very smart thing to assume things about others if you have very little information about them.

  143. “I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.”
    Dr. Rob, I appreciate that you do look further, but those of us who’ve lived through endocrine hell know that a case of Cushing’s, or other endocrine disease, can slip past really good physicians if they believe that it’s so rare that “nobody gets it”, as some of us have been told. An excess of cortisol (very similar to the steroids many people have to take for arthritis or asthma) actually makes a person extremely hungry. High cortisol also wreaks havoc on blood sugar levels and that can make a person hungry, too. So if you tell someone with this kind of hunger that their weight is their own fault for eating so much, chances are they will believe you. We feel guilty enough about our appearance and are already blaming ourselves before even seeing a doctor. To further your endocrine education, I hope you will check out http://survivethejourney.blogspot.com. Robin has a great post about her hunger resulting from high cortisol that might really illuminate the subject for you.
    Oh, and Drackman, yes most people do lose weight after surgery. I easily lost 50 pounds post-surgery, with little effort. I’ve not lost all that I gained, but am earnestly working on losing the rest. I’ve been thin and I’ve been fat, and I prefer thin. Thin people don’t get insulted by doctors as often, for one thing.

  144. “I also think that other causes are under-diagnosed (I always check thyroid and BMP on most patients with obesity, but rarely find abnormalities). If other things suggest cushings, I may look further, but I am getting an education in the comments on this post.”
    Dr. Rob, I appreciate that you do look further, but those of us who’ve lived through endocrine hell know that a case of Cushing’s, or other endocrine disease, can slip past really good physicians if they believe that it’s so rare that “nobody gets it”, as some of us have been told. An excess of cortisol (very similar to the steroids many people have to take for arthritis or asthma) actually makes a person extremely hungry. High cortisol also wreaks havoc on blood sugar levels and that can make a person hungry, too. So if you tell someone with this kind of hunger that their weight is their own fault for eating so much, chances are they will believe you. We feel guilty enough about our appearance and are already blaming ourselves before even seeing a doctor. To further your endocrine education, I hope you will check out http://survivethejourney.blogspot.com. Robin has a great post about her hunger resulting from high cortisol that might really illuminate the subject for you.
    Oh, and Drackman, yes most people do lose weight after surgery. I easily lost 50 pounds post-surgery, with little effort. I’ve not lost all that I gained, but am earnestly working on losing the rest. I’ve been thin and I’ve been fat, and I prefer thin. Thin people don’t get insulted by doctors as often, for one thing.

  145. An unreal thing I heard today from the author of “Why are you so fat” (his blog): He says that pituitary surgery is … and I quote, “the easy way out of dieting and exercise” (!!)
    Oh dear. Well, thankfully he’s not a doctor. He just pretends to be one.

  146. An unreal thing I heard today from the author of “Why are you so fat” (his blog): He says that pituitary surgery is … and I quote, “the easy way out of dieting and exercise” (!!)
    Oh dear. Well, thankfully he’s not a doctor. He just pretends to be one.

  147. Oh my! I hope he isn’t a doctor!Pituitary surgery might be considered the easy way out of disability and death, but it’s a rather elaborate and extremely dangerous way to lose weight!

  148. Oh my! I hope he isn’t a doctor!Pituitary surgery might be considered the easy way out of disability and death, but it’s a rather elaborate and extremely dangerous way to lose weight!

  149. I know this is topic is about obesity, but I feel the need the stick up for all the Cushing’s patients out there!!!!Cushing’s is NOT as rare as some doctors that may think. I belong to a supprt group of other Cushing’s patients that has 4,855 other members and I know there are many more out there. Many that don’t sign up for this support group. I know this because when myself or one of the other memebers goes to the specilists we see, there are many other “Cushies” in the waiting rooms, who do not know about the support group. Unfortunitly the word is not out there enough yet, and we have to travel to see these Cushing’s specialists. The doctor I see that specializes in only Cushing’s will flat out tell you “Cushing’s is not nearly as rare as once thought.”

    So please, when looking at a obese person please don’t pass judgement on them, they may have a real dease, that if not treated is deadly, just like cancer.

  150. I know this is topic is about obesity, but I feel the need the stick up for all the Cushing’s patients out there!!!!Cushing’s is NOT as rare as some doctors that may think. I belong to a supprt group of other Cushing’s patients that has 4,855 other members and I know there are many more out there. Many that don’t sign up for this support group. I know this because when myself or one of the other memebers goes to the specilists we see, there are many other “Cushies” in the waiting rooms, who do not know about the support group. Unfortunitly the word is not out there enough yet, and we have to travel to see these Cushing’s specialists. The doctor I see that specializes in only Cushing’s will flat out tell you “Cushing’s is not nearly as rare as once thought.”

    So please, when looking at a obese person please don’t pass judgement on them, they may have a real dease, that if not treated is deadly, just like cancer.

  151. I would like to thank you for your wonderful article, and commend you on such an enlightened perspective. If you will indulge me, I will add my experience and point of view. I believe that judging any degree of healthful habits based on weight is prone to great inaccuracy. I lost over 50 pound over a period of 4 years, despite 3 pregnancies. During this time, I developed a very pronounced and life threatening arrhythmia. I was also hypokalemic, however the only person to recognize and devise treatment for this was my pregnancy caregiver. My point in this brief history is to illustrate that weight loss can be a concern, and yet in our “thin” obsessed culture, no one thinks twice to mention or ask about it. It is often overlooked or even commended. Had I GAINED 50 lbs, I feel more than certain it would have been mentioned, likely with condescension. However, as it was not, I went years without realizing a potentially life-threatening issue was developing. I was thrilled to lose the weight, though I felt increasing fatigue, etc… Yet the weight loss required no effort on my part. My current DR believes it’s quite possible that I had Addisons, then went into spontaneous remission. I was active before the weight loss, and was active during….and am currently quite active though I now have lab verified hypercortisolism, and have regained some weight, despite a healthy diet, exercise (what I can tolerate, due to extreme muscle wasting and bone catabolism) and relaxation/meditation.
    I am happy to “do the time” with regard to exercise. I am disciplined with regard to cooking as well as how I eat and feed my family. I am seeing an endocrinologist, but not for a quick fix. I don’t relish the idea of pituitary or adrenal surgery. Though, if I have to have it, the very LAST reason will be for weight loss. Primarily, and I believe you will find this is true for many of not most overweight patients, weight is not the biggest issue. I felt as tired and unwell when I was thin as I do now that I am heavier. Quality of life, the ability to care for and enjoy our loved ones, living with joy and vibrance, these are the things that we miss and wish to restore to our lives. And to attain that, we need compassionate DRs who are willing to listen to us, believe us, and work with us to remove the obstacles to good health or at least do no harm.

  152. I would like to thank you for your wonderful article, and commend you on such an enlightened perspective. If you will indulge me, I will add my experience and point of view. I believe that judging any degree of healthful habits based on weight is prone to great inaccuracy. I lost over 50 pound over a period of 4 years, despite 3 pregnancies. During this time, I developed a very pronounced and life threatening arrhythmia. I was also hypokalemic, however the only person to recognize and devise treatment for this was my pregnancy caregiver. My point in this brief history is to illustrate that weight loss can be a concern, and yet in our “thin” obsessed culture, no one thinks twice to mention or ask about it. It is often overlooked or even commended. Had I GAINED 50 lbs, I feel more than certain it would have been mentioned, likely with condescension. However, as it was not, I went years without realizing a potentially life-threatening issue was developing. I was thrilled to lose the weight, though I felt increasing fatigue, etc… Yet the weight loss required no effort on my part. My current DR believes it’s quite possible that I had Addisons, then went into spontaneous remission. I was active before the weight loss, and was active during….and am currently quite active though I now have lab verified hypercortisolism, and have regained some weight, despite a healthy diet, exercise (what I can tolerate, due to extreme muscle wasting and bone catabolism) and relaxation/meditation.
    I am happy to “do the time” with regard to exercise. I am disciplined with regard to cooking as well as how I eat and feed my family. I am seeing an endocrinologist, but not for a quick fix. I don’t relish the idea of pituitary or adrenal surgery. Though, if I have to have it, the very LAST reason will be for weight loss. Primarily, and I believe you will find this is true for many of not most overweight patients, weight is not the biggest issue. I felt as tired and unwell when I was thin as I do now that I am heavier. Quality of life, the ability to care for and enjoy our loved ones, living with joy and vibrance, these are the things that we miss and wish to restore to our lives. And to attain that, we need compassionate DRs who are willing to listen to us, believe us, and work with us to remove the obstacles to good health or at least do no harm.

  153. The doctor I see that specializes in only Cushing’s will flat out tell you “Cushing’s is not nearly as rare as once thought.”

    I reckon that this could be said about other (non-obesity related) diseases as well.

    So please, when looking at a obese person please don’t pass judgement on them, they may have a real dease, that if not treated is deadly, just like cancer.

    I honestly don’t think that the fat stigma will ever go away. Has education ever worked in the past? And this goes for all other people who appear as if they cannot defend themselves including those with AIDS etc. With that said, since we cannot change the ignorant playground bullies out there, we must change our mindset… somehow. So, lose weight? Regarding someone’s looks, there are some things that we can change and some things that we cannot. People so thin-skinned to take someone’s life style and looks so personally just may have worse problems than we (obese people) do. Think about it. 🙂

  154. The doctor I see that specializes in only Cushing’s will flat out tell you “Cushing’s is not nearly as rare as once thought.”

    I reckon that this could be said about other (non-obesity related) diseases as well.

    So please, when looking at a obese person please don’t pass judgement on them, they may have a real dease, that if not treated is deadly, just like cancer.

    I honestly don’t think that the fat stigma will ever go away. Has education ever worked in the past? And this goes for all other people who appear as if they cannot defend themselves including those with AIDS etc. With that said, since we cannot change the ignorant playground bullies out there, we must change our mindset… somehow. So, lose weight? Regarding someone’s looks, there are some things that we can change and some things that we cannot. People so thin-skinned to take someone’s life style and looks so personally just may have worse problems than we (obese people) do. Think about it. 🙂

  155. […] for dessert (it’s mainly fruit actually, he rationalizes), I read this excellent post from medical blogger, Dr Rob – it was highlighted in New York Times* which is how I found it – and […]

  156. Jeanne Horvath

    Doctors and other medical personnel are not immune from the problem of stating the obvious. I have a couple of examples that are not obesity related. My husband who had polio at the age of 5 (he is now 60) saw a physician’s assistant for a back spasm. The PA looked at his clearly curved back and said ‘Have you considered a lift?’ My husband just waved his built-up left shoe.
    I have ichthyosis which makes my skin extremely dry and scaly. As an adolescent, I was very self-conscious about this. Almost every visit with a doctor for any reason started with the doctor sayin ‘Do you know you have extremely dry skin? Have you tried xxx?’ I finally saw a doctor in my late 20s who said ‘Well, you probably know more about this than I do.’

  157. Jeanne Horvath

    Doctors and other medical personnel are not immune from the problem of stating the obvious. I have a couple of examples that are not obesity related. My husband who had polio at the age of 5 (he is now 60) saw a physician’s assistant for a back spasm. The PA looked at his clearly curved back and said ‘Have you considered a lift?’ My husband just waved his built-up left shoe.
    I have ichthyosis which makes my skin extremely dry and scaly. As an adolescent, I was very self-conscious about this. Almost every visit with a doctor for any reason started with the doctor sayin ‘Do you know you have extremely dry skin? Have you tried xxx?’ I finally saw a doctor in my late 20s who said ‘Well, you probably know more about this than I do.’

  158. Obesity certainly is a complex condition, and in any individual, it is hard to tell without workup (and often times *with* workup) what the underlying causes may be — Cushing’s, other metabolic/endocrine cause, intestinal bacteria, differing metabolic “set point”, lack of exercise, overeating, etc..
    However, it *IS* true that we as a nation are getting more and more obese, at an almost ridiculous rate:
    http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/

    It would be hard to believe that our increasing obesity as a nation over the last 20 years can be attributed to much other than changing diets/lifestyle habits.

    What does this mean in an individual obese person’s case? Very little. It could still be caused by any number of factors, and even if the obesity *IS* primarily due to overeating/sedentary lifestyle, it still means a long, difficult battle with physical/mental/emotional components.

  159. Obesity certainly is a complex condition, and in any individual, it is hard to tell without workup (and often times *with* workup) what the underlying causes may be — Cushing’s, other metabolic/endocrine cause, intestinal bacteria, differing metabolic “set point”, lack of exercise, overeating, etc..
    However, it *IS* true that we as a nation are getting more and more obese, at an almost ridiculous rate:
    http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/

    It would be hard to believe that our increasing obesity as a nation over the last 20 years can be attributed to much other than changing diets/lifestyle habits.

    What does this mean in an individual obese person’s case? Very little. It could still be caused by any number of factors, and even if the obesity *IS* primarily due to overeating/sedentary lifestyle, it still means a long, difficult battle with physical/mental/emotional components.

  160. Epigenetics could promote obesity in next generation :
    “There is an obesity epidemic in the United States and it’s increasingly recognized as a worldwide phenomenon,” said Dr. Robert A. Waterland, assistant professor of pediatrics – nutrition at BCM and lead author of the study that appears in the International Journal of Obesity. “Why is everyone getting heavier and heavier? One hypothesis is that maternal obesity before and during pregnancy affects the establishment of body weight regulatory mechanisms in her baby. Maternal obesity could promote obesity in the next generation.”

    This not new news. Can genes explain rising obesity?
    Contrary to conventional wisdom, the obesity epidemic is not restricted to people in Western countries who eat bad diets and are not very active.

    In developing countries, it is estimated that over 115 million people suffer from obesity-related problems.

    Experts believe that in many of these people these problems are not due to lifestyle but a condition called metabolic syndrome…There are many uncertainties about metabolic syndrome but one thing is certain – it cannot be explained entirely by genetics or lifestyle factors.

    … Professor Mark Hanson, Director of Developmental Origins of Health and Disease Division and professor of cardiovascular science at the University of Southampton believes the answer lies in the study of epigenetics.

    A student newspaper caught wind of it recently, though. Yes, you can tell it’s a student, but the sources are excellent. Well worth reading.

    “This tells us that nutrition in utero is largely responsible for our epigenetic
    programming and that under nutrition in one generation could explain the rise in
    obesity, heart disease and diabetes in the next! It’s a far cry from the popular
    cultural view that lifestyle changes are the be all and end all determinants of
    good, or poor health – that everything boils down to personal decision
    making…”

    Again, I hope my coding is readable. Apologies ahead of time if it isn’t.

  161. Epigenetics could promote obesity in next generation :
    “There is an obesity epidemic in the United States and it’s increasingly recognized as a worldwide phenomenon,” said Dr. Robert A. Waterland, assistant professor of pediatrics – nutrition at BCM and lead author of the study that appears in the International Journal of Obesity. “Why is everyone getting heavier and heavier? One hypothesis is that maternal obesity before and during pregnancy affects the establishment of body weight regulatory mechanisms in her baby. Maternal obesity could promote obesity in the next generation.”

    This not new news. Can genes explain rising obesity?

    Contrary to conventional wisdom, the obesity epidemic is not restricted to people in Western countries who eat bad diets and are not very active.

    In developing countries, it is estimated that over 115 million people suffer from obesity-related problems.

    Experts believe that in many of these people these problems are not due to lifestyle but a condition called metabolic syndrome…There are many uncertainties about metabolic syndrome but one thing is certain – it cannot be explained entirely by genetics or lifestyle factors.

    … Professor Mark Hanson, Director of Developmental Origins of Health and Disease Division and professor of cardiovascular science at the University of Southampton believes the answer lies in the study of epigenetics.

    A student newspaper caught wind of it recently, though. Yes, you can tell it’s a student, but the sources are excellent. Well worth reading.

    “This tells us that nutrition in utero is largely responsible for our epigenetic
    programming and that under nutrition in one generation could explain the rise in
    obesity, heart disease and diabetes in the next! It’s a far cry from the popular
    cultural view that lifestyle changes are the be all and end all determinants of
    good, or poor health – that everything boils down to personal decision
    making…”

    Again, I hope my coding is readable. Apologies ahead of time if it isn’t.

  162. This was a very interesting post. It reminded me of a radio program I heard several years ago on the CBC by Kelley Jo Burke. It was called Fat Girls Sweet. In it she mentions that any health issue she needs to go to the doctor about is dismissed by the doctor as being a result of her weight. She rants, justly, that her sore throat will not just go away if she loses weight.
    You can listen to it here:

    http://www.cbc.ca/ideas/features/fat/index.html

  163. This was a very interesting post. It reminded me of a radio program I heard several years ago on the CBC by Kelley Jo Burke. It was called Fat Girls Sweet. In it she mentions that any health issue she needs to go to the doctor about is dismissed by the doctor as being a result of her weight. She rants, justly, that her sore throat will not just go away if she loses weight.
    You can listen to it here:

    http://www.cbc.ca/ideas/features/fat/index.html

  164. Hey Dr. Rob,don’t you think that last comment of Drackman’s is personal?

    And I challenge ANYONE who has had lapbanding to describe it as “non-invasive” and easily tolerated or some such nonsense. Throwing up for WEEKS is common as dirt, plateauing after 40-50 pounds is NORMAL, not being able to attend a normal meal is terribly mentally debilitating.

    As a fat man who neither eats fast food nor makes Doritos a regular part of his diet, I can only say that I pay as much attention to the naturally skinny MD lecturing me about weight as I do the 20-something hygenist who lectures me about flossing. And I can probably walk you into the ground, because at 51 I can still knock off 12-minute miles for approximately forever (I walk at least 15 miles/week. It hasn’t done a damn thing for my weight, but my dog enjoys it. So THIS to the doc up-thread: come walk with me, and then come back and talk about walking the dog, you small-minded idiot.)

  165. Hey Dr. Rob,don’t you think that last comment of Drackman’s is personal?

    And I challenge ANYONE who has had lapbanding to describe it as “non-invasive” and easily tolerated or some such nonsense. Throwing up for WEEKS is common as dirt, plateauing after 40-50 pounds is NORMAL, not being able to attend a normal meal is terribly mentally debilitating.

    As a fat man who neither eats fast food nor makes Doritos a regular part of his diet, I can only say that I pay as much attention to the naturally skinny MD lecturing me about weight as I do the 20-something hygenist who lectures me about flossing. And I can probably walk you into the ground, because at 51 I can still knock off 12-minute miles for approximately forever (I walk at least 15 miles/week. It hasn’t done a damn thing for my weight, but my dog enjoys it. So THIS to the doc up-thread: come walk with me, and then come back and talk about walking the dog, you small-minded idiot.)

  166. Sometimes those types of things are worth leaving up due to the fact that they so obviously indict the one saying it. There are a very small number of people who agree with or sympathize with his opinion. Leaving it up there simply lets more people draw opinions on him based on the statements he made.
    The whole point of this, however, was to avoid making moral judgments of another person based either on their weight or anything else. Another recent post on the NY times blog states that the psychological damage is equal to those who bully and those who are bullied. We need to step beyond that kind of stuff and start acting like adults.

  167. Sometimes those types of things are worth leaving up due to the fact that they so obviously indict the one saying it. There are a very small number of people who agree with or sympathize with his opinion. Leaving it up there simply lets more people draw opinions on him based on the statements he made.
    The whole point of this, however, was to avoid making moral judgments of another person based either on their weight or anything else. Another recent post on the NY times blog states that the psychological damage is equal to those who bully and those who are bullied. We need to step beyond that kind of stuff and start acting like adults.

  168. Gee John, for someone who is so concerned about comments being “personal”, you don’t seem to mind making personal attacks yourself(“…THIS to the doc up-thread….etc..”, you know what you wrote. To quote myself, since you didn’t, “Walking the dog is not sufficient exercise to lose weight for anyone”. Since you are a self-described “fat man”, I guess I’m right about those 12 minute miles while you’re out walking Lassie!

  169. Gee John, for someone who is so concerned about comments being “personal”, you don’t seem to mind making personal attacks yourself(“…THIS to the doc up-thread….etc..”, you know what you wrote. To quote myself, since you didn’t, “Walking the dog is not sufficient exercise to lose weight for anyone”. Since you are a self-described “fat man”, I guess I’m right about those 12 minute miles while you’re out walking Lassie!

  170. When I speak to my patients about losing weight (or smoking cessation, quitting drugs, safe sex practices, e.t.c.), I find it best to be honest and up front with them, but in a way that doesn’t make them feel like I think they’re losers. Patients can tell when the physician cares about them and when the physician is judging them. I find that one of the ways I can communicate to the patients that I care for them is to spend extra time with them during those visits. I don’t just recommend weight loss and leave. Obesity is an epidemic in our country that needs to be tackled by physicians, but it has to be done with compassion, kindness and honesty. Great post Dr. Rob.

  171. When I speak to my patients about losing weight (or smoking cessation, quitting drugs, safe sex practices, e.t.c.), I find it best to be honest and up front with them, but in a way that doesn’t make them feel like I think they’re losers. Patients can tell when the physician cares about them and when the physician is judging them. I find that one of the ways I can communicate to the patients that I care for them is to spend extra time with them during those visits. I don’t just recommend weight loss and leave. Obesity is an epidemic in our country that needs to be tackled by physicians, but it has to be done with compassion, kindness and honesty. Great post Dr. Rob.

  172. Gee Paul, where did I say I was concerned about comments being personal? That was Rob. RFC, please. I was pointing out an inconsistency, which was explained to me.
    And the point, sorry that it whipped by you, is that even fast walking, and being relatively fit, don’t translate into weight loss. Out here in the real world, very little does, sanctimonious MDs nonwithstanding.

    But you go right ahead and nag and bitch at your patients, and see if compliance goes up or down.

  173. Gee Paul, where did I say I was concerned about comments being personal? That was Rob. RFC, please. I was pointing out an inconsistency, which was explained to me.
    And the point, sorry that it whipped by you, is that even fast walking, and being relatively fit, don’t translate into weight loss. Out here in the real world, very little does, sanctimonious MDs nonwithstanding.

    But you go right ahead and nag and bitch at your patients, and see if compliance goes up or down.

  174. Sanctimonious or not, stop acting like Jr. High students. Discussion and disagreement is one thing, but nobody enjoys watching these kind of comments. The point of the post was to encourage a mature approach to treating people. Clearly the name calling can happen from both sides. This point is well proven and any more sticking your tongue out won’t accomplish anything. For anyone else who is subscribed to these comments, I ask you to stop.

  175. Sanctimonious or not, stop acting like Jr. High students. Discussion and disagreement is one thing, but nobody enjoys watching these kind of comments. The point of the post was to encourage a mature approach to treating people. Clearly the name calling can happen from both sides. This point is well proven and any more sticking your tongue out won’t accomplish anything. For anyone else who is subscribed to these comments, I ask you to stop.

  176. OK, Sorry for the snark, Dr. Rob.
    But the reality of weight loss is that even with Weight watchers, and a lot more exercise than usually called for, I AM NOT LOSING WEIGHT. I am not alone in this.

    And when I go to my doctor, that’s all I hear about, never mind the ringing in my ears that I went for.

    So, I stop going. THAT’S the point.

    I’ve read everything I can get my hands on about weight loss, the original papers when possible. And the one thing that is clear is that we don’t know why people gain weight, we don’t know why they can’t lose it and we don’t know why they can’t keep it off.

    But we do know that a sympathetic ear in the Dr.’s office is more likely to be listened to than “tough love” (meaning yelling and folding arms and being tough.) It is entirely possible to be committed to telling your patients what they need to hear without making them feel like they are losers for not losing. At least then you have them coming into your office, so that you can monitor them for other health issues.

  177. OK, Sorry for the snark, Dr. Rob.
    But the reality of weight loss is that even with Weight watchers, and a lot more exercise than usually called for, I AM NOT LOSING WEIGHT. I am not alone in this.

    And when I go to my doctor, that’s all I hear about, never mind the ringing in my ears that I went for.

    So, I stop going. THAT’S the point.

    I’ve read everything I can get my hands on about weight loss, the original papers when possible. And the one thing that is clear is that we don’t know why people gain weight, we don’t know why they can’t lose it and we don’t know why they can’t keep it off.

    But we do know that a sympathetic ear in the Dr.’s office is more likely to be listened to than “tough love” (meaning yelling and folding arms and being tough.) It is entirely possible to be committed to telling your patients what they need to hear without making them feel like they are losers for not losing. At least then you have them coming into your office, so that you can monitor them for other health issues.

  178. Thank you. As a former obese person, I can only say that we KNOW we are fat. When we see the doctor for an injury or illness, we want help for that – not a lecture about something we must live with every day. Lectures will not motivate us to lose weight. Motivation comes only – only – from within. So God bless you for being a doctor who understands and truly cares.

  179. Thank you. As a former obese person, I can only say that we KNOW we are fat. When we see the doctor for an injury or illness, we want help for that – not a lecture about something we must live with every day. Lectures will not motivate us to lose weight. Motivation comes only – only – from within. So God bless you for being a doctor who understands and truly cares.

  180. Thanks for the blog! On the other hand, I do cringe when I read of stories about how the government is getting involved with our weight. My son, when he was in kindergarden, was so drilled on what to eat and what not to eat that he wouldn’t eat. Later changing schools, I waved a note from his physicians to the school administrators that he could have anything he wanted to eat. He is nine now, and getting enough food down him is a battle. He is 4′ tall, and weights 54 lbs.
    I too have Cushings. I build hospitals for a living. At the first of my diagnostic journey, ten years ago, I was pretty intimidated by the road that lay ahead (picture dirt road ending at the grand canyon). It took a long time to find a doctor who would listen and put the puzzle together. As more physicians were added, the roads became rockier. In time though, inroads were made, bridges built, and alot of “gravel” was hauled off (some relationships just didn’t work.) In looking at my journey, I think the biggest difference is that I had one doctor who was very encouraging. He turned my thinking about the weight issue to me being healthy. He encouraged me to excercise and take care of my health as best as possible in the face of a potential debilitaing illness. Where all of the other doctors had written me off as a nut, or someone who just wanted attention, he was an example of patience, of steadiness, of calm decision making. He helped calm me during some pretty rough storms. Gradually, I added other doctors that had similar approaches to my care team. It made a difference in how I saw myself (esteem), how I decided to approach my illness (diligence), helped me develop postive relationships with co-workers and family members, and helped me drastically improve the relationship with God and my church.

    I still build hospitals. I still have cushings too. I am at 201lbs, 5’4, with a BMI of 44. The first surgery was not successful. Now, I am on a cortisol inhibitor. I hope to be able to stay on it for about 3 more years, until the current hospital is complete. I started nutrisystem 4 months ago, not to lose weight, although I did lose 8 lbs. Remarkably, my labs were the best they had been in 2 years! My doctors marvel at how well I am doing (under the breath of paddling through uncharted waters)

    Point is… encouragement and caring can make a big difference. The positive effects can have a wider reach that what might be otherwise considered. Some of it is circular too…I renovated the same O.R. that my surgeon operates in 3 times a week.

    🙂

  181. Thanks for the blog! On the other hand, I do cringe when I read of stories about how the government is getting involved with our weight. My son, when he was in kindergarden, was so drilled on what to eat and what not to eat that he wouldn’t eat. Later changing schools, I waved a note from his physicians to the school administrators that he could have anything he wanted to eat. He is nine now, and getting enough food down him is a battle. He is 4′ tall, and weights 54 lbs.
    I too have Cushings. I build hospitals for a living. At the first of my diagnostic journey, ten years ago, I was pretty intimidated by the road that lay ahead (picture dirt road ending at the grand canyon). It took a long time to find a doctor who would listen and put the puzzle together. As more physicians were added, the roads became rockier. In time though, inroads were made, bridges built, and alot of “gravel” was hauled off (some relationships just didn’t work.) In looking at my journey, I think the biggest difference is that I had one doctor who was very encouraging. He turned my thinking about the weight issue to me being healthy. He encouraged me to excercise and take care of my health as best as possible in the face of a potential debilitaing illness. Where all of the other doctors had written me off as a nut, or someone who just wanted attention, he was an example of patience, of steadiness, of calm decision making. He helped calm me during some pretty rough storms. Gradually, I added other doctors that had similar approaches to my care team. It made a difference in how I saw myself (esteem), how I decided to approach my illness (diligence), helped me develop postive relationships with co-workers and family members, and helped me drastically improve the relationship with God and my church.

    I still build hospitals. I still have cushings too. I am at 201lbs, 5’4, with a BMI of 44. The first surgery was not successful. Now, I am on a cortisol inhibitor. I hope to be able to stay on it for about 3 more years, until the current hospital is complete. I started nutrisystem 4 months ago, not to lose weight, although I did lose 8 lbs. Remarkably, my labs were the best they had been in 2 years! My doctors marvel at how well I am doing (under the breath of paddling through uncharted waters)

    Point is… encouragement and caring can make a big difference. The positive effects can have a wider reach that what might be otherwise considered. Some of it is circular too…I renovated the same O.R. that my surgeon operates in 3 times a week.

    🙂

  182. mottsapplesauce

    Kudos to you Kristina, you are a real inspiration for others suffering from Cushings.Best wishes always.

  183. mottsapplesauce

    Kudos to you Kristina, you are a real inspiration for others suffering from Cushings.Best wishes always.

  184. Right on! Its not until we stop feeling guilty about our weight that we can actually lose it! Thank you so much for you insight and understanding!

  185. Right on! Its not until we stop feeling guilty about our weight that we can actually lose it! Thank you so much for you insight and understanding!

  186. As someone who has lost a lot of weight and continues with the journey to lose another 15 to 20 pounds, I can affirm that the stock exercise advice of 30 minutes a day is insufficient for weight loss unless it’s accompanied by fairly strict food intake.
    Now, by strict food intake, I don’t mean under 1000 calories, I mean high nutrient, reduced calorie foods: fruits, veggies, lean protein, etc.

    The mindset that got me where I am and will get me where I am going is that I will do what it takes. If I reach a state of stasis, then something has to change. If I am honest with myself and know that my diet is all it should be (and it never is, honestly) then it’s time to change the exercise or increase it.

    This is something I am doing for me. I never take the attitude of “I’ve done enough, if that doesn’t lose the weight, then I’m not doing any more”…because that’s the attitude that will defeat me and my purpose.

    Always reach for more. More time, more heartbeats per minute, more sweat, more pounds on the barbell. The more you do, the more you CAN do. Think of your time spent exercising NOT as putting in the minimum, but pursuing a new personal best, a world record for YOU. You will always come out a winner.

  187. As someone who has lost a lot of weight and continues with the journey to lose another 15 to 20 pounds, I can affirm that the stock exercise advice of 30 minutes a day is insufficient for weight loss unless it’s accompanied by fairly strict food intake.
    Now, by strict food intake, I don’t mean under 1000 calories, I mean high nutrient, reduced calorie foods: fruits, veggies, lean protein, etc.

    The mindset that got me where I am and will get me where I am going is that I will do what it takes. If I reach a state of stasis, then something has to change. If I am honest with myself and know that my diet is all it should be (and it never is, honestly) then it’s time to change the exercise or increase it.

    This is something I am doing for me. I never take the attitude of “I’ve done enough, if that doesn’t lose the weight, then I’m not doing any more”…because that’s the attitude that will defeat me and my purpose.

    Always reach for more. More time, more heartbeats per minute, more sweat, more pounds on the barbell. The more you do, the more you CAN do. Think of your time spent exercising NOT as putting in the minimum, but pursuing a new personal best, a world record for YOU. You will always come out a winner.

  188. I just…I just wanted to say thank you. For the honesty, for the understanding, for seeing a problem that is a phantom in our society and that hurts far more than most people seem to see.
    That’s it, really.

    Thank you.

  189. I just…I just wanted to say thank you. For the honesty, for the understanding, for seeing a problem that is a phantom in our society and that hurts far more than most people seem to see.
    That’s it, really.

    Thank you.

  190. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs.
    I wish more doctors were like you. I have been in six car accidents, and additionally a work-related injury to my back. Unfortunately, with the work related injury, I lost any chance at workman’s comp because the doctor I went to claimed my injuries were due to my weight and not the fact that a woman weighing more than I was falling from a greater height, and instead of allowing her to fall, I caught her. And I was too young and ignorant at the time to get a lawyer involved to actually make sure I got the care and support I deserved.

    I live with constant back pain. I do my PT related exercises in order to have any kind of reasonable movement. But I’ve always been fat. NO matter what diets, what exercise programs, or whatever, I have never been able to lose more than 50 pounds. I eat less than my husband, who is stick thin.

    And I’m sick of the doctors who are convinced that I must be lying about my caloric intake.

    So, to you sir, I tip my hat. Thank you for being at least one doctor that wants to PARTNER with his patients on their health instead of being a close-minded martinet that thinks shame is an appropriate response!

  191. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs.
    I wish more doctors were like you. I have been in six car accidents, and additionally a work-related injury to my back. Unfortunately, with the work related injury, I lost any chance at workman’s comp because the doctor I went to claimed my injuries were due to my weight and not the fact that a woman weighing more than I was falling from a greater height, and instead of allowing her to fall, I caught her. And I was too young and ignorant at the time to get a lawyer involved to actually make sure I got the care and support I deserved.

    I live with constant back pain. I do my PT related exercises in order to have any kind of reasonable movement. But I’ve always been fat. NO matter what diets, what exercise programs, or whatever, I have never been able to lose more than 50 pounds. I eat less than my husband, who is stick thin.

    And I’m sick of the doctors who are convinced that I must be lying about my caloric intake.

    So, to you sir, I tip my hat. Thank you for being at least one doctor that wants to PARTNER with his patients on their health instead of being a close-minded martinet that thinks shame is an appropriate response!

  192. I disagree with some of the points here — I don’t believe that being fat is a sign of self-hatred on any level (my self-esteem is just dandy, thanks!) or of an unwillingness to “do something” about it — but those are just my opinions, and I don’t argue with people in areas where they are expert and I am not.
    That said, this is a great post, and a wonderful attitude to see from a doctor. Physicians are (obviously) not immune to cultural attitudes, and the hatred and contempt for fat people that is so widespread now is bound to affect them. It’d be great if more physicians were professional enough, and kind enough, to keep their prejudices and judgments out of the doctor-patient exchange, but that doesn’t seem to be realistic.

    It’s funny, though. Many doctors would, quite properly, never dream of criticizing someone for other choices (assuming being fat is a choice) in terms like the ones they routinely use to speak to fat people. Say a wildly promiscuous person came in to be treated for an STD for the umpteenth time. A doctor might say, “Have you considered condoms?” but would never say, “Stop sleeping around, you silly slut.” Yet the same doctor might tell a fat person she is lazy or a glutton or say, “Push yourself away from the table” or “Just stop stuffing yourself.”

    And that disbelieving smirk so many doctors adopt when a fat person talks about his or her weight is every bit as bad as a crude remark. Worse, in fact, because it’s so much harder to respond. I speak up when I see it — but I’m fiercer than most.

  193. I disagree with some of the points here — I don’t believe that being fat is a sign of self-hatred on any level (my self-esteem is just dandy, thanks!) or of an unwillingness to “do something” about it — but those are just my opinions, and I don’t argue with people in areas where they are expert and I am not.
    That said, this is a great post, and a wonderful attitude to see from a doctor. Physicians are (obviously) not immune to cultural attitudes, and the hatred and contempt for fat people that is so widespread now is bound to affect them. It’d be great if more physicians were professional enough, and kind enough, to keep their prejudices and judgments out of the doctor-patient exchange, but that doesn’t seem to be realistic.

    It’s funny, though. Many doctors would, quite properly, never dream of criticizing someone for other choices (assuming being fat is a choice) in terms like the ones they routinely use to speak to fat people. Say a wildly promiscuous person came in to be treated for an STD for the umpteenth time. A doctor might say, “Have you considered condoms?” but would never say, “Stop sleeping around, you silly slut.” Yet the same doctor might tell a fat person she is lazy or a glutton or say, “Push yourself away from the table” or “Just stop stuffing yourself.”

    And that disbelieving smirk so many doctors adopt when a fat person talks about his or her weight is every bit as bad as a crude remark. Worse, in fact, because it’s so much harder to respond. I speak up when I see it — but I’m fiercer than most.

  194. Good points, Tuxer. No, I am not saying that obesity is a sign of self-hatred, but that it often is a cause of self-hatred. When society treats you like contempt, it is not hard to start going along with society.
    Very good point on the STD. I truly feel more sympathy with the obese than with the over-sexed. The latter, however, is a sign of significant psychological pathology.

  195. Good points, Tuxer. No, I am not saying that obesity is a sign of self-hatred, but that it often is a cause of self-hatred. When society treats you like contempt, it is not hard to start going along with society.
    Very good point on the STD. I truly feel more sympathy with the obese than with the over-sexed. The latter, however, is a sign of significant psychological pathology.

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