How to Address Obesity in a Fat-Phobic Society

A friend of mine -- I'll call her Ellen -- recently went to her regular medical clinic after realizing that she was newly suffering from an old family problem: acid reflux. Her doctor was out on maternity leave, so she met with a replacement. Without asking Ellen any questions about her relationship to her weight (she is overweight and well aware of it), he launched into a robotic exposition about dieting.

Ellen explained to him that she worked out regularly and also did her best to eat healthy, but had a philosophical problem with turning food into the enemy. He simply retorted: "The only way you're going to lose weight is to cut the carbs. So ... cut the carbs."

"When he brought up my weight I wanted to have a real conversation with him, but instead he gave me his version of my 'problem'," Ellen said. "It made me really angry."

My friend's experience is not an anomaly. In fact, it is representative of a still unchanged attitude among too many medical doctors and nutritionists that fat people are problems to be solved; if they can just come up with the perfect equation, they figure, BMIs can be lowered and the supposed obesity epidemic eradicated.

This attitude shows up in doctor's offices where overweight and obese patients are often subjected to inquisition-like questioning. Yet they are rarely asked other, arguably more important questions: What's your experience of your body? How is your quality of life? How do you feel about your weight?

It also shows up in obesity intervention programs throughout the country, where a person's culture, class, education, or even genetics, are overlooked in the dogged pursuit to motivate what too many clinicians see as "lazy Americans" to lose pounds.
It's not as if we don't have the evidence that these factors -- culture, class, education, genetics -- matter. Yet another study just came out by University of Washington researchers who found gaping disparities in obesity rates among ZIP codes in the Seattle area. Every $100,000 in median home value for a ZIP code corresponded with a 2 percent drop in obesity.

Adam Drewnowski, director of the UW Center for Obesity Research, told the Seattle Post-Intelligencer,"If you have this mind-set that obesity has to do with the individual alone, then ZIP codes or areas really should not come into this. But they do, big-time."

This is not to say that individual behavior doesn't play a vital role in our country's obesity rate, but we too often neglect to think about the cultural and institutional influences on a person's behavior when it comes to eating and exercise.

You would never look at a working class, single mother driving a jalopy with three kids crawling around in the back and say, "Gees, what's her problem? Why can't she drive the Lexus hybrid like me?" You understand that she doesn't have the means, and furthermore, probably doesn't have the peer influence that would make it seem like a viable option.

Our judgmental, fat-phobic society seems even more ridiculous when you consider that there is a strong genetic component to weight. We now have ample scientific evidence suggesting that we are each born with a set point within which our metabolism will automatically adjust no matter how many calories we consume. It's like our working class mom could be dedicatedly saving up for that hybrid, but the money just keeps disappearing from her bank account.

Instead of vilifying fat people, this country needs to look long and hard at the roots of our obesity epidemic. While we can't change someone's genetics, we can work to change the institutional disparities that make maintaining a healthy weight difficult for people with less money. Encouraging supermarkets to open up in poor neighborhoods by adjusting zoning laws and creating tax-incentive programs is a start. More funding for public schools in low-income areas would translate into better quality food in the cafeterias and more nutrition and physical education.

In addition to addressing these classist systems, we need to do some soul searching about our own attitudes about fat. Until those of us who care about public health can truly separate the potential health risks of being overweight from our own internalized stigmas about fat, we won't be effective. We have to learn to distinguish between those who are satisfied with their current body size and those who wants to lose weight, and then, learn to provide complex guidance that takes societal and genetic factors into account.

Those in the field of public health need to remember how motivation really works (hint: not by coercion or humiliation) and rethink how quality of life is measured when it comes to overweight patients. It is not the clinician's -- often prejudiced, frequently rushed -- point of view that matters most, but the individual's.

Dr. Janell Mensinger, the Director of the Clinical Research Unit at The Reading Hospital & Medical Center, also recommends shifting the goals of obesity intervention programs: "Focusing on health indicators such as blood pressure, cholesterol, blood sugar would serve to de-stigmatize obese individuals and help them engage in better eating habits and physical activity for the purpose of healthier living as opposed to simply being thinner. Although I see some programs shifting in this direction, I don't think they have gone far enough."

Mensinger adds, "We have to avoid promoting the dieting mentality! Encourage acceptance of all shapes and sizes while promoting the importance of physical activity and eating well for the purpose of living and feeling better, mentally and physically. The people that most successfully achieve this goal are those with an expertise in eating disorders as well as obesity. They know best what can happen if the message is misconstrued."

Whether you are a primary care provider, a nurse practitioner, a nutritionist, or a community health advocate, I urge you to treat your next patient like a living, breathing human being with complicated feelings, economic concerns, and cultural affiliations. Weight loss isn't the ultimate goal; economic equality, cultural diversity, wellness and happiness are.