The big problem…

‘We are healthy only to the extent that our ideas are humane.’
Kurt Vonnegut Jr., Breakfast of Champions

I’ve written a few times on this blog about my different ‘sides’ and how the lines between these different versions of me are blurring. My online, personal and work personas were originally well demarcated and I worked hard to keep each separate to avoid awkward discoveries. But that is changing – I am still Livvy the secret sex blogger, but I’m also Livvy the woman who told her family she ran naked around London Zoo and who has a glow-in-the-dark dildo on semi-permanent display in our bedroom. I’m Dr Livvy who advocated for my patient who wanted to masturbate in his side room on the ward and who is trying to change how doctors approach sex and sexuality in their interactions with patients, even if only on an individual basis.

As well as my sexual self having more of a presence in my real life, I am becoming more comfortable expressing my opinions from a medical perspective. And I feel personally responsible every time I hear a horror story about how doctors have let someone down through ignorance or wilful blindness. I am truly sorry for the dismissal and disbelief that people experience at the hands of doctors. I am ashamed that my colleagues and my profession can treat people with such disdain or that their prejudice can be so blatant. I am frankly devastated by how dehumanising the actions of some doctors can be.

But, but (and this is where I write a trigger warning that this is a post about weight, obesity and health) when it comes to weight and health care, I don’t think that doctors are wrong to talk about weight and ask about weight loss, even if that’s not the purpose of an appointment. How they talk about it can be genuinely terrible and focusing on weight to the exclusion of everything else is definitely wrong, but I want to defend my colleagues and explain why doctors are right to ask.

Put simply, obesity is a significant public health issue and one that shouldn’t be ignored.

This is where my personal and professional sides have the steepest divide between them. Having read what you’ve just read you may disagree but I consider myself to be a sex positive and body positive woman. We should all be happy and accepted for however we wish to look and I am so happy that the popularity of plus-sized models has been increasing, changing the ‘beauty norms’ to be more accepting and inclusive. I love the variety of body sizes and shapes that I see celebrated within the sex blogging community, particularly in the Sinful Sunday erotic photos, and I love love love hearing of the confidence that we all draw from our bodies, unique as they are.

But you don’t see your doctor to be validated on your fashion or beauty choices. You see your doctor because of a physical or mental health problem and I would be negligent if I didn’t recommend weight loss when you saw me in my professional capacity, regardless of how happy you are with your size. As your doctor, it really is my duty to talk about where your health and your weight cross over, just in case you’re one of the many who will suffer ill health because of your weight. Sometimes, such as in sleep clinics where I diagnose and treat obstructive sleep apnoea, weight loss is a specific treatment for the condition. In other cases, it can be as simple as recommending weight loss to reduce the risk of future problems, just as I’d recommend that my patients quit smoking and don’t drink so much. They may be fine now but I want them still to be fine in 10, 20, or 50 years time.

Now I may be labouring this point but I want to make sure that I am being clear. I strongly believe that you can be fat and beautiful, and fat and happy, and fat and having ridiculously hot sex and be in a fulfilling relationship, and I really do believe that you can be fat and healthy. But I also believe that the risk of future health problems associated with obesity is very real and it is a public health worry. I believe that public health campaigns to tackle obesity are necessary and valuable, and I think it’s right that doctors take our weight into consideration when approaching medical issues.

Obesity is proven to increase the risk of type 2 diabetes, heart disease and certain cancers, and it’s even worse for women, thought to be due to the complex role of oestrogen in both weight gain and development of disease:

‘Women who are obese are estimated to be around 13 times more likely to develop type 2 diabetes and four times more likely to develop hypertension than women who are not obese. Men who are obese are estimated to be around five times more likely to develop type 2 diabetes and 2.5 times more likely to develop hypertension than men who are not obese.’

This quote was taken from the GP guidance known as the Quality Outcome Framework or QOF. These are health targets that the government sets for GPs whose funding levels then depend on meeting these targets. Along with smoking, blood pressure, contraception, cervical screening, and cardiovascular risk reduction, obesity has been declared a public health concern that GPs need to address in a certain percentage of patients and, rightly or wrongly, they get paid to ask. Just as teachers work towards exam results targets and salesmen will have sales targets, GPs also have best practice targets and so will regularly ask about weight loss, if only to tick that box and meet their quota. There’s often even an onscreen prompt to remind them to do it. It’s not personal, it’s how the targets work.

In fact, it’s best to remember that none of the interactions with healthcare professionals are personal or based on personal opinion. The NHS is an evidence-based healthcare system and should be based on fact. Take me as an example – I am a respiratory registrar; my day job involves treating smoking-related lung diseases like emphysema and lung cancer but I still believe that in the right circumstances, smoking can be really fucking hot! Think James Dean’s full lips barely holding the cigarette that balances against them as he talks, think Humphrey Bogart squinting through the smoke wearing that white tuxedo in that gin joint as that girl walks in, and I will genuinely never forget the cunt-clenching swoon I felt when my scruffy stoner crush turned up for the university summer ball in a sharp tuxedo and nonchalantly pulled a silver cigarette case out of his inner pocket like he was Don Draper. Literally and figuratively smoking hot!

But I will still tell smokers to quit if they see me as their doctor, just as I will have no hesitation telling an obese patient that they ought to lose weight. Outside work, I don’t give a fuck – no one needs me to evangelise on the dangers of smoking when they’re written on the packages! But I won’t date smokers, regardless of how sexy it can be, because I don’t want to fall in love with a smoker or have kids with a smoker. I know that smoking increases the risk of cancer and lung disease and heart disease and I know that smoking increases risk of lung diseases and cot death in smoker’s children, and that’s not the future I want. It’s not personal, it’s risk-awareness. And as your doctor, it is this risk that I have to focus on.

Despite all of this, I don’t think the way that our healthcare systems approach weight is perfect. It is far from that. The horror stories where overweight patients are alienated and treated like they deserve their health problems are undoubtedly true, and I cannot apologise enough if you have experienced this attitude. Just as I feel responsible for mistreatment when patients’ sexuality is disregarded, articles such as this by Eleanor Jones titled ‘How Do Doctors View The Body Positivity Movement?’ that was posted earlier this month make me indescribably sad and ashamed of my profession:

‘[People] become so self-conscious that they stop seeking medical help altogether or, as Michelle recalls, the symptoms they do report are overlooked because of their size…Many felt “disrespected” by their doctors and embarrassed by the frequent unsolicited advice they received about losing weight.’

And she is also right that the clash between doctor’s poor communication, ignorance and good intentions leads to ‘higher incidences of misdiagnosis and mistreatment’ among overweight patients. In defence of doctors, common problems are common. We are frequently told to look for horses not zebras when we hear hooves, more formally known as Occam’s Razor, so I don’t find it that surprising to read in that article about the patient whose knee pain was blamed on her weight when it was a tumour because bony tumours are ridiculously rare! The crucial and hardest part of being a doctor is noticing when symptoms vary from a recognised pattern or don’t respond as we’d expect or raise suspicions because of other symptoms. It’s why I couldn’t be a GP – I’m not smart enough to see the needle in the haystack. And it isn’t only obese patients who run the risk of misdiagnosis due to misplaced attention. For every tumour pain that was blamed on weight, I could show you a smoker’s cough that turned out to be lung cancer, or a headache caused by a brain tumour that was blamed on stress. Doctors aren’t infallible.

Fat bodies are also harder to examine – there’s simply more covering that mass or muffling that murmur. Again, this isn’t an excuse but it is a fact, and it’s not something medical students are taught to overcome. Thinking about it, a lot of the faults in doctor’s behaviour could be blamed on our training, or lack of training. Obesity is taught as a ‘modifiable risk factor’ – something that can be changed in order to improve general health and reduce the chance of developing common conditions – rather than as a complex and multi-layered condition in its own right. There is so much to learn that most medical conditions are taught with a worrying superficiality and we learn the rest when we start working.

With conditions as emotionally loaded as weight, prejudices risk becoming common practice, concern becomes over-emphasis, and errors become magnified. Communication skills teaching focusses on passing on key information and showing empathy, but doesn’t teach the skills necessary to demonstrate that empathy. We’re supposed to find them ourselves, often through trial and error.

In a powerful blog post about being a fat medical student, Raspberry Stethoscope perfectly describes how issues surrounding being fat and accessing healthcare start in medical school:

‘When you talk to a fat patient about their weight, it is not the first time they have thought about it. It probably isn’t even the first time that day…Fat patients know that we are fat and we know what doctors think of us…I don’t think you would find a medical student in my class who thinks it’s okay to treat fat patients with anything other than respect. But we are all passing through a medical education system and into a medical workforce that churns out doctors who make many of their fat patients feel like crap.’

And there it is – whatever our intentions, the healthcare system is failing to treat obese and overweight people with respect and so is failing to create a safe space where these patients can be confident that they will be treated with dignity and their concerns met with the deserved attention.

Doctors need to ask you about your weight and encourage weight loss. You might be the one who will not suffer any adverse consequences, just as every smoker knows someone who smokes 80 a day for 60 years and is as fit as a fiddle, but you might not and it’s always better to have a proactive approach to disease prevention. So when your doctor asks, shrug and don’t think much of it, but then push to make sure your concerns have been addressed. You shouldn’t leave the encounter without being reassured or at least with a plan that feels right. If you don’t have that, write a complaint to the practice. If you’re dismissed or treated like a freak or blamed for your symptoms or made to feel like less than a person, write a complaint. This is not acceptable and should not be allowed to continue, but my profession won’t learn until we are shown how we are wrong, how the body positive world has moved on, and how there are ways to approach these issues with compassion.

I asked the panellists at Scarlet Ladies ‘Body Positive Sex’ event earlier in May about my difficulties broaching weight loss with my patients. Their answer was simple – acknowledgment and understanding, actual empathy and not fake platitudes, conversation and not lecturing.

Attitudes that I couldn’t help but feel would be beneficial in all aspects of medical practice…

8 thoughts on “The big problem…

  1. I understand that you are approaching this from the perspective of a medical professional, rather than an overweight person, but I really think that seeing excess weight as a root cause of medical issues rather than a symptom is missing the point.
    People of all sizes develop mental and physical health issues throughout their lives. Both mental illness and physical incapacity tend to reduce our ability to eat healthily and exercise, even if we were previously able to follow a doctor-approved regimen. People’s bodies also respond differently to diet and exercise. To advise patients to “lose weight”, as a proactive measure, is to fundamentally misunderstand the levels of control some of those patients have over their weight. Often, losing weight is a goal in itself for the patient, who may have been struggling for years to do just that. Pointing out that their failure to do so has had, or may cause, further damage to their health is simply demoralising.
    If, as you say, each of those patients is being told that their excess weight will likely cause further problems, and then those problems (as they statistically must) happen anyway, what is the justification for the guilt placed on those for whom weight was not a contributing factor?
    And one last point – I assume your argument against dating smokers also applies to dating fat people.

    1. The approaches to discussing weight will obviously vary depending on the patient and circumstance, and I agree with some of your comments – these conversations can evoke unnecessary amounts of guilt if handled badly and many doctors, me included, struggle to communicate in a beneficial way. It’s complex and imperfect, but unfortunately that doesn’t mean we don’t have to try.

      As for dating rules, on a personal level I don’t feel so strongly either for or against as I do with smoking, nor is it such a simple divide as smoker/non-smoker, so a potential partner’s weight has never factored in my decisions any more than their hair colour or sense of humour etc.

  2. As a health care provider, I understand a lot of what you’ve expressed here perfectly. It’s a line that’s hard to walk when you want to be supportive but know the poor affects of some health care decisions. You’re brave for writing it

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