The Thesis - Executive Summary

So sorry about the lack of updates.  I have been working on my thesis.  I thought briefly about posting the whole thing on here.  But then I realized that I don’t want to inflict that on anyone. 

Here’s the executive summary.

1. People seem to think obesity is a big deal.  Two thirds of American adults are overweight or obese – everybody panic!

2. Obesity stigma is prejudice against overweight and obese people.  It’s a real thing in the world, especially the world of healthcare.  It turns out lots of doctors think obese people  are lazy, weak-willed, stupid, annoying, incompetent, non-compliant, and generally icky.

3.  People justify these beliefs by claiming that obesity is under personal control.  See, it isn’t like race, because I am not white on purpose.  But being fat is a choice.  So if fat people didn’t want to be discriminated against they could just stop being fat.  (Kind of like how poor people should just work harder and pull themselves up by their boot straps.) 

4. Nope, turns out that obesity is not a choice.  Turns out nothing else you thought you knew about obesity is true, either:

            Myth: Obesity is primarily caused by poor individual choices about diet and exercise.

Fact: Obesity is caused by a complex interaction of genetic, microbial, neuroendocrine, environmental, social, economic, psychological, and cultural factors – most of which are NOT under personal control.

            Myth: Obese and overweight people could lose weight if they actually tried.

Fact: Diet and exercise do not work.  Not only are 95% of weight loss attempts unsuccessful at producing long-term weight loss, evidence also indicates that dieting often actually leads to weight gain, increased stress, and disordered eating behavior.

Myth: Obesity is a serious medical problem.

Fact: The lowest mortality risk is actually associated with BMI values officially in the “overweight” range, especially for non-whites. Few studies of the association between BMI and health problems bother to control for exercise or dietary quality.  The truth is, you can be fit and fat.

5. Our society’s prejudice against fat people comes from our psychological need to protect ourselves from the possibility of bad things happening to us.  In our society, thin = beautiful, and therefore being fat is a bad outcome.  Rather than just feel sorry for fat people, we need to insulate ourselves against the threat they represent. We need to convince ourselves that the universe is a just place, that hard work pays off, that good things happen to good people and bad things happen to bad people.  Ergo, fat people must be bad. 

6. Obesity stigma is a problem because it is a prejudice just like sexism, racism, and homophobia and it has no place in a just society.  A full two thirds of the US adult population are victims of obesity stigma, so the effects are wide-spread.  These effects include psychological distress as well as more concrete discrimination in the areas of education, employment, housing, parental rights, and others.

7. Obesity stigma is a particular problem for doctors because it means we are violating the principles of beneficence and non-maleficence.  Our current treatment of obesity (nagging patients about dieting and exercising) does not work and is often actively harmful to patients’ overall well-being.  Fat patients find the experience of coming to the doctor to be so shaming (what with the nagging, lack of appropriate waiting room chairs, gowns, exam tables, and blood pressure cuffs, and mandatory weighing) that they avoid seeking care altogether.

8. For physicians and other healthcare providers, the solution lies in embracing the principles of Size Acceptance and practicing a medical model known as Health At Every Size (HAES).  HAES is a new approach to fat patients that emphasizes overall well-being rather than weight loss.  The core principles of HAES include, “accepting and respecting the diversity of body shapes and sizes; recognizing that health and well-being are multi-dimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects; promoting all aspects of health and well-being for people of all sizes; promoting eating in a manner which balances individual nutrition needs, hunger, satiety, appetite, and pleasure; and promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.”

9. Health At Every Size interventions have been proven to be effective in improving psychological markers of well-being, decreasing disordered eating behaviors, and improving cardiovascular markers of health such as cholesterol level and blood pressure.  Furthermore, no randomized controlled trial of HAES has shown weight gain to be an effect, and several such studies have pointed to HAES leading to modest weight loss. (Not that we care about the weight loss, but just in answer to all the critics who think intuitive eating will lead to weight ballooning out of control - it doesn't.)

10.  In addition to using HAES interventions with individual patients, physicians should also combat obesity stigma in their roles as practice managers and community health advocates. (For example, resisting public health messages that participate in fat-shaming in the name of advocating for personal responsibility.)

11.  In conclusion, obesity stigma is bad, doctors have been responsible for perpetuating it, and now it is our responsibility to fight it.

Whew.  That is all.

Where I Stand Now

A tremendous amount has changed in the past year, and even more is going to change in the year to come.  And so it occurs to me that now might be a good time to take stock of my life, my writing, and myself.

I set out to write this blog about medical stories – you know, those anecdotes where doctor sees a patient and learns something profound about herself or the human condition or how to be a better doctor.  At the very least, patients often say funny and entertaining things.  But it turns out I haven’t seen very many patients in the past several months; most of the stories I have written have been about old patients or my own patient and family side of interacting with the medical profession.

It isn’t as if the patients I have had have been uninteresting.  I had one particular patient that presented a fascinating medical mystery and was a great character that I really clicked with.  I meant to write a post about him for months, but I never really knew what to say about it, there wasn’t really a point or a lesson to the story.  Talking about how well we got along seemed a little self-congratulating.  And also, the story of what happened to him wasn’t my story, it was his.

I tried to re-read Kitchen Table Wisdom recently and I couldn’t make it through.  It’s a book of essay/stories about healing, you would think it would be right up my alley, but I just found it annoying.  Because every patient story had to have a lesson or universal truth you could extract from it.  It just seemed so reductive and a bit contrived.  Sure, sometimes my patients remind me of things going on in my own life and that lends itself to good blog posts.  But should it?  Maybe if I were less self-involved, things wouldn’t have to relate back to me all the time.  Maybe I would be a better healer if I were focused enough on my patients that they reminded me of themselves. 

Writing a blog makes you look a little self-obsessed by nature.  It’s a place for self-reflection, yet that reflection is all public. And really, self-reflection for public consumption is a strange phenomenon. 

I re-read all my posts so far and I realize that I have mostly been processing the same theme from every angle: the medical experience is dehumanizing.  I am so glad to have gotten a chance to process this, to move from analyzing my own experiences as a patient to integrating how I will do better as a doctor. 

Personally, having this time and space for self-reflection is a blessing. (Both the blog as a place to record my thoughts and having the past two years of relatively relaxed academic schedule to have time to reflect).  This time and space was instrumental in my re-defining myself as a healer, re-examining existing relationships and forming new relationships, and re-engaging with some of the “big issues” that had gotten shoved aside for lack of time.

But one of the most important transformations that I’ve been taking stock of lately is one that I haven’t written much about.  I’ve become an adult.  I’m twenty-seven years old.  The process feels a bit delayed to me.  I thought I was an adult at fifteen.  I thought I was an adult at twenty.  I thought I was an adult at twenty-three.  So maybe this is nothing new or special; maybe at thirty I will think how silly I was back at twenty-seven.  And I’m sure part of me will think that, because I don’t think I will ever be done growing. 

But I do want to acknowledge that an especially important transition has been happening over the past two years.  The major transition has been in the relationship with my parents.  I haven’t written much about this, because it has been incredibly difficult and feels very personal to be putting on the internets (even though I realize that functionally means sharing the information with about six people). 

But here is the shortest of short stories:  I got engaged to Benjamin and my parents lost their minds.  They strenuously objected and tried to break us up.  We got married anyway. 

This whole situation has exposed an area of my life that I don’t know I ever would have examined if I weren’t forced to.  I thought my relationship with my parents was good.  I knew we had some differences during the teen years, but I thought that we had a good relationship now and didn’t need to work on it at all.  But it turns out I had never actually separated from them in any meaningful way.  I was still looking to them for approval. 

The wedding situation became explosive because it was one of the only times in my life when my parents had actively disapproved of something I was doing.  Growing up, I was always looking for their approval.  I always wanted to impress them.  Nothing I ever did seemed to be enough; I distinctly remember my dad saying he was proud of me at my white coat ceremony because it was the only time I remember hearing those words. But nothing I did was ever met with active disapproval either.  Every accomplishment seemed expected rather than noteworthy, and every decision I made was merely interesting, never good or bad. 

Now, in the aftermath of this explosion, it’s really clear to me just how much I crave their approval, even as an adult. It’s also clear to me just how unhelpful that is to me having a good relationship with my parents, to my growth as an individual, to my marriage, and to adult functioning in general.  Seeing how much I want my parents’ approval also opened my eyes to how much time and energy I spend ferreting out approval from others as well. 

And ultimately, it is unimportant.  I don’t know how I came to this place, really.  I have always been so driven by external judgment that it would have felt impossible to accept that this is actually unimportant. But now, I find myself at peace with it.  It feels like a weight has lifted, like a requirement has been dropped.  It feels like getting to the end of the semester and having your professor tell you there won’t be an exam after all.

Approval-seeking is still my M.O. Unconsciously, I will slip back into this mode almost automatically.  It takes mindfulness to break out of it.  But now that I have given myself permission to do so, I feel stronger, more centered, more myself.  I look forward to seeing how this plays out in my role as a daughter, partner, parent, and healer.

Quick Updates

1.  I got my maternity leave details - they are simple pushing my start date back from 6/25 to 9/17.  So yay, I get maternity leave and don't have to worry about working when I am about to pop.  I will have to make up the three months later.  Also, this means I don't use up my vacation time, which is excellent because I am betting I will want some vacation.  The only bummer is that health insurance coverage does not start until the start date.  Welcome to the world kid, don't you wish you had been born in Australia?

2.  The day after my post about how I don't like to cook and am not good at it - I got volunteered to be the assistant teacher of a cooking class.  Woot.

On Cooking

I am not good at cooking.  I don’t particularly like doing it.  It’s not really my thing.

Turns out, cooking should sort of be everybody’s thing, because everybody eats.  If cooking isn’t your thing, you end up eating a lot of EZ-mac and Chipotle.  I didn’t eat great when I lived alone – things certainly got repetitive and sometimes there was some emergency EZ-mac.  Ok, there was a lot of canned soup.

Choosing, preparing, and eating food has always been sort of stressful, actually.  In high school, my mom had what I would now call an undiagnosed eating disorder and there wasn’t a lot of edible food in the house.  (Though there was always a lot of spoiled, slimy, or mold-covered food that she felt too guilty to throw away).  So perhaps I did not have the sturdiest food-behavior foundation.

Then, when I lived alone, food choices always represented this three-way balancing act between cost, health, and time.  If it was healthy, it took forever or cost too much.  If it was cheap, it was full of processed sugars and simple carbohydrates and had never seen a vegetable.  If it was quick, it cost too much and had never seen a vegetable.  As a medical student, I was short on both time and money and felt like a hypocrite if I ignored my health. 

One of the best things Benjamin did when he moved in was start cooking me dinner.  I was trying to drag myself to the finish line of my semester fueled only on coffee and desperation, and he swooped in and steamed some broccoli.  I thought he was a god. 

And he still often does this.  Last night, a girl friend came over and we hung out and Benjamin made turkey burgers and oven fried potatoes and mixed vegetables.  It was amazing.

But I’m not really pressed for time so much these days.  I have my internship and my thesis, but it is nothing like the end of the semester crunch.  Or, you know, residency.  So I feel like I should still contribute to the household eating by occasionally preparing a meal.

And it is still stressful.  I still feel that juggling act between health, time, and cost (though I have both more time and money than I did before). But the new layer I have to deal with now is performance anxiety.  I want Benjamin to actually want to eat what I cook, and I feel self-conscious about my lack of culinary talent.  Perhaps it’s some internalized sexism that makes me feel that as the woman, I should be better at cooking than he is.  Or maybe I’m just a competitive person.  But in any case, I just want to be better at it than he is.  And I am just not.  The man has talent.  And I have...a semi-edible track record.  There was some artichoke pasta I made recently that he soldiered through but I just could not even stomach.

Tonight, I made this recipe: http://www.epicurious.com/recipes/food/views/Mashed-Potatoes-with-Carrots-and-Leeks-109125.  It’s really just mashed potatoes with leeks and carrots thrown in.  It tastes like mashed potatoes with leeks and carrots thrown in (nothing magical happens with them really) but it was pretty tasty once I got enough salt in there.

I was feeling very flustered and hypoglycemic the whole time I was cooking.  And I thought seriously about just asking Benjamin if we could divide up the food chores from here on out – I would shop and do dishes if he would cook all the dinners.

But I didn’t.  Because I don’t think partnership is necessarily about specializing and not developing diverse skills.  It’s about specializing in the moment – dividing and conquering everything that needs to get done that night and still being flexible enough to switch jobs the next night.  Deconstructing rigid gender roles should mean something more and better than “I always mow the lawn and my husband always cooks dinner,” it should make men and women more competent and flexible. 

So in the name of self-improvement and a flexible partnership, I will continue to struggle through preparing dinner once in a while.  And Benjamin will continue to struggle through eating those dinners.

At least until July, when I fully anticipate everything to go to hell.  

Race and the "Default Experience"

Following the Trayvon Martin story has gotten me thinking about race. 

First, I just want to say that I am probably not properly qualified to speak on any of these topics.  These thoughts are not the well-crafted ideas of someone who has a deep and nuanced understanding of race issues.  These are the fledgling ideas of a privileged white woman who learned the word “privileged” within the past year.  So bear with me. 

As a white blogger, I feel it is important for me to share these thoughts, rather than just, say, continue to whine about the uncertainty of my maternity leave status.  Because the black community doesn’t have the option of not being affected by this story. 

I was listening to Elon James White’s podcast, “Blacking it Up,” where he describes just feeling hopeless and confused about what to do.  An older woman called in and said she was just “broken.”  How do you react to concrete evidence that your society simply doesn’t value the lives of people who look like you?

I have trouble wrapping my mind around that, I have trouble engaging with it.  It’s too big, too scary, too unjust.  And I think this is why a lot of people just walk away from this discussion – or justify why Zimmerman’s actions were legitimate.  It’s a lot easier to deal with one kid who really was up to no good than it is to acknowledge that the society you live in (in which you may be personally very comfortable) is fundamentally dehumanizing, wrong, and unfair.

I’m not ready to bite off a chunk that large.  So, I have tried to stay aware of race in other ways.  Here are just two of the things I noticed in the past few days:

1. I volunteer at a sliding scale clinic and wellness center in East Baltimore.  Most of our patients are black, most of our staff and volunteers are white.  Today I was helping with a session on stress management and we showed a movie about the physical effects of stress.  The doctor they interviewed was a black man, but all the actors that they had demonstrating the effects of stress were white.  Moreover, they were all white men in ties.  The language the narrator used was generic, he would say “stressful jobs,” but the actor would be a white guy in a tie massaging his temples as he sat before a computer screen in an office.  Clearly, he had a very stressful pie-chart presentation to give.  Bummer. 

This is not the kind of stress my patients are dealing with.  My patients are dealing with losing their jobs for taking too much sick time after their daughter was killed and they took over raising their autistic grandchild.  My patients are dealing with having a stroke at 45 and re-learning how to walk.  My patients are dealing with being laid off from the job that was already barely getting them by.  And sure, on some level stress is stress and we can all relate to that experience.  But it’s always non-whites who have to do the relating.  Because my experience as an upper middle class white person is always the default experience, even in places like Baltimore where it is not the majority experience, either in terms of race or in terms of class.

When I can expect that my experience as a white person is the default experience, that is privilege.  When you are in a position to craft how you represent the default experience, and you perpetuate that privilege – is that racist? It’s not racist the way not arresting Trayvon Martin’s killer is racist, no.  But I think it’s probably a more subtle angle of the same beast.

2. Later, I was working on my thesis, which is about obesity stigma.  I was doing some research into the Body Mass Index and found that one of the problems with it is that the cutoffs for overweight (>25kg/m^2) and obesity (>30kg/m^2) is that they were developed based on studies of mostly white people.  Theoretically, the normal weight range (BMI 20-25kg/m^2) was chosen because it represents the range associated with lowest all-cause mortality.  But it doesn’t apply to non-whites. 

For African-Americans, the lowest mortality rates are found at BMI values in the “overweight” range.  This means the NIH has duped thousands of (probably) well-meaning doctors into nagging black patients to lose weight when they are already in the healthiest range. I myself have done this, I am sure, trying to be the good little medical student supporting lifestyle change.

Here we see the consequences of white being the default experience.  Studies are done on whites and results inappropriately extrapolated to every other race.  Even when studies on other racial groups demonstrate that there are differences, the guidelines remain rigid.  The NIH claims that “there are no studies that would support the exclusion of any racial/ethnic group from the current definitions of obesity.” 

I think this example is particularly interesting because it exists at the intersection of two different kinds of prejudice – that based on race and that based on body size.  (Please note that I am not stating that one is worse than the other or that they are comparable, just that both are coming into play in this situation.)  It isn’t overt racism – no one is using the N word or shooting anyone.  Instead, it’s just this insidious and officially sanctioned suggestion that black people should internalize discomfort with their own bodies, that they should conform to medical standards designed for white people. 

I guess I am frustrated and anxious to move on to the next step.  I’ve noticed this, so now what do I do about it? Even the relatively smaller examples seem too large to wrap my mind around when I consider how to eliminate them. 

So, in conclusion, I am frustrated that racism still exists.  I was raised by hippies and would say I am oriented towards activism (not that I am particularly good at it).  But I have a feeling that on this one, I have a lot of internal work to do before I start grabbing petitions or taking to the streets.