Do you judge your overweight classmates?

[mwsapphire]

Yeah 25 is the “overweight” cutoff.
as a first year, my BMI was as low as 17. My weight has fluctuated almost 50 pounds since i started.

I will say i do have underlying bipolar disorder that really contributes to all of this.

Ooof.I hope you're getting proper help for that ( the BPD, not the weight). And I thought anxiety/ADHD was bad.

---

Members don't see this ad.

 

[deleted480308]

Don’t do what? I stick by what I said. It’s highly problematic in regards to what that poster said. People not going to the doctor due to being shamed for being overweight and/or fat is 100% a problem. Myself and my friends have experienced it first hand and there is plenty of data on that. Their post said that I have no excuse for not being 135 pounds and should eat 3 heads of lettuce and not be hungry (let alone no mention of the nutrients one would be missing if they just ate lettuce). I don’t think a person who thinks like that should be a doctor because they clearly don’t understand how the human body works and how bodies are different. That kind of thinking is harmful to patient care.

Oh calm down with the hysterics

 

[AMEHigh]

You don't know enough about someone based on a few internet posts to judge whether or not they should be a doctor.

I disagree.
When interviewing med students for our residency program often get to only talk to them for 10 minutes, we make plenty of judgement based on that 10 minute conversation. In addition, social media is also looked at in regards to a judge of a person’s character and hence why people have often been reprimanded or removed from residency programs for their social media postings. So I absolutely think that we often make judgements based on people’s ability to be a competenent and empathetic physician based on very short conversations and brief social media postings. If you disagree then that is fine, but that is my opinion and I stick by it.

As a patient I don’t want a physician to judge me for being 175 pounds vs 135 pounds and tell me to just eat 3 heads of lettuce when I work out for an hour a day. I certainly would have a serious problem if one of our residents counseled a patient in such a way as well. People can decide the type of physician they want to interact with and I certainly don’t want to interact with one who has that mindset and doesn’t seem to understand how the body works.

And if they really don’t think that way and were being a troll just to get laughs off of being offensive then yeah that’s another reason this person has misguided judgement that probably shouldn’t be a physician either.

 

[IsleyOfTheNorth]

Don’t do what? I stick by what I said. It’s highly problematic in regards to what that poster said. People not going to the doctor due to being shamed for being overweight and/or fat is 100% a problem. Myself and my friends have experienced it first hand and there is plenty of data on that. Their post said that I have no excuse for not being 135 pounds and should eat 3 heads of lettuce and not be hungry (let alone no mention of the nutrients one would be missing if they just ate lettuce). I don’t think a person who thinks like that should be a doctor because they clearly don’t understand how the human body works and how bodies are different. That kind of thinking is harmful to patient care.

Just for clarity, I don't fat shame. I've struggled with my weight my whole life and I know how difficult it really is. What I do have a problem with is people (especially physicians) throwing up their hands and saying "It can't be done!". That's baloney and we all know it.

My point with the lettuce is that you diet without being hungry if you choose the right foods. Fill up on low calorie foods and you won't be hungry.

 

[deleted480308]

I disagree.
When interviewing med students for our residency program often get to only talk to them for 10 minutes, we make plenty of judgement based on that 10 minute conversation. In addition, social media is also looked at in regards to a judge of a person’s character and hence why people have often been reprimanded or removed from residency programs for their social media postings. So I absolutely think that we often make judgements based on people’s ability to be a competenent and empathetic physician based on very short conversations and brief social media postings. If you disagree then that is fine, but that is my opinion and I stick by it.

As a patient I don’t want a physician to judge me for being 175 pounds vs 135 pounds and tell me to just eat 3 heads of lettuce when I work out for an hour a day. I certainly would have a serious problem if one of our residents counseled a patient in such a way as well. People can decide the type of physician they want to interact with and I certainly don’t want to interact with one who has that mindset and doesn’t seem to understand how the body works.

And if they really don’t think that way and were being a troll just to get laughs off of being offensive then yeah that’s another reason this person has misguided judgement that probably shouldn’t be a physician either.

Frankly if we’re judging posts quickly for knowledge implications here, you said you physically couldn’t be 135 without starvation....soooooo

Everyone should just dial it back to 7 instead of 11

 

[VA Hopeful Dr]

I disagree.
When interviewing med students for our residency program often get to only talk to them for 10 minutes, we make plenty of judgement based on that 10 minute conversation. In addition, social media is also looked at in regards to a judge of a person’s character and hence why people have often been reprimanded or removed from residency programs for their social media postings. So I absolutely think that we often make judgements based on people’s ability to be a competenent and empathetic physician based on very short conversations and brief social media postings. If you disagree then that is fine, but that is my opinion and I stick by it.

As a patient I don’t want a physician to judge me for being 175 pounds vs 135 pounds and tell me to just eat 3 heads of lettuce when I work out for an hour a day. I certainly would have a serious problem if one of our residents counseled a patient in such a way as well. People can decide the type of physician they want to interact with and I certainly don’t want to interact with one who has that mindset and doesn’t seem to understand how the body works.

And if they really don’t think that way and were being a troll just to get laughs off of being offensive then yeah that’s another reason this person has misguided judgement that probably shouldn’t be a physician either.

Yes because we all have to be perfect to be physicians.

 

[Sephirakra]

Very. At my height, I'd only have to be 165 pounds to be overweight. That's absurd.

We may be the same height.

BMI's utility, I think, come more from measurements over time than one single data point. I like it simply because I don't have a great frame of reference when I hear height/weight on a patient. "Oh, they're 5'11" and 180 pounds? Is that good or bad? No idea." But, as many physicians I respect have taught me, you don't treat a number.

 

[VA Hopeful Dr]

Yes because we all have to be perfect to be physicians.

Additional thoughts:

Your residency interviews only last for 10 minutes? That's clearly a problem as that's barely enough time to learn someone's name much less anything about them. When I left residency in 2013 each faculty interview was an hour long.

The post in question had nothing to do with being competent, in fact, as the odds are good said poster is a medical student, I wouldn't expect them to be competent especially in the area of nutrition which I think we can all agree isn't taught very well in med school. I would suggest this is actually a teachable moment - explain why that's a bad idea using what evidence we have and suggest alternate approaches. I mean, I absolutely get that its easier to write people off especially online but that's not exactly being empathetic either now is it?

As for the trolling part, I think most of us have said things we later regretted on the internet in general and likely SDN in particular. I know some of the things I said here in my med school days now make me kind of ashamed. Luckily there was no one around to deny me a future as a doctor because of it.

 

[deleted407021]

Frankly if we’re judging posts quickly for knowledge implications here, you said you physically couldn’t be 135 without starvation....soooooo

Everyone should just dial it back to 7 instead of 11

Honestly I’m stuck on imagining you in a chipotle, sporting a No Step On Snek shirt, just staring daggers at someone sticking their gross hands over the counter.

 

[VA Hopeful Dr]

We may be the same height.

BMI's utility, I think, come more from measurements over time than one single data point. I like it simply because I don't have a great frame of reference when I hear height/weight on a patient. "Oh, they're 5'11" and 180 pounds? Is that good or bad? No idea." But, as many physicians I respect have taught me, you don't treat a number.

Of course not. You look at the BMI and then look at the patient. A few weeks back I had a guy come in, BMI of somewhere in the low to mid 30s. When I entered the room I saw a guy with enormous arms and legs who could probably bench press the exam table. I mentioned his weight (because CMS makes me) but told him he didn't actually need to change anything and to not worry about it.


Later that week another patient, same height and roughly the same weight except this patient's stomach stuck out a good 8-9 inches further than his chest. He did get an exercise and healthy eating discussion.

We need to factor in abdominal measurements into all of this, but until CMS lets me include that part in the quality measures we're kinda stuck.

 

[Sephirakra]

Of course not. You look at the BMI and then look at the patient. A few weeks back I had a guy come in, BMI of somewhere in the low to mid 30s. When I entered the room I saw a guy with enormous arms and legs who could probably bench press the exam table. I mentioned his weight (because CMS makes me) but told him he didn't actually need to change anything and to not worry about it.


Later that week another patient, same height and roughly the same weight except this patient's stomach stuck out a good 8-9 inches further than his chest. He did get an exercise and healthy eating discussion.

We need to factor in abdominal measurements into all of this, but until CMS lets me include that part in the quality measures we're kinda stuck.

I'm still in the preclinical portion of my medical training, so I rarely get to actually see the patient.

Back in my researcher days, though, part of my duties involved taking body fat measurements with a bunch of different instruments to determine the best utility in pre-dialysis kidney disease patients. Some of these instruments cost an arm and a leg and took several minutes to use. The most consistently useful and accurate? Good ol' skin calipers. Not perfect, but the data didn't lie.

 

[TwoHighways]

You really need a dexa scan or to be weighing people in and out of water to get an accurate body fat percentage. Skin calipers don’t detect visceral fat. A kinesiology department in the town I used to work had this thing called a bod pod that was reportedly pretty accurate, and I even went in for myself once to be measured, but I have no idea how accurate it actually is.

 

[On_The_Way_Up]

I don’t judge overweight people. It is interesting though how studies show obese doctors are more likely to NOT talk to patients about their unhealthy eating habits, importance of exercise, or obesity.

 

[Sephirakra]

You really need a dexa scan or to be weighing people in and out of water to get an accurate body fat percentage. Skin calipers don’t detect visceral fat. A kinesiology department in the town I used to work had this thing called a bod pod that was reportedly pretty accurate and I even went to for myself once to be measured, but I have no idea how accurate it actually is.

We used a Bod Pod as our reference, and it's supposedly designed to be a gold standard. Like I said, the calipers weren't perfect, but they were the most consistent and accurate (when used correctly) in addition to being cheap. Like any tool, though, you have to know the limitations.

 

[Pepe18]

.

 

[ExplodingUlcers]

Her are my thoughts on the subject based on my experiences traveling to Europe and very rarely encountering an obese person (unless they were American tourists).

1. Portion sizes are much smaller.
2. People walk everywhere and use public transportation.
3. Smoking is more commonplace and it's a pretty good appetite suppressant. Not gonna lie, I sorta indulged in this too while I was there.
4. Fresh fruits and vegetables are relatively inexpensive and widely available. As a result of this and a robust/inexpensive transportation system, food deserts are not that common. Even in northern europe, despite the cold and lack of sunlight, ample fresh foods are available because they are grown hydroponically.

At the end of the day, we're all a product of our environment. Because of that simple fact alone, I won't judge someone for being obese.

Sent from my SM-G955U using SDN mobile

 

[IsleyOfTheNorth]

Here's my hypothesis: I think that people are so afraid of being judgmental that they ignore or downplay health issues to the detriment of their patients.

Further, I think that when a physician smokes a cigarette or remains obese I think they are communicating to the patient (intentionally or not) that the issue (smoking, overeating, etc.) is not as serious as it might otherwise be.

"If the expert is doing it, it can't be that bad."

People keep "disliking" this post. I dislike it also. Unfortunately, this. Here are the relevant bits:

Pediatricians’ Own Weight: Self-perception, Misclassification, and Ease of Counseling

Perrin, Eliana M, Kori B Flower, and Alice S Ammerman. “Pediatricians’ Own Weight: Self-Perception, Misclassification, and Ease of Counseling.” Obesity research 13.2 (2005): 326–332. Web.

"... self-identified “overweight” pediatricians reported nearly four times as great counseling* difficulty as “average” weight physicians (OR 3.84; 95% CI 1.11, 13.3), after adjustment for self-reported BMI weight status and other potential confounders."
*Note: "Counseling" here is referring to obesity counseling.

Also interesting:
Does Physician Weight Affect Perception of Health Advice?

Hash, Robert B et al. “Does Physician Weight Affect Perception of Health Advice?” Preventive Medicine 36.1 (2003): 41–44. Web.

"Conclusions. Patients seeking care from nonobese physicians indicated greater confidence in general health counseling and treatment of illness than patients seeing obese physicians."

 

[ciestar]

Ooof.I hope you're getting proper help for that ( the BPD, not the weight). And I thought anxiety/ADHD was bad.

Thanks. I have been for years.

 

[AMEHigh]

Additional thoughts:

Your residency interviews only last for 10 minutes? That's clearly a problem as that's barely enough time to learn someone's name much less anything about them. When I left residency in 2013 each faculty interview was an hour long.

The post in question had nothing to do with being competent, in fact, as the odds are good said poster is a medical student, I wouldn't expect them to be competent especially in the area of nutrition which I think we can all agree isn't taught very well in med school. I would suggest this is actually a teachable moment - explain why that's a bad idea using what evidence we have and suggest alternate approaches. I mean, I absolutely get that its easier to write people off especially online but that's not exactly being empathetic either now is it?

As for the trolling part, I think most of us have said things we later regretted on the internet in general and likely SDN in particular. I know some of the things I said here in my med school days now make me kind of ashamed. Luckily there was no one around to deny me a future as a doctor because of it.

Things must’ve been done differently when you did interviews. When I was interviewing myself, when I was a resident and now where I’m an attending generally each interview is about 10-12 min and your rotate through a variety of faculty and residents. So that’s a sample of about 20 programs and my friends in other specialties have had similar experiences. I can’t imagine how long the interview day lasts if you spend an hour with multiple faculty members. It’s just not feasible these days with the number of people each interview day.

As far as a teaching moment with the poster in question, that’s exactly what I did. They responded to my post saying I was using it as an excuse and I wouldn’t be starving. I nicely responded saying that no you are incorrect, my body frame is not meant to be at 135 pounds. Then that’s where the poster came back saying I’m not disciplined enough and should see a neurologist if I’m still hungry after eating a bunch of lettuce.

So yeah, I did try to be empathetic and use it as a teaching moment, but they dug their heels in about this issue while being dismissive and incorrect. That’s one of the number one things I look at when giving feedback to med students (and residents). Are you able to take feedback or constructive criticism. It’s ok to be wrong about something, but don’t just dig your heels in to an issue, especially about nuanced topics that require empathy/understanding such as weight, race, gender, etc.

 

[KeikoTanaka]

Even that's supposed to be drunk in moderation...

Hopefully they screened the blood of Christ for hepatitis

 

[Pepe18]

.

 

[Sephirakra]

People keep "disliking" this post. I dislike it also. Unfortunately, this. Here are the relevant bits:

Pediatricians’ Own Weight: Self-perception, Misclassification, and Ease of Counseling


"... self-identified “overweight” pediatricians reported nearly four times as great counseling* difficulty as “average” weight physicians (OR 3.84; 95% CI 1.11, 13.3), after adjustment for self-reported BMI weight status and other potential confounders."
*Note: "Counseling" here is referring to obesity counseling.

Also interesting:
Does Physician Weight Affect Perception of Health Advice?

"Conclusions. Patients seeking care from nonobese physicians indicated greater confidence in general health counseling and treatment of illness than patients seeing obese physicians."

I'm all for including research in this thread, and thank you for including your citations, but don't try to sneak one past us. The full quote from the abstract of the first article states: "Self-classified “thin” pediatricians had nearly six times the odds of reporting more counseling difficulty as a result of their weight than “average” weight pediatricians (OR5.69; 95% CI2.30, 14.1), and self-identified “overweight” pediatricians reported nearly four times as great counseling difficulty as“average” weight physicians (OR3.84; 95% CI1.11,13.3), after adjustment for self-reported BMI weight status and other potential confounders." So... it's hard to draw any conclusion. And, in fact, the authors expressed their trouble with exactly that in the discussion.

 

[deleted480308]

Things must’ve been done differently when you did interviews. When I was interviewing myself, when I was a resident and now where I’m an attending generally each interview is about 10-12 min and your rotate through a variety of faculty and residents. So that’s a sample of about 20 programs and my friends in other specialties have had similar experiences. I can’t imagine how long the interview day lasts if you spend an hour with multiple faculty members. It’s just not feasible these days with the number of people each interview day.

As far as a teaching moment with the poster in question, that’s exactly what I did. They responded to my post saying I was using it as an excuse and I wouldn’t be starving. I nicely responded saying that no you are incorrect, my body frame is not meant to be at 135 pounds. Then that’s where the poster came back saying I’m not disciplined enough and should see a neurologist if I’m still hungry after eating a bunch of lettuce.

So yeah, I did try to be empathetic and use it as a teaching moment, but they dug their heels in about this issue while being dismissive and incorrect. That’s one of the number one things I look at when giving feedback to med students (and residents). Are you able to take feedback or constructive criticism. It’s ok to be wrong about something, but don’t just dig your heels in to an issue, especially about nuanced topics that require empathy/understanding such as weight, race, gender, etc.

If I recall, you said you were fat. That is different than “my bodyframe isn’t meant to be 135 lbs”. Henry cavill isn’t meant to be 135lbs, he isn’t fat

 

[Perrotfish]

I don’t know your muscle mass to determine if 135 is what it takes for you to not be “fat”, but you can totally be an appropriate weight without starvation. You aren’t so unique that the laws of physics don’t apply to you

I think the poster meant that, at what would be a normal set weight, his/her body would send signals that it is starving. Which is true. All of the literature indicates that our bodies very reliably maintain a set weight and that trying to count calories to meet your ideal weight rather than your set weight is psychologically debilitating because you have a very complex neuro-endocrine system that is constantly telling your mind to drop whatever you are doing and to go seek food. Which is why every study of calorie restriction diets has found that they have a long term (>1 year) success rate just a hair over 0%.

We have a handful medications, dietary interventions (change in diet composition), and surgeries that can alter a set weight. My experience is that most physicians don't know about most of them, have never looked up any research concerning obesity, and either never recommend any evidence based medical interventions for obesity or recommend just bariatric surgery for their most obese patients. There is a reason that there is a push for obesity to be a board certification. The amount of misinformation that physicians spread about obesity is just horrifying.

 

[deleted480308]

I think the poster meant that, at what would be a normal set weight, his/her body would send signals that it is starving. Which is true. All of the literature indicates that our bodies very reliably maintain a set weight and that trying to count calories to meet your ideal weight rather than your set weight is psychologically debilitating because you have a very complex neuro-endocrine system that is constantly telling your mind to drop whatever you are doing and to go seek food. Which is why every study of calorie restriction diets has found that they have a long term (>1 year) success rate just a hair over 0%.

We have a handful medications, dietary interventions (change in diet composition), and surgeries that can alter a set weight. My experience is that most physicians don't know about most of them, have never looked up any research concerning obesity, and either never recommend any evidence based medical interventions for obesity or recommend just bariatric surgery for their most obese patients. There is a reason that there is a push for obesity to be a board certification. The amount of misinformation that physicians spread about obesity is just horrifying.

Nobody has a set weight of 400lbs, when we are fat (barring a unicorn disease) we weigh what we do because we make bad choices and good choices are harder. Long term calorie restriction works fine if you do it. It only doesn’t “work” because people stop. It’s like saying insulin doesn’t work because my diabetic is non-compliant. Nope, insulin works

I get impulses, my weight hasn’t always been right. It’s hard to make the choice to do the right thing

 

[AMEHigh]

I think the poster meant that, at what would be a normal set weight, his/her body would send signals that it is starving. Which is true. All of the literature indicates that our bodies very reliably maintain a set weight and that trying to count calories to meet your ideal weight rather than your set weight is psychologically debilitating because you have a very complex neuro-endocrine system that is constantly telling your mind to drop whatever you are doing and to go seek food. Which is why every study of calorie restriction diets has found that they have a long term (>1 year) success rate just a hair over 0%.

We have a handful medications, dietary interventions (change in diet composition), and surgeries that can alter a set weight. My experience is that most physicians don't know about most of them, have never looked up any research concerning obesity, and either never recommend any evidence based medical interventions for obesity or recommend just bariatric surgery for their most obese patients. There is a reason that there is a push for obesity to be a board certification. The amount of misinformation that physicians spread about obesity is just horrifying.

Yes exactly, thank you. Thank you for your understanding and explanation.
The OP question was "do you judge overweight classmates"
My set weight certainly is not 135 pounds which is "healthy weight" for my height per BMI tables. So I have always been and likely will be "overweight" or fat which is what the original question was asking about in regards to judgement.

I know 135 pounds is not my set weight because my lowest adult weight was 133 pounds and in order to achieve that was when I was in college as a D1 athlete so working out 6 days a week via practice/games, plus I did an extra hour on the elliptical 7 days a week and limited my calories by eating a lot of veggies and egg whites. Once I went back to normal activity levels and normal healthy eating I went back to 145-147. I now weigh more than that almost 20 years later, thanks metabolism. So no I’ll never be 135 pounds unless I eat like I have an eating disorder.

Body frames of people from Nigeria vs Denmark vs Japan for example are generally very different so exactly as you said set weight varies. And yo-yo dieting wrecks havoc on ones metabolism so advocating for people to restrict calories is not helpful.

Lastly, let’s talk about the food industries role in obesity. Hello high fructose corn syrup in everything from bread to ketchup to spaghetti sauce. I pretty much try not to eat those things (or make from scratch) because I’m knowledgeable enough to understand the hidden sugar in everything, but really we should be able to eat some toast or spaghetti without having to make it from scratch to avoid sugar being the 2nd ingredient. I lived overseas for a couple years and the food supply and ingredients were vastly different than here.

 

[VA Hopeful Dr]

Things must’ve been done differently when you did interviews. When I was interviewing myself, when I was a resident and now where I’m an attending generally each interview is about 10-12 min and your rotate through a variety of faculty and residents. So that’s a sample of about 20 programs and my friends in other specialties have had similar experiences. I can’t imagine how long the interview day lasts if you spend an hour with multiple faculty members. It’s just not feasible these days with the number of people each interview day.

As far as a teaching moment with the poster in question, that’s exactly what I did. They responded to my post saying I was using it as an excuse and I wouldn’t be starving. I nicely responded saying that no you are incorrect, my body frame is not meant to be at 135 pounds. Then that’s where the poster came back saying I’m not disciplined enough and should see a neurologist if I’m still hungry after eating a bunch of lettuce.

So yeah, I did try to be empathetic and use it as a teaching moment, but they dug their heels in about this issue while being dismissive and incorrect. That’s one of the number one things I look at when giving feedback to med students (and residents). Are you able to take feedback or constructive criticism. It’s ok to be wrong about something, but don’t just dig your heels in to an issue, especially about nuanced topics that require empathy/understanding such as weight, race, gender, etc.

Three interviews: two faculty and one resident. Takes 3 hours out of a roughly 6 hour interview day. All of the 8 places I interviewed at were similar. Might be a geographic thing as I didn't travel very far. But I still maintain that 10-15 minutes is not enough time for anything productive.

My old program may be unique, but the number of interviews in a year has stayed pretty steady from when I started in 2010 and last year when they last posted their Match statistics. Applications went up massively but actual interviews didn't change by very much.

And no, a single personal anecdote isn't what I'd call teaching. A response like what @Perrotfish posted is.

 

[VA Hopeful Dr]

I think the poster meant that, at what would be a normal set weight, his/her body would send signals that it is starving. Which is true. All of the literature indicates that our bodies very reliably maintain a set weight and that trying to count calories to meet your ideal weight rather than your set weight is psychologically debilitating because you have a very complex neuro-endocrine system that is constantly telling your mind to drop whatever you are doing and to go seek food. Which is why every study of calorie restriction diets has found that they have a long term (>1 year) success rate just a hair over 0%.

We have a handful medications, dietary interventions (change in diet composition), and surgeries that can alter a set weight. My experience is that most physicians don't know about most of them, have never looked up any research concerning obesity, and either never recommend any evidence based medical interventions for obesity or recommend just bariatric surgery for their most obese patients. There is a reason that there is a push for obesity to be a board certification. The amount of misinformation that physicians spread about obesity is just horrifying.

I'm curious what medications you're talking about here.

 

[PikminOC]

I'm curious what medications you're talking about here.

Contrave, Phentermine, qsmia?

 

[VA Hopeful Dr]

Contrave, Phentermine, qsmia?

He said medications that work

 

[PikminOC]

He said medications that work

Then there must be a list IDK about. He said meds that can alter set weight. He didn't say for how long or if it's sustainable

 

[TwoHighways]

Yes exactly, thank you. Thank you for your understanding and explanation.
The OP question was "do you judge overweight classmates"
My set weight certainly is not 135 pounds which is "healthy weight" for my height per BMI tables. So I have always been and likely will be "overweight" or fat which is what the original question was asking about in regards to judgement.

I know 135 pounds is not my set weight because my lowest adult weight was 133 pounds and in order to achieve that was when I was in college as a D1 athlete so working out 6 days a week via practice/games, plus I did an extra hour on the elliptical 7 days a week and limited my calories by eating a lot of veggies and egg whites. Once I went back to normal activity levels and normal healthy eating I went back to 145-147. I now weigh more than that almost 20 years later, thanks metabolism. So no I’ll never be 135 pounds unless I eat like I have an eating disorder.

Body frames of people from Nigeria vs Denmark vs Japan for example are generally very different so exactly as you said set weight varies. And yo-yo dieting wrecks havoc on ones metabolism so advocating for people to restrict calories is not helpful.

Lastly, let’s talk about the food industries role in obesity. Hello high fructose corn syrup in everything from bread to ketchup to spaghetti sauce. I pretty much try not to eat those things (or make from scratch) because I’m knowledgeable enough to understand the hidden sugar in everything, but really we should be able to eat some toast or spaghetti without having to make it from scratch to avoid sugar being the 2nd ingredient. I lived overseas for a couple years and the food supply and ingredients were vastly different than here.

Would be curious to know your fasting insulin levels and OGTT results.

 

[Matthew9Thirtyfive]

Her are my thoughts on the subject based on my experiences traveling to Europe and very rarely encountering an obese person (unless they were American tourists).

There are plenty of obese people in Europe. The rates there are lower than here, but there are still plenty of them in much of the UK. The US isn’t even in the top 10 for obesity rates, despite everyone wanting to say we are the fattest country, though we are probably at the top of the list when you don’t count countries that just culturally are larger.

Now if you want to walk around without ever seeing an obese person, go to a place like Japan or Singapore. I deployed out there, and I don’t remember seeing a single overweight person.

 

[AMEHigh]

Would be curious to know your fasting insulin levels and OGTT results.

No clue. Is that something you’re routinely checking on your non-pregnant patients? I only know my a1c and fasting blood sugar.
I only consider checking those in my patients with pcos. Not aware of any indications for routine screening.
My labs haven’t changed much from when I weighed 145 vs 170.

 

[IsleyOfTheNorth]

Did you look at the stats for the first paper? And directly from that paper, "Some previous research has found that pediatricians’ BMI itself is not associated with differences in attitudes, behaviors, or skills of obesity management or rates of healthy weight counseling ((9),(10),(11))."

"The extent of misclassification of weight status that we found, coupled with the strength of the association between weight self-perception and ease of counseling, may help to explain why looking at BMI alone as a predictor of counseling patterns has yielded conflicting results (9–11,13,15,16). Rather than actual BMI, it may be the perception of weight that more influences counseling. Although likely difficult, helping pediatricians overcome personal weight-related obstacles may enable them to become better counselors for achieving healthy weight in their patients."

For the second paper, I'm only looking at the abstract because I don't have access to the whole thing. "The difference for weight and fitness counseling did not reach significance (P = 0.075)."

The statement from the abstract that you must have seen:
"Results. Significant differences were found for patient receptiveness to counseling for treatment of illness (P 0.038) and health advice (P 0.049), with the patients of nonobese physicians indicating greater confidence scores. The difference for weight and fitness counseling did not reach significance (P 0.075)."

That's my only point from that article.

None of these articles are meant for you to draw any kind of conclusions or establish any kind of causation.

What are you basing that statement on? The fact that they were published in medical journals with significance numbers and conclusions kind of implies that they were indeed meant to draw conclusions.

 

[TwoHighways]

No clue. Is that something you’re routinely checking on your non-pregnant patients? I only know my a1c and fasting blood sugar.
I only consider checking those in my patients with pcos. Not aware of any indications for routine screening.
My labs haven’t changed much from when I weighed 145 vs 170.

Insulin is quite anabolic to fat tissue. High fasting insulin and impaired glucose tolerance (or a larger than normal insulin response to dispose of ingested glucose) would be an indication to me to cut dietary carbohydrates back. It’s also difficult to trigger lipolysis with elevated baseline insulin levels.

A1C isn’t a very helpful value by itself. Rising A1C is a lagging indicator of insulin resistance. You can be profoundly insulin resistant before your average blood sugar begins to rise. You want to get in front of the problem well before glucose homeostasis is affected.

I’m not a doctor, I just have an intense interest in this subject matter (the metabolic syndrome in general). As far as I’m concerned, it’s the driver of a ridiculous amount of healthcare dollars being spent in our country.

 

[IsleyOfTheNorth]

I'm all for including research in this thread, and thank you for including your citations, but don't try to sneak one past us. ... So... it's hard to draw any conclusion. And, in fact, the authors expressed their trouble with exactly that in the discussion.

People trying to "sneak one past you" don't include full citations.

"Conclusions. Patients seeking care from nonobese physicians indicated greater confidence in general health counseling and treatment of illness than patients seeing obese physicians. It is not known if this can be translated into increased success in obesity prevention and treatment."

I wish I could post the full article for you here, but I imagine that's a copyright issue.

 

[IsleyOfTheNorth]

Oh this is grand.

As far as a teaching moment with the poster in question, that’s exactly what I did. They responded to my post saying I was using it as an excuse and I wouldn’t be starving.

I did say it was an excuse and that if she choose different foods she would not be "starving". Legit.

I nicely responded saying that no you are incorrect, my body frame is not meant to be at 135 pounds. Then that’s where the poster came back saying I’m not disciplined enough and should see a neurologist if I’m still hungry after eating a bunch of lettuce.

*emphasis mine

Here's what you actually said:

My body is not meant to be 135 pounds unless I’m literally supposed to sit around doing nothing except eat 1100 calories and not exist in life. Hence me saying I would be starving. In case you have made it through life without recognizing that different people have different body frames and shapes then you probably should not be in medicine.

*emphasis mine

Again, my point with the vegetables is that, if you fill up on low calorie foods, you won't be hungry. If you are physically full of food and you are still hungry, then something else is going on and you need to see a specialist.

So yeah, I did try to be empathetic and use it as a teaching moment,

Ladies and gentlemen, I present to you an empathetic teaching moment:

I see you’re just being a troll so I’m going to ignore you.
While everyone is freaking out about usmle becoming pass/fail we still haven’t figured out how to screen out people who aren’t intelligent and aren’t empathetic.

*emphasis mine. She is referring to me.

... but they dug their heels in about this issue while being dismissive and incorrect.

I am happy to consider any points you have on this topic, despite you saying that I'm stupid and shouldn't be a physician. I'm cool like that. The only caveat is that has to be a good argument. I will be dismissive of bad arguments, but I'm willing to entertain any argument that you have.

Some things a wise person once told me that I think you should consider:

Are you able to take feedback or constructive criticism. It’s ok to be wrong about something, but don’t just dig your heels in to an issue, especially about nuanced topics that require empathy/understanding such as weight, race, gender, etc.

 

[hallowmann]

Agree. It’s just hard not to shoot them a judgemental look when we’re talking about healthy diets on rounds....

Is it that hard for you to hide disdain for people, the way their lives have worked out, or their choices? I recommend that this is a skill you should develop preferably before 2nd year of residency, if not earlier.

Are you saying we shouldn’t bring up the weight issues with our patients?

I don't know anyone who says that. I'm technically in the obese range. I bring up weight and diet with every patient at least annually.

Some methods work, and you need to actually expand on why someone finds calorie counting, exercise, etc. difficult. Their lives vary significantly. If you're working 14 hrs a day at a desk, your chances of having 30-60 min/day for exercise is different than someone working 6 hrs a day. Your advice to each of those people will vary.

Calorie reduction is absolutely the way to handle things, but saying that someone should only eat steamed vegetables and 3 heads of lettuce is ridiculous.

Thanks for clarifying. I agree that shaming people for losing weight is an extreme that is actually contradictory to the underlying message of HAES. Although, there are some data out there that intentional weight loss can increase mortality... The idea that a high BMI on its own is harmful and having a lower BMI is always better is where things aren't as clear cut. Statistically speaking, yes, higher BMIs are correlated with increased risk of cancer, heart disease, etc. There are well established links there. But when I am looking at an individual patient, their BMI doesn't really tell me how healthy they are. Their cholesterol, BP, glucose, etc. could look amazing (maybe not likely at a BMI of 45, but not improbable), and unless there are other weight related issues going on (joint pain, sleep apnea, intertrigo, etc.), I don't know if I have enough evidence to say that the high BMI itself is harmful, and that weight loss is going to be beneficial.

Anecdotally, I've seen a couple of people with BMIs of 45+ with perfect cholesterol, BP, CMPs, and A1c's of 5%. They win the genetic lottery. I have pretty impressive alterations in my labs when my diet hits >1400 cal/day or my BMI goes above 32.

Speaking from experience, this is very much the case with the poor in the US. So many poor in the US are obese because unhealthy food is such a cheap source of pleasure.

Its not just the fact that bad food is a cheap source of pleasure. Its the fact that it is cheap, food is essential for life, and healthy options are both more expensive and very difficult to find in poor communities (i.e. in some cases you'd have to drive 30-45 min to find grocery stores that even offer fresh fruits and vegetables). Its not just the fact that its a source of pleasure.

As for the trolling part, I think most of us have said things we later regretted on the internet in general and likely SDN in particular. I know some of the things I said here in my med school days now make me kind of ashamed. Luckily there was no one around to deny me a future as a doctor because of it.

Absolutely a universal thing.

Later that week another patient, same height and roughly the same weight except this patient's stomach stuck out a good 8-9 inches further than his chest. He did get an exercise and healthy eating discussion.

Honestly, I've seen people that are built like trucks (big arms, big legs, etc.), whose labs are terrible, and once they lose some of that mass they suddenly no longer have elevated LFTs, insulin sensitivity improves, etc. I still talk to those people about their lifestyles and screening labs, because its possible their bodies simply aren't meant to have that amount of mass or they're doing something unhealthy to maintain it.

"The extent of misclassification of weight status that we found, coupled with the strength of the association between weight self-perception and ease of counseling, may help to explain why looking at BMI alone as a predictor of counseling patterns has yielded conflicting results (9–11,13,15,16). Rather than actual BMI, it may be the perception of weight that more influences counseling. Although likely difficult, helping pediatricians overcome personal weight-related obstacles may enable them to become better counselors for achieving healthy weight in their patients."

The statement from the abstract that you must have seen:
"Results. Significant differences were found for patient receptiveness to counseling for treatment of illness (P 0.038) and health advice (P 0.049), with the patients of nonobese physicians indicating greater confidence scores. The difference for weight and fitness counseling did not reach significance (P 0.075)."

That's my only point from that article.

What are you basing that statement on? The fact that they were published in medical journals with significance numbers and conclusions kind of implies that they were indeed meant to draw conclusions.

You haven't really addressed the part where the sample size of that second paper was 5 pediatricians and only 2 characterized themselves as overweight. That's a pretty small sample size. Even if the p < 0.0005, I'd have trouble making any generalizable conclusions from that.

 

[MedicineZ0Z]

I never personally judged them for being overweight. But I feel that if I can workout routinely on a resident's schedule, then it's doable for anyone.

I think we also tend to make too many excuses for people's poor choices.

 

[TwoHighways]

Still pretty frustrating that people are approaching this problem from the calories in, calories out paradigm.

 

[AMEHigh]

Insulin is quite anabolic to fat tissue. High fasting insulin and impaired glucose tolerance (or a larger than normal insulin response to dispose of ingested glucose) would be an indication to me to cut dietary carbohydrates back. It’s also difficult to trigger lipolysis with elevated baseline insulin levels.

A1C isn’t a very helpful value by itself. Rising A1C is a lagging indicator of insulin resistance. You can be profoundly insulin resistant before your average blood sugar begins to rise. You want to get in front of the problem well before glucose homeostasis is affected.

I’m not a doctor, I just have an intense interest in this subject matter (the metabolic syndrome in general). As far as I’m concerned, it’s the driver of a ridiculous amount of healthcare dollars being spent in our country.

Yes I know that in regards to fasting insulin. I was just saying that as far as I’m aware there’s no indication to check that or ogtt on a routine basis hence why I don’t know my numbers. If there’s evidence that we should be checking those in our patients then I’d love to read the source so I can expand my knowledge base.

I track my macros and I eat pretty low carb. I pretty much eat the same meals over and over so it’s pretty easy for me to know what my carb, fat and protein ratios are. I was vegetarian for many many many years, but now I’m more pescatarian with the occasional chicken because I find it easier to keep my macro ratios how I want them with higher protein and fat and lower carb. If I had a personal nutritionist and chef I would be all about perfect macros and a plant based diet but I don’t have the personal dedication for that, so pescatarian it is!

 

[VA Hopeful Dr]

Then there must be a list IDK about. He said meds that can alter set weight. He didn't say for how long or if it's sustainable

That's the problem with most weight loss medications, they DON'T alter set weight. Its why the results rarely last.

 

[AMEHigh]

Still pretty frustrating that people are approaching this problem from the calories in, calories out paradigm.

Yep agreed.

ETA: I would love to know how many men in here are saying this. Like I said before rarely do people, especially men, take in to account the fact that women’s hormones play a role from monthly menses, to pregnancy, breastfeeding, peri-menopause and menopause. It’s not just a calories in and out issue.

 

[VA Hopeful Dr]

Yes I know that in regards to fasting insulin. I was just saying that as far as I’m aware there’s no indication to check that or ogtt on a routine basis hence why I don’t know my numbers. If there’s evidence that we should be checking those in our patients then I’d love to read the source so I can expand my knowledge base.

I track my macros and I eat pretty low carb. I pretty much eat the same meals over and over so it’s pretty easy for me to know what my carb, fat and protein ratios are. I was vegetarian for many many many years, but now I’m more pescatarian with the occasional chicken because I find it easier to keep my macro ratios how I want them with higher protein and fat and lower carb. If I had a personal nutritionist and chef I would be all about perfect macros and a plant based diet but I don’t have the personal dedication for that, so pescatarian it is!

I suspect that sort of thing is coming in the next 10 years or so. The theory is that by the time other labs are abnormal - A1c, LFTs, whatever the patient is well on their way down the insulin resistance path.

But the data is not all that robust yet, hence why no one is taking this approach. But I think before you and I retire it will be something that's done routinely.

 

[TwoHighways]

Yes I know that in regards to fasting insulin. I was just saying that as far as I’m aware there’s no indication to check that or ogtt on a routine basis hence why I don’t know my numbers. If there’s evidence that we should be checking those in our patients then I’d love to read the source so I can expand my knowledge base.

I track my macros and I eat pretty low carb. I pretty much eat the same meals over and over so it’s pretty easy for me to know what my carb, fat and protein ratios are. I was vegetarian for many many many years, but now I’m more pescatarian with the occasional chicken because I find it easier to keep my macro ratios how I want them with higher protein and fat and lower carb. If I had a personal nutritionist and chef I would be all about perfect macros and a plant based diet but I don’t have the personal dedication for that, so pescatarian it is!

The “evidence” may not be there yet, but it gives profound insight to the metabolic state of a person. Most of my own understanding of this comes from the work of Peter Attia. He’s got some great YouTube lectures and has a phenomenal podcast that I can’t speak highly enough of.

How do you define “pretty low carb”? What were your macros like as a vegetarian?

 

[IsleyOfTheNorth]

Calorie reduction is absolutely the way to handle things, but saying that someone should only eat steamed vegetables and 3 heads of lettuce is ridiculous.

Its not just the fact that bad food is a cheap source of pleasure. Its the fact that it is cheap, food is essential for life, and healthy options are both more expensive and very difficult to find in poor communities (i.e. in some cases you'd have to drive 30-45 min to find grocery stores that even offer fresh fruits and vegetables). Its not just the fact that its a source of pleasure.

I mostly agree. I find it hard to get to the store so the veggies I eat tend to be frozen. Even on a trailer-park budget, buying frozen veggies is very inexpensive. (I speak from experience on this one.) Unfortunately education is an issue. I'm not saying that food deserts aren't a thing - they definitely are.

You haven't really addressed the part where the sample size of that second paper was 5 pediatricians and only 2 characterized themselves as overweight. That's a pretty small sample size. Even if the p < 0.0005, I'd have trouble making any generalizable conclusions from that.

I agree. With such a small sample size I would consider it supporting but definitely not definitive.

 

[IsleyOfTheNorth]

Like I said before rarely do people, especially men, take in to account the fact that women’s hormones play a role from monthly menses, to pregnancy, breastfeeding, peri-menopause and menopause. It’s not just a calories in and out issue.

What would you say is the relative effect on body weight of women's hormones? Like, would you say that the difference between the lows and highs in a given month would be 1%? 10%? 40%?

If we imagine a woman on a controlled diet who is 100 lbs (for easy numbers). What would you guess her lowest monthly weight and highest monthly weight would be based purely on hormonal changes. (Let's assume non-pregnant, pre-menopause.)

 

[deleted480308]

Still pretty frustrating that people are approaching this problem from the calories in, calories out paradigm.

there are a lot of things that change the effectiveness of the calories in and the efficiency of burning those calories out......but it's still the same in vs out

 

[Mass Effect]

I don't judge, but I am curious about them. I grew up poor, so I equate obesity with lack of nutrition, education, options, and I don't look down on my friends and family members in general. I am often surprised to see wealthy people with weight issues because they have the resources to deal with it, the recreational time to exercise, etc.

It's not just about that. I work with eating disordered patients and you'd be amazed at the number of people who have lifelong struggles with food and exercise due to other factors, such as home life, relationships, bullying at school (particularly in college-aged girls), traumatic experiences, etc. Genetics also plays a role. I had a patient who was very well-to-do whose entire family was obese -- parents, grandparents, siblings, aunts/uncles. She actually showed me a family reunion photo at one point and I couldn't believe how heavy that whole family was. When you grow up in a family where your relatives don't have a healthy relationship with food, it follows you no matter how much money you have/how successful you are.

Just for clarity, I don't fat shame. I've struggled with my weight my whole life and I know how difficult it really is. What I do have a problem with is people (especially physicians) throwing up their hands and saying "It can't be done!". That's baloney and we all know it.

My point with the lettuce is that you diet without being hungry if you choose the right foods. Fill up on low calorie foods and you won't be hungry.

The fact that you think eating three heads of lettuce and 4 pounds of soybeans a day in order to lose weight shows a profound lack of knowledge about nutrition.