“You’re Perfectly Healthy, Except…”
A friend recently went to the doctor and, for the umpteenth time, was told:
“Everything indicates you’re in perfect health; except you’re overweight.”
When she shared this, my own countless experiences hearing the same line came rushing back. One memory bubbled to the surface: a comedian doing a bit about his doctor saying the same thing, calling the extra weight “cosmetic.”
“Well doc, I’m not here to find out whether I’m cute, I just want to know if I’m healthy, so let’s focus on that,” was the gist of his response.
Why are we being warned about our weight when we’re healthy?
On paper, warning people about excess weight is the responsible thing to do. After all, being overweight or obese increases the risk of type 2 diabetes, high blood pressure, heart diseases and strokes, kidney disease, certain types of cancer, and more. Doctors likely just want to be sure their patients are aware (in case they already weren’t) that they’re in a “risky” demographic with their weight.
Unfortunately, however, this is one area of healthcare doctors are ill-prepared to discuss.
Primary care doctors are not trained in weight management and nutrition, and thus are woefully under-armed for conversations about weight with patients. The most common conversation is likely similar to the ones my friend and I have had: “You’re overweight. I recommend diet and exercise.” End of conversation.
Making this harder is the fact that fat bias is well documented in the healthcare industry. Stories abound about people with chronic health conditions that went undiagnosed for years before a doctor decided to run tests that would have been run sooner for people with a “normal” Body Mass Index (BMI).
For just about any other health indicator that signals risk of future complications, doctors ideally sit down with patients and go over symptoms to look out for and specific actions and medications that can be taken to reduce risk. Healthcare plans get mapped out, and future check-ins are opportunities to revisit indicators, track progress, and stay realistic but positive about what could be a scary diagnosis someday.
Otherwise healthy, overweight people are rarely afforded this attention. Doctors actively avoid it, even. They don’t have the training, and it leaves patients feeling confused about why it even gets brought up.
Instead, patients are reminded at each visit of their failure to change what may be the only negative health indicator on their chart.
“Diet and exercise. Keep trying.”
No wonder overweight people avoid going to the doctor.
For those who don’t, many deny themselves food, exercise to exhaustion, and develop eating disorders in an attempt to “get healthy” and make their doctor happy. Even children fall victim to the need to please their doctor and have an “all clear” check-in.
And yet, the chances of a woman classified as obese achieving a “normal” weight are just 0.8%. Clearly, the current approach isn’t working.
What is “Normal” Anyway?
Compounding the issue is our reliance on BMI as an indicator of healthy weight.
BMI is completely bogus when it comes to measuring an individual’s health.
It was invented by a mathematician in the early 19th century to measure the degree of obesity of the general population in Belgium. The goal was to inform decisions about resource allocation. It was not meant to be a measurement of individual health — it was, and is, a simple formula of averages calculated by weight and height.
BMI does not account for body fat, muscle mass, waist circumference, or any other number of things that could more accurately determine whether someone’s body weight increases risk of later complications. And yet, our healthcare system stubbornly sticks to this oversimplified metric to guide conversations about weight with patients.
This doesn’t mean that everyone with a non-normal BMI isn’t at an increased health risk; many probably are. It does mean that BMI absolutely shouldn’t be the sole measure relied upon in determining that.
Because of its formulaic, bell-curve nature, multiple individuals in a population will inevitably fall below or above “normal” on the BMI scale. Some people will spend their entire lives below or above normal BMI with otherwise great health.
If that’s the case, what’s the problem with non-normal BMI? Why even bring it up with otherwise healthy patients?
The short answer is: nothing’s wrong with a non-normal BMI on its own. If BMI is someone’s only health problem throughout life, that’d be a sign of a healthy life lived. In a 2018 article, all experts interviewed said BMI is not a good way to tell if one’s weight is healthy.
BMI is a screening tool that can indicate need for deeper analysis. It is not diagnostic. Someone with a high BMI, for example, who is an athlete with a lot of muscle mass, is probably healthy and needn’t be concerned.
Someone like me, however, perhaps needed a different conversation — one doctors aren’t trained to have.
Two years ago, my doctor noted that though all my tests indicated I was healthy, I’d “crossed the line” into obesity after years of slow weight gain. Obesity came with more severe health risks, he warned. He gently encouraged me to change my diet before sending me on my way.
For me, the obesity label was new. I hadn’t been in normal BMI range since college, but I’d dismissed being overweight as a problem because I was active (my job involved hiking miles a day and climbing trees), I ate a relatively balanced diet on most days, and I was able to physically do all the things I wanted to do. I also had read that being overweight, not obese, didn’t come with the health risks attached to obesity.
I was overweight, but it didn’t bother me. I wasn’t ashamed of my body like I had been when I was younger— something I credit age, the body positive movement, and my amazing friends with. I was proud of my body’s ability to climb trees, hike trails, dance, hold people I love, and get on planes taking me all over the world.
After being told I was obese, I still felt that way: it was still my body, and it could still do those things. The only thing new for me was the health risks.
Not everyone is able to feel this way; many people have lifelong scarring from childhood experiences surrounding weight. Others have actually already started to experience negative health affects, or changes to daily life. News like this can be hard to take, and hard for untrained doctors to give.
I knew that my recent weight gain had to do with my lifestyle and mental health. Over the years, I’d become more sedentary and turned to food for comfort when going through depressive episodes.
Having new health risks that I hadn’t had before, and knowing that I was capable of reducing those risks, motivated me to get more active, adjust my diet, and get out of the “obese” designation. I renewed my efforts in therapy and set small, attainable weight-loss goals. I’m now back to being overweight, according to BMI, and I was able to achieve it at a healthy pace without making myself sick.
I love my body; I loved it even when it was obese. I chose to lose weight because I could, and because I didn’t want to worry about the associated health risks.
But not everyone can do that.
The Conflation of Fighting Fat and Fighting People
Whether it be due to disability, mental health, medical condition, genetics, or a some combination of these things, not everyone can lose weight with diet and exercise. Thankfully, bariatric surgery is becoming destigmatized as more doctors recommend it to patients who desire weight loss and have tried diet and exercise to no avail, or who have other complications.
Increasing awareness surrounding America’s overarching weight-related health problems is also bringing healthier food options and more physical activity to schools in hopes of setting young people up for healthier weight in the future.
Still, there is a struggle to decouple the war against obesity from the war against obese people.
I think efforts to combat weight, but not overweight people, can be executed without the sort of fat shaming and bias that remains pervasive today. The fat acceptance and body positive movements have been catching a lot of flak for “encouraging unhealthy lifestyles,” but the truth is that while being overweight increases risks, it doesn’t make me or anyone inherently unhealthy.
Regardless of size, all of our bodies are valid. Our bodies are what carry us through this world. No one has the right to treat anyone differently based on the shape and volume of skin, bone, muscle, organs, and yes, fat that we use to experience all the wonders life has to offer.
However, if our desire is to extend and optimize this temporary earthly experience as much as possible, one of many ways we can do so is by putting the effort in to reduce health risks associated with being overweight.
Still, that’s our choice, or ability — just as much as quitting smoking, TV, or high-risk hobbies is.
The moves to fight obesity aren’t, in my opinion, inherently fat-shaming, even if some of the people pushing for it are. Yes, the healthcare industry is rife with fat bias. Yes, some portion of the population will always be overweight.
The number of people in that portion has undeniably skyrocketed in recent years, and I think working toward reducing it in a non-shameful way is worth doing.
The shaming of large bodies in day-to-day life makes it such a hard blow when doctors bring it up on an otherwise clean bill of health. It’s why doctors need to do better when it comes to these conversations.
The National Institute of Diabetes and Digestive and Kidney Disease has tips for primary care providers who want to talk about weight loss with patients. In it, they suggest making a plan with patients, setting goals, and/or referring them to a registered dietitian. The institute also reminds doctors that BMI is a screening tool, not a diagnostic one, and to be sure to really listen to patient health concerns before assigning weight as the culprit or main concern.
In other words, don’t be condescending or evasive about health issues; be honest, but kind. Give overweight people the same respect you would give anyone else.
I think that should go without saying.