The Battle Against Fat Continues

Let's kick of some 2023 blogging with a controversial topic, shall we?  The Battle Against Fat continues.  If you've never met me in person, you may not know that I am fat.  I don't say that in a derogatory or negative way.  It is simply a descriptor of my body.  I'm not really short or tall - average in height.  But I am apple-shaped and thus, fat is an accurate adjective to describe me. I don't choose to be fat. In fact, I spent my first 30 years yo-yo dieting in an effort to make myself smaller, having great successes followed by even greater reversals. With support from a therapist and a dietician, I've learned to accept that this is the body that I've got and overall it does it's job pretty well, even if it isn't the socially approved size. That doesn't mean I don't wish I was smaller - it just means I'm no longer torturing myself to try to achieve that and instead strive to live healthily. 

cartwheel

I've previously written a few posts about my own experience with binge eating disorder and recognize that this impacts my beliefs about weight loss and body size. I have endured plenty of weight stigma and fat shaming both personally and professionally. My body size has come up in conversation as a healthcare provider during hiring processes and I've received derogatory comments from colleagues.  

In Physical Therapy World, there are physical therapists who think we need to be thin, fit, and muscular to do the job we do... but the way I look is not an indicator of my level of fitness and it certainly has no relationship with how smart I am or how much I care about my patients.  Imagine if we had to be capable of performing all the things our patients and clients do?  I wish I could shoot a basketball as well as some of the basketball players I've been fortunate enough to work with. I treat dozens of gymnasts and have never been able to do a cartwheel... I don't think that's because I'm fat. It's because I'm terrified of landing flat on my face.

I have also been a patient with doctors telling me that losing weight would fix whatever problem I was in for. Problems which also occur in people whose body weight is in the normal range on the (horrible) Body Mass Index Scale. There are numerous articles about how bad the BMI scale is, including this one. It was NEVER intended to be used in the way that it is. I went to have a sleep study a few months ago and the physician kindly explained to me that the findings would not be as accurate if I did a home study because the equipment used at home can't accommodate higher BMI as well as the equipment in the hospital does.  I asked my doctor, "If I was skinny, which test would you have me do?"  He said "the home test," so that's what we did. I respected him for presenting the data around the differences and for placing the blame on the equipment rather than on my body, and for ultimately treating me the same way he would treat a smaller person. 

Often ignored in this conversation are the kids I work with who also have higher body weight who whisper that they're so glad they don't have to work with the skinny PTs because it makes them uncomfortable.  The ones who have cried because a previous medical provider blamed their pain on their body, or that they hate their own bodies and are self-harming or thinking about it.  In some ways, my body size has made several teens comfortable enough to tell me there was an issue for which I got them help. In the clinic, it crushes my soul when I'm working with pediatric patients whose parents call their own kids lazy or fat rather than encouraging them to be active and work towards health. Or that time I told a little girl that she was strong and she looked me dead in the eye and said "only boys can be strong, not girls."  Or the kids who come into the clinic and walk on the treadmill only to be excited by how many calories they're burning. Are we even teaching them the right things? Where does this messaging come from?! 

I have been asked numerous times from parents how to help their kids lose weight, and when I point out all the things their body is capable of doing as it currently exists, it's like I have a third eyeball. Follow that up with asking about nutrition at family meals or physically active habits the family shares and you would think I'm suggesting families should be surviving on raw broccoli and running marathons together.  The American Physical Therapy Association has a Position Statement indicating that it is within PT scope of practice to "screen for and provide information on diet and nutritional issues" in collaboration with a registered dietician. The problem with this is that there are conflicting views about weight and what "proper nutrition" is in the United States. If all the doctors are skinny, the fat patients will never be heard or given medical care. We have a serious problem, but I don't think we're fighting the right battle. Instead of the Battle Against Fat, we should be fighting The Battle Against Too Expensive Nutritious Foods, The Battle Against Unsafe Play Areas For Kids, The Battle Against Decreasing Recess and PE in Schools, The Battle Against Unaffordable Child Care and Housing, and so many other battles.  Instead, our healthcare system is again doubling down on the Battle Against Fat, but now they're doing it against children. 

On January 9, 2023, the American Academy of Pediatrics published a new "Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity." I really didn't want to share the link to the paper because it's downright awful, but I also think people should have the chance to read it and make their own conclusions about the contents, so here it is. It's really long.  It's hard to include clips of the guideline here, so I've only selected this one clip about Parental Obesity which is considered a strong predictor of pediatric obesity.  And yet we're targeting these interventions on the children. 

The goal of these Guidelines is to streamline clinical practice for kids who are fat.  There are numerous recommendations made, and perhaps they may have done the right thing in suggesting that more kids get screened for metabolic disorders, but all the recommendations are based on use of the BMI Scale, which was created by a mathematician studying white men to find averages - never intended for use in children or even to be applied at the Individual level. The Guideline even hints at this, mentioning that BMI is not the Gold Standard to assess body composition, but it is easy to use. 

To be very clear, I believe that this guideline will be harmful and do not support the recommendations, and I am fully aware that this goes beyond my scope of practice as a PT, but not beyond my understanding as a human. Two particular recommendations worry me above the rest. Depending on BMI, recommendation #11 indicates weight loss medications should be provided for kids over age 12 and recommendation #12 directs bariatric surgery for kids over age 13.  Teenage girls who haven't yet started menstruating and will undergo considerable body development over the subsequent several years should not be having surgical interventions to change their digestive systems. I'm shaking with disbelief typing these thoughts. I know I am not a researcher.  I know that I am not a surgeon who could conduct surgeries like this on kids, and I don't know which surgical methods they would even use. Nor am I a pharmacist who would be prescribing kids drugs which could be needed for their entire lives rather than focusing on so many alternative options. I'm constantly seeing teens in the clinic with body dysmorphia, body dysphoria, eating disorders or disordered eating, and low self esteem and there is already data indicating the severity of depression in teens.  How much worse can it get as we start to prioritize weight loss even more?

I've finally finished reading the Guideline in all of it's terror, but before I could finish, I helped facilitate discussions at an event through the University of Washington on January 19, 2023 on a similar topic.  The event was part of the University of Washington Center for Health Sciences Interprofessional Education Program where students work to increase engagement with different medical disciplines. Thirteen programs including nursing, dentistry, public health, pharmacy, and physical therapy require their students to select from a variety of topics for interdisciplinary discussions and there were about 100 students at this event discussing Weight Stigma in Clinical Care. 

Participants received two articles prior to the talk, which was led by Dr. Lisa Erlanger, a Family Medicine Physician in Seattle, and Dr. Erin Harrop, a Licensed Clinical Social Worker and Professor at the University of Denver. First, "Everything You Know About Obesity Is Wrong," a publication from The Huffington Post written by Michael Hobbs that exposed some really eye opening patient testimonials about the harms of healthcare providers participating in weight stigma practices.  The article begins by demonstrating the delay between science finding solutions and medicine implementing them: The story of sailors dying from scurvy, easily cured by eating citrus fruits, but that fruit wasn't provided as different (more cost effective) options were tried instead, resulting in more death. Startling statistics were included that try to paint the picture of how unlikely it is to maintain considerable weight loss.  How many children will need to be medicated in order for one child to achieve and maintain normal weight?  I don't think this type of study has been done yet.

The other article, "How and Why Weight Stigma Drives the Obesity 'Epidemic' and Harms Health," by Tomiyama et al, an opinion piece from BMC. When will physicians catch up to the studies that show that weight cycling is bad for health and that weight stigma is even worse!  It's like this quote from the movie Mean Girls, "I don't hate you because you're fat, you're fat because I hate you." (Also - that movie is somehow 19 years old!)

So the session began with didactic education including review of the statistics and memorable anecdotes from these articles and additional research, followed by discussions of case studies.  Students elected to participate in this discussion for a variety of reasons which they shared - concerns about their families, wanting to learn how to challenge fat bias, growing up overweight as a child and experiencing weight stigma, wanting to learn how to talk to patients or friends battling weight-related challenges, and more. 

Even as a facilitator, I learned new things.  For example, "fat" as a word is a descriptor of having adipose tissue, however the moral judgement applied to using the word has created a negative connotation. More recently, "fat" has been re-claimed by those who live in larger bodies in a similar way to how "queer" was reclaimed by the LGBTQ+ community and the associated attitude towards these words are evolving.  Previously considered as a slur, "fat" has been  reclaimed as an identifier and we need to move forward to increase awareness and reduce stigma. 

"Headless Fatty"

Diet culture was discussed. An overarching set of societal beliefs that confuses health with weight, healthcare providers contribute to diet culture and weight stigma constantly and in harmful ways.  Diet culture encourages weight loss and correlates this with improved health, but it wrongly accuses fat as the cause for other conditions. It also moralizes things like: healthy food vs unhealthy, standing vs sitting, good movement vs bad.  It perpetuates a weight normative approach with a focus on BMI and having an "ideal" body weight. Health-ism occurs, as well, where providers may be accepting of higher weight AS LONG AS there are no metabolic health concerns. A common representation of diet culture was also mentioned: The "Headless Fatty" - showing pictures of large bodies without a face, a common, dehumanizing weight stigmatizing behavior. 

How does diet culture show up in healthcare?  The most common scenarios I've come head to head with are surgery being denied due to higher BMI and inadequate equipment availability. Orthopedic surgeons are frequent flyers in weight stigma, opting to avoid surgeries because there may be higher risk of infection in larger body sizes or predicted outcomes being less than desirable, sometimes including required weight loss prior to intervention. It's a frequent occurrence that poorly fitting blood pressure cuffs are used on larger bodied patients, which elicits inaccurate readings.  Waiting rooms at clinics may not have chairs that can accommodate a larger bodied person. Sometimes tests have limitations so they're not conducted on patients, thus increasing their risk of illness due to equipment and lack of training.  I already mentioned my own experience with sleep testing at home.

The discussion at UW did touch on the new Clinical Practice Guidelines, which was timely.  There were some resources shared including a blog from Ragen Chastain who writes about why the guidelines are harmful here. She included mention of unlisted conflicts of interest for many of the authors for the Guideline, as well as the American Academy of Pediatrics, with financial incentive from the pharmaceutical company that makes weight loss medications. I just feel icky reading this, but agree with her that while the authors may have good intentions to improve pediatric health, they may also be misguided and lacked input from eating disorder specialists and mental health providers who could have helped improve the guidelines to make them safer. 

Healthcare providers - if you congratulate your patients for weight loss without asking them about the behaviors around their weight change, you could miss serious diagnoses.  Like cancer, or an eating disorder, or celiac disease, irritable bowel syndrome, heart failure, diabetes, or thyroid problems.  You may have good intentions, but plenty of people lose weight and do not gain health - or even feel poorly.  The underlying goal should be health - not small bodies. Think about how you define health?  I've previously written a blog post about the different types of health, but I think that we, as healthcare providers, often exert our own beliefs of health onto our patients rather than hearing what they find important.  Usually people defining health choose functional answers, like ability to do certain activities.  The common medical definition of health is "Freedom from disease," but if this is the case, most of us will have periods of episodic or constant non-healthy time.  I used to think health was a thin body, but at my smallest, my mental health was poor and I was restricting so many foods, I couldn't maintain that lifestyle.  My smallest was bigger than many people will ever be, and it didn't bring me any happiness because I was in a constant brain fog from hunger and distracted by constantly wanting my next meal.  My biggest size didn't necessarily make me feel good, either, but at least then, I was able to eat and focus on my work and the challenges I faced were different.  Regardless, I have been the same person at every size I've been.

I'm sure I could continue discussing this topic ad nauseum, but I think I'll stop here.  Here's to hoping the kids stay healthy and safe. And good on you, University of Washington, for finding a place for these more challenging conversations in your medical programs' curriculums.