S2E14: Discussions of Weight Bias in Health Care

Harjit: I'm eating a Reese's Pieces.

Margaux: It's not a Reese's Pieces. Okay, finish your . . .

Harjit: I sound like a Slytherin.

Margaux: . . . so I can begin. Okay. Hey everyone, welcome to the "Bundle of Hers." Margaux and Harjit in the studio today. Bushra and Leen are hard working in their clerkships late tonight, so wish them luck. Anyways. That was so awkward.

Harjit: That was the funniest intro ever.

Margaux: So today I wanted to talk about something that's kind of relevant in current news as well as connected to my research that I'm doing in bariatric surgery and then something that we've had conversations about before, Harjit, but I think would be great to put on the podcast.

So if you may or may not have heard recently in the news, the CDC has put out a warning for patients seeking bariatric surgery in Mexico given that there are many patients coming back with multi-drug resistant Pseudomonas infections. Through this research I've had the chance to listen to the stories of some of these patients who've come back from Mexico and had these surgeries. And it's not the fact that they had the surgery and came back and had these pretty bad complications that kind of got to me, it was more of the reason that they were seeking the surgeries in the first place.

And one of the reasons that people are seeking surgery outside is that insurance doesn't cover it here. But you can go to Mexico without any sort of filter and get a bariatric surgery. And many patients are going down there with BMIs less than 30 and getting bariatric surgery. And so this kind of piqued my interest in wondering why people feel the need to take such drastic measures for weight loss.

And now as I'm practicing for my shelf in internal medicine, I noticed many question answers are weight loss. So a patient has hypertension, obesity, diabetes. What is the best non-pharmacological treatment that they can do to have the best outcome? And usually the answer is weight loss.

But as I think about it, we're not ever really taught how to have that conversation. And I've seen in clinic with doctors who say this to their patients, they just say, "Oh, you know what? Losing weight and changing your diet would be really helpful for you." And that's it. But to the patient that might sound really awful. Also, it kind of breeds this sort of, I don't know, despair in patients. What do you think about it?

Harjit: I actually think this topic is really interesting that of like weight bias or also in a different sense, also known as fat phobia. I'm really happy we're having this conversation because, you know, I've been kind of grappling with that issue as well because we have no education on how to effectively have a conversation with patients to lose weight as a treatment and when is it needed as a treatment and when is it that we're just putting that on them, like blaming all their problems on them being a certain number of BMI, right? Not all high BMI means every problem can be blamed on that thing. But I think we get blinded by that, right, because we're like, "Oh, that person's fatter, so it's contributing XYZ." And it maybe is, but there also might be a deeper problem that we're not looking at, right?

Margaux: I agree, yeah.

Harjit: So I think it kind of clouds our judgment. And the reason it clouds our judgment is because we're not taught the nuances of being "fat." We're just taught, you know, this person's fat, so they're going to have problems, right? If we were taught the nuances and it wasn't so vague, we maybe wouldn't have that problem communicating that to patients. So a lot of what third year, I've learned is it's a lot of self-directed learning and it's being critical of every problem. So yes, maybe we don't get that in education, but that's something I think we as future physicians should seek.

It's kind of like, yeah, there are issues because people have a certain weight number. Like I remember today, I'm in my obstetrics and gynecology rotation and we were learning that if people have fat, they can convert more estrogen. And estrogen is a kind of like a risk factor for certain type of cancer. So there is some direct correlations of having more fat on your body and it being a risk factor for or predisposing you to a certain condition. Right? But that's a very specific one thing. But we can't blame everything on being overweight.

Margaux: I agree with that Harjit. And I think you mentioned there's something like outside problems or views. And I think a big umbrella issue of this topic is our cultural and social view of body image on Instagram, on the news, on TV, in magazines and books. Everything that we see kind of breeds this sort of fat phobia that you're talking about or that the image that is normal and healthy and beautiful in our society is not the overweight or the obese person, and so I think we already coming into medical school have a bias.

Harjit: A hundred percent we have a bias. We did an episode on this in season one, right, about our body image. We all struggle with this. Be it man, woman or someone non-binary, right? Like, we all struggle with the image of self, and fatness is a huge part of that. And that's where I'm saying like I think one thing that I just wish more humans did was, and I say this over and over again, is be critical thinkers. Just don't believe something because someone told you. Just don't practice something because that's how you were taught, right? We are here to solve problems that no one else has ever solved or solve it in a way that no one else has ever solved before, right?

And this is my biggest pet peeve, and it's also something I strive for. Like, I want to be the type of person you give me a random problem and I'll use everything in my brain, all the tools and figure out a solution for it. You know, that's what's the biggest sadness around this whole topic for me. It's because I feel like we're just taught, like I said XYZ, so they must be XYZ, right?

I read this really cool article yesterday, because I was kind of doing research on this topic because I was still trying to formulate my own opinions on it, right? It was basically about this woman who had endometriosis but she was overweight. Her issues with her pain while she was on her cycle were kind of like, "Oh, it's because you're fat. If you lose weight . . ." Like, they didn't even know she had endometriosis. Then she lost a whole bunch of weight, and then they were like, "Oh, you have endometriosis." And she was just saying, "It's so interesting how I was treated when I was bigger and how I'm being treated now because I lost weight."

Margaux: I agree. I feel like we tend to have a lot more sensitivity of people, you know, of different races and religions, but then when it comes to different body types, we have still have those biases that are still very strong and nobody really talks about them and confronts them in the way that I think you're talking about that we need to start addressing the root of the reason of why we are treating these people differently of like, "Oh, you have coronary artery disease because you're fat." But it doesn't help the patient to tell them that or to treat them any differently or to believe that because they're already obese or whatever that they can't make life changes.

And you know what, there's not a lot of research done on obese people or people who are overweight that exercise and walk and eat healthy versus like their counterparts who do not. We don't have that evidence to say like you can be overweight and healthy. So I think it's kind of unfair that in medical school there's kind of this umbrella term of like obesity is a risk factor for everything, but there's so many nuances, like you were saying, that plays into it. Does that person walk like two miles every day? And are they very active in other ways? Like that can counteract the risk factors of estrogen.

Harjit: This is another thing I want to talk to you about. I struggle with this a lot too because I think that we notice that people are overweight, right? And what do we usually say to them? Like exercise, eat right. And we have like a two-minute conversation. It's another cue from the world along with images, along with like social media, along with what my mom says to me about how big I look. It's another cue of being judged by your body. And I honestly feel like those are the people that struggle the most to actually lose weight are the ones who are told constantly lose weight, right?

So, you know, we only have certain amount of time to actually have a conversation with our patients. And I think that's another thing that contributes to this problem because we tell them like eat better and exercise, but there's really no tools. That is one treatment I will say that's not effective. And again, I'm pretty sure there's no research on this, I may be just like saying this, but it's not effective. It's a treatment that we're giving them through our conversation, but it's something that's heavily dependent on the way they understood it.

Margaux: Yeah, and their understanding of what it means. It's so complex, you know, weight loss or like . . . Basically, you know, what we're trying to tell them is there are other things you can do in your life. And it's not just weight loss. It's the specifics of your diet, whether you lose weight or not, can make a huge impact on hypertension and diabetes. And same thing with exercise. Even if you're just walking a little bit and not losing weight, that still has impact on your life. And I think what's lost on patients is that if you don't do it extreme and you don't lose the weight, then it's not worth it at all. But what I try to do and what I think medicine should start shifting into is just encouraging a little bit at a time.

Harjit: Right.

Margaux: Like just going for a 10-minute walk when you were previously sedentary is a huge difference. And that's like those little baby steps can maybe lead to something bigger or not. But just encouraging and being there with your patients. Like you said, understanding their social situation, their economic situation of like, what can they do?

Harjit: What is the reason you are in the situation right now, right? And then maybe targeting those areas, indirectly helping them but actually it's directly helping them. Working on all the other areas so you can also . . . I think it makes our job easier too, right, just to blame it on their fat so they should work out so I don't need to do extra work. And I think it is more work, but isn't that what we're supposed to do?

Margaux: What I'm learning now, my initial draw into medicine is like the human body, inside and outside, is so amazing and beautiful. And being on medicine is kind of very interesting because I've gotten to see so many different body shapes and sizes, and it kind of debunks this idea of what we're inundated with on Instagram of all these like thin, beautiful, "beautiful models" that are not real life.

Harjit: Yeah. Another thing that I was thinking is all because someone is skinny doesn't mean they're healthy. And all because someone is bigger doesn't mean that they're in a worse health than that skinny person, right? I had this uncle who was like super thin, but his cholesterol was like so high. All because you're a certain size doesn't mean you're rid of all health problems, right?

Margaux: Right.

Harjit: And again, that comes into the critical thinking aspect. It kind of bothers me when people in the healthcare field talk about these patients that they like describe as fat behind their back. Like what do you feel about that? Have you seen that ever happen?

Margaux: No, but I've heard . . . Like, not in my experience. I haven't been on surgery which I think, what I've heard from people is where that tends to happen the most is attendings talking about patients when they're under anesthesia. But I would agree with you because that continues to breed our own biases about that patient. When that comment is not relevant, it doesn't really help. So I don't believe that that has a place in the OR.

Harjit: I have actually heard a lot of comments being made about certain patients behind their back. And I think that's really toxic, because the thing is, even though you're not saying it to their face, you have had some type of thinking of that that you're verbalizing it, right? That normalizes that type of conversation when it should not be okay to talk about people like that, right? Because we don't even know in our own team group who's struggling with weight. It could leave a negative impact on them. Like, we need to be conscious of the people around us.

The true thing is there must be a reason why we feel the need to say that, right? It's maybe the way we grew up and like we might have our own insecurities that we need to say, "Oh my gosh." Like, I remember even with your friends, you're like, "Oh my gosh, I can't eat junk food." Just before now I was like, "Margaux, you can have half of my KitKat because I don't want to eat junk food."

And the truth is I will say I have a weight bias too. I'm having this conversation, and I will be the first to say that there's a lot of biases that I have. What I'm trying to do is trying to think about them so one day, hopefully, they'll be gone. And I think that's the most that we can hope for from everyone. So I hope that all our listeners, especially the ones that are pre-med, in medical school, or even have graduated, these are things that we should consciously be thinking about.

Margaux: I kind of have a personal story on this too. Like you said, Harjit, we all have biases and that includes me. And I used to be really, I don't know if more so than the others because of the act of verbalizing and normalizing how we all feel, but I used to focus a lot on weight and my own body image and have really negative thoughts about it. And then I became a yoga teacher before medical school.

And I remember when my first yoga class, I was so aware of everyone around me, and I was judging everyone around me and worried that everyone around me was judging me. And then maybe a couple years later into doing yoga, I finished a class and I realized that the whole time I wasn't aware of anyone around me but myself, and the thoughts that I had about myself were positive. And it was kind of just like a weird awakening of like, "Oh, when I don't worry about people judging, when I don't judge other people and worry about people judging me and I'm happy with myself, then I feel like my mindset shifted." And I don't look at people like I used to when I used to judge myself for having a negative body image. And now I've changed that view of myself, I don't look at other people with that same lens.

I, in fact, I don't really see, well I do, you know, you can see it, but I don't like judge people like, "Oh, you're obese and so you have all these negative factors associated or you're obese and I feel the need to point that out when you're under anesthesia." Like our perception, like you're saying, of just letting things go or trying to understand why you need to verbalize that in the first place is a really impactful thing to do, not just with fat phobia or fat weight bias, but other biases in your life. Just get to the root of why you are having that bias in those thoughts. And by sitting on it and thinking about it you can really overcome these things.

Harjit: Right. And I think along the same lines, I think it really comes from within. Like I feel like I'm a more positive person now because I've started accepting how I look and kind of my shape and being okay knowing that it's going to take some time and weight does matter. I hope from this whole conversation, that's not taken away that like it's not important to be healthy. It is important, but I think, like I said, everything's multifactorial. How do you think we can move towards a more fat-positive environment, Margaux?

Margaux: I feel like it's not focusing on the weight or the BMI number. And usually when I have a patient, like in family med or in clinic that, you know, needs to have the conversation of weight change and diet, I usually start with, "What's your relationship with food?"

Harjit: Oh, I love that question.

Margaux: Because that opens a non-judgmental way to talk about their diet. And usually people are like, "Oh, I, I don't have a good relationship with food." And that's a really great place to start. You don't even have to address, like, weight loss. Just getting them to a place where food is a positive thing can make such a big impact without even addressing the very stressful, very stigmatized world of weight. So that's how I think we can start to approach it differently.

Harjit: And I 100% agree with that. I think we really need to work on our language. Like, even going to one doctor's appointment, one doctor very rudely saying to you like, "Oh, you're fat, you need to lose weight." It can leave a long, long, long term impact because I've seen that. I've seen that with my family members.

Margaux: Yeah, you want to make it a positive experience because, like you said, sometimes if you shame them into it, they may never not want to come back to the doctor's office. And that's way more harmful than them being overweight and you still seeing them.

Harjit: And it serves no purpose.

Margaux: Yeah.

Harjit: So kind of on this journey of me trying to be more open with my mindset, I have been following this person on Instagram for a couple months, and her name is Sonalee and she has the Instagram handle @thefatsextherapist.

Margaux: I love her.

Harjit: Do you follow her too, Margaux?

Margaux: Yes, I do.

Harjit: Okay. And I really like her because I love the way she talks about how all those small things that we say matter. It's really important that we think about the way we speak about things especially when our judgments are going to impact the people we care for because that's where our treatment is going.

Margaux: And just a plug for their Instagram account, a lot of their advocacy is about anti-diet culture. And I find it very interesting that in medicine when patients ask us, "What's the best diet?" There isn't one. That's the answer you give patients. The best diet is the one that works for you. There isn't a single proven diet that actually is medically backed up. So I feel like that's really in line with also what she's saying.

Harjit: Just a plug. So I'm really happy I had this conversation with you Margaux. This is one conversation that I wasn't on one side or the other. It's something that I've been thinking about consistently, and it's something that I will continue to think about. I hope to educate myself in being open and non-judgmental when I treat patients no matter what their size is.

Margaux: And being non-judgmental towards yourself as well.

Harjit: I know. I know that's where it starts. We're really happy you could join our conversation. Oh, also, even though I missed Bushra and Leen, it was so fun talking to you, Margaux.

Margaux: You too.

Harjit: We're so cool.

Margaux: Yeah.

Harjit: Just kidding. Bushra and Leen, I miss you too.

Margaux: No.

Harjit: No, not really. Anyways, so we're really happy you could join us on this conversation. Please let us know what you think about this topic. You can find us on Instagram and Facebook. Our handle is @bundleofhers. Please like, subscribe and comment and hope you guys have a beautiful day. And we don't have Bushra here to say bye-bye but . . .

Margaux: You can do it.

Harjit: Should I try?

Margaux: Yeah.

Harjit: Bye-bye. She has more inflection in her voice. It's like wavy.