After seeing an overweight patient with a back problem, Dr. Robert Lamberts of Augusta, Ga., decided to blog about it. Last week, I linked to his blog and asked readers “Should Doctors Lecture Patients About Their Weight?”
More than 700 of you responded. Many readers were grateful that Dr. Lamberts seemed to understand their plight. Others offered their own stories of being lectured by doctors.
“If shaming and being a social pariah was sufficient to get people to lose weight, there would be no fat people,” wrote reader Jill. “The stress of dealing with fat-hatred is, I believe, a bigger threat to health than weight is.”
Dr. Lamberts thinks it’s counterproductive to “scold” patients about their weight. “It makes people not want to come into the office,” he said. “They don’t want to walk into scorn.”
To hear more from Dr. Lamberts and his views on helping patients with weight issues, listen to the podcast below.
Listen to the Podcast (mp3)
Healthy living doesn't happen at the doctor's office. The road to better health is paved with the small decisions we make every day. It's about the choices we make when we buy groceries, drive our cars and hang out with our kids. Join columnist Tara Parker-Pope as she sifts through medical research and expert opinions for practical advice to help readers take control of their health and live well every day. You can reach Ms. Parker-Pope at 
The easiest and most pleasurable way to eat well is to cook. Recipes for Health offers recipes with an eye towards empowering you to cook healthy meals every day. 
From 1 to 25 of 157 Comments
I just listened to the podcast. I think overweight patients can be a little too oversensitive (Dr. Lambert’s patient excluded) to their doctors addressing the weight issue.
However, it is not beneficial for the doctor to take will power off the table. To do so sends a message that there is nothing the patient can do.
Is it the doctor’s responsibility to tell the patient how to lose weight? With all the reliable information out there from the American Heart Association, the American Society for Nutrition, the USDA, FDA, etc on how to lose weight, it is just a matter of picking a method from one of these reliable sources and sticking to it.
“Yeah, right Jack. You’re full of it. I’ve tried everything, stuck to it, and still can’t lose. It’s my metabolism, and there’s nothing I can do to change my genes.”
Just one question. If it’s your metabolism, why are there twice as many obese people in America today as there were only 10 years ago???????
Genetic factors that affect metabolism in an entire country don’t change that quickly. It’s all about reducing the calories and increasing the exercise. Period. Don’t believe me? Read Jane Brody’s columns.
— jackJack have you ever tried to lose weight?
— anneFirst of all, props to you, Tara, for this post and other recent ones dealing with weight loss, obesity and the NEJM study of three diets. The issue of obesity is inportant and you should be applauded for helping to shine a light on the issue.
Second, props to Dr. Lambert. If all physicians were as empathetic as he is, I suspect that our health care system would be in much better shape.
Regarding weight loss and obesity: I believe that the results from the NEJM article you cited are important, because they help to rethink the conventional diet wisdom to which we have been shackled for at least 30 years. Some of this conventional wisdom was displayed in your podcast when Dr. Lambert talked about his lapses in exercise and diet. It may very well be that many obesity problems are not a sign of mental weakness on the subject’s part, but a part of the physiological reality of how our bodies process carbohydrates.
In your comments on the study, you seem to be clinging to conventional wisdom. I admit that my college training (my BS is in Nutrition and was earned in the 80’s) makes me instinctively cringe at low carb diets. On the other hand, we cannot ignore the results published in the NEJM (which, by the way support an older, pre-1970’s conventional wisdom that low carb diets were the way to lose weight).
I hope you continue your exploration of obesity and weight loss and do so with an open mind.
FROM TPP — I’m not against low-carb diets. And I have written in the past that Dr. Atkins was ahead of his time on many things including no transfat and the notion that processed carbs are a problem. But I’m frustrated by this study which didn’t really seem designed to get at the truth. It bothers me that there were no comparison data for the Atkins and Mediterranean diet. Everything was compared to a moderate fat diet (wrongly described as a low-fat diet) that seemed destined to fail and make the low-carb plan look better. The researchers boast of high compliance, but if the compliance rates had been as high as claimed,then the weight loss would have been far greater. There should have been data provided on therange of weight loss — some subjects lost a tremendous amount of weight and no doubt many people also gained. How many subjects had a net loss and how many had a net gain? Those data also aren’t presented. The study subjects were mostly men — others research has noted men tend to do better on the low-carb plan. But the few female dieters are very interesting — they lost 14 pounds on the Mediterranean diet and only five on low-carb. This study would have had a completely different outcome had women been adequately represented. There are certainly things to be learned from this study, but I think it would have been more useful had it had an independent source of funding and had the researchers themselves appeared less biased in evaluating the findings.
— PangaeaHaving been thin and active most of my life until I developed a thyroid problem, I know first hand that losing weight is not just a matter of will power, particularly among older women. It is also not a simple matter of eat less and exercise more.
At one point before my diagnosis, I was working out over an hour and a half per day, eating between 1200 - 1400 calories and still not losing more than a pound per month. (Side note: I have always enjoyed exercise and never been fond of fast food or processed food.)
I can attest that my weight impacted both the quality of health care I received and my willingness to care for myself - I am convinced that my development of Posterior Tibial Tendon Dysfunction, a serious ankle impairment that now limits the types of exercise I am allowed, was in part due to my own and my caregivers’ fat phobia.
While I do believe that health care practitioners must counsel their patients about weight and weight loss, I know that lecture alone will not do the trick. Nor will ignoring the topic so as not to scare a patient away. The problem is that it can take a lot of discussion / assessment to find out what is really going on with someone who has a weight problem.
However, it is rare in our current medical system for Dr.s / Clinicians to have more than 15 minutes at a time with a patient - not long enough to really investigate the problem, even though controlling weight can contribute to preventing so many serious medical conditions.
— SiobhannDoctors have a responsibility to tell the patient that they need to do something about their weight. Doctors are professionals and should not mollycoddle their patients when it has a bearing on their quality of life in later years. Why should doctors try to be nice to people who need to wake up and have a hard look in the mirror? Everyone else including friends and family do that already.
Please note that I speak this as someone who was close to being clinically obese, with an ethnic background and family history of diabetes. But I finally woke up when blood tests at a health screening (by my employer and not my doctor) revealed that I was pre-diabetic. After doing some research, that scared me enough to take charge of my life and lose weight seriously. I have now lost 44 lbs, fighting fit and have beaten my pre-diabetes with my blood sugar under control for 2 years now. Yes, I too had been trying to lose weight for many years, but the medical wake up call was enough to motivate me to finally do it. Don’t underestimate the power of such motivation.
Doctors in the US think too much about trying to please their patients and too little about basic health care and prevention. Why didn’t any doctor tell me to have a blood lipid profile tests during the many times I went to them for other reasons? It had to finally happen through my employer. BTW I have a good health plan and visit doctors in some pretty decent hospitals (maybe that is the problem).
There is too much emphasis in this country on fixing things after they have gone bad, and not much at all by way of prevention or trying to counsel patients to do the right thing and take charge.
Who cares what the patient thinks? What will they do next? Not tell the patient about some serious life threatening problem? So what about ones that will come many years down the line due to being obese?
— ShivHi TPP (6:43 pm):
Thank you for your response to my comment. It is refreshing to have a NYT poster who directly responds to their readers.
I agree that the NEJM study needs follow up. I hope that the results prompt further studies funded from less biased sources.
Regarding independent sources of funding, it should be noted that Dean Ornish has a vested interest in seeing his dietary philosophy prevail. Additionally, as per the book, “Good Calories, Bad Calories,” much of the current percepction of healthy diet was established with funding from self-interested parties (I wish I could be more specific, but the book is so darned thick that I cannot readily find citations. :) Sorry…)
FROM TPP — I don’t disagree. Don’t even get me started on corn subsidies, food companies and the rest of the fat industrial complex.
— PangaeaWe tend to weigh more than earlier generations because our jobs tend to be more sedentary. Our grandparents didn’t have to go to exercise clubs, etc.
Doctors don’t know why we can’t lose weight and keep it off, so they can’t tell us how to do it. That’s not their fault.
As for blaming the patient, it only takes 96 extra unburned calories a day to gain 10 lb. in a year. Very few people keep track of what they eat to that level. I lost 35 lb. and kept it off — by losing the weight as SLOWLY as I could. I think it’s our obsession with losing it fast (include the medical people, who frequently recommend losing 2 lb. a week even though all the evidence is that we’ll gain it back and more at that pace). Slow but steady wins the race. I went from a size 22 to a size 16 and have stayed there a year. I hope to lose more but not at 2 lb. a week, because I want to keep it off.
— Gail PerryHi TPP (7:20 pm):
Thanks for responding to my comment. It seems like we have common ground. Further study is warranted to address the questions raised in the first study and that the funding should be as non-biased as possible. Regarding your litany of interest groups, I would specifically add those who have an interest in minimizing the deleterious effects of simple carbs (especially high fructose corn syrup).
— PangaeaAt #1 (and all the misinformed):
Obesity rates have NOT “doubled” in the past 10 years.
In fact, since the government arbitrarily lowered “overweight” from BMI 27 to BMI 25 in 1997, rates of “overweight” and “obesity” have barely changed. Children are no fatter than they were in 2000, but that doesn’t stop all the sensationalist news stories.
As TPP recently reported, 90% of children get 2 OR MORE HOURS of exercise a day? While it was reported in the context of how they become less active as teenagers (duh?), no one pointed out that children getting 2 hours of activity daily are obviously not meeting the stereotype of fat, gluttonous couch potatoes.
We are obsessed with weight when we should be focusing on health. They are not the same thing! Someone with a weight-associated illness like diabetes should NOT be told to lose weight. He or she should be counseled in the nutrition that can help manage the condition, with the understanding that losing weight is extremely difficult (and rarely maintained) and a certain diet will help REGARDLESS of weight loss.
The world has gone mad. With our obsessive demonization of fat, we are fueling a culture of self-hate and eating disorders.
— melissaIf the physicians don’t say something, who will?? Being overweight is a risk factor in heart disease and many types of cancer. Every patient should be well-informed about how being overweight contributes to the chance of getting these diseases and how they can lead to one’s death.
— MI grew up in a hunting culture, where people ate wild meat, and only the basic vegetables, mostly root vegetables. Even the most wealthy of us bought things like peaches and pears once a year, and canned them. We all walked. Out of a population of about 15,000, I can count the people who had vehicles.
I never saw a fat person in my life, not ONE, until I left that community at 18 and moved to the city.
My mother walked 20 miles a day, to work, home for lunch, back to work, back home. And then worked at night cooking, cleaning, responding to various childhood needs. We ate only at meals, only at the table. We had to ‘clean your plate’ before we got dessert, and no one got second helpings. Everything we ate was baked or cooked by us. We never ate out. There wouldn’t have been anywhere to do it had we wished to.
I have to think that’s why I saw no-one overweight for all those years. Everyone lived like that.
— NROoops. That last post should have said 5,000, not 15,000.
— NRI believe that the increase in obesity is due to two factors: 1) Higher levels of inactivity (such as time spent in front of the t.v. and computer), and 2) increase in production of high fructose corn syrup. U.S. food production is up 700 calories/person/day from 1980 (to a total of 3,900 calories/person/day) and most of it is from an increase in soybean and corn production. High Fructose Corn Syrup production is up 1000% in the same time period and has snuck its way into everything we eat** (Thank you Farm Bill!). The loaves of the super yummy whole wheat bread that I used to buy at the grocery store… whole wheat may have been the first ingredient, but the second was HFCS (or maybe it was third after water). Needless to say, when I noticed that ingredient, I switched to bread from the local bakery… ingredients consisting of: whole wheat, water, honey, yeast, and salt. I pay $5/loaf for this bread, which we can neither afford to spend nor not to spend. Low-quality and low-cost processed food is feeding a large portion of the people of this country. I spend a huge amount of our income on “whole” food. $1,400/year to belong to our local, organic C.S.A. program, and $400/month on other food from the local farmer’s markets and grocer. I choose to feed my family (and spend our money) this way because I have seen my husband’s entire family ail from eating “cheaply.” Both his parents and both his brothers battle their weight (my husband does not and has always been referred to as the “throwback” due to his natural thinness). His mother suffers from edema, breathlessness, soreness, exhaustion, high blood pressure, etc. His father lost a portion of his colon to cancer (both parents are in their mid 50s). And his youngest brother (17) had his gallbladder removed at 16. All are currently working at changing their lifestyles, but it is a slow process (yay for mom… she has lost 50 lbs this year and has had improvement in energy levels and overall health!).
Anyway, I agree that doctors should be sensitive when addressing their patients’ weight issues… stressing nutrition, such as other posters have noted, should definitely be the focus. Warning patients about all the junk manufacturers are sneaking into the “foods” they are trying to sell us might not be a bad conversation to have either. Someone might also want to get all the government agencies on the same page… the Farm Bill should more closely reflect the advice we get from the government on how to eat healthfully.
** Info from Barbara Kingslover’s book Animal, Vegetable, Miracle, chapter 1
— brynShaming works, and should be encouraged. Only shaming reduced the smoking rate from the majority of the adult population to an unusual vice, despite the fact that nicotine is more addictive than any illegal drug. Only shaming led people to pick up their dogs’ excrement, a repulsive procedure. Before people started being shamed for violating these new norms, very few would have predicted that these habits could be changed, but they were. Go ahead and shame people who smoke, leave pet excrement in public places, are flagrant homosexuals or are fat! Shaming works.
— Jonathan KatzI don’t understand the constant assertion “diets don’t work.” It seems like the only diet that could “pass the test” would be one where you would lose weight while on it (and restricting calories), and then when you went off it you could eat anything you wanted and never gain the weight back.
Diets do work to help people lose weight. Aside from a tiny portion of people who have serious medical issues that mean they will never lose weight no matter how much they restrict their calories, if you cut back on what you eat and exercise you will lose weight. What you do after you stop dieting will determine whether the weight stays off or on, not the diet itself.
In my book, a diet works if it helps you lose weight. And most, even the very unhealthy ones, do help you lose weight. What you do after that is your own responsibility.
— MatildaDoctors should discuss obesity-related health risks with their patients, if only for preventative measures. There is a way for doctors to voice their concerns empathetically; indeed, a doctor needs to not patronize his/her patients. It seems to me that the question this blog poses, the issue of whether or not a doctor should counsel his/her patients is a false dichotomy; we shouldn’t approach it as an either-or situation, as there is no simple solution.
One of the many problem with the existing medical establishment is that doctors do not have adequate training in nutrition and fitness and thus their exhortations are just words without substance. OK, I need to lose some weight. How? Moreover, doctors are often harried and they do not know their patients. It’s easier to judge and cast aspersions on strangers. It’s harder to chide openly someone with whom you have a personal relationship and with whose habits and proclivities you are familiar.
Also, to poster #9. Eating disorders are genetically transfered diseases, and they are not caused by the nation’s obsession with fat. Only 1-2% of the population suffers from anorexia, after all. Disordered eating, on the other hand, may or may not be associated with our country’s perception of ideal beauty…
— Ash“Shaming works.”
Oh good! Shame on you, Jonathan Katz!
— Gail PerryFar too much emphasis is being placed on doctors approaches to obese patients, and far too little on personal responsibility. We’ve, as a culture, drifted away from any semblance of accountability and responsibility, and have substituted a finger-pointing and blame game rationale. Please explain to me how, if you were obese before your doctors visit, your doctor is responsible for you inability to lose weight. Yes, its hard to lose weight, much as it’s hard to accomplish many things in life. Yes, your doctor should TRY to be sensitive, but the ultimate responsibility rests with you, as in anything related to health care. If you do not carry out your doctors instructions he is powerless to help you. As someone with a PhD in molecular biology and 3 years post doctoral experience, I can comfortably say that the human genome is fundamentally unchanged from that of 10,000 years ago. We have not “suddenly” suffered a host of genetic mutations in the last 20 years that have rendered us a nation of fatties (sorry if thats offensive). Yes, there is too much high fructose corn syrup in foods, too much processed starches and sugars, and way too much consumption of these foods because we’ve been sold on the idea of “ease and convenience”. However, as a counterbalance, there is a plethora of informational websites and magazine articles explaining the dangers of these foods and how to avoid them. As a counter point to many of these posts; there’s far too much doctor bashing in these comments, and we are mired in an acutely hypersentive phase in society where people take offense to anything thats not stated with perfect sensitivity and correctness. Thats not an ADULT approach. Your doctor does not (and should not be expected to) have the time to devote to carefully monitoring every single statement to avoid hurting your feelings. If you’re this sensitive, then see a mental health professional also.
— TImTo Jack (#1): Dieting has long-term effects on metabolism.
After we got married, my husband started gaining weight — different lifestyle, different commute, etc — and became obese after a broken bone left him sedentary for six months.
Three years ago, he decided he’d had enough and went on a diet. He decided to lose two pounds a week. He strictly counted every calorie he ate. At the start of the diet, he ate 1800 calories a day. Every time his weight plateaued, he would cut something out of his diet. By the end of the diet, he was he was living on 600 calories a day. In about 9 months, he lowered his BMI from 37 to 23.
Before the diet, my husband was always warm. In the winter, he was always the last to put switch from a lightweight coat to a parka, and the first to switch back. After the diet, he was always cold. It took two years for his metabolic rate to return to its pre-diet levels.
Our bodies have complex and powerful mechanisms for maintaining homeostasis. Study after study has shown that less than 5% of the population have the willpower to override those mechanisms sufficiently to lose weight and keep it off. My husband, fortunately, is in that 5%. I know I am not, but again, fortunately, I have never been obese.
And one last thing…those of us who have never been obese need to stop patting ourselves on the back for our superior willpower. It is our lifestyle that has kept us slim, and it takes far less willpower to maintain established healthy habits that it does to lose weight.
— Amy#14, Jonathan Katz — It’s not true that the majority of people ever smoked. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm#fig Nor is it true that you can shame people out of their sexual orientation, but that’s another whole discussion.
The smoking/obesity connection — “make fatties the pariahs that smokers were and they they’ll quit too” — is often made and I think it’s mistaken. Most obviously, people don’t have to smoke to live. The health information campaign against smoking is not just a deluge of information, but includes concrete restrictions on advertising, and not just on TV. Taxation which increased the cost of smoking convinced some to quit. Smoking is banned in more and more public places, not because it was repulsive but because secondhand smoking is harmful to others.
Try to consider anti-obesity measures that would be comparable! Tobacco companies fought tooth and nail from admitting their product was unhealthy. How hard do you think some food manufacturers would resist? (For starters, Google the UN’s experience with sugar producers in the US when they tried to suggest that a healthy diet should include only 10% sugar). Some advocacy groups would like to see some children’s TV marketing restricted, but I think they face a hard slog as food choices are all about personal responsibility — unlike smoking, right?
And in personal terms, neither is the smoking experience comparable to fat hatred. At worst, a smoker who’s smoking in someone else’s vicinity, especially indoors, might get snarled at. But you can walk down a street or sit in a park with a cigarette and not be called names. Not so for a “fatty”, “lardass”, “cow”, “heffalump”, “porker”, “heifer”. What are the comparable pejorative terms for a smoker? If you’re a Hollywood star or similar public figure you won’t land on the cover of the National Enquirer because you smoke but you sure will if you’re fat. Supermodel Tyra Banks famously put on a fat suit and went forth into the world and was shocked, shocked! at how poorly she was treated.
Smokers might be considered stupid by unsympathetic nonsmokers or addicted by those more compassionate, but would for instance, a comment section on a news article about smoking generate the amount of name calling and hatred that one on obesity will? This UK newspaper asked, “Is Fattism Fair?” The resounding answer was yes! http://www.telegraph.co.uk/news/yourview/2298398/Is-fattism-fair.html Fat people are “bone idle and greedy”, “lack self discipline”, “useless”, “selfish”, “lazy” “stink”. My favorite juxtaposition of comments was “go find a job, you fat, lazy blob of lard!” and “I would not employ someone who is obese”.
Some other commenters took these people to task for their lack of knowledge, empathy and unkindness, some even suggesting they should be ashamed.
— JLMy 2 cents.
It is a valid argument that weight going up over time shows more of an environmental effect than disease-related. It is always imperative for the physician to rule out medical problems, but once this has been done the role of the physician is to help get the weight down. Shaming by a physician only serves to keep people away. Obesity is a problem that needs help, not a moral deficiency. Certainly just accepting a BMI over 30 is not being responsible for a physician. We need to do whatever we can to HELP.
Society is giving enough shame and guilt, so physicians piling on just doesn’t make sense to me. I think it just keeps people from your help.
— Dr. RobRe Tim, letter #18–As a matter of fact, using the term fatties is offensive. What purpose does it serve except to allow you to lash out somehow? Did I call you a dummy? I do have a question on the study of yesterday…if, as so many like to expound, eating 100 cals less a day than you “need” means losing a lb a month, why didn’t those controlled subjects lose more, no matter what food groups they cut or eliminated?
— StarAmy, it sounds like your husband lost a lot of muscle mass, eating so few calories. Extreme dieting can remove significant muscle mass, in addition to fat - and this is a negative, because it results in an overall lower metabolic rate.
I’ve kept 80 lbs off more than 4 years. I did it slowly (not all by advance design, but that’s how it turned out). My first impulse was to get fit again: I did that, by getting into bicycling. I also started weightlifting, to build strength and muscle mass.
A couple of years later, I joined Weight Watchers. I was careful to eat as much as I could: I probably never ate less than 1500 calories a day, unless I was ill. I also kept up all my activity, including my weight training.
So, where am I now? I’m 3 years post-menopause, 55 years old, and easily maintaining my loss. I attribute this to losing it slowly, and preserving muscle mass. Before and after approximations of my body fat, indicate that my lean mass loss was less than 10 lbs.
One some extreme diets, including the Duke rice diet, lean mass loss can approach up to 1/3 of total weight loss, if I’m remembering correctly.
Everyone: if you want to lose weight, focus on losing FAT. Not “weight.” Preserve muscle. Lose slowly. Don’t do anything to lose the weight you’re not willing to keep up a lifetime. This means your food and exercise plan should be reasonable, enjoyable, and not extreme. Because to keep the weight off, you have to keep watching your intake, though you should be able to eat more than when you were losing.
There are good ways and bad ways of losing weight (i.e., fat). Most of today’s diets, as well as popular culture, focus on quick results. That a completely wrong approach.
— DebbieMy husband is a compulsive eater and his weight has fluctuated between overweight and morbidly obese for about ten years now, and the only thing any doctor has ever done is refer him to a nutritionist, at his request. His “numbers” (blood pressure, cholesterol, etc.) range from good to not terrible, so the doctor hasn’t said anything to him about losing weight. My fear is that when the real problems start (as they have for his parents, just twenty years older than him) it will be too late to regain the health he enjoys now. He knows his eating has an emotional component but hasn’t been offered help by the medical community because health care is mostly disease-based and not focused on prevention.
— Denisefour things:
1:the nation is facing a health care/insurance crisis. as weight-related conditions/diseases add more than 3 billion dollars annually to the cost of health care (CDC), obesity is not just about aesthetics or about an individuals right to eat whatever he wants and avoid exercising, it is very much about adversely affecting people who are trying to afford health care.
2:the surgeon general has gone on the record as saying that obesity is preventible and reversible without surgery if individuals will make a committment to healthier diets and lifestyles.
3: bryn (13) is right, we must pressure our government to do better than subsidizing corn with our tax dollars!
4:please consider that if you are overweight, you stand a higher risk of being put into a nursing home if you are injured or sick simply because it takes several people to move a heavy person around. visit a nursing home to get really motivated to lose weight! get a walking buddy or try one of the many exercise videos if you prefer working out in privacy.
Animal, Vegetable, Miracle is a great read. we are heading to our local farmers markets regularly now. and with fuel costs going up, it stands to reason that locally grown, even organic, food will soon not be more expensive than the mass-produced food imported from other countries or even california.
— nina