Many of the financial and administrative structures doctors work within help reinforce this bad behavior. The problem starts in medical school, where, according to a 2015 survey, students receive an average of just 19 hours of nutrition education over four years of instruction—five hours fewer than they got in 2006. Then the trouble compounds once doctors get into daily practice. Primary care physicians only get 15 minutes for each appointment, barely enough time to ask patients what they ate today, much less during all the years leading up to it. And a more empathic approach to treatment simply doesn’t pay: While procedures like blood tests and CT scans command reimbursement rates from hundreds to thousands of dollars, doctors receive as little as $24 to provide a session of diet and nutrition counseling.
Lesley Williams, a family medicine doctor in Phoenix, tells me she gets an alert from her electronic health records software every time she’s about to see a patient who is above the “overweight” threshold. The reason for this is that physicians are often required, in writing, to prove to hospital administrators and insurance providers that they have brought up their patient’s weight and formulated a plan to bring it down—regardless of whether that patient came in with arthritis or a broken arm or a bad sunburn. Failing to do that could result in poor performance reviews, low ratings from insurance companies or being denied reimbursement if they refer patients to specialized care.
Another issue, says Kimberly Gudzune, an obesity specialist at Johns Hopkins, is that many doctors, no matter their specialty, think weight falls under their authority. Gudzune often spends months working with patients to set realistic goals—playing with their grandkids longer, going off a cholesterol medication—only to have other doctors threaten it all. One of her patients was making significant progress until she went to a cardiologist who told her to lose 100 pounds. “All of a sudden she goes back to feeling like a failure and we have to start over,” Gudzune says. “Or maybe she just never comes back at all.”
60%of the calories Americans consume come from “ultra-processed foods”SOURCE: BRITISH MEDICAL JOURNAL, 2016And so, working within a system that neither trains nor encourages them to meaningfully engage with their higher-weight patients, doctors fall back on recommending fad diets and delivering bland motivational platitudes. Ron Kirk, an electrician in Boston, says that for years, his doctor’s first resort was to put him on some diet he couldn’t maintain for more than a few weeks. “They told me lettuce was a ‘free’ food,” he says—and he’d find himself carving up a head of romaine for dinner.
In a study that recorded 461 interactions with doctors, only 13 percent of patients got any specific plan for diet or exercise and only 5 percent got help arranging a follow-up visit. “It can be stressful when [patients] start asking a lot of specific questions” about diet and weight loss, one doctor told researchers in 2012. “I don’t feel like I have the time to sit there and give them private counseling on basics. I say, ‘Here’s some websites, look at this.’” A 2016 survey found that nearly twice as many higher-weight Americans have tried meal-replacement diets—the kind most likely to fail—than have ever received counseling from a dietician.
“It borders on medical malpractice,” says Andrew (not his real name), a consultant and musician who has been large his whole life. A few years ago, on a routine visit, Andrew’s doctor weighed him, announced that he was “dangerously overweight” and told him to diet and exercise, offering no further specifics. Should he go on a low-fat diet? Low-carb? Become a vegetarian? Should he do Crossfit? Yoga? Should he buy a fucking ThighMaster?
“She didn’t even ask me what I was already doing for exercise,” he says. “At the time, I was training for serious winter mountaineering trips, hiking every weekend and going to the gym four times a week. Instead of a conversation, I got a sound bite. It felt like shaming me was the entire purpose.”
All of this makes higher-weight patients more likely to avoid doctors. Three separate studies have found that fat women are more likely to die from breast and cervical cancers than non-fat women, a result partially attributed to their reluctance to see doctors and get screenings. Erin Harrop, a researcher at the University of Washington, studies higher-weight women with anorexia, who, contrary to the size-zero stereotype of most media depictions, are twice as likely to report vomiting, using laxatives and abusing diet pills. Thin women, Harrop discovered, take around three years to get into treatment, while her participants spent an average of 13 and a half years waiting for their disorders to be addressed.
“A lot of my job is helping people heal from the trauma of interacting with the medical system,” says Ginette Lenham, a counselor who specializes in obesity. The rest of it, she says, is helping them heal from the trauma of interacting with everyone else.