649848 tn?1534633700

"Scaling Back on Weight as a Measure of Patient Health"

Yoni Freedhoff, MD
May 08, 2019

"Back when he was a graduate student, my friend, Dr Travis Saunders, was a ridiculously active runner and cyclist who primarily ate home-cooked meals made from whole ingredients. Despite living a healthier lifestyle than what I'd venture 99.9% of us are, he was told at his yearly physical to "watch his weight," as he was approaching a BMI of 25 (the start of the medical descriptor "overweight").

In a similar interaction, a patient of mine told me about how she had lost more than 100 lb by maintaining a lifestyle of high physical activity and eating an unabashedly healthful diet. But after being weighed by her new family physician, she was quickly lectured about the risks of obesity and told that she ought to try exercising more and eating healthier.

Meanwhile, how many thin patients do you think have never had their physician explore the fact that their diets are made up primarily of ultra-processed and fast foods, and that their exercise is limited to changing the channel on the remote control or scrolling on their phones?
What Does a Scale Measure?

The problem in all of the cases above tracks back to faulty scale use, and perhaps it isn't all that surprising. When I was a medical student in the 1990s, I wasn't taught how to use a scale, and I'm betting that the same is true for most medical students today. Don't get me wrong; it's not that I think scales are complicated pieces of equipment, but after exclusively practicing obesity medicine for the past 15 years, I do think that their proper use is worth discussing.

Scales do measure the gravitational pull of Earth at a given moment in time. Scales don't measure the presence or absence of health, nor do they measure lifestyle or effort. And for patients, it's useful to note that scales don't measure happiness, success, or self-worth, either.
The only [noncommunicable disease] for which patients are judged if they don't...tackle it on their own is obesity.

Although weight is undeniably a risk factor for a host of medical comorbidities, especially at its extremes, it's not a guarantee that any of them will occur. And so the use of a scale to infer the presence or absence of health ignores the actual person standing on the scale.

Similarly, scales don't measure lifestyle. There are scads of patients with obesity doing all of those good things—exercising regularly, getting enough sleep, not smoking, cooking with whole ingredients, etc. Similarly, plenty of thin patients' lives are spent living on junk food, smoking, drinking to excess, and spending all of their off-hours binge-watching television and being inactive.

Relying on scales to measure things that they can't leads physicians to make assumptions that undermine the care and understanding of all of their patients, and is no doubt reflective of weight bias. This, in turn, has been shown to affect the quality of care for patients with obesity.[1]"


I found the above article on Medscape and it really hit home for me because this reminds me of my husband and myself.  I'm the one that tries to eat well and exercise, but I struggle with my weight due to hypothyroidism, pre-diabetes and metabolic syndrome.  My doctors constantly chide me about my weight and assume that I'm not doing anything to change it, in spite of my efforts.

My husband stays very thin on pizza, fast food and other junk and spends hours in front of the TV every day, with basically no exercise.  No, he's not "healthy" because he has high cholesterol, high blood pressure; he's had a TIA and some other issues, but he's not overweight so his doctor says nothing to him about his diet or exercise.
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Avatar universal
I have made this point repeatedly, but have been yelled at so much for it.  I keep saying, weighing oneself repeatedly is an obsession, as weight doesn't change that fast.  Weight isn't necessarily a main factor in lifespan, though it may be in how you feel and what you're able to do.  Genetics play a major role in weight -- interestingly, just saw a teaser this morning for a news story on DNA that purports to tie genetics even into what an individual should eat, though I'd be a skeptic on that -- I remember a craze a while back on eating according to blood type.  Life is hard, and individuals do vary.  Peace.
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Using the scale frequently isn't the problem; it's the assumption that the scale is telling us something it isn't.  It's the perception that thin people are automatically assumed to be healthier than those that are heavier/overweight and is evidence that doctors exhibit weight bias by assuming that the heavier/overweight person must have a poor lifestyle or that the thin person has a better lifestyle, when there's plenty of evidence that this isn't true.

I've weighed myself most days for the past 20 yrs.  For about half of that time I was tiny and thin (pre-hypothyroid) and about half of that time I haven't been (post-hypothyroid); the simple act of getting on the scale doesn't change that, but I've seen, personally, the difference in the way my doctors treated me when I was very thin vs how they treat me now that I struggle with my weight and there's a huge difference.  I can say, with all honesty, my lifestyle is much healthier now than it was when I thin but when I was thin no one ever mentioned healthy eating or exercise; now those are the first things on the "to do list" when I go to a doctor.
I do agree that getting on the scale isn't the issue.  It helps me stay on track when I'm focusing as I'm either pleased and continuing what I am doing in the weight maintenance (or weight loss) game or to change it up.  When I don't weight myself, I'm usually avoiding the truth.  ha ha.

My doctor goes for the 'sweet spot' on the BMI scale.  For me, this is kind of important because if I'm over it, then I see things like higher blood pressure, higher cholesterol.  It seems to really correlate directly to excess weight for me.  She does also ask about lifestyle things too like how much I exercise, vitamins, eating my fruits and vegi's, etc.  

If someone is super thin so the weight doesn't trigger a doctor's attention to health issues, I wonder if the other barometers they use will?  When I was young, it was by chance that I was at my office they day they were testing a machine that looked at bone health through your hand.  It predicted osteoporosis.  That is when I learned that women who are very thin are more prone to osteoporosis.  I was really skinny at the time as this was LONG ago prior to kids and middle age.

It's a good discussion for doctors to take all things into consideration when looking at patient overall health. Weight is one factor but not the only one to make sure someone is on track for good health!
I think there might also be something else going on here.  I'm a guy, and mostly I've been within normal weight, but I did gain a lot when on medication and then lost it when I stopped and am now gaining again because of chronic pain that has severely limited my normal fairly heavy exercise lifestyle.  But when I see the doc, while they mention diet and weight, they don't really go into it much.  I'm starting to wonder if this is a bias against women, because again, my docs don't really mention it.  Based on looking at both of what you two post over many years, I'm guessing neither of you is obese.  Maybe not where you want to be, but not obese, so that fact it's being focused on for you and not for me -- maybe because I'm a guy?  Maybe some bias here?  Now, my cholesterol is always really really good because I have high HDL levels and my blood pressure has always been on the low side despite a long time anxiety problem.  But again, I did gain a lot on that med -- 50 pounds over the years -- and not a mention from my docs.  Bias?
Bias against women?? You bet your sweet behind medical personnel are biased against women, ranging from not taking our complaints as seriously as they do men's to thinking that we are to blame for our weight issues (poor diet/lack of exercise, etc), not other factors.   I had this very discussion with someone earlier in the week and it's a fact that if a man were to go to a doctor or ER with some of the same complaints we go with, they would be taken much more seriously than they are when we present them.  

I don't doubt that we get a "double whammy" when we have weight issues because doctors tend to think thin people are healthier than overweight people, plus they take men more seriously than women...
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