The Scarlet O

I went to a new doctor today. Didn’t love him, probably won’t go back (though I didn’t say that to the coworker who recommended him, of course). He was fine, but he did that particular doctor thing where they tell you to stop doing something without asking first whether you do it or not. Honestly, I’m probably never going to get along with a doctor who can’t bother to ask me about my habits before telling me to change them.

But he was pretty good on the subject of weight. He did bring up weight when he thought it was relevant to my complaint, and was overly dogged when I explained why it wasn’t, so points off for that. But I really appreciate that he didn’t berate me, or try to sell me on the Celery and Oxygen Diet.

Less appreciative is Dr. Sanjay Gupta, writing in Time. He reports that too few doctors are emblazoning their patients with what he calls “the scarlet O”:

Researchers at the Mayo Clinic in Rochester, Minn., recently released the results of a survey of more than 2,500 obese patients who went to their doctor for a regular checkup over the course of a year. The investigators found that the charts of only 1 in 5 of those people listed them as obese. What isn’t on the charts is probably not communicated between doctor and patient either, and that means trouble. Those in the study who got the diagnosis were more than twice as likely to have developed a weight-management plan with their doctor than were the other obese patients.

Dr. Gupta is quick to invoke the universal and totally unchallenged conventional wisdom about fat; he only takes a couple of paragraphs before he nods sagaciously, taps his nose, and pronounces: “Obesity, of course, means a higher risk of heart disease, diabetes, hospitalization and early death.” Of course. And yet all these doctors, who presumably know that OF COURSE you shouldn’t let a fat patient walk out of your office without a meal plan, are declining to diagnose “obesity” on their charts.

Gupta flails around a bit, trying to guess why this would be. He can’t really come up with anything beyond “doctors don’t want to embarrass their patients,” which is handily conflated with “doctors don’t want to give their patients eating disorders.” The two are, of course, indistinguishable; an eating disorder is just a particularly acute form of embarrassment! This can be avoided, Gupta tells us, by saying that a child has “a weight problem” instead of that she’s “obese.” Why, of course.

One doctor quoted in the article points out that it can be harmful to scare patients away from the medical profession. Gupta follows this up with a non sequitur worthy of Miss South Carolina:

“You don’t want to make people feel embarrassed and not want to come back to you. You want them to get treated,” he says. Jacobson stresses that every pediatrician should determine a child’s body-mass index (BMI)–a figure arrived at by factoring weight and height to produce a two-digit number that roughly diagnoses obesity.

Of course, you don’t want people to stop getting medical treatment. You just want to slap a number on them that calls them “diseased.”

Here’s my theory, and I ain’t got no medical degree like Mr. Every-Byline-Must-Say-“M.D.”-So’s-Nobody-Thinks-I’m-Just-Some-Reporter. I think that doctors “diagnose” things that are medical issues. Regardless of conventional wisdom, regardless of the fact that of course Dr. Gupta knows that obesity will kill you, if they see a patient come in who is in good health, or whose health problems are not correlated with obesity, or whose health problems are correlated with obesity but whose habits are good (say, they’re fat and diabetic, but managing their blood sugar beautifully), some doctors are going to be too sensible to diagnose them with a spurious disease.

If I went in to the doctor for a cough, and the doctor looked at me and said “fair skin and moles are risk factors for skin cancer, I recommend you have them removed, and let’s start you on a sun-avoidance program,” I would be not only offended but horrified. I can’t see any difference here. If I go in for an illness, or a broken arm, or an STD test, or when my kidneys finally fail from the genetic disease I’ve almost certainly got, I don’t expect my doctor to point out everything about me that might plausibly be correlated with other diseases I don’t have. I consider the doctors Gupta mentions to be eminently responsible, and I’m encouraged to hear about them. In fact, I don’t think there are enough of them. The Mayo study said that only 1 in 5 patients had “obesity” listed on their charts; I’m not at all convinced that 1 in 5 people going in for a regular checkup had illnesses even remotely correlated with fat, let alone caused by it.

Why are doctors not “diagnosing” obesity? It is plausible that once, long ago, they read the Hippocratic Oath, whose modern version includes avoiding overtreatment and considering your patient as a human being. Dr. Gupta would be wise to do the same.

(Thanks Zuzu for sending Kate the link!)

35 thoughts on “The Scarlet O

  1. The Paid Media does not exist to inform people. The Paid Media exists to scare people into purchases, whether directly or indirectly. I so wish you guys had the exposure Sanjay Gupta does. People need to read this stuff, big time.

    My personal experience with doctors has shown me that the older the doctor is, the less likely s/he is to just randomly recommend a diet for anything you walk in the door for. YMMV, of course, but I get the feeling with the last couple of doctors I had, none of whom was anything close to being a Spring Chicken, that they’ve been-there-done-that-the-patient-gained-it-back-and-then-some, over and over and over again. One of them said, “If we could flip and switch and make everyone thin, that would be one thing, but it’s always a struggle. Always.”

  2. If diets even worked, then there wouldn’t be any fat people to berate for their weight. But, let’s just keep pretending. ::eyeroll::

    I’ve gained and lost the same 60 lbs, many times. I don’t feel my life is significantly different “lighter”. I still look the same (like my mom and sisters). I still think the same things. I still have the same credentials and the same job. But, I wear clothes that are two sizes smaller–and that’s all that is different. It never changed my blood pressure. It never made my PCOS disappear. So honestly, I just don’t buy the claims. Maybe some people treat me differently–but that has more to do with them than it does with me, because **I** am not fundamentally any different of a person when thinner.

  3. All I’m saying is that I don’t need no stinking “scarlet O” to let people know I’m fat. Fer chrissakes.

    I also think it’s surprisingly encouraging to see doctors not charting fiction….if that’s what the lack of “diagnosis” actually means. I’m skeptical as to whether or not it actually indicates doctors aren’t bringing it up with their patients, regardless of what is or isn’t in the chart.

  4. But if doctors aren’t diagnosing obesity, then they can’t recommend drugs and WLS, and the diet industry and related companies lose money. It’s not that those industries are worried about our health, they are worried about their bottom line. If they can keep up the hysteria about the ‘obesity epidemic’, people will keep buying into the diet mentality that doesn’t work, ad infinitum. I don’t think it’s ever been a health issue, it’s always been a money issue.

  5. All I’m saying is that I don’t need no stinking “scarlet O” to let people know I’m fat.

    Worse, Gupta seems to be implying that you need a scarlet O to let YOU know you’re fat. Because goodness, how else will patients ever realize it??

  6. I didn’t used to have an opinion on Dr. Gupta until I heard him make some really ridiculous and broad comment on something. I don’t remember what it was – rape, obesity, something – but it offended me to the core and ever since then, every word out of his mouth has pissed me off to no end.

    But on a different note, I have a fabulous ob/gyn who has never once told me that all of my problems would be solved if I just lost weight. In fact, she told me that if my recent weight gain bothered me so much (as it did then), then I knew what I could do – find an enjoyable activity and eat more veggies. But only if I really wanted.

    I came to a realization a while ago that echoes what Celeste said, more or less. I won’t be a different person if I lose a bunch of weight. I will still like the same things and if people treat me a lot differently (read: better) when I’m thin as opposed to when I’m fat, then those people need a swift kick in the babymaker for being such douchebags.

    Just my opinion, of course :)

  7. Good heavens, how will we all know that we’re fat if our personal doctors don’t bring it up at every single visit? I thought I was a size 2 until my doctor intervened!

  8. Well, everyone knows that if you’re already obese, a smoker, or female, you’re already too braindead to know that you’re engaging in risky behavior. Srsly.

    Your first visit with this doctor made me think of my first visit with a GP when I changed cities. I was there for a physical so I could work with the Red Cross, but he had to do the little pre-exam interview first. It went almost exactly like this:
    Dr: Do you drink coffee?
    Me: Once or twice a day.
    Dr.: Good, you’ll live longer. Do you drink alcohol?
    Me: Once or twice a week.
    Dr.: Good, you’ll live longer. Do you smoke?
    Me: No.
    Dr: Good, don’t start. Do you have unprotected sex?
    Me: Um…
    Dr.: Don’t do that, use protection.

    Perfect, I think. He was well aware he wasn’t telling me anything I didn’t know. He was obligated to tell me those things anyway. Then we got down to the real business of testing my blood cholesterol or whatever. He can be Gallant to the general Goofus cloud of know-it-all Guptas. : )

  9. Call me paranoid, but I suspect some doctors are probably trying to /avoid/ writing down the “Scarlet O” (seriously? Scarlet O? for fuck’s sake!) on a patient’s chart unless they have no choice. Why? Because the whole obesity epidemic started because insurance companies were looking to make obesity the new smoking – a grand way to deny coverage to a whole passel of insureds, by claiming they had knowingly risked their health by “choosing” to be fat.

    Over the years I’ve had a few doctors who have sat there and gone, “Okay, this is the end result we want, but if I say ABC then the insurance company is going to give you a hard time. So I’m going to write down XYZ, which they can’t argue with, and you call me if anything weird comes up.”

    I could easily be completely wrong there, but I suspect that may be the motivation behind a few doctors who might mention obesity or weight loss to their patient but not mark it on the patient’s chart.

  10. tanglethis, holy crap, I’m in love with that doctor! If you’re fat and he also didn’t give you crap about weight, you should write him up for the Fat-Friendly Health Professionals list. He deserves recognition for having his head screwed on straight.

    Thorn, you’re not being even a little bit paranoid. I actually had a doctor refuse to TEST me for something because she thought I would have a hard time getting insurance in the future if I turned out to have it. I thought that was… a little overboard. But they are certainly alive to the fact that draconian insurance policies can harm patients’ health.

    As far as getting insurance, they ask you to write down your height and weight, and at least when I was trying to get private insurance, a BMI over 30 was enough to render you uninsurable, regardless of your habits. But I’m sure it’s true that insurance companies will decline to pay for necessary treatment if the patient is also recorded as being “obese.” Certainly the doctors are not the only devil in this equation.

  11. Right on! I hate that Gupta guy….I’ve hated him ever since he made it his personal mission to deny any truths that may have come out of Michael Moore’s movie “Sicko”. He’s a tool of the insurance companies and the weight loss industry.

  12. As far as getting insurance, they ask you to write down your height and weight, and at least when I was trying to get private insurance, a BMI over 30 was enough to render you uninsurable, regardless of your habits.

    Uninsurable as in your premiums would be prohibitively high, or uninsurable as in they flat out refused? Given that 30% of Americans have a BMI above 30, flat out refusing seems like cutting out a huge portion of potential business.

    I started with a new doctor in May, and she didn’t say anything about my weight, and I assume she didn’t write anything down in her chart about me being obese either. Because I’m healthy!

  13. Flat-out refused. Two different insurance companies! One of them sent me info about an insurance pool for uninsurable people, where I would be permitted to pay astronomical premiums.

  14. I’m starting to know firsthand the problems we have with doctors. It is time for my annual gynecological visit, and I am having to hunt for a new gyno because the one I’ve gone to for 20 years, who never hassled me about my weight, went on a fad crash diet, lost 40 pounds in 2 months, and not only advocates it for her overweight patients, but also talks about my “chafing” which doesn’t exist and the “pressure on my organs.” The one I was going to go to, I’m afraid to try because she is affiliated with the same hospital and they might know each other. How awful is this? So now I’m going to try one farther away in the hope that maybe she won’t be so awful. If that doesn’t work out, I’ll start trying male doctors. God knows they can’t be any worse.

  15. Those same insurance companies who won’t take anyone with BMI > 30? I’ll betcha a year’s supply of tempeh they’d take a two-pack-a-day smoker who was thin; someone on the Fat Studies list said once she experimented by submitting herself as a 140-pound heavy smoker and a 240-pound nonsmoker, and guess who was accepted?

    The data I’ve seen suggests that fat only equals smoking in health risk in terms of someone 150 pounds over “chart ideal” being the risk equivalent of a pack-a-day smoker (I think it was it Paul Campos’s The Obesity Myth that I saw that). So I’m pretty sure their turning down teh fatzors has a lot more to do with an instinctual “ewwwww, fat” response than it does with actual “risk.”

  16. What really frosted my cookie was that at least one of these applications ASKED me about my eating or at least my exercise habits. So my declaration of regular exercise was not enough to counter the assumption that I couldn’t possibly be exercising. Which, you know, we see on the blogosphere all the time — but these are people with the power to basically condemn me to ill health!

    They also asked me if I’d lost any weight recently, and indeed I had lost some since stopping Lexapro and starting Metformin. But they didn’t take that into account either. For all they knew, for all the information they had, I could have been doing exactly what they wanted — starving and overexercising myself until I was skinny. But until I reached the magical slimness cutoff, well, I was cut off.

  17. A couple of weeks ago, my husband was opening a tube of super glue, and got something in his eye. Understandably worried that it might have been the glue, we took a trip to Urgent Care to get him checked out. Before he could be seen by the doctor, of course, he had to be weighed — and lectured about his weight. Why?? What did that possibly have to do with getting something in his eye?! No wonder I can’t get him to go in for a physical anymore.

  18. i wonder if Gupta has read The Scarlet Letter? Does he know that it is about the hypocracy of the people who sew the letter on Hester’s clothes and not about her adultery? Does he understand that when he suggests the Scarlet O he is telling us more about the state of his soul than the state of our bodies?

    The ignorant will do themselves in, one way or another.

  19. I’m all for fat acceptance, but I think your analogy to fair skin and moles is a bit off base. Having fair skin and a lot of moles *absolutely* increases your risks for getting malignant melanoma, which is the biggest cause of cancer deaths among young adults. So why would you be offended if a Dr. cautioned you that you should be checked for skin cancer? If your argument is that being obese, without other factors, is *not* in itself a reason to be examined for health issues relating to that obesity, your analogy falls apart. Just wanted to point that out, as someone who is young, has fair skin and lots of moles, has been diagnosed with several malignant melanomas, and is borderline obese on the BMI charts. The extra 30 pounds I’m carrying won’t kill me, and I’d be pissed if a Dr. implied it would. My moles absolutely WILL kill me if I don’t get checked every 4 months, and I’d consider any new Dr., of any specialty, who didn’t bring it up to be totally irresponsible and kind of a moron.

    Thanks for letting me rant a little… hope it’s not out of place.

  20. Granted I don’t have a lot of moles, but my understanding was that if they weren’t dark, irregular, or changing in shape, they were just moles. In other words, they can be medical issues, or they can be merely aesthetic, and someone who tries to turn an aesthetic issue into a medical issue is being terrifically irresponsible. That’s all the analogy was supposed to do. Sure, if a doctor noticed that I had dark, irregular, or growing moles, or found out that I was fair and spent lots of time in a tanning bed, she’d be more than justified in considering me to be high-risk. But if someone were getting up in arms about how doctors are letting all these fair-skinned patients slip through by not putting “fair skin and moles” as a diagnosis on their charts at each checkup, my first thought would be “well, maybe the doctor has determined that they just have moles, without medical implications.” My reaction here is the same: it is true that fat CAN indicate poor habits which CAN affect health, and a doctor can determine the level of risk with a fairly short question and answer session. But when I find out that, gasp, not every fat patient is diagnosed with “fat” when she goes in for a checkup, my thought is not “good lord, what is the medical profession coming to,” but “gee, maybe their fat is not medically relevant.”

  21. Gotcha. I totally see what you’re saying now, I guess I’m a little touchier than most on the subject! =) Probably because melanoma is so endemic in my family and among the people I know who are fair-skinned.

  22. Ooops, sorry to double post, but I can’t edit … I also meant to say that having a *lot* of moles, even if they aren’t irregular in any way, is in itself a risk for developing melanoma, which is why I misinterpreted what you wrote. But of course you are right, having a smallish number of normal moles isn’t anymore medically relevant, in itself, than being overweight if there aren’t other risk factors.

  23. I guess I should have chosen a condition I was more familiar with! It was the only one I could think of offhand that could be purely aesthetic if unaccompanied by other complaints.

  24. Before he could be seen by the doctor, of course, he had to be weighed — and lectured about his weight. Why??

    “Had to” is a relative term. When I was in the hospital a while back (for something completely unrelated to weight – specifically a nasty soft-tissue bacterial infection that I’d let go too long), a volunteer announced she was going to bring in the scale and weigh me. I suppose I moaned a little – I was extremely dehydrated, feverish, possibly physically unable to stand, and certainly I didn’t want to get out of bed, let alone deal with the obligatory scolding.

    A friend who was with me, bless her heart, leaned over the bed and whispered, “It’s a medical test. You have the right to refuse it.” It is and I do, so I did. The volunteer was upset – ran to the nurse with “She doesn’t want to be weighed!!!” – but the nurse was unruffled.

    Since then I adopt a “just say no” policy to being weighed whenever possible. It actually seems to help: if I’m being seen for something that couldn’t possibly be weight-related, such as a sinus infection or a cut that needs stitches, I don’t get the “have you ever considered losing teh WEIGHT?” lecture. It’s hard to tell, but I think I also get better medical treatment. Somehow, not having the exact number seems to obviate some of the revulsion reaction from the doctor. It’s nice being treated as a person.

  25. It’s hard to tell, but I think I also get better medical treatment. Somehow, not having the exact number seems to obviate some of the revulsion reaction from the doctor. It’s nice being treated as a person.

    Now that is really interesting. I know some people decline to be weighed, and I’ve even seen a form letter that you can give your doctor. (Anybody know where this is?) But I usually get on the scale because I figure that if they’re going to lecture me about being fat, well, they can tell I’m fat. I also worried that refusing what they see as a routine procedure would actually make me a target for weight talk, because they would see it as me being embarrassed or anxious about my weight and therefore vulnerable. I think it’s really interesting that you’re experiencing better treatment. Maybe this is worth an experiment!

  26. My new female doctor has been like this, never once mentioning my weight; which has been a very weird experience for me. She’s the first one ever that hasn’t commented on it. The last time I went to a male doctor I weighed 165 (keep in mind I’m 5’10” with H cup size breasts (thats a good ten pounds right there), he took one look at me and told me my all my health problems were due to my ‘obesity’. I was absolutely shocked.

  27. I once went to a doctor who, when I went in to get antibiotics because I was coughing up bloody scabs from acute tonsilitis, told me if I just lost 50 lbs my throat would stop bleeding.

    I had to threaten a malpractice lawsuit just to get some damn antibiotics. It’s insane.

    Needless to say, I’ve never been back to that doctor.

  28. @jade:
    I’m 5’10” too, and my boobs aren’t that big, but I’m not certain that if I were anorexic I could weigh 165 pounds! The top end of the BMI “healthy range” for 5’10” is 174. I am intimately familiar with that number, as during my bout of bulemia I was obsessed with it. Even vomiting everything I ate immediately, I could only hit 179. I ended up at a bariatric doctor (someone who deals with weight, but not the surgery) because I do have a binge eating problem (although I know many, if not most, overweight people do not.) She did a measure of my lean body mass, and was like, “Well, actually, your bone structure doesn’t fit in the chart. You could weigh s much as 195 and still be healthy. [Her words]) I was elated, At the same time, I have slowly become appalled. How could it escape every doctor I’ve had my whole life that my structure was this big? It isn’t like I can bloody hide it! My family (except for my mom, who has some serious, undiagnosed food and body issues) looks like a Viking. We look like we should be pillaging and carrying people off left and right. If someone had figured this out earlier, could I have avoided the hell of bulemia and a lifetime of disordered thinking about my body? It’s wrong. Just wrong. I’m much fatter now, because of a medication that’s keeping me alive. OOOh, I must be told I’m fat by EVERY doctor!!! They’re all a**holes, and I don’t know what to do if I have kids. I do know Iwon’t let a sick establishment make them hurt like I do.

  29. The mole thing was kind of addressed, but another point is that – in order for your doctor to notice if a mole is behaving abnormally (growing in size, for example) there is a certain degree of being aware of what your moles look like on a routine basis necessary. So I’d personally also be inclined to worry more about a doctor who DIDN’T make some comment if I had a lot of moles than one who did. (Granted, I would not expect the comment to be ‘we should remove them all now’ but rather ‘I see you have a lot of moles. We should schedule regular skin cancer screenings for you as part of your routine care.’)

    I think I’m pretty lucky with my doctors, though. My GP also sees both of my parents, who are overweight, and he’s never once said anything to me about it, even though I’m firmly overweight according to the BMI chart. Actual health issues, sure? Weight? Nope. Likewise, the doctor I see for arthritis has mentioned exercise to me – but in the context of keeping my joints moving to reduce swelling and fluid build up. She doesn’t care if I do 60 minutes a day in a gym or 10 minutes a day leisurely walking my dog. (Actually, she’d probably complain about 60 minutes a day in a gym because that’d be over-stressing things.)

    So it is possible to find doctors who’ll stick to the things that matter, not just numbers on a chart.

  30. recently my employee insurance instituted a “wellness program.” i was sent to a health screening with an n.p. i’d never met before. actually, the clinic i had to go to was affiliated with the “other” local medical system, which has never failed to reinforce how much i like my own providers.
    it went surprisingly well. the (thin) n.p. was actually pretty cool. part of the exam was a waist measurement, and she wasn’t at all mean or smug or shaming about it, or my weight, even though i think that was meant to be the point. just sort of “this is on my list.” she even told me that she was jealous of my cholesteral score! i left feeling pretty good about my overall health. only my size and triglycerides (wtf?) were high. she mentioned that more activity was a good idea, but hey, you have a new baby so i can see where that’s low on the list.
    i got a health reveiw a week or so later with all the same numbers explained in greater depth, only EVERY SINGLE PAGE warned me that i needed to LOSE WEIGHT. or i’d get really, really sick. really. yeah. i’ll get right on top of that, AND i’ll drop my pediatrician, midwives, and really AWESOME hospital all for you guys, who, btw? have a mcdonald’s in the basement of your hospital. right.

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