Monday, October 13, 2014

The consequences of weight bias: beyond making you feel bad.

Debra came to me frustrated about her climbing weight, now about 20 pounds out of her normal range. This is nothing unusual for me—plenty of women and many men reach this point, desperate for answers and guidance to help them take charge of their weight. Others present for help managing symptoms or medical outcomes—like high blood pressure or cholesterol or GERD that have more to do with the quality of their diet than with their weight.

Debra was an active woman in her 50s, a non-emotional eater—yes, they do exist—who felt like she was doing most things right. She ate regular meals and snacks; she had to, as she started to feel really low energy, and fuzzy headed if she didn’t. And she’d start to get the sweats, too. She had a history of very high cholesterol, and a family history of Type 2 diabetes as well. And the weight she had previously maintained, her normal weight, was nothing crazy, nor did it require heroic measures to achieve it. Her goals were quite realistic.

After reviewing Debra’s intake and activity, I made modest recommendations to ensure she was doing whatever was reasonable in terms of change. Was she still getting the workout that she thought she was, or does she need to evaluate her intensity or duration? Perhaps with better conditioning she could prevent further weight gain. Was she inadvertently influenced by the halo effect—having more of those foods she believed to be healthy, such as lean protein sources or nuts—without an awareness of just how much was enough? ( Fullness was challenging to observe, she had stated. Perhaps she needed to evaluate just how much she needed as opposed to portioning her food on autopilot, without much attention to her need or While these recommendations were helpful—and prevented further weight gain—it was clear to me that another explanation was responsible. She had many markers for polycystic ovarian syndrome (PCOS) or hyperinsulinemia, a condition where high circulating levels of insulin result in symptoms of low blood sugar (including the sweats, fuzzy headedness, irritability and immediate need for food). (For more on hyperinsulinemia

At my suggestion, she went to see an endocrinologist—an MD appropriate for evaluating such conditions. From Debra’s report she shared her sense of despair about her climbing weight and belly fat, yet the doctor began to dismiss her, like all the overweight women who presented before her, with a simplistic, patronizing “Eat less and exercise more”. Yes, judgment was decreed without even listening to how high her activity already was and how appropriate her eating has consistently been. 

But once she added the comment about the symptoms between eating—those low blood sugar-type symptoms—he got it. He finally recognized that it was unfair to put the blame on her—to simply tell her she needs to exercise more or eat less because after all, weight management is about energy balance. He put her on metformin, which addresses the underlying issue—it’s an insulin sensitizer, so it helps prevent excess levels of circulating insulin.

The outcome? Most importantly, her symptoms stopped and she felt so much better. No more shakiness in between meals, and the sweats ceased, too. And, her weight dropped about 9 pounds over the past year, in contrast to the weight climb the preceding year that felt so out of her hands.

Weight bias in reverse

Another active woman—at a normal and stable weight, recently had a physical. She’s a 51 year old who enjoys food and eats a healthy diet. By healthy, I mean rich in healthy fats, whole grains, fruits and vegetables, with a reasonable intake of desserts and chocolate and wine. She’s not vegetarian—but her intake of meat is minimal—nor gluten free, nor dairy free, nor carb free. She’s a reliable reporter.  I know, because she is me! For the first time in her/my history, my cholesterol was high! The good cholesterol was high too—likely the result of my activity (I’d attribute it to genetics except neither parent had a high HDL)—but the bad, the LDL was out of any lab’s range of acceptable. Add that to my high blood pressure and that places me at further risk.

And what did my doctor do? Nothing. Other than telling me to continue to ‘watch my diet’ and maintain my activity (about which he knew little), that is. Yet the variables that I can control are already in order. My diet and exercise aren’t going to change for better so I don’t suspect there will be any astounding improvement. Most likely, my hormone status was likely the greatest factor increasing my levels—LDL can increase 15-25% with menopause! But heart disease risk similarly increases with postmenopausal elevations in cholesterol. 

Me (in Robin's hand-me-downs) and my slim father who had type 2 DM,
high blood pressure and high cholesterol
In spite of my high cholesterol, my doctor didn’t suggest that I have it rechecked in 3 months or that I start a statin to lower the levels. He didn't explore my exercise frequency, intensity or duration. While the updated 2014 cardiac risk calculator concludes statins for cholesterol lowering aren't necessary for me, (and doesn't include weight in the assessment) he didn't plug the numbers into this risk analyzer (I did later though.) No, I did not look like a high cholesterol patient so my cardiac risk was minimized.

I share this for those of you still blaming yourself—for your health, and for your weight. That is not to say that there aren’t things you can do to take charge of your health. Physical activity in moderate levels can improve insulin sensitivity, lower cholesterol, improve blood sugar and assist in energy balance. Oh, and it certainly may help mood and sleep, too. And eating portions appropriate for your need can help everything from reflux to fatigue to your weight climbing out of your normal, healthy range. Eating more home prepped meals can give you more control of portions and meal content. Even for you non-cooks, there are plenty of easy-to-prepare, yummy dishes you can make, with practical strategies for pulling it all together. And avoiding long periods without food certainly will improve your energy level and your control of eating when you finally take the time to eat.

But if you’re already doing what’s in your hands to do, don’t let others burden you with blame. And start to advocate for the care you deserve.

When I see my new doctor, you can bet I’ll be discussing my labs and inquiring about any treatments that might lower my risk. Because truly, my high cholesterol is not my fault.

thanks for reading!


  1. Are you having trouble posting a comment? I'm testing this. If you like, email me at eatwrite(at)

  2. Been there.
    Just the other day, I was diagnosed with severe GERD, got a flyer with a long list of do-nots and was told to lose weight. I wanted to discuss it in a bit of detail and the reply was Eat less, move more. Oh yes, maybe I could eat only five times a week instead of 10-ish. And while the doc refused it, I'm pretty sure that the GERD meds suppress appetite.

    About a month ago, I suffered some acute back pain, was brought to ER by a family member who kept repeating that it's because I'm obese. The staff was nice, helpful, considerate... and everyone told me that I should lose weight. Yeah, sure, whatever, but it's not the most timely advice when one walks by hanging onto the railing. Back at parents', when I was barely able to get to the loo, I kept being told off every half an hour for lounging around wearing an office skirt - because that material wouldn't get crinkled in no time and I wasn't able to put on sweatpants, for goodness sake - and that I should start working out to make the muscle spasm go away. And that it's all because I'm obese. At a time when it wasn't clear whether it's muscle spasm or herniated disc or cauda equina syndrome, when the doctor's advice was basically Lie flat, keep yourself warm, if you weren't be able to hold your pee or stopped feeling your legs, call ambulance immediately.
    When I recovered, the doc explained what's the problem - knee dysplasia caused weaker leg which caused my pelvis to tilt, resulting in a muscle spasm, was taught specific exercises to alleviate the problems and was told to lose weight - but not in that cursory manner of eat less, move more. I got explained how excess weight affects the joints and muscless and worsens any underlying problems. And then a miracle occured. The doc didn't tell me to eat less and move more, he actually started talking quite reasonably about both - an orthopaedist, one of the big, loud, boisterous and scalpel-ready guys, of all people. Well, instead of a brochure and generic advice, I got a referral to the psych department re: eating disorder. I wasn't told that I can't really have an eating disorder because I'm overweight/don't throw up after every meal.

    Let's hope for the better. I have an appointment in around two weeks.