Why Patients with Eating and Weight Concerns Are Frustrated

(Can’t Doctors Trade in Their Stethoscopes for Magic Wands?)

■What it often feels like to live in a body on the higher end of the weight spectrum

■What makes higher-weight patients uncomfortable in medical settings

■How to stop the blame game between provider and patient

■What patients want out of their provider-patient relationship

■What providers and patients need to focus on to improve their relationship

If doctors are frustrated with failing to meet their goals of helping patients eat more healthfully and attain a comfortable weight, that frustration is nothing compared to that of their patients, many of whom have been on more diets than they can count. It’s not as if people with high weights don’t know that they’re large. They have mirrors, buy clothes, listen to and read the news, and have families and friends who encourage them to be healthy and fit. Is there really anyone left in this country who doesn’t recognize that thin is in and fat is out, and that this narrow (pun intended) standard isn’t going to change any time soon?

In the next chapter, you’ll learn why the well-intentioned efforts of doctors, health care providers, and patients alike haven’t resulted in permanent weight loss, enhanced self-efficacy, or increased body acceptance for the majority of our patients. For now, we ask that you put stock in either your own experience with dieting and weight regain or what you’ve observed about others—patients included—circling through this revolving door.

For now, our goal is to help you understand what concerns patients bring to each medical visit aside from a desire to leave the office feeling better than they did when they came in. Those of you who never have considered what visiting the doctor may be like for higher-weight patients might be very surprised to learn what’s going on inside their minds. If you’re a doctor or health professional, you’ve probably been focused, quite naturally, on what’s going on with your patient’s body, and less so on their hearts and minds. Moreover, you might find surprising all the things we’ll describe about what and how these patients feel as they enter, sit in, and leave your office.

Not to worry. After all, you may not have thought much about this subject before. Commendably, you want to learn, which is why you picked up this book.

Brain food for providers: What judgments about higher-weight patients are crowding out your curiosity to learn more about them? What judgments about yourself are barriers to being curious about your own reactions? Gently remind yourself to stay curious and let go of judgments about yourself or your patients. Be compassionate with your own imperfections, and you’ll have an easier time being compassionate with those of your patients.

HOW DO PEOPLE WHO HAVE HIGH WEIGHTS AND EATING PROBLEMS FEEL?

Readers who struggle with eating and weight concerns will no doubt recognize our description of feelings you’ve experienced with your doctor or health practitioner. You may have had experiences strikingly similar to the ones we describe, finally feel validated by our words, grow angry or sad, or sink into despair that the doctor-patient relationship will never change when it comes to eating or weight concerns.

You may be shocked at the intensity of your rage, which has built up over the decades and has had no place to go. Maybe you tried to tell your doctor how you felt, but he or she didn’t have time to listen or didn’t try to understand. Maybe you stopped going to certain health practitioners who were highly skilled because you left your appointments feeling miserable about yourself or were scared that if you stayed for one more minute, you would bite their heads off and say something which would bias them even more strongly against you. Or perhaps you’re ashamed that you never stood up for yourself and now feel riddled with anger or regret.

Patients and providers, we urge you not to judge your feelings. Simply observe that these are your emotions for now and that they are neither wrong nor right, but true expressions from the heart. Patients, pay special attention to your desire to blame yourself for “being fat” and feeling “difficult to treat,” for thinking of yourself as a failure, and for feeling more compassion for your poor doctor who has to treat “over-sized” you than you do for yourself. Understand that viewing yourself negatively due to your size or weight is an assumption that keeps you feeling down on yourself. With self-compassion, patience, and practice, you will learn to view yourself in a more positive, accepting light and, from that place, your chances of successfully reaching your eating goals will improve markedly.

Brain food for patients: What are you feeling right now? What judgments are crowding out your curiosity to learn more? Gently remind yourself to stay curious and let go of judgments about yourself or your providers. Find the place in your heart that has compassion for yourself no matter what your size, weight, or eating problems are.

SO, WHOSE FAULT IS THE “OBESITY CRISIS,” THE DOCTOR’S OR THE PATIENT’S?

Let’s stop the blame game right here. Patients have been doing their best and so have doctors! We know this may be a mind-blowing statement, but it’s based on one of the basic tenets of psychology which goes like this: We’re all doing the best we can all the time and sometimes our best at that moment isn’t good enough.

Both parts of this axiom are true. We are doing our best at all times and, sadly, often our best just doesn’t cut it. This may be a difficult concept to wrap your mind around. Psychotherapists spend a good deal of time explaining this principle to clients, followed by lengthy and intense debates about its validity. Eventually, clients do come around to this way of viewing humanity.

Understanding this concept is crucial because it generates compassion and validation, acceptance, and humility. When you accept that people (including yourself) are doing the best they can do all the time, due to previous experiences and current internal resources, it moves you to acknowledge their (and your) humanity. It validates that sometimes our best is woefully inadequate precisely because we are imperfect human beings. The point is that holding these two thoughts gives you permission to fail, yet also says that you can strive to do better, which, for doctor and patient alike, is what this book is all about. There is hope and powerful potential in the decision not to give up, no matter how challenging a task appears.

Now, let’s move on to the focus of this chapter: why patients are so frustrated with the doctor-patient relationship as it relates to dealing with their eating and weight concerns. Here’s what we’ve learned and want to share with you from the patient perspective.

In general, heavy patients are uncomfortable stepping on the medical office scale and, therefore, dislike and wish to avoid this ritual

We all know that hopping on the scale at the doctor’s office is de rigueur. Believe it or not, many patients start thinking about this anxiety-producing aspect of the appointment weeks or days before an office visit. They dread standing on the scale because they either know what they weigh and are miserable about it or don’t wish to know because it will make them miserable due to what their doctor will have to say about it.

To them, a scale is not a neutral mechanical object. It’s a shame machine. As it’s busy doing its calibrating, it might as well be announcing, “You are a big, fat person and bad for it,” or “Have you no shame weighing what you do?” While the nurse records a number—137, 201, 314—the patient is experiencing herself as bad, defective, and a huge disappointment. Because of their internalized shame, critical self-talk, and societal stigma, it can feel awful for some patients to confront what they weigh. There is powerful, emotional work that patients can do to improve their self-talk, including not judging themselves harshly when they step on the scale1 but, in the interim, making that most-feared number public knowledge is like shouting out their deepest, darkest secret disgrace to the world. It is a recipe for despair that can actually derail patients’ ongoing efforts at wellness for days, weeks, months, or even years.

Some brave patients may request not to be weighed and see where that gets them. Other patients may tell the nurse that they do not wish to know what they weigh and turn around so that they’re not facing the numbers on the scale but away from them. However, even making these requests draws attention to their large size when, at the point of being weighed, all they want to be is invisible. The whole business is embarrassing and feels stigmatizing enough to keep patients away from entering a doctor’s office and receiving much-needed medical attention. According one study, “A total of 19% of participants reported they would avoid future medical appointments and 21% would seek a new doctor if they felt stigmatized about their weight from their doctor.”2 This is a frightening truth: some patients may not come to appointments if you insist on weighing them.

Patients are fed up with deprivation and denying themselves the pleasure of foods that are considered “too high-calorie” and “too high-fat” for them to eat

Whether life has been one long diet or they’ve jumped on and fallen off the diet bandwagon dozens of times, it is not easy for people to watch others eat yummy foods knowing they’re verboten to them. Or, more accurately, to know that the price they’ll pay for a few, fleeting moments of mouth-watering ecstasy will be far steeper than it is for the majority of folks. Generally, “normal” eaters say yes and no to food more or less in balance. They can eat a little bit of high-calorie or high-fat food and stop before they go overboard. People with eating problems (which usually morph into weight dissatisfaction) are different.

For whichever combination of biological, environmental, and psychological reasons, they are unable to say yes and no to food in balance. Maybe it’s due to all-or-nothing thinking (to be discussed later in this book), so that they’re either off “forbidden” foods or eating nothing but them. Maybe it’s because they’re genetically programmed to have a high-weight set point—that is, our (more or less) biologically determined weight. Or maybe it’s sheer habit from food being their only comfort in childhood. Or possibly it’s because they stopped listening to their own feelings and appetite signals decades ago when a parent or doctor put them on a diet and, over time, with repeated dieting, they lost the ability to sense hunger or satiation. Or they were taught to believe that their worth was measured by their success in attending to the needs and concerns of others at home, in school, at work, and in relationships, and therefore disconnected from their own desires, both physically and emotionally, and turned to food for solace and reward.

Whatever the reasons, it’s time to stop making a moral issue of it by insisting that patients lack self-discipline and self-control. This premise is false and you will learn more about why later in this book. The truth of the matter is that it’s painful and frustrating for patients to walk around feeling as if they’ll be forever on the outside looking in, their noses pressed up against the glass watching other people eat what they believe they must deprive themselves of. They end up feeling like they’re damned if they do eat something they crave and equally damned if they don’t. Sometimes saying no just gets too hard and feels too unfair and so they throw in the towel and say, “The hell with it,” and then seek solace by eating whatever they want, forgetting about good intentions as well as bad consequences.3 Honestly, when that kind of tension builds up and they lack the self-awareness and skills to intervene, the inevitable response is that they end up lost in the all-too-short-lived pleasurable gastronomic moment.

Patients bring to every doctor’s visit their deeply felt helplessness, hopelessness, self-contempt, and despair about their body size

In most cases, these patients are not actually helpless. There is usually (but not always) something, even one small thing, that they can do to take care of themselves better to become healthier. But, sometimes not. Sometimes all they can do—what they’ve been struggling to do for decades—is to avoid gaining any more weight than they already have. The truth is that they often are not totally helpless, but relentlessly feel as if they are. Anyone and everyone can tell them not to feel that way, but they needn’t bother. We all feel what we feel—until we learn to feel another way.

Telling patients that they shouldn’t feel helpless because rationally they’re not is a waste of your time and energy. They feel powerless, not necessarily about the present and losing weight, but about keeping it off so they won’t be back in a doctor’s office having this same conversation a year or two from now. Trust us, they remember every diet they ever began, their high energy and bright hopes, the power they invested in the conviction that this time would be different, the initial outpouring of support from family, friends, and coworkers, and the dreams of a slimmer future and what that would mean for them.

And they remember, even more clearly, how nothing worked, or at least not for the long term. All their diet failures, whether long ago or recent, are etched in their memories and take up a wide swath of mental real estate. They loom far larger than happy memories of success, love, achievement, and other pleasures. Take note: These deeply felt, perceived failures are often the defining feature of these patients’ lives and the basis of their identity: I am doomed to be fat no matter what I do. I Am A Fat Failure. Forever.

You may wonder why we include both the terms “helplessness” and “despair” in describing how these patients feel. Think of it this way: Despair is helplessness on steroids. It is believing not only that you cannot do anything about your situation right now but also that you never will be able to. Despair is giving up the dream or the fight, surrendering to any future possibility of weight loss because you’re never going down that road again. Despair is giving up trying because you believe you cannot bear another weight loss and regain, that you’d rather be fat and stay fat than taste thinness and have it stolen from you by the greedy gods of appetite.

Brain food for patients: Which of the above-mentioned problems have you experienced in a doctor’s office? Which has been most difficult for you? Say aloud or jot down what you would like your doctors to know about what you’ve experienced and how you felt.

Patients often have lost and regained hundreds of pounds

Most of them know they can lose weight, or, at least, they know they used to be able to do so. They’ve done it, more than once, sometimes two or three or eight times. Do the rest of us have any idea of the discipline that is required to lose 100 or maybe 200 pounds by dieting? That’s like trimming off half of yourself in the most excruciating fashion, day by day, meal by meal, mouthful by mouthful. So many people complain about being unable to lose those “darned last 10 pounds,” while many patients have lost ten or twenty times that much and sometimes have kept it off for months or years. If anyone is an expert on weight loss, it’s the person who’s gone down three or five sizes more than once. How many of us can imagine the deprivation and determination that took?

While others—doctors, family, friends, coworkers—look at them and think, “Why can’t they lose weight?” people who are currently deemed fat but who’ve lost large amounts of weight are wondering, “Why can’t I keep weight off? Why do I always gain it back? What is wrong with me?” This is a different experience than most of us will ever have: to succeed and fail, then succeed and fail again. The problem isn’t weight loss, but rather weight regain. Many in the medical establishment are looking at these patients as folks who’ve done nothing, while they’re looking at themselves as folks who’ve done everything they were supposed to do and still failed. And how do you think that makes them feel?

Many of these “yo-yo dieters” also know that each time they’ve gone through the ordeal, the gradient has become steeper. The same push to shed mega pounds leads to less reward each time, and often, sadly, more effort does not reap commensurate success. Rather than previous dieting making it easier to give a repeat performance, it actually makes the process harder.

Ironically, “yo-yo dieters” see themselves as compliant patients: They’ve done exactly what doctors have asked—dieted and dieted and dieted again—and they still can’t make the number on the scale go down or stay down. Paradoxically, doctors often view them as noncompliant because they haven’t kept weight off. These opposing views get in the way of having productive conversations about what can be done. And, truly, if the only answer to weight loss is dieting and patients have done this ad nauseam, then they and their doctors are at an impasse, unless they’re going to consider weight-loss drugs or surgery.

Patients are tired of hearing and believing that if they wish to be fit, they will have to suffer and punish their bodies, because, in this culture, “fit” means “thin”

Don’t get us started on programs like The Biggest Loser and Extreme Weight Loss. These programs are nothing like reality—at least none we’ve experienced. How many of us would embark on an endeavor that we know will be long on pain and short on pleasure? Okay, other than suffering through the sleep deprivation endured in medical school and residency. It’s not that patients don’t want to be fit. They do, sometimes more than anything else in the world. But, let’s face it, it’s harder to move a large object than a small or medium-size one. It’s often difficult for many patients to walk, never mind jog. We’re not making excuses for them. It does take more effort. And they worry about what to wear to the gym, especially to the kinds of clubs where hard-bodied folks are decked out in fashion-statement workout wear. They worry excessively about what people will think of them, that they’ll look silly, that others will view their efforts as too little too late, that they will be laughed at and pointed at (because it’s happened before), and that it will take so long to get fit that they’ll be old or dead before they succeed.

Even if they’re eating better and exercising, if their weight doesn’t drop, patients of high weight feel like failures

Because this culture is so fat phobic and weight obsessed, if these patients do manage to eat more healthfully, consume smaller portions, and reduce mindless or emotional eating on a consistent basis and don’t lose weight, or lose it quickly, they still feel like failures. If they’re fortunate, their lab numbers improve and they cling to that small blessing to prove that, in fact, they are doing what they were told to do and desperately want to do: take better care of themselves. If their lab numbers don’t budge and their weight remains the same, even if they are on the right track and engaging in healthy lifestyle behaviors, who will cheer them on?

Basically, they feel like huge disappointments if they’re not getting healthier quickly or quickly enough. It’s not like our culture encourages slow and gradual change. No, we’re all about to do it now, do it right, and get it done. More is better than less (except in the fat body department) and faster trumps slower. Where do we ever hear the message that slow is better than not at all? Whoever champions the gradual, yet enduring, solution?

Mostly, people feel like failures because they are frustrated when they are eating healthfully and exercising and still can’t shed much weight. They also feel like failures because most are unremittingly hard on themselves. (You will learn more about this personality trait in Chapter 4.) Even when others, doctors included, praise their small achievements, they often see only what they didn’t do and have yet to do, not what they’ve already achieved. And, they can be very convincing about their failures unless the people around them adamantly refuse to allow them to see themselves as walking disasters and, instead, zealously point out their everyday successes, however minor.

Brain food for providers: When you look at your heavy patients and hear their weight-loss and regain histories, do you see someone who’s tried or someone who’s failed? Do you feel pressure to help them change quickly or can you champion the most minimal improvements in behavior?

Most high-weight patients are aware that their bodies may not fit the current cultural ideal and feel demeaned, shamed, and infantilized when doctors tell them that they need to lose weight

Patients get rightfully annoyed when they’re told that their BMI or weight is too high as if they had no idea this was so, as if they mistakenly thought they were Ken or Barbie, as if this were some sort of breaking news bulletin. They have mirrors and buy clothes and are perfectly capable of comparing their bodies to other people’s bodies (which they are usually obsessed with doing, much to their chagrin, unless they’ve given up completely due to despair and depression). If anything at the doctor’s office will enrage them, it’s being told in whatever way—sternly or kindly, patiently or impatiently, with concern or aloofness—that they are “overweight” and need to lower the number on the scale.

Upon hearing doctors tell them that they’re “overweight,” or have gained weight recently, what many really want to say (and rarely, if ever, are bold enough to do so) is “Really? No kidding? Gee, I had no idea. I’m shocked, but so glad you mentioned it.” Why don’t they share these thoughts? Well, because most of them would rather put on 20 more pounds than offend a doctor whom they often see as an authority figure, whom they want to like them and care about them, and whom they need desperately when they have medical problems. So, when they’re told they’re overweight, they nod and smile and make it seem like doctor and patient are on the same page. Nothing could be further from the truth.

Imagine these perspectives: Either patients have totally given up on the idea of losing weight because they have come to believe from experience that nothing will work for them or they tell themselves that they are so fat that it would take them several lifetimes to slim down. Alternatively, they may have spent the time since their last doctor visit eating more moderately and healthfully and haven’t seen the number on the scale budge. Whatever the case, hearing that they’re “overweight” will almost always compound their frustration and make a bad situation a great deal worse. At best they will feel enormous shame—and at worst they’ll feel enormous shame.

Patients with eating and weight concerns, like everyone else in the world, hate to be lectured

No one likes to be lectured. On one level, especially if they genuinely like their physician, most patients recognize that their doctor means well. Really they do. Therefore, they will most likely sit meekly through the lecture that the doctor is none too happy to be giving in the first place. So, here you have a doctor who feels helpless but duty bound to give the Lose Weight Or Else 101 (or 202 or 303) lecture to an audience of one who feels more ashamed and disempowered with every word that’s uttered. Or, alternately, an audience of one who tunes out the blah-blah-blah completely because he or she has heard it a gazillion times before, so often that he or she can almost repeat it verbatim.

When patients are lectured by even the most well-meaning doctors, they only feel smaller. It doesn’t actually help them get smaller.

Knowing their doctors are unhappy with them, patients fear upsetting them more by asking questions

These patients may already feel unlikable, or maybe even unlovable, because of their large size. So very many of them were teased and bullied in childhood or adolescence for their girth. They are often desperate to be liked and highly sensitized to even the tiniest whiff of disapproval. They are so sensitive that they experience a kind of paralysis when they are lectured about their weight so that they just sit there and tune it out or wish they could disappear on the spot. Afraid they might antagonize the doctor further (beyond what they fear their largeness already has done to cause disfavor), they clam up and forget or ignore the questions they came in to ask.

Not asking these important questions does two things. First, it increases their sense of helplessness, powerlessness, and the power differential between doctor and patient. Second, it leaves patients at a disadvantage because they forgo finding out information that is crucial to taking good care of their health. Such lack of information may lead them to not doing what is necessary to manage their health problems and to putting themselves at further disadvantage at their next visit, a vicious cycle if ever there was one.

Patients become upset when doctors say or imply that every ailment they have is due to their poor eating habits, lack of fitness, or weight

No other complaint by these patients about doctors (except perhaps mandatory weigh-ins) is as anger producing as being told (or having it intimated by their providers) that every physical problem they experience is due to their weight. Perhaps not all, but many patients understand that weight puts stress on their hearts and joints, may make surgery more difficult, and may put them at risk for certain serious diseases. But they also know that their thin and average-weight friends visit doctors with symptoms similar to theirs and that many physical ailments have little or nothing to do with weight.

Between the two of us, we know thin, average-weight, and heavy people who have spinal stenosis, knee and back problems, sleep apnea, acid reflux, high cholesterol, hypertension, cancer, and a plethora of other physical conditions. The fact is that sometimes a cigar really is just a cigar. This doesn’t mean that a high weight might not aggravate some conditions, such as arthritis/degenerative joint disease, obstructive sleep apnea, high blood lipid levels, and inflammatory illnesses, but it doesn’t necessarily cause the problem and losing weight won’t necessarily eliminate it, even if we assume it might help. Patients want to know and trust that whatever physical ailments they bring to their doctors’ office will be viewed from a neutral, nonweight-biased perspective and taken seriously.

On a related matter, patients become frustrated when they make an appointment to talk about, say, a sore throat or a pain in their groin, and the discussion ends up being about their unhealthy diet and lack of exercise. If doctors overfocus on patients’ weights, they’re going to be less effective in treating the range of conditions we all have. And their patients may trust them less and avoid making appointments until they are in dire need of medical attention. These patients want to know that they will be looked at as patients first and fat second (or maybe third or fourth), not the other way around.

Brain food for patients: What do your doctors do that makes you feel demeaned or shamed? What do they do that makes you feel they are in your corner? How do you usually handle upsetting interactions in a medical office? How will you take charge at your next appointment and ask the questions you want about any of the medical problems you have?

Some patients fervently wish their doctors could fix their eating problems and are frustrated and angry when they can’t

Though some people insist they don’t find doctors helpful, most of us are enormously grateful for the medical skill and knowledge that keeps us healthy. We know we are! Rightly or wrongly, we expect doctors to make us feel better, heal our physical problems, and ease our suffering. This is in part due to our views of their expertise and authority (e.g., valuing their education, training, and experience) and also due to the way some doctors present themselves as omnipotent.

We are not here to debate how we got to this point in the history of medicine. We’re trying to explain the mixed feelings that patients with eating and weight concerns may have about how doctors interact with them. These patients may not even be in touch with their conflicting feelings. After all, physicians are amazing healers for so many conditions and diseases. Most of us leave a doctor’s office with the appropriate diagnosis, prescription, set of exercises, or the right protocol to follow to feel better. We recognize that we are so dependent on doctors to keep us disease free and healthy that we sometimes forget that they are not magicians (even when they act as if they are), but mere mortals.

When it comes to lifestyle changes, doctors can do little more than make recommendations, but patients sometimes demand more: bariatric surgery, the “right” weight-loss diet, the newest drug or supplement that advertisers swear will take away their appetite and slim them down. Because physicians can actually cure and heal so much of what ails us, it can be enormously frustrating for these patients that their major concern above all else—their eating or weight—cannot actually be fixed by their physician because the small, daily, incremental decisions and choices that determine lasting success or failure happen outside the clinician’s office. And because the underpinnings of their “weight” problems actually may be based on their genetics or their difficulties managing the rest of their lives and their conscious and unconscious beliefs about food, eating, and many other things.

Patients who have eating and weight concerns are insulted when their doctors lack compassion for them and, in fact, may be judging them for their high weight

These patients are often very, very, very, very sensitive to judgments about their size. They sometimes see slights where none exist, take things personally which aren’t meant that way, and think that other people are as down on them as they are down on themselves because of their weight. The truth is that sometimes they’re right and sometimes they’re wrong. Studies show that many doctors, reflecting the society we live in and the perceived realities of the enhanced risks that excess fat creates for patient care, do hold a bias against large-size patients.4 5 Their prejudice may slip out via their words and tone when they don’t even realize it.

However, doctors also may be perceived as judgmental when they don’t mean to be. It can be very difficult for heavy people to discern when they’re being viewed pejoratively, because they’re so super-sensitive on the subject and because they have often been judged harshly and cruelly in the past. They are used to being shamed, stigmatized, harassed, bullied, teased, criticized, and demeaned. Society does it all the time implicitly and explicitly.

There’s no question about it. Folks make a fat-phobic remark, but, when called on it, insist they were just joking around. Moreover, people who have high weights are ridiculed on TV and in the movies, as if they had no feelings at all! Weight is truly the last bastion for prejudice. It is the job of all of us—fat, thin, and average weight—to be part of the solution to this injustice.

Rightly or wrongly, people look to their doctors not only due to their intelligence and skill but also for compassion. Most of us assume that physicians chose their calling to help people and, therefore, we expect them to be compassionate. The fact is, some doctors with terrible interpersonal skills are brilliant diagnosticians and others are only fair to midland practitioners with the most caring bedside manners. Most people can shrug off the former, but doing so is often very difficult for patients who so desperately want acceptance at their large size, to not feel judged, and to believe that doctors are in their corner.

Patients may get confused about the difference between being cared for and being controlled, which leaves them frustrated with what they want from their doctors

An internal conflict that is not well understood outside of psychological circles is the issue of care versus control. This means that we are often confused about whether someone is caring for us or trying to control us. This common psychological quandary is hardly limited to patients or folks with eating or weight concerns. But, the fact is, for this population, it can be extra difficult to discern what a doctor’s motivation is: Is he or she telling patients to do something eating- or weight-related due to genuinely caring about them or is the doc trying to control their behavior to feel less helpless and more successful? How can patients tell the difference? And what can they do if doctors don’t seem to really care, but just want them to do what they advise because it’s expedient and they have no other constructive approaches to offer?

This care-versus-control conflict comes up frequently with people who weren’t cared for well in childhood. Starting back then, parents and teachers told all of us what to do, insisting that we comply with their advice or demands because they cared about us—and because it was good for us. Well, sometimes they did care and sometimes they didn’t—and maybe it was good for us and maybe it wasn’t. What if they regularly wanted us to do things because it made their life easier or made them feel better? What if their directives really were more about their needs (the unhealthy parent-centered household) than about ours (the healthy child-centered household)?

So, when patients who encountered rigidly controlling and demanding parents, teachers, coaches, or other authority figures are told to do something about their weight, even by a caring physician—even by a caring anyone—they may perceive that this individual is trying to control them. This happens more than you would think and is part of transference, a generally unconscious process by which, in adult life, we ascribe to others the personality traits of our parents or other significant people in our early lives. Some patients are so wary and resentful of being controlled, especially about their weight and particularly if they’ve had eating problems or were made to diet in childhood, that they think all authority figures (and even nonauthority ones) are trying to control them even when this is not the case. The slightest hint of pressure to do this or not do that may cause an automatic fight or flight response when they feel they’re being manipulated. This psychological dynamic crops up often during interactions with authority figures, not just doctors, and can totally derail the doctor-patient relationship unless it is well understood, addressed, and resolved.

A doctor might really worry about a patient’s poor eating habits, but express his or her feelings in such a cold or authoritarian manner that the patient feels not cared about but controlled. Doctors must be highly attuned to their tone of voice and choice of words in order to sound as far from controlling as they possibly can. Additionally, it’s vital that patients reflect on whether they often feel controlled when people express caring and the desire to help them. These patients would benefit greatly from acknowledging if they have issues about being controlled and then working to resolve them, especially in the doctor’s office. They need to recognize that not everyone in authority is out to manipulate and dominate them and that their physicians may genuinely care about what is in their patients’ best interest.

Patients of higher weight are often uncomfortable when asked to disrobe and required to wear a medical dressing gown

One additional reason for discomfort is that patients may be wildly uncomfortable when health care practitioners request that they undress for examinations. Most patients with high weights are terribly ashamed of their bodies and many don’t ever look in the mirror because they can’t bear what they see. So, imagine what it’s like to have a virtual stranger, whom they expect will be judging them harshly for their size and shape, see them up close and extremely personal. Moreover, imagine what it’s like to put on a dressing gown that you fear will be or actually is way too small for you. Truth be told, there are patients who avoid going to the doctor simply because they must undress to be examined.

Brain food for patients and providers: What mixed messages do you get or give in the doctor-patient relationship? How can providers best express caring? How can patients share concerns when they feel controlled or don’t feel cared about?

After reading these first two chapters, doctors, health care providers, and patients will hopefully have a greater understanding of the barriers that have prevented them from communicating effectively about health and enjoying a collaborative, productive relationship.

If you are a person on the higher end of the weight spectrum, we hope you now feel understood regarding what it has been like for you to make medical visits—and maybe even why you chose to stop going to them. If you are a doctor or other type of health care provider, we hope you now have an insider’s view of what it is like to receive medical care in a large body.

Are we saying that every heavy person in this society has experienced everything we’ve written in this chapter? Of course not. But, the truth is that there is a wide gulf that has continued to widen between patient and medical provider as our culture has become more fat phobic and weight obsessed. Our intent is for providers to start looking at their higher-weight patients in a more respectful and compassionate manner and work with them more constructively and compassionately so that both patient and provider can achieve success.

Providers, try . . .

1.Phrasing your wish or expectation as a request such as, “How would you feel about . . . ?”

2.Explaining—briefly, rather than lecturing. The first time we say something, we’re giving new information. After that, it’s called nagging.

3.Training your staff to ask patients how they feel about getting weighed and disrobing and respect their wishes whenever medically appropriate or feasible.

4.Reducing pressure on yourself to “fix” your patients, even if the pressure is coming from them.

5.Paying attention to how you feel about patients who have eating and weight concerns and seek to feel compassion for them.

6.Noticing patient’s body language which may mean they’re anticipating a lecture, are uncomfortable with what you’re saying, or wish to speak.

7.Validating patients’ smallest efforts in a positive direction—what they’re doing well—and avoiding mention of what they’re doing wrong or have yet to do.

8.Putting yourself in patients’ shoes and consider what it’s like—without judgment!—to be a person who is large in this culture. Be humbled! And empathize, empathize, empathize.

Patients, try . . .

1.Relaxation exercises (deep breathing works wonders) before going to doctors’ appointments that you anticipate might be stressful.

2.Watching out for conflicting feelings about doctors—wanting them to fix you, but knowing you must fix yourself; wanting to do what they say, but hating being told what to do.

3.Making a list of your questions before your appointment and giving a copy to the doctor at the start of the visit.

4.Telling providers if you’re sensitive about your weight, especially about disrobing or being weighed, and speaking up if you feel he or she is shaming or putting you down.

5.Describing to providers in writing your entire dieting and weight-loss history, all your successes and failures, especially what works for you and what doesn’t.

6.Sharing your hopelessness over your eating or weight concerns and requesting referrals to registered dieticians, Intuitive Eating counselors, fitness trainers, wellness coaches, and psychotherapists who are appropriately trained and specialize in eating problems.

7.Viewing the provider-patient relationship as a collaboration, with them doing their part and you doing yours.