Money, Motivation, and the Medical Machine
“It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
—Upton Sinclair, from I, Candidate for Governor: And How I Got Licked
Not long ago, I rode up in a hospital elevator with a bariatric surgeon, a trim, smiling man in his forties holding a box of doughnuts. I didn’t know he was a bariatric surgeon—he wore no white coat, no identifying badge—but we got off on the same floor, which housed both the bariatric wing and the ICU, and headed in the same direction, and I saw him approach a cluster of nurses (all women, as it happened) and present the doughnuts with a little bow. “This is for you lovely ladies,” he announced. He turned, recognized me from the elevator, and explained, “Always looking for new customers.” He patted his own flat stomach and rolled his eyes, as if to say he couldn’t imagine eating a doughnut himself, and walked away.
That encounter disturbed me for days. For one thing, the surgeon was assuming (jokingly or not) that eating doughnuts makes people fat, that weight issues are all about personal responsibility, just saying no to sugar or carbs or fat. That bugged me; shouldn’t a doctor who specializes in treating fat people know better? Then there was his self-righteous stomach-patting, the way he implied both his horror at the idea of eating doughnuts and his disdain for anyone who did. But what really bothered me, what has stayed with me since that day, was his self-serving cynicism. Can you imagine a lung surgeon handing out cigarettes as “gifts”? Or a hepatologist distributing bottles of vodka? And if they did, would they roll their eyes afterward, as if to say “People are idiots to smoke/drink/eat, but better for my business”?
I know the bariatric surgeon was only one doctor, and hey, maybe he just happened to be a jerk. I’m sure there are plenty of surgeons who genuinely care about their patients and who would never make that kind of tacky joke. At least I hope there are.
But I also know that bariatric surgery is very, very lucrative. And popular, especially since 2009, when Medicare started covering some weight-loss surgeries. In 2000, some 37,000 bariatric surgeries were performed in the United States; by 2013, the number had risen to 220,000. “Right now, every hospital wants to have a bariatric surgery program because so many obese people are looking for the surgical way out,” says Bradley Fox, a family physician in Erie, Pennsylvania, who’s written about money and medicine. “Bariatric surgery is a booming business. It’s huge.”
Other weight-loss treatments are cash cows, too, as evidenced by a series of advertising campaigns rolled out by the Center for Medical Weight Loss, a national for-profit program. With headlines like “Jenny Craig didn’t go to medical school,” “How weight loss improved my family practice,” and “Increase your practice income by $20,000 per month,” the ads try to recruit doctors to incorporate the center’s programs into their practices. And it’s no coincidence that they started running in late 2011, soon after Medicare announced it would cover treatments for obesity as long as they were supervised by doctors.1
Weight loss is a big business, and, since it’s rarely successful in the long term, it comes with a built-in supply of repeat customers. And doctors have been involved in the business one way or another for a long time. Some two thousand years ago, the Greek physician and philosopher Galen diagnosed “bad humors” as the cause of obesity, and prescribed massage, baths, and “slimming” foods like greens, garlic, and wild game for his overweight patients. More recently, in the early twentieth century, as scales became more accurate and affordable, doctors began routinely recording patients’ height and weight at every visit.2 Weight-loss drugs hit the mainstream in the 1920s, when doctors started prescribing thyroid medications to healthy people to make them slimmer.3 In the 1930s, 2,4-dinitrophenol (DNP) came along, followed by amphetamines, diuretics, laxatives, and diet pills like fen-phen, all of which worked only in the short term and caused side effects ranging from the annoying to the fatal.
The national obsession with weight got a big boost in 1942, when a life insurance company created a set of tables that became the most widely referenced standard for weight in North America. The Metropolitan Life Insurance Company crunched age, weight, and mortality numbers from nearly five million policies in the United States and Canada to create “desirable” height and weight charts. For the first time, people (and their doctors) could compare themselves to a standardized notion of what they “should” weigh.
And compare they did, using increasingly clinical-sounding descriptors like adipose, overweight, and obese.4 The new terminology reinforced the idea that only doctors should and could treat weight issues. The word overweight, for example, implies excess; to be overweight suggests you’re over the “right” weight. The word obese, from the Latin obesus, or “having eaten until fat,” handily conveys both a clinical atmosphere and that oh-so-familiar sense of moral judgment.
By the 1950s, even as Hollywood glamorized voluptuous actresses like Marilyn Monroe and Elizabeth Taylor, medicine was taking a different stance. In 1952, Dr. Norman Jolliffe, director of New York City’s Bureau of Nutrition, warned doctors at the annual meeting of the American Public Health Association that “a new plague, although an old disease, has arisen to smite us.”5 He estimated that 25 to 30 percent of the American population at the time was overweight or obese, a number he essentially made up. “No one loves a fat girl except possibly a fat boy, and together they waddle through life with a roly poly family,” wrote Paul Craig, an MD from Tulsa, Oklahoma, in 1955.6 Craig was enthusing over a 1907 study that claimed “gratifying results . . . on the problem of obesity” by putting people on eight-hundred-calorie-a-day diets and dosing them liberally with amphetamines, phenobarbital, and methylcellulose. (Craig concluded, in a comment that fails to inspire confidence in his methods of scientific inquiry, “Not all people who eat gluttonously grow fat, but no fat man or woman eats, as they claim, like a bird, unless they refer to a turkey buzzard.”)
In 1949, a small group of “fat doctors” created the National Obesity Society, the first of many professional associations meant to take obesity treatment from the margins to the mainstream. Through annual conferences like the first International Congress on Obesity, held in Bethesda, Maryland, in 1973, doctors helped propagate the idea that dealing with weight was a job for highly trained experts. “Medical professionals intentionally made a case that fatness was a medical problem, and therefore the people best equipped to intervene and express opinions about it were people with MDs,” says UCLA sociologist Abigail Saguy.
Those medical experts believed that “any level of thinness was healthier than being fat, and the thinner a person was, the healthier she or he was,” writes Nita Mary McKinley, a professor of psychology at the University of Washington–Tacoma.7 This attitude inspired a number of new treatments for obesity, including stereotactic surgery, also known as psychosurgery, which involved burning lesions into the hypothalami of people with “gross obesity.”8 Jaw wiring was another invasive procedure that gained traction in the 1970s and 1980s. It quickly fell out of favor, maybe because it stopped working the minute people starting eating again. (At least one dentist in Brooklyn still promotes it.)9
Bariatric surgery is the latest medical development in the world of obesity treatment. While such surgeries are safer now than they were ten years ago, they still lead to complications for many, including disordered eating, long-term malnutrition, intestinal blockages, and death. “Bariatric surgery is barbaric, but it’s the best we have,” says University of Alabama’s David B. Allison, PhD. “And I hope we’ll look back at some point in the future and say, ‘We can’t believe we did that.’”
Long-term success rates for these surgeries are hard to analyze because they take varying forms and they haven’t been around that long. There’s lapband surgery (laparoscopic adjustable gastric banding), where a band with an inflatable balloon is surgically fixed around the stomach; the balloon can be inflated or deflated to control how tightly the band restricts the size of the stomach. There’s the sleeve gastrectomy, where part of the stomach is amputated and what’s left is formed into a small tube that can’t hold much food at one time. There’s the duodenal switch, where most of the stomach is amputated and parts of the small intestine are altered so food is rerouted away from the intestine and calories and nutrients can’t be absorbed. And finally there’s Roux-en-Y gastric bypass, one of the most popular surgeries, which involves the same kind of intestinal rerouting as well as reshaping the stomach into a small pouch that holds very little food at one time.
The best estimates suggest that about half of those who have some kind of bariatric surgery regain some or all of the weight they lose.10 Some doctors say the surgeries cure type 2 diabetes (though remission is likely the better word, since many cases recur) and therefore save health-care dollars. A 2013 review of thirty thousand cases found no such savings,11 maybe because the surgeries are expensive—between $12,000 and $35,000, according to the National Institutes of Health—and require a lot of follow-up care.
The more weight loss is reframed as “obesity treatment” best left to medical professionals, the more doctors stand to gain from it. Medicalization tends to lead to more diagnoses, as the definition of a disease inevitably expands. And more diagnoses lead inevitably to higher revenues and profits. I don’t have a problem with doctors making money; I want my physicians to be rewarded for their expertise and knowledge and dedication. I want them to stay in practice.
But I do have a problem with the fact that profits drive a lot of the research into and treatment of obesity. In these days of dwindling medical salaries, many doctors look for other revenue streams, and they find them. Bariatric surgeons and other physicians own weight-loss treatment centers and clinics. They hold stock in or take money from meal-replacement companies and pharmaceutical makers. They own surgical practices or are partners in hospitals that do bariatric surgeries. And these other ventures create conflicts of interest that directly affect patients.
Some doctors argue that being involved in these so-called subsidiary services—say, owning a bariatric surgery center—means better care for patients, since they’re in a position to oversee and direct treatments, and can offer improved continuity of care. But the research does not bear this out. In fact, patients in doctor-owned clinics wind up going to (and paying for) 50 percent more office visits but getting no better care.12 That’s no surprise; in fact, professional medical organizations have been warning doctors of the dangers of double-dipping for years. “A perception that a physician is dispensing medical advice on the basis of commercial influence is likely to undermine a patient’s trust not only in the physician’s competence but also in the physician’s pledge to put patients’ welfare ahead of self-interest,” says a 2002 position paper from the American College of Physicians–American Society of Medicine.13 A list of best-practice recommendations from the Pew Charitable Trusts suggests setting clear, strong boundaries between academic doctors and industry.14 A report from the National Academy of Sciences says bluntly, “Physicians’ ownership interests in facilities to which they refer patients constitute a conflict of interest.”15
Well, yes, though that doesn’t stop them from doing it. Some people believe that telling patients about such potentially profitable ties makes them ethical. “No doctor is unconflicted, and there is no unconflicted research,” says Justin Bekelman, a professor of radiation oncology at the Hospital of the University of Pennsylvania who has studied medical research. “But doctors should be disclosing their financial interests. If a doctor says, ‘I recommend this but you should know I have a stock ownership in it because I believe in the company,’ I don’t think that discredits the doctor or interrupts the doctor–patient relationship.”
Subsidiary services are only one of several kinds of conflicts of interest that plague the medical profession, especially when it comes to weight loss. One of the most fundamental of those conflicts came to a head on a cool June afternoon in 2013, when hundreds of doctors from around the country streamed into the Grand Ballroom of the Hyatt Regency Chicago. They were there, on Day 3 of the American Medical Association’s annual meeting, to vote on a list of organizational policies—boring but necessary stuff, for the most part. But one item on the ballot that day would prove contentious, and not just within the paneled walls of the Grand Ballroom. Resolution 420 was short and to the point: “That our American Medical Association recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”
The question—whether to classify obesity as a disease in and of itself, or continue to consider it a risk factor for diseases like type 2 diabetes—had been under discussion for years, both within the organization and outside it. Months earlier, the American Medical Association (AMA) asked its own Committee on Science and Public Health to explore the issue; the committee came up with a five-page opinion suggesting that obesity should not be officially labeled as a disease, for several reasons.
For one thing, said the committee, obesity doesn’t fit the definition of a medical disease. It has no symptoms, and it’s not always harmful—in fact, for some people in some circumstances it’s long been known to be protective rather than destructive.
For another, a disease, by definition, involves the body’s normal functioning gone wrong. But many experts think obesity—the body efficiently storing calories as fat—is a normal adaptation to a set of circumstances (periods of famine) that’s held true for much of human history. In which case bodies that tend toward obesity aren’t diseased; they’re actually more efficient than naturally lean bodies. True, we live in a time when food is abundant for most people and life is more sedentary than it used to be, when we don’t have the same need to store fat. But that simply means the environment has changed faster than we can adapt. The body’s still doing what it’s supposed to, so how can you call that a disease?
The AMA committee also pointed out the correlation-but-no-causation links between obesity and illness, and obesity and mortality. Katherine Flegal and others had established over and over that carrying some extra weight often correlates with living longer, which again argued against the disease appellation. Finally, the committee worried that medicalizing obesity could potentially hurt patients, creating even more stigma around weight and pushing people into unnecessary—and ultimately useless—“treatments.”*
The AMA membership didn’t agree with the committee; they passed Resolution 420 in an overwhelming voice vote. I asked the organization’s president, Ardis Hoven, MD, an internist who specializes in infectious diseases, to help me understand why the membership voted that way despite the committee’s recommendation. She wouldn’t talk to me directly, instead writing through a spokesperson, “The AMA has long recognized obesity as a major public health concern, but the recent policy adopted in June marks the first time we’ve recognized obesity as a disease due to the prevalence and seriousness of obesity.”
In other words, obesity is a disease because there’s a lot of it and because it’s serious (though Hoven wouldn’t define “serious.”) And because there’s a lot of it we should consider it a disease. This is just the kind of circular reasoning that’s gotten us where we are on weight issues in the first place.
There are, of course, other possible explanations for the AMA’s decision. As James Hill, director of the Anschutz Health and Wellness Center at the University of Colorado, told ABC News, “Now we start getting some standardization for reimbursements and treatments.”
In other words, follow the money. Doctors want to be paid for delivering weight-loss treatments to patients (even if such treatments are ineffective and often futile). Coding office visits for Medicare, for instance, is a complex process that involves counting the number of bodily systems reviewed and the number of diseases counseled for. “Every time we see someone for a twenty-minute visit, we do a complete review of systems because we get paid more,” explains Bradley Fox. “If someone comes in for a hangnail, you still ask if they’re having chest pains. The more diagnoses that are covered, the more you can increase your coding.” So, for instance, if Medicare goes along with the AMA and designates obesity as a disease, doctors who even mention weight to their patients could charge more for the same visit than those who don’t.
But that level of cupidity is trivial compared with the sorts of financial conflicts of interest defended by some in the field. It’s rare to find an obesity researcher who hasn’t taken money from industry, whether it’s pharmaceutical companies, medical device manufacturers, bariatric surgery practices, or weight-loss programs. The practice isn’t limited to lesser-known luminaries, either. In 1997, a panel of nine medical experts tapped by the National Institutes of Health voted to lower the BMI cutoff for overweight from 27 (28 for men) to 25. Overnight, millions of Americans became overweight, at least according to the NIH. The panel argued that the change brought BMI cutoffs into line with World Health Organization criteria, and that a “round” number like 25 would be easier for people to remember.
What they didn’t say, because they didn’t have to, is that lowering BMI cutoffs put more people into the overweight and obese categories, which in turn made more people eligible for treatment. More patients to treat means new markets and more money to be made by everyone from doctors and hospitals to pharmaceutical companies and, yes, researchers.
The 1997 panel was led by Columbia University professor Xavier Pi-Sunyer, a researcher with a long history of taking money from the weight-loss industries. In fact, eight of the nine panelists had financial conflicts of interest.16 Pi-Sunyer may have been the worst, with a list of ties that reads like a Who’s Who of the weight-loss business, including pharmaceutical giants Eli Lilly, GlaxoSmithKline, Arena, Novartis, Novo Nordisk, AstraZeneca, Amylin Pharmaceuticals, Orexigen Therapeutics, Sanofi-Aventis, and VIVUS.17 When questioned about how these relationships might affect his objectivity, he defended his industry ties to a reporter from the Newark Star-Ledger, insisting that pharmaceutical companies “have no influence over what I say.”
© Deb Burgard
Pi-Sunyer’s attitude is fairly typical, says Eric Campbell, a professor of medicine at Harvard Medical School and director of research at the Mongan Institute for Health Policy in Boston. “If you ask doctors whether an industry relationship affects what they do, they almost universally say it doesn’t,” explains Campbell. “But if you ask them how industry relationships affect their colleagues, they say it affects them in negative ways.” In other words, I’m too smart to be swayed like this, but those other doctors aren’t. (It’s a lot like the phenomenon known as the third-person effect, where people believe they aren’t personally influenced by media messaging but other less discerning people are.)
The perks that come with those industry relationships range from throwaways, like $5 refrigerator magnets, to big-ticket items, like research support worth hundreds of thousands of dollars. And it turns out the small stuff may actually shift doctors’ thinking and behavior more than the bigger perks. “If I said I was going to give you $100,000, you’d wonder what I was about,” says Eric Campbell. “If I gave you a ten-cent pencil that said ‘Harvard’ on it, you’d think, ‘This won’t influence me; it’s so small.’” But you’d be wrong; smaller perks may carry more weight precisely because they seem innocuous.
In reality, the size of the perk is less important than the fact that such gifts reinforce the relationship between the company and the doctor. And those relationships are what it’s all about, according to Michael Oldani, a former sales rep for Pfizer who’s now an anthropology professor at Princeton University.18 “As a rep you had to build trust and a rapport,” he told the Princeton Weekly Bulletin. “You did those things in the industry because the bottom line was you wanted to generate prescriptions—that’s the number-one goal.”19
Those relationships build a sense of obligation between doctors and pharmaceutical companies, which can be subtle, even invisible, but still very effective at, say, getting doctors to change their prescribing habits.20 In 2003, bioethicist Dana Katz and colleagues at the University of Pennsylvania found that even small, seemingly trivial gifts from pharmaceutical companies like note-pads, lunches, and travel reimbursements set up a feeling of obligation that strengthened doctors’ loyalties to the givers. There’s a reason drug companies deduct the cost of such gifts as marketing expenses.21 “Denying the influence of those relationships is akin to denying gravity exists,” says Eric Campbell.
Yet doctors and researchers—like Pi-Sunyer—do deny such influences. So are they corrupt? Or impossibly naïve? Maybe the truth lies somewhere in between. Campbell observes that drug companies are really, really good at manipulating physicians. “They tell the doctors, hey, this doesn’t affect you,” he says. “But there’s all kind of empirical data to show it does.”
Other studies have proven, over and over, that when doctors attend drug company presentations, they go on to prescribe that company’s drugs more often than docs who didn’t attend—even when they were reminded beforehand of the potential for influence.22 Apparently knowing that you might be swayed is no protection from actually being swayed. “One thing we can say with absolute certainty,” says Campbell, “is these relationships benefit drug companies’ bottom lines. Because if they didn’t, they wouldn’t cultivate them.” No matter how ethical, educated, and professional doctors may be, they’re still human beings whose inevitable and necessary self-interest blinds them (as it can all of us) to their own biases and conflicts of interest.23
How else to explain the blatant and plentiful industry ties of some of the top physicians and researchers in the weight-loss field? For instance, George Bray, chief of the division of clinical obesity and metabolism at Louisiana State University’s Pennington Biomedical Research Center, recently coauthored an article arguing that drugs must be part of obesity treatment and that, in fact, we need to develop more obesity medications.24 Given the utter lack of long-term success for diet drugs, you might wonder where Bray was coming from. A partial list of his financial disclosures sheds a little light: consulting fees from Orexigen Therapeutics, whose new diet drug, Crave, is under review by the FDA; Abbott Labs, makers of the diet drug Meridia, withdrawn from the market in 2010 because it increased the risk of heart attack and stroke; GlaxoSmithKline; Medifast; Amylin Pharmaceuticals; Theracos, which holds a number of patents for obesity treatments; and Herbalife, makers of Formula 1 Shakes meal replacements.25 And that was just a partial list. Even the best-intentioned doctor might be influenced by the sheer number and breadth of those relationships.
The Doctor Thought I Was Lying
Terri, thirty-eight, is a bank examiner in New York City.
I went on my first diet at age eleven with my aunt, which made it seem very grown-up. And then over the next twenty-five years I gained and lost a ton of weight. For a while I dated a health nut, and he was always on some crazy diet or another and usually dragged me along on it. I yo-yo’d between 122 to over 250, and I’m five two.
I started seeing a doctor who was adamant about my losing weight. We talked about options. I did what she told me and nothing worked. I tried for certain calories, and worked out more, and my body was just done. Just done with it. But the doctor thought I was lying about doing what she told me to do. The fact that I couldn’t lose weight, in her mind, meant I needed therapy.
So I found a therapist who specialized in eating, who’s a big proponent of intuitive eating, and with her I lost weight and started working out and got to really the healthiest I’ve felt. I got to 215, which is still fat but feels like a natural place for me. Maybe I would be smaller if I hadn’t screwed up my metabolism.
I hope I don’t diet again. Sometimes I find myself slipping into it again, thinking, “What if I’m wrong, what if the choices I’ve made are unhealthy?” It’s hard to be on the minority side of an issue that’s so prevalent. Sometimes I find myself saying things like, “Everybody dies.” Because the message is if you don’t diet, you’re going to die.
Medical journals, too, can be subject to bias. In 2013, the prestigious New England Journal of Medicine published “Myths, Presumptions, and Facts About Obesity,” an article (rather than a study or original research) that promised to set the record straight on obesity. Some of the article’s “myths” seemed a little tongue in cheek, like challenging the number of calories burned having sex (closer to fifteen than three hundred, calculated the authors). Other claims were less entertaining. The authors dismissed the often-observed link between weight cycling and mortality, saying it was “probably due to confounding by health status,” which is a more sophisticated way to say “We’re sure this isn’t right, but we don’t know exactly why not.” And the article’s “facts” included plugs for meal replacements like Jenny Craig, medications, and bariatric surgery.
The New England Journal of Medicine is one of the few journals that publishes financial disclosures along with articles (many bury them online or don’t run them at all), so it was easy to see that five of the twenty authors disclosed grants, consulting fees, or paid board memberships from Kraft Foods, makers of (among other products) South Beach Diet meal replacement bars. Three of the twenty took money from Jenny Craig, purveyors of packaged Jenny’s Cuisine diet food and meal replacements. Two authors, Arne Astrup and UAB’s David Allison, reported payments from multiple companies, including pharmaceuticals, surgical instrument manufacturers, the World Sugar Organisation, Red Bull, and the Coca-Cola Foundation. As one outside commentator wrote, “I don’t think there is much doubt that these relationships influenced the content of the paper, and not for the better. How else to explain the choice of ‘facts’ the authors chose to highlight in the paper, and those they inexplicably left out?”26
I asked Allison how he would respond to the critique that financial conflicts of interest sway researchers and doctors. “My feeling is, that’s essentially not a critique,” he told me. “It would be no different than anybody saying about any other person who puts forth an idea, ‘I want to comment that you have this background or personality, this sexual orientation, weight, gender, or race.’ It’s all irrelevant. These conflicts were disclosed, we didn’t hide them, we weren’t ashamed of them. And what’s your point?”
It’s not my point, actually. A large body of research confirms that conflicts of interest absolutely affect the way doctors practice, whether they’re disclosed or not, whether doctors believe it or not, and whether they come from Big Pharma or other entities.
And if you still have any doubt at all about the intentions of Big Pharma, consider this story from a syndicated newspaper business column on how companies could improve their sales of diet drugs. After pointing out a number of medications that have been taken off the market because of “adverse cardiovascular events,” the writer concluded that doctors see the risks of diet drugs as outweighing their potential benefits. “The path forward is becoming clear,” he wrote. “Each of these drug makers must work on changing this common perception.”27 Note the wording here. He’s not recommending that manufacturers actually make their drugs safer, but rather that they make doctors believe they’re safer. I don’t know about you, but that makes me want to question every word out of a drug marketer’s mouth.
ONCOLOGIST BENJAMIN Djulbegovic knows all about medical conflicts of interest. The MD/PhD and professor of internal medicine at the University of South Florida–Tampa has studied and written about the issue for years.28 “It’s not a question of whether we’re conflicted,” he says. “We’re all conflicted by definition. The question for me becomes ‘What’s the mechanism?’”
Some of those mechanisms take place behind the scenes, invisible unless you’re looking for them (and sometimes even then). And some of the tactics pharmaceutical companies use to skew research results go way beyond the realm of reasonable. One of the most common is manipulating a study’s methodology, or how it’s set up and conducted, to change its results. A drug company testing its new medication against competitors’ older ones can deliberately slant the outcome by, say, testing a higher dose of its new drug against lower, nontherapeutic doses of older ones. Believe it or not, this kind of deck-stacking happens in about half of all industry-sponsored medication trials.29
Companies often refuse to publish studies that don’t make their products look good. Only half of all drug trials are ever published, says Djulbegovic; the rest are suppressed in a number of creative ways. Pharmaceutical companies fund about 70 percent of the research in the United States; the NIH funds the other 30 percent.30 “If you want to do a bariatric surgery, and five negative trials of the surgery were never published, you’ll have a really distorted view of whether that surgery works,” explains Djulbegovic.
Funders usually control the raw data, which companies can and do withhold from researchers. (As one anonymous company executive explained, “We are reluctant to provide the data tape because some investigators want to take the data beyond where the data should go.”) They hire “ghostwriters,” usually professional medical writers whose names never appear in print, to write up studies from a packet of materials that make the company’s product look good. They can and do threaten legal action if researchers try to publish results they don’t like. They hold up the prepublication review process for months, hoping researchers will get frustrated and give up. They pull funding, or threaten to. And when researchers don’t fall into line, they might deliberately set out to discredit those scientists.31
Another popular tactic is to influence definitions of diseases and guidelines for treating those diseases. Typically, panels of practicing doctors work together to develop guidelines for when, where, how, and how much to treat the ailments specific to their medical specialty. So, for instance, the American College of Endocrinology and the American Association of Clinical Endocrinologists, two professional organizations, put out guidelines detailing exactly how type 2 diabetes should be treated.32 In theory, the doctors on those panels consider all the evidence and produce unbiased recommendations. In practice, it doesn’t always work that way. A 2012 investigation by the Milwaukee Journal-Sentinel found that in nine of the twenty expert panels the newspaper examined, more than 80 percent of the doctors had financial ties to pharmaceutical companies.33 That’s a whole other level of industry influence.
Other kinds of conflicts can subtly (or not) shape how professionals look at and talk about weight and health. Plenty of top obesity doctors and researchers, for example, have written diet books. Amanda Sainsbury-Salis, an Australian researcher who last year called for an “urgent rethink” of body positivity for overweight and obese people,34 wrote The Don’t Go Hungry Diet: The Scientifically Based Way to Lose Weight and Keep It Off Forever. Harvard’s Walter Willett is the author of Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating. David Ludwig, Robert Lustig, Yoni Freedhoff, David Katz, James Hill, Nicole Avena, David Heber—some of the most prominent names in obesity research—all have diet books or programs to sell.
Other “experts” build academic and clinical reputations around treating obesity. Internationally known doctors like Arya Sharma, a professor at the University of Alberta who’s often quoted in the media, or Penn’s Thomas Wadden, who’s brought in millions of dollars in grant money, have staked their careers on the ongoing need for patients to lose weight. They stand to lose a lot more than money if the weight-loss paradigm ever shifts.
THE DOCTOR WITH the doughnuts is only one of many, many medical professionals with a financial stake in a particular view of weight and health. And, let’s face it, money talks in just about every aspect of medicine, business, and life. But the doughnut doc and others who research and treat weight-related issues share another specific perspective that skews their views, and so our views, on weight and health: they don’t like fat, and in many cases they don’t like fat people. And they’re not shy about showing it.
In fact, says the Rudd Center’s Rebecca Puhl, medical professionals show sky-high levels of weight bias, which affect both their research and clinical judgments. “Weight bias remains very, very socially acceptable,” says Puhl, a slender, dark-haired woman with an air of reserve. The doctors, nurses, and medical students she’s studied don’t even bother to disguise their attitudes around weight the way they might try to hide, say, racism or sexism. “Those aren’t so politically correct anymore,” says Puhl. “But with weight bias, I don’t need to trick people. I can give them straightforward self-report surveys about their attitudes, and boom!” They’re not embarrassed to say demeaning things about fat people.
In one of Puhl’s surveys of primary-care doctors, for instance, more than half the physicians described their obese patients as “awkward, unattractive, ugly, and noncompliant.” A third of the doctors went further, saying those patients were “weak-willed, sloppy, and lazy.”35 A slew of studies by Puhl and others have fleshed out those findings: doctors say fat patients are more annoying and less likely to benefit from treatment than thinner patients.36 Nurses say they’re “repulsed” by obese patients.37 More than half the nurses in a recent survey agreed that overweight people were not as good, successful, or healthy as thinner people.38 Psychologists, too, show a marked disdain for heavy patients, judging them as lower functioning, less sexually satisfied, more severely impaired, and less likely to improve than thinner patients.39
I’m not surprised by any of these findings, in part because I’ve heard so many stories of medical professionals disparaging fat patients. One woman I talked to saw an emergency room white-board with the word “whale” written in the slot for her room. Medical students say it’s common to joke about finding Oreos or TV remotes in the folds of fat patients’ bodies in the operating room. One medical student told researchers about a doctor who said to a woman on the operating table, “Jesus Christ, why can’t you lose some goddamn weight and make my job a little easier?” Even the other members of the surgical team, not generally known for their sensitivity, were appalled. The woman, thankfully, was unconscious.40
On the flip side, many doctors overvalue thinness, to the detriment of their thin patients. When my father had a stroke and was hospitalized for several weeks, practically the first thing every doctor and nurse mentioned when they saw him was his weight. “He’s a good patient,” one nurse commented. “No fat on him. He must take excellent care of himself.” Not a single one bothered to ask about my father’s eating or exercise habits; if they had, they’d have known he never exercised and often skipped meals—not the healthiest regimen.
Even doctors who devote their careers to researching or treating obesity often dislike fat patients. In one 2003 study, bariatric doctors said they strongly believed their patients were lazy, stupid, and worthless.41 (Stupid enough to eat the surgeon’s doughnuts? I doubt it.) Imagine a neurologist saying that about her patients. Imagine going to a doctor who felt that way about you. You’d pick up on it, whether it was conveyed in words or not. As George Blackburn, an MD and professor of nutrition at Harvard, pointed out a few years ago,42 plenty of medical conditions may involve some level of personal responsibility; he offered the examples of high cholesterol, lung cancer, and sports injuries. People who go to the doctor with those conditions, wrote Blackburn, “routinely receive medical treatment without being questioned about their lifestyles.” Not so for anyone who’s even a few pounds over the “normal” BMI category.43 Which helps explain why overweight and obese women tend to delay or avoid going to the doctor44 and get fewer Pap smears, mammograms, and other routine cancer screening tests,45 which may in turn help explain the link between higher BMIs and cancer deaths.46
Why are medical professionals so biased against fat and fat people? Doctors live in the same world as the rest of us, and so are subject to the same cultural influences and attitudes and biases. Then, too, there may be a self-selection process involved. “Obesity researchers and physicians, compared to the general population, are more likely to be thin,” points out Asheley Skinner. “They’re less likely to have experience with this. People who are thin, there’s a tendency to think, ‘I’m thin. Why can’t you act just like me?’”
If you believe doctors are entitled to their perspectives on weight, think about this: as obesity treatment and prevention have gained legitimacy and entered the medical mainstream, more and more people are being pushed by doctors to lose weight and encouraged to see weight loss as a medical issue. For women, whose bodies already come under more scrutiny (and are more subject to judgment) than men’s, this can have profound effects on the quality of their health care.47 One of Rebecca Puhl’s studies found that it takes only an average weight gain of twelve or thirteen pounds for women to start experiencing weight discrimination. (Men had to be a lot heavier before they became targets.)48
So gain a few pounds—whether from lack of exercise, eating junk food, taking psychotropic medications, or plain old menopause—and you may find any health problems that crop up, from tennis elbow to depression, are automatically attributed to your weight. Your doctor may not believe your description of your eating and exercise habits, and that in turn may change the way he or she prescribes treatment.49 And it will certainly damage your relationship, which is a key part of any treatment.
Doctors’ biases around weight can take other forms, too. In 2010, six-year-old Claudialee Gomez-Nicanor died in New York City after a pediatric endocrinologist—a specialist in childhood diabetes—misdiagnosed her with type 2 diabetes because the child was overweight. The doctor, Arlene Mercado, prescribed weight loss, and when the girl did lose weight the doctor stopped monitoring her blood. Mercado’s only prescription, diet and exercise, was working; no need to keep checking.
Kate, thirty-eight, studied anthropology at the graduate level at New York University.
My pediatrician and mother pretty much created a conspiracy of two to harass me as a child. I had asthma and was on prednisone for years, so there was a clear reason for weight gain, but everything was about focusing on how I was wrong and needed to do more exercise. It was all shame and guilt. I remember the doctor painfully pinching my stomach when I was seven or eight, when I was maybe a little overweight but not fat. My mother was very overweight so that was the fear, that I’d “turn out like my mother.”
When I started seeing a primary care doctor in Sacramento, I’d already been diagnosed with ankylosing spondylitis, an autoimmune disease. He’d sit across the room and talk to me. When I was twenty-seven I got a sebaceous cyst under my armpit that got bigger, and I had some anxiety about it, so I went in to show him. And he wouldn’t get near me. I said, “I need to make sure what this is, I’m having panic attacks about it.” He got a glove and some tissue. And it was in that moment I realized he’d never listened to my breathing or actually touched me.
If Mercado had continued to order blood work, she’d have seen Claudialee’s blood sugar levels were continuing to rise even as she was losing weight. She’d have realized that Claudialee actually had type 1 diabetes, an autoimmune illness requiring immediate treatment with insulin. And the six-year-old would almost certainly not have collapsed into a diabetic coma and died.
The last time I needed a new doctor I went about it differently. I would go in and meet a doc and say, “I have a chronic disease that needs treatment. I have a lot of experience being judged for my weight. I’m doing the best I can to be healthy, so I need to know how you feel about fat people.” I went through four doctors that way. They got defensive about the fact that I was asking them how they felt. They’d say, “I’m sure we’ll be fine.” And I would say, “The tone of your voice is telling me you do have a problem, and if I make you my doctor I’m just not going to come in, so I’m going to try somebody else.”
I wound up with a really good doctor. The more I become an advocate for my own right to have a quality relationship with a health-care provider, the better health care I get. Sometimes it means kicking and screaming.
According to the Centers for Disease Control and Prevention, one in 5,000 children under age ten has type 1 diabetes, while only one in 250,000 has type 2.50 Craig Alter, a pediatric endocrinologist in Philadelphia who reviewed Claudialee’s records, later told a jury, “If you tell me there is a five-year-old with diabetes, the chance that they have type 1 is probably 99.99 percent. If you tell me they are obese, I would say, okay, the chance is 99.7. It’s almost definitely type 1.”51 Type 2 diabetes, while certainly serious, is far less of an emergency than type 1 and requires completely different treatment. And while other issues likely contributed to the misdiagnosis, the doctor’s weight bias here clearly played a major role.
Claudialee’s death was preventable and horrific. (A jury found Mercado guilty of malpractice and awarded Claudialee’s mother millions of dollars. As I write this, Mercado is still treating patients.) But while it may be an extreme example of how weight bias shapes medical care, it’s not an isolated one.
A few years ago I gave a talk on eating disorders to a group of pediatricians. I meant to raise awareness of early symptoms and new treatments, since pediatricians are often the first professionals to see a child with an eating disorder. Some of the doctors were receptive, taking notes and asking questions, but a few sat with their arms folded, scowling or pointedly looking away. I had no idea why until one silver-haired pediatrician spoke up. “I have children in my practice who are obese and have type 2 diabetes,” he said challengingly, as if that invalidated any potential concern about eating disorders. “My patients are too fat, not too thin.”
Of course doctors are right to be concerned about diabetes; whether it’s type 1, the autoimmune kind, or type 2, more often associated with age and obesity, diabetes is a devastating, potentially life-threatening illness. And while type 2 does correlate with obesity, we still don’t know which comes first, the weight gain or the disease. Are more children developing type 2 diabetes these days? It’s hard to tell. Few if any statistics were kept on type 2 in kids before the 1990s, so there’s no true basis for comparison. The 2014 National Diabetes Statistics Report says the percentage of Americans under age twenty who are diagnosed with type 2 has gone up about 3 percent since 2002.52 Are doctors now more aware that children and teens can develop type 2, and are they looking for it? Or does this represent a genuine leap in prevalence? We don’t know yet.
Even if the pediatrician was right, though, and more kids and teens are developing type 2 diabetes, the question I keep coming back to is whether our efforts to reduce those rates through weight loss are causing more harm than good. The message that comes through loud and clear in the literature, in the media, and from doctors (“My patients are too fat!”) isn’t particularly helpful. And by now we have plenty of evidence that pushing kids to lose weight is not only ineffective but counterproductive, contributing to (if not out-and-out causing) the very conditions it’s meant to prevent.
Now that obesity has been thoroughly medicalized, and treatments are backed by the full weight of the medical establishment (despite their less-than-stellar track record), it’s more important than ever to understand that doctors are human, that money talks, and that you can’t believe everything you’re told. Or sold.
*Rarely does the move toward medicalizing actually help people; for instance, the classification of homosexuality as a mental disorder in the DSM-1 in 1952 led to President Eisenhower’s ban on hiring gay employees in the federal government, Senator Joe McCarthy’s claims that gays in the military posed security risks, and an uptick in anti-gay prejudice in American society that’s only now, sixty-some years later, quietly evaporating.