Bias Weighs on My Mind

I’m a very large person. Lemme put it to you this way: You don’t want to have the seat next to me on an airplane. Many doctors have started conversations with me by asking, "Have you thought about bariatric surgery?" And my cardiologist’s nurse had to ask me how much I weighed because the scales didn’t go high enough.


Last year, I vowed not to book another cruise until I had lost at least 50 pounds. So far, I’ve lost 17 pounds, gained 21 back, and lost 14, for a net loss of 10 pounds. I don’t believe it’s for lack of trying. I swear my body decides to lose weight when it wants to — and gains when it wants to. I don’t know why. I’d much rather lose weight. (For one thing, I like going on cruises!)

And, yes, I’ve thought about — and rejected the idea of — having bariatric surgery. Even people who have had bariatric surgery frequently pack some weight back on. Even Al Roker of NBC’s “Today Show” looks to be a bit more padded than after his surgically induced weight loss.

I don’t think anybody consciously decides to gain weight. Except maybe for one of my brothers who couldn’t put weight on no matter how hard he tried. The fink. I don’t think people who are naturally slim understand how difficult it is to lose weight, just as people who don’t have diabetes fail to understand how hard it is to try and control the Diabeastie.

Apparently, gaining weight and getting Type 2 diabetes is so heinous that AstraZeneca “buried” three clinical trials in an effort to minimize the fact that its antipsychotic drug quetiapine (brand name Seroquel) put people at risk for the conditions.

Even most diabetes drugs contribute to weight gain, although doctors sometimes deny that. A couple of years ago, I met woman who was newly diagnosed with Type 2. She was packing on pounds despite her efforts to keep them off. It turns out she was taking a diabetes drug that is known to cause weight gain, and I told her so. She, in turn, said something to her doctor, who denied the link. I gave her a printout of the drug’s patient information and told her to take it to him and say, “Yes, it does. It says so. Right here.” (And that doctor’s wife is a registered pharmacist and CDE. Tsk.)

As I mentioned in my blog entry last week (“Careful, Your Prejudice is Showing”), weight bias is so widespread that the Yale School of Medicine has developed a continuing medical education (CME) course to address the subject with health-care professionals. (Thanks go out to fellow blogger and Diabetes Self-Management magazine’s editor, Ingrid Strauch, for passing that along to me.)

Authors of the CME point out that weight bias is expressed more often “when obese people are blamed for their weight because of personally controllable factors such as overeating or sedentary behavior. On the other hand, when obesity is perceived to result from causes outside of personal control, such as a thyroid condition, weight bias is less likely to occur.”

It’s the old “it’s all your fault, so we haven’t bothered to do any research to find out differently.”

But research is now showing that “obesity is determined by an interplay of biological, genetic, and environmental factors. Personal lifestyle behaviors are important for health, but reflect only one contributing factor among the complex causes of obesity,” the authors note.

Perhaps results of research on obesity will eventually catch up with popular opinion on why people are overweight. I’m not counting on it happening anytime soon. Even the authors of the CME course say that “False assumptions about the personal causes of obesity can foster weight bias and may interfere with scientifically based efforts to prevent and treat obesity.”

Weight bias can manifest itself in both overt and covert ways. Do you detect a grimace or a tightening of the mouth when you weigh in? Does it seem that the first thing out of your health-care provider’s mouth when you have a medical problem is “You need to lose weight?” I’ve learned to say, “If I were a normal weight, what would you tell me to do?”

And covertly? Check out the results of a study of health-care providers:

  • 91% did not have scales for patients over 350 pounds (I would like to point out that my cardiologist’s scale did not even go that high!)
  • 79% did not have gowns for very large patients
  • 54% did not have armless waiting room chairs
  • 24% did not have a longer speculum for pelvic exams
  • 17% did not have extra-large blood pressure cuffs

I have felt guilty for years because I am overweight and because I “gave myself” Type 2 diabetes. I’m trying to get over it and to like myself as a person at any size or condition.

Does being overweight make me a bad person? I don’t think so. I’m not lazy, as is frequently believed when an overweight person is pictured. I work, I do community service, I interact with my grandchildren and their friends, I travel. Heck, I’ve even stimulated the economy in several countries on three continents and in various small island nations.

Our day will come. Especially if there’s ever a worldwide famine…when excess weight and slow metabolisms will reign.

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  • sara Smartypants

    i sat next to you on a plane and wasn’t THAT put out (but then, i know AND love you :-)) you are not a bad person and it is not your fault, as you well know! Thank you for this awesome article. There is that stigma associated with type 2 diabetes…have you ever noticed how quickly someone with type 1 diabetes will say, “it is type 1, not type 2” upon receipt of THAT tsk tsk look from someone who has just learned you have diabetes…I am guilty of the disclaimer, I must say, but i have had more than a few people tell me I could get off that pump and insulin altogether, if i just lost a few pounds….Well, I’ll be, I wonder why no doctor ever told me that!!!

  • Steve Parker, M.D.

    Sounds like you can lose weight, Jan, but gain it back. Extremely common problem.

    The journal, Clinical Diabetes, last year had an article on prevention of weight regain. I think the article is available free online, or interested readers could see my blog post about it here:

    You may know all these techniques already.

    Maybe it’s best to quit beating yourself up about your weight, and make peace with it.


  • Jan Chait

    Hey SSP! Yes, I remember sitting beside you on a plane. Dang, that was a great trip! We were both in San Francisco at the same time. You, me, our friend Liz and Michael Robinton who is the grand poobah of Insulin Pumper’s, headed for Noe Valley on a rainy day. Had lunch, then moved on to a coffee shop for a lingering cuppa and long conversation. You and I hopped on a plane and met George during a pre-dawn layover at the Dallas/Fort Worth airport. We brought goodies from the Noe Valley bakery and George brought the coffee. I think my biggest riches (along with my husband and grandchildren)are my friends and I treasure you all.


  • Jan Chait

    Hi Dr. Steve. Great blog. And it brings to mind that the most successful weight loss I had was when I wrote down everything I ate – including carb and fat counts and calories. Perhaps I should go back to that. It sure makes you think about what you are putting in your mouth.

    Jan Chait

  • emily

    Thanks for talking about this, it’s an important topic. No one should feel ashamed of their weight but so many of us do. It starts with us feeling better about ourselves and hopefully the rest will come along. If not, at least we’re happy!

  • ddallas

    I am with you Jan! My endo’s office doesn’t have a large enough cuff or scale going over 350 lbs. At least at last visit to my GP, they have 1 scale in the clinic that can handle up to 450, but still no cuff big enough for my upper arm. Considering the size of folks these days (including the body builders…), you’d think that care givers would stock these as well as normal sizes. I’ve been a “person of size” for as long as I have memory – this includes even pre-elementary school and being 120 lbs when I broke my leg in 5th grade. There’s not a doc in my life that hasn’t hit me with having bariatic surgery from just about the day it was invented. I think at least 10% of any seating area should be WITHOUT arms, pre-indented seating or related for those of us who need such. We pay as much or more than the average folk, so we have an equal right no matter what’s causing us to be large.

  • livegr8

    I really appreciated this blog and all the commentary that followed. I too am an overweight person, not by hundreds of pounds but enough to mark me obese on the heatlth charts. I am a type 1 diabetic, which really shouldn’t matter, but I am so sick of hearing from people telling me that I could “cure” my diabetes by loosing weight. I always mention that this is a common misconception as well as the misconception that only large size people can have type 2 diabetes. I don’t understand why people feel a need to comment with the fervor they do, but it is really offensive. Thanks for the shared wisdom and humor.

  • Cathy Type2

    Thanks for this article! I too am very overweight. I’m quite frankly tired of people assuming that I am lazy, or have uncontrolable eating habits, etc. I have also heard it all and know the risks associated with my weight. I AM a good person. I AM a productive member of society. I am NOT happy about being overweight. I am NOT happy about having diabetes. But it is what it is and life is to precious to be miserable. Just do and be the best you can.

  • Marcie

    Jan —

    Reading your article did give me some hope, but it also could have brought tears to my eyes.

    Both my husband and I have been large since childhood, despite having lived very active, athletic lives well into adulthood. Now we’re at retirement age, and have slowed down.

    We’re both quite large. He was 405 pounds, I was 295. We have been losing some weight for the last year or so — probably not in the healthiest ways — and have lost about a whole person total. We do really enjoy being even this much less bulky, though we’re no where near where we’d like to be.

    We both have type 2 diabetes, though it’s under good control for both of us at this time.

    We’ve dealt with all of those doctors’ office issues that you listed. It’s not just embarrasing, but dehumanizing.

    We’ve had only one doctor urge my hubby to get bariatric surgery, which he declined because one of our friends died of one of the “risks.” Nobody has mentioned it to me, but I have considered lap-band surgery — but our insurance doesn’t cover it. And even if we had the more drastic one, our insurance wouldn’t cover the “cosmetic” surgery of removing the pounds of extra skin we’d be left with. (This, to me, is not a vanity issue, but one of preventing skin irritations/infections in the creases.)

    I don’t believe that he or I will live to see the day when fat-prejudice even begins to fade. As easy as it is for “them” to separate themselves from “us” with the “disgusting habits” that lead us to be this “disgusting size” — although they may use smoking or eating disorders to keep weight down — why should it ever change?

    In the meantime, how to deal with the lack of respect dealt us, how invisible we become to being acknowledged, the overt negative behaviors from others that we face. . .? Sometimes knowing that we’re actually quite nice and humane and intelligent and responsible and funny we are gets pushed aside with the realization of yet another prejudicial slight happens.

    To overweight others, I’d say, lose some weight if you can, because it really is healthier. But don’t obsess about it — that’s more unhealthy than the weight itself. Know that you’re in a common situation and that if others can deal with it, so can you. Pat yourself on the back for being the good person you are. Stick up for yourself and other big people when needed.

    Best to us all — Marcie

    PS. . . Seroquel is not the only psych med that is known to put people at a great risk for developing type 2 diabetes. Any of the “atypical” antipsychotics can do this. One of them is advertised pretty heavily on tv — the one where we should ask our doctors for it if our regular anti-depressants aren’t working. In a discussion of this problem with these meds, a doctor once said that if the med worked to help the psychiatric problem, then the risk of type 2 was worth it. Hmmmmm. . . quite a rock and a hard place to live within.

  • Cathy A.

    Wow, what a good article and a good bunch of comments. I too am in the Type 2 boat and I have been overweight.

    A little over 4 years ago, just before I turned 54, I had a heart attack. Now THAT’S something that gets your attention! After surgery and 3 months of rehab, I realized that donuts and French Fries were no longer parts of my version of a balanced diet. Yes I had lost weight before and yes, I had gained it back and then some. I was 226 pounds when I was diagnosed as a diabetic, then about 210 at the time of my heart attack.

    The simple fact is that I have 2 feet and I needed to use them. So I walked, then walked some more. Now I walk up and down hills. I got a treadmill so I could walk when the weather was bad. I took the dogs. I bought an MP3 player. I got good shoes and a coat with a hood for rain days. In short: no obstacle was going to keep me from getting out there and walking.

    With the walking came a realization of what I was eating. If that piece of pizza made it into my stomach, I would have to walk 3.5 miles to keep it from sticking to my hips. If I cranked up the treadmill while watching TV, during commercials I could burn up to 20 calories! It became a game for me and I was enjoying it because I was winning. How could I lose? A better body and a healthier heart? You bet!

    Today I weigh 163, not exactly trim, but my body mass index number is within normal limits (upper limits of normal, but NORMAL!).

    Thank you, Marcie and everyone else who contributed comments. Jan, you started a very good discussion. I am guilty now that I can buy jeans in the Misses rather than the Women’s section of having negative comments about overweight people. We need to see beyond personal appearance to what is inside ALL people, including those who are extremely thin. At the same time, we have to somehow get the internal fortitude to walk PAST the bakery and not TO it.

    Thanks to all for keeping me grounded. Let’s take a walk and talk more.

    Cathy A.

  • Al F.

    Prejudice, discrimination and harassment against “fat people” will never significantly diminish until the society gets both educated and sensitized. But these problems are partly fueled by us the victims, so we should eliminate the part that we contribute.

    First, there is a very important concept that I drive home by using the following antic. Whenever a couple of people inquire about “how much I weigh”, I tell them to guess. No matter what their response it, I tell them that they guessed too high, so guess again. They usually lower their guess by 20# or so, and then get the same answer. Usually on about the 5th guess, they either give up or else get it — they guess “zero”, and I tell them “That’s right. I don’t weigh anything at all.” The important idea here is that we are not our bodies; we are spirits (or souls or psyches or whatever other term you want to use). The body is simply the imperfect shell we live in, in order to interact with and function in the world. It’s the body that weighs 200 or 300 or 400 pounds, not the person. We who are stuck with fat bodies have to get this straight first, before we can hope that others will. It is only when the person and the body are understood to be different that critics will be able to attack only the body and leave the person unscathed, and the victim’s personhood will not be damaged.

    Next, we need to educate others on the fact that the time-worn simplistic formula that most people believe is not accurate. It is not true that fat-bodied people simply eat a ton, while skinny people eat moderately or little. Bodily functions such as metabolism play an enormous part in the true formula. I had a friend who always ate 4 double burgers + fries whenever he ate at a certain fast-food joint, but was tall and totally slim though he hardly exercised at all. I never ate half as much as him, and I exercised more, but my body got to be highly spherical. Probably all of us can point to an example like this, and we should. “Obesity” is almost always used to mean “having way too much fat”, but it really means a condition in which the body’s normal fat/weight controlling functions are shot and nearly worthless. We need to emphasize that too.

    It would be good to get clear on another concept. People are not disapproving of us because of our body weight. They are turned off by our body’s size. This may sound like splitting hairs, but it’s not. If a marshmallow were the size of a “300-pound” person, it would only weigh a few pounds, but it would still freak people out. On the other end of the spectrum, there are metals that compact an emorous amount of weight in a small amount of volume, but their small/trim appearance affects no one.

    The most important thing we can do as a group is to make the society aware that prejudice, discrimination and harassment are just as wrong when committed to our group as they are when committed against people of a certain race, ethnicity, religion, sexual orientation, disability status, or anything else. 50 years ago, insensitive bigots could have a field day cutting down all of the above, and hardly anybody would stand up and chastise them. But over the next few decades, all of these areas experienced some level of transformation, often extremely so. Right now, “size-ism” is the last frontier. It is the only category that is not legally protected anywhere. People and establishments who wouldn’t dare take a chance on discriminating against, say, a black person, have no hesitation about doing so against a fat-bodied person, because there’s no legal repercussions for it, and the society doesn’t condemn it. This is what we need to change.

  • becca

    i to am pretty large woman. But I ‘ve bee lucky that my weight has been coming down this past year due to me being in and out of the hospital. I just lost my right leg in May 2008 so now they say to my think about losing more weight so yopu can walk better on that prostic leg of yours.

  • Mayumi

    Thank You for writing this article. So many people automatically assume because a person is overweight that they are lazy and not worth the effort to acknowledge them as intelligent people. My own Mother said to me when I was a young person in my late twenties, “I could love you more if you would lose some weight.” That remark cost me 8 years of not talking to her. Don’t forget…whatever you weigh-you are a worthy person.