Tong Yan grew up in a Chinese-American enclave of Los Angeles in a family that revered food but didn’t think of those who were overweight.
“Certainly, there was kind of an implicit fattist perspective, like little comments that are made about people’s weight,” Yan says. Obesity didn’t affect him or his family, but a friend – who wasn’t even that heavy – became the butt of jokes. “It was also implied that obese people are lazy and unmotivated,” he recalls.
It wasn’t until George Washington University School of Medicine that Yan thought more deeply about weight stigma, which is prevalent in American culture. In the second year, he attended an obesity education summit hosted by one of his professors. As part of the summit, Yan took an implicit bias test which identified her slight bias towards thinner people. Patients also shared personal stories of discrimination experienced in exam rooms, and how it affected their health and their relationship with doctors.
And he learned how factors other than the exercise of willpower go into dieting and exercise — things like genetics, brain chemistry, stress level, and community design — contribute significantly to disease.
Today, Yan believes that such training dedicated to obesity is essential for future doctors.
“I think it’s the start of a kind of re-education, because whether we talk about it or not, we absorb all the messages about what it means to be called obese, what it means to having a bigger body, since we were very small,” he says.
And yet, training in obesity in medicine is still relatively unusual.
“Doctors traditionally don’t learn anything about obesity, either in medical school or in residency,” says Dr. Scott Kahan, who teaches at Johns Hopkins and George Washington universities, and is the medical director of the National Center for Weight and Wellness, a clinic in Washington DC.
“What we’ve learned is basically, ‘Obesity is very common and you’re going to see it in a lot of your patients. And it’s really important that people eat less and exercise more “that’s about it,” he says.
Obesity affects so many people – 42% of Americans – and is linked to more than 200 other chronic diseases and the leading causes of death, from heart and kidney disease to diabetes. Its impact on patients and their healthcare is difficult to overestimate. And yet, even as scientific understanding of the disease rapidly evolves, doctors learn very little about the causes of obesity in medical school, let alone how to advise or help those who have it. .
A 2020 survey found that medical schools spend an average of 10 hours on obesity education. Half of the schools say the increase is a low priority, or not a priority at all.
This is insufficient, given the considerable impact of obesity on the medical profession, according to Dr. Robert Kushner, professor of medicine and medical education at Northwestern University and co-author of the survey.
He says the problem is self-perpetuating too: “There aren’t a lot of people trained in obesity,” he says, and “if you haven’t been trained in medical school and you don’t If you haven’t taken it upon yourself to learn about it, you won’t be able to be an informed and expert faculty member.”
Training out of step with science
Due to the lack of training, health care providers themselves perpetuate weight stigma or misconceptions about the best way to treat patients who have it.
Nor has the standard medical curriculum kept pace with obesity research, which has transformed the field in recent decades. It is now understood as a complex disease involving many body systems. Factors such as genetics, hormones, sleep quality, and even stigma can lead to weight gain. Therefore, treating it often requires more than limiting or burning calories.
New and promising — so very expensive – drugs that act on the areas of the brain that regulate appetite point out that obesity, like many other illnesses, can be treated with medication, rather than willpower alone.
It’s hard to challenge old notions about obesity in medical training because courses tend to focus on specific organ-based disciplines, like cardiology or endocrinology – but obesity crosses many different categories. It tends to be mentioned a few minutes here and there, and only in the context of other illnesses, not as an overall illness on its own, Kushner says.
Additionally, “there is a prevailing bias that this is soft science; it’s not something we need to teach and people just need to take better care of themselves,” adds- he.
The result, he says, is that most doctors aren’t equipped to help obese patients.
This is something Tong Yan witnessed first hand. Yan, now in her fourth year of medical school, recalls one of her supervising physicians talking to a patient suffering from pressure headaches related, in part, to complications of obesity. Yan says the doctor was in a rush – and was talking to the patient through a translator, which took twice as long. And then he scolded the patient, saying things like, “You need to go out and exercise. You can’t just sit there” or “Don’t you know that’s a problem?
Yan backed down from the exchange. He knew this went against what he had learned in the obesity and bias training. But the doctor’s seniority scared Yan and the patient into silence, without challenging the tone or content of the lecture.
“I’m ashamed to say that I didn’t really say much,” admits Yan. “It was just an observation that left a big impact.”
Patients suffer from doctor’s ignorance
The impact is profound for patients like Patty Nece, who, in her 64 years, says she has never been free from the stigma of living in a big body. She calls herself, compared to cows or whales – insults that amplify her own wild inner voice.
“I would kind of become my worst enemy, my worst tyrant,” she says. “I’ve won awards as a lawyer and been active in the community and nothing has overcome all the weight bias and stigma I’ve faced.”
But, she says, the greatest clinical damage has come from the doctors themselves, including an orthopedic surgeon she saw several years ago about hip pain.
Almost immediately, without listening to her, examining her or even touching her, she says the doctor launched into a lecture about her excess weight, attributing her pain to obesity.
“He said, ‘See, you’re even crying because of your weight,’ which was so far from the truth; I was crying because of him,” Nece said. “I didn’t want to see another doctor in my life.”
When she finally saw someone else for her hip pain, the root cause turned out to be a severe curve in her spine. Nece says healthcare workers often seem to assume that overweight people don’t know their bodies, even though that’s something she thinks about all the time. She says the orthopedist wasn’t the only one to fire her; she also felt rejected for her weight by others – dietitians, mammographers, rheumatologists.
This type of alienation is particularly harmful for racial minorities, where disparities in care already create many challenges. This is also true for obesity care in black and Latino communities, where rates of obesity is highest, but people are underdiagnosed and undertreated.
Kofi Essel, a pediatrician and nutritionist in Washington DC, says young doctors often don’t come from the same background as those who tend to suffer from obesity. They don’t understand how things like neighborhood design, food insecurity and access to fresh produce contribute to obesity.
“Why? Because most of us in medical education come from middle to high income backgrounds, so there’s often an economic discord with many of our patients,” says Essel.
He argues that the solution, again, is to increase education about obesity — not just on the science, but also on how to speak to patients with compassion and without stigma. Essel also leads the Obesity Summit at George Washington University and says he has seen it transform the way students think about obesity. “Their new awareness, their new knowledge, their new attitude, their new behaviors are night and day,” he says.
Student Tong Yan agrees. He plans to become a family doctor in urban areas underserved by medical care.
“I’m especially motivated to improve those kinds of skills for the benefit of my patients in the future,” he says.