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Dr Tanvir Kapoor opens up about his journey in overcoming stigma from obesity, saying judgement has no place in medicine.
A few weeks ago, on a popular online forum for Australian general practitioners (GPs), there was a discussion about using the label “obesity” in medical documentation. I want to share my perspective as a patient with this disease who also has the privilege of a medical education.
The first time I was given this label was by a paediatrician when I was 12. I remember him encouraging my mum to give me more fruits and vegetables. This was when my immigrant parents had just arrived in the United States and were working at 7–11. We slept on the floor because we could not afford mattresses. Highly processed carbohydrates were tasty, cheap and in abundance. I did not realise until later this was by marketing and design. To paraphrase my colleague Dr Abby Harwood, we lived in an obesogenic environment, so perhaps it was unsurprising that some of us became obese. And yet the blame seemed to fall on my poor mum alone. As a doctor, I made the same mistake when I told a First Nations person from outback New South Wales with heart failure to cut down on salt. They quickly put me in my place by telling me to go to the local supermarket and report back with their options.
The parameters used to define this disease are also parameters used to define my body. And, hence, the unspoken message is that, instead of something to be celebrated and respected, my body is a problem — a problem that can never be hidden from others. It took me 20 years to unlearn this message and finally enjoy movement without shame. I have been on countless diets, and yet, now that I have refused to weigh myself and instead focused on being kind to my body, I have never felt healthier and happier.
It is curious to me that I generally work hard, and yet, in this one domain of life, I have been told that I am essentially slothful and gluttonous — I need to stop being lazy and eat less. However, the best available evidence shows that this model of treatment does not actually work that well at all (here). Now that highly effective medications are available, we are told as doctors not to prescribe it for one disease but instead prescribe it for another, without any data traditionally used to ration treatment like quality-adjusted life years. As Associate Professor Louise Stone once wrote, there is an unspoken hierarchy of disease (here). Obesity seems to fall very low in that hierarchy indeed.
Of course, medicine has a history of moralising disease it does not fully understand. Cholera was once described as a disease of “moral miasma”, until John Snow discovered it was actually a disease of infection and poverty (here). Acquired immunodeficiency syndrome (AIDS) was once called GRID: gay related immunodeficiency — an accumulation of risk from the “gay lifestyle” instead of something caused by a virus (here). We have known for decades that obesity is an endocrinopathy in the setting of an increasingly obesogenic environment (here), and yet the standard advice feels like one of Victorian moral virtue: to just show restraint and fortitude in the face of temptation.
In the final analysis, you can use any label you would like to describe me. I am always a little disappointed when doctors do not bring it up with me, because it is an important part of my health. I would appreciate it if they asked my permission first, because sometimes I just do not want to deal with a lifelong struggle that is endlessly stigmatised. You might appreciate that this label often entails judgement and bias in almost all domains of life, as has been demonstrated in countless studies (here).
I wrote this essay after a beautiful morning walk without shame about my body. My dear colleagues, it has taken almost my entire life to get to this point: a point where I can, in Walt Whitman’s words, “finally sing the body electric” in order to achieve “the exquisite realisation of health”.
Dr Tanvir Kapoor is Medical Superintendent and Senior Medical Officer at Jandowae Multipurpose Health Service at Darling Downs Health, a Lecturer of Medicine at Griffth University and a Rural Generalist Registrar at Wambo Medical Centre. He is also the RACGP Registrar Liaison Officer for rural Queensland.
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Thank you for sharing, Tanvir.
I think this article (and its messages) should be available to the general public!
We should be compassionate in our interactions with patients with obesity. The balance of personal responsibility and government regulation is a controversial one but when there is an obesity epidemic then the upset of that balance is clear.
Governments have a responsibility to reduce the obesogenicity of the environment- walkable neighbourhoods, Active travel options and disincentives for cars, and subsidies for healthier foods / higher taxes or regulation for worse ones.
I am uncomfortable with the degree of externalisation of responsibility here though. The environment makes it easier to make bad choices, and the economics, convenience and parental choices are significant hurdles to overcome. However there is no level of obesity that can’t be overcome with an affordable (if often inconvenient) correct diet.
A constructive approach is to acknowledge the shared ownership and be kind in our interactions.
Wonderful and insightful article Tanvir. Thank-you for sharing and speaking your truth.
I am a Dietitian with extensive experience in Community Health and also Mental Health in the realm of eating disorders, with most patients facing various hardships or disadvantage. The social determinants of health are taught very well in Dietetics degrees, so I wish more Doctors of all disciplines would value and refer to Dietitians more. This is our area of expertise and we have much more time to explore the nuances of weight on an individual level to then feedback to the GP in order to collaborate.
There are so many reasons for one to become overweight, including personal and environmental. Yes we do live in an obesogenic environment, however our Government requires the political will to address the broader issues of food supply, advertising of junk food, etc. When the Government realises that our health system will/is crumble(ing) without some urgent change to address obesity on a population level, perhaps something might be done!
On a personal note, I have gained 10kg in 12-18 months due to anti-depressant medication and/or ?perimenopause/hormonal changes (under investigation) and no matter how low my calorie intake gets and how much I exercise, it will not shift. My BMI is now only 27, however the distress and discomfort I feel in my body leaves me to only image how someone may feel in a larger body with BMI >30 for example.
Let’s not shame patients- let’s work with them, support them and treat them with respect to restore dignity. And, yes please ask permission to talk about weight management with your patients.
I must disagree with some key points.
I am also a child of immigrants, but grew up in a family of 10 children – we were by no means wealthy. if you speak to the many other ‘double digit’ families (as we are referred to) you will find a common theme.
For large families with access to a supermarket, it is generally far more cost effective to feed wholesome foods including fresh vegetables and to limit the purchase of processed or take-away food, contrary to your assertion about feeding the highly processed carbohydrates that you describe as “tasty, cheap and in abundance.” A simple comparison between a bag of potatoes vs a bag of potato chips – a similar cost, one feeds a family for weeks whilst one lasts for a morning snack. For this reason, I do not draw similarity between your situation and an Indigenous Australian from a remote location where supply is scarce.
We should not undervalue the importance of empowering our patients with health education, food choices, lifestyle modification and an understanding of key concepts such as daily energy intake vs output. We should also not undervalue the importance of parental decision making and responsibility in this process. Whilst obesity is more prevalent in the lower socioeconomic status in Australia, given that 67% of adult Australians now have a BMI above the recommended range and this trend is rapidly increasing across the socioeconomic spectrum, it would be difficult to support an assertion that income disadvantage is the key driving factor.
I have great compassion for those with obesity. As a vascular surgeon I deal with their complications on a daily basis and the suffering is extreme. Terrible chronic wounds. Diabetic foot ulcers and amputations. Renal failure. Respiratory failure. Increased rates of cancer.
This is why it is so important to talk about the disease and to offer help…… always.
As doctors we would not ignore cancer. Why should we ask permission to address obesity?
I’m an obese doctor who also happens to ride a motocycle. I tried to buy the safety jeans in my size and you can’t buy them in over size 40 waist. So I went looking. Safety clothing generally has limited sizes and styles. Ladders have a safety weight limit. So operate beyond the limit of the ladder and risk injury or do even less. Lots of fitness equipment including pushbikes have a weight limit. There are restrictions on access to the equipment required for for health and safety. Then there is prejudice against heavy patients by nurses and doctors. The only worse things you can have is black front teeth or facial tattoos. The first time I saw a specialist about a family cancer history for an unfortunately sited tumour mostly he wanted to give me weight loss advice. Most of which had no evidence to support its claimed efficacy. Thank you for your essay Doctor.
Thank you so much for this lovely article. Beautifully written and such important messages for all medical professionals.
Thank you Dr Kapoor. I too am an obese doctor, after living with disordered eating from childhood which kept my body weight “normal” until I hit menopause. You illustrate so well that people living with obesity often know far more about diets and exercise than the general population, despite the assumptions made about their lack of knowledge and its application. In my experience as a consumer of medical services, I am happy to report that things are improving. In the past 12 months I have had multiple positive experiences which have started to undo the shame I’d been carrying. May that continue and spread.
It is increasingly evident that you can be overweight ( or even obese) by BMI definition and yet be metabolically healthy, because there are many other factors that play a part in overall health. Doctors should look beyond simple measures such as height and weight, and assess the whole person, including mental health ( which is pretty crucial) . “Obese ” has become a pejorative term which I have avoided using in medical communications the last couple of decades ( giving the BMI number is a good alternative ). This is an interesting perspective by Dr Kapoor that i suspect will resonate with other doctors.
This was both a powerful and uplifting read. Thankyou.
Thanks for throwing a light on this topic Tanvir – and its complexity. I have struggled with weight my whole life – and as a close friend once said to me – ‘obesity’ cannot be hidden – and many people think they therefore have a right to comment on it. And as professor, who is a good friend said, if insight were the magic cure, we would all be thin and beautiful – if we could be kinder to ourselves! I also was put on medication as a 10year old to lost weight in 1970 – I think this started a similar unhelpful journey to yourself. But over the last 10 years I stopped weighing myself – got a personal trainer who is kind and encouraging and I now feel I have control. However, the ‘fat kid’ at school and the damage that did, has never left me, but it no longer defines me.
Cheers
Ralph
An interesting article but I have to disagree with some of the sentiments. While it can be hard to live healthily or lose weight and I’m sure people suffer while trying (in many ways including hunger, lethargy, shame, depression, stigmatisation etc), it is NOT comparable to cholera, AIDS or diabetes which, with the exception of some type 2 diabetics are not treatable by lifestyle changes. To completely outsource responsibility to the environment, genes etc is to absolve oneself of any requirement to make difficult choices. It also downplays the efforts some people make in the face of these obstacles. If there is no personal responsibility taken for weight/diet/lifestyle and even a celebration of acceptance of unhealthy choices and weight, then the logical conclusion is that the same should apply to smoking, drugs, and even crime. Obviously education, addressing the availability and cost of fresh food, potentially limiting (eg financially with a sugar tax) access in some way to high calorie processed foods, encouraging excersize could all play a part but personal responsibility has to be part of the equation and as medical professionals we should be leading by example as well as educating our patients
“… I need to stop being lazy and eat less. However, the best available evidence shows that this model of treatment does not actually work that well at all” – completely agree, the standard dietary approaches to obesity based on calories in / calories out have > 97% failure rate. Can you imagine recommending a medication with this success rate? Since I started recommending low carb eating, the vast majority of patients then lose weight, with a large number achieving a normal BMI and finding it very sustainable. I tried it myself and worked a charm!
Very well written, Tanvir. As a society we need to address the obesogenic environment- when we see that the chips costs more than potatoes/frozen vegetables & fruits cost more than fresh ones, there is a problem. Governments and organisations need to address this issue. No doubt the obesogenic environment helps corporate multinational companies, but as you rightly pointed out the most vulnerable people are people with limited resources.
Thankyou for sharing. Great insights and I like the idea of asking permission to discuss the issue.
Its a struggle many people would relate to. I learnt tgr term “lifestyle drift “ the other day -where we tend to blame the individual making poor lifestyle “choices”.
Takes responsibility away from govt / public health policy
Thank you for sharing Tanvir. It takes courage an to share a personal journey of vulnerability, but it is deeply powerful to use narrative to shine a light on lived experience.
My work is in medical education and I plan to use your article in a unit on implicit bias with our students. All to often I hear the sentiment “if only they lost some weight they ( the patients) wouldn’t have this problem”. Your words “It took me 20 years to unlearn this message and finally enjoy movement without shame” have struck a chord with me, no doubt they will help our future physicians see another lens.
So refreshing to read an article that is real, truthful and raw. You are an amazing human Tanvir!
As an obese doc who has multiple medical conditions, I related to this article so strongly. I resonated with your body acceptance having found my own in the past few years after yo-yo-ing constantly. Thank you for sharing your thoughts and so many interesting hyperlinked articles.
Surely we need societal help.
Currently food companies can advertise flavoured yoghurt to toddlers. When the most cost effective way to fill children involves high sugar, high fat, high salt, highly flavoured foods they become addicted to such foods before they can make conscious choices.
Thank you for your article! As someone who also lives this intersectional life, it’s so refreshing to hear such a well-written discussion of our shared experiences.
Well written.
Oh hugs n much gratitude dear Dr kapoor for being vulnerable and open. So so many people, obese not, walk thru life with the mental baggage of body shame. I too have done it all my life. I am not obese yet had a mother who spent our lives together wishing I was skinny like twiggy(her words). Eating disorders and shame, guilt, unable to know my weight, uncover my body… My self worth was intrinsically tired to my size.
Thanks, mate
Having lived with obesity as a medical practitioner all my life (I am 56 now), I enjoyed reading this article immensely. The stigma (and at times, abuse) I have experienced by doctors and patients (usually other people’s patients) is always upsetting. I have been 124kg at my heaviest.
Once, I walked through the corridors of the hospital when a patient called out “go to the gym”. Once, I was told by my asthma doctor….’you really should exercise’. I had to point out that I did a brisk walk for 30min 5 days per week and ask what she meant.
I have given up sugar and all carbs for about 3 years now and am 84kg. I still exercise regularly. I have a lot of compassion for those with the disease of obesity….but shouldn’t we all? Why should we have more compassion for diabetes sufferers than obesity sufferers?
Thank you