The Level of Discourse

During our most recent "Practice of Medicine" small-group session, we were discussing interventions for a hypothetical obese pediatric patient. We started off OK, as we generally do, but it only took a few moments for people's real feelings about the issue to make themselves apparent. Let me make something very clear: I love my classmates, I really do; and I have great respect for the vast majority of them. However, even estimable people sometimes believe (and vocalize) less-than-estimable things.
Within ten minutes, we had gone from using the terms "obese" and "overweight" to 'fat;' within fifteen, 'fatty' and 'Porky' had been thrown out (I regret to say that our faculty preceptor was among those to use those epithets, though admittedly in jest). I felt like my head was going to explode, showering my tablemates with gray matter, if I didn't say something.

I raised my hand, and as calmly as I could, said that I would explain the need for change to the patient/family by emphasizing the importance of healthy eating habits and healthy exercise routines, and not necessarily focusing on weight or a need to slim down (In fact, in all but a few cases, it's best to try and keep overweight children's weights STABLE, and let them grow into their 'extra' weight--ie, let a 100 pound fourth grader become a 100 pound sixth grader; no weight loss necessary). I also said, through more or less clenched teeth, that I was not entirely comfortable with the level of discourse in the room, and that placing undue emphasis on weight rather than healthy behaviors could encourage or 'set off' an unhealthy relationship with food, particularly in girls. Another student (a guy!) agreed, and mentioned self-esteem issues, eating disorders, cutting--all those uglinesses that derive from body hatred. "We're going downhill fast!" the preceptor exclaimed, to general laughter, at which point I all but jumped on the table and said,
"We're acting as if precipitating an eating disorder is a remote possibility, as if an authority figure's judgement of a young person's physique carries no value. It does. Yes, there is an obesity epidemic. One in three kids is overweight. But by the time they reach college age, between one-tenth and one-quarter of women have an eating disorder. This isn't coming out of left field."

After this the preceptor sort of propitiated me, saying that in his experience girls with eating disorders actually start out slightly overweight. We reined ourselves in a little bit. I was still struck, however, by how glibly we treated what is for many people a lifelong and seemingly unwinnable struggle against weight issues, and how we assumed that obesity is largely the result of laziness and gluttony--how quickly we turned a medical issue into a moral one, patting ourselves on the back for eating five servings of veggies a day and deriding those who cannot, as we can, run five miles a day. I wanted to say that actually, having had an eating disorder for more than half my life, it would be much healthier for me to have carried around an extra twenty or even thirty pounds than to have done all the things I've done over the years (and still, unfortunately, do sometimes) to control my weight--things that have lead to arrythmias and seizures, things that have screwed with my reproductive and skeletal systems, and most importantly, with my brain. As students at one of the top medical schools in the country (as we are repeatedly reminded), we have a responsibility to become competent physicians not only in the realms of diagnosis and hard science, but in the realms of ethics and communication as well.