How to counsel about health w/o talking about weight (@Margaret1473)

First, just bc obesity is associated with a condition doesnt mean its the cause. Correlation doesn’t mean causation! There’s no evidence showing wt loss (isolated from nutrition & exercise) improves health.
2. dieting/weight loss is not sustainable for 9/10 people. Most regain the weight...and risk feeling like failures.

3. Every body has a set point range it likes to maintain. The body works hard to keep it, like increasing hunger on a diet. Yoyo dieting increases the set point😳
4. Weight is not an indicator of health. Ex: There are athletes of all sizes, including higher weights. There’s a also a thing called the obesity paradox that shows people who are overweight or “stage 1 obesity” (BMI 30-35) actually live longer than those that are normal weight.
5. BMI is crap!! Yeah, I said it. It was created from insurance tables that were used to decide policies based on moral (not medical) body ideals. These ideals came from stereotypes that fatness was a sign of laziness and no self-control, assumptions rooted in racism (yikes!).
BMI charts for children are even less scientific🤦🏾‍♀️.

6. Weight stigma, like other forms of oppressions can lead to anxiety, depression, eating disorders, distrust, healthcare avoidance, and even further weight gain. By trying to help, we can actually cause harm.

So what now?
When I take any behavioral history, I start off by declaring a no-judgment zone. I might even tell them about the time I lied about exercise on my doctor’s form 🤣 to show we all fear being judged. I explain that I’m asking these questions to get the truth and see how I can help.
If talking about physical health, I say, “I don’t care about your weight or what number it is. I care more about the nutrition you’re giving your body and how you find ways to be physically active. Those are better indicators of health than a number. Sometimes weight changes...
Sometimes it doesn’t. If it doesn’t change, you didn’t anything wrong. You’re just at your body’s set point.” I intentionally avoid words like diet and exercise because they can bring strict ideas of what people should be doing. Instead, I encouraged regular meals with balance.
Physical activity can look like different things for different bodies. I recommend some type of movement that brings them joy, ideally gets their heart pumping, and that they can sustain. If they hate running, they don’t have to run. Some kids help parents with chores for fitness
I take an activity and 24 hr food recall and ask the child, with parents’ assistance to decide one or two goals they want to work on i.e. eat breakfast or try youtube workout videos. Then, we discuss barriers because spoiler alert PEOPLE GENERALLY KNOW HOW TO CARE FOR THEMSELVES.
Doctors spend so much time learning and “educating” patients who know what to do, but may not have the time, resources, or privilege to do it. Education is most likely NOT the problem.

Then, I ask patients, would you like to talk about your weight. If no, I just move on.
If yes, I give them a little BMI context and explain that I care more about trends and our goal is to find a routine that allows the body to maintain its set point. I never give an answer to, “how much should they lose?” Or “what weight should they be?” Also, trends matter!
One of my mentors said, every change tells a story. So ask about what’s going on with a sudden drop or increase. It could be stress, food insecurity, trauma, etc. The best way to address is connecting them to appropriate resources or mental health support, if indicated.
Finally, screening labs are still recommended. I introduce them as nutrition-sensitive conditions, not obesity-related. I explain that wt is related but not causing them. The risk can be higher if there’s a family history. If abnormalities, then nutrition and activity can help.
Phew! This thread was a lot longer than I planned. For more reading, check out Fearing the Black Body, Body Respect, and The Body is Not An Apology.

I really need fo write this somewhere more formal than twitter, but y’all got the first pass 🤣


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More from @RFentonMD

15 Oct
Some UIM applicants have approached me about if they should "go there" in an essay or interview aka tell THOSE stories where they witnessed racism at work in healthcare. My thoughts in a thread (I welcome others):

Own the motivation for your interest in health and stay focused.
I wrote about an experience in my residency essay and honed in on the patient's condition & what I offered to intervene. The team perceived the family was non-adherent while I saw a a Black mother who was a fierce advocate. I sat with her. I learned about the barrier to follow-up
and the stressors (new and ongoing) at home that challenged the family. I brought that knowledge to rounds along with my overnight events and exam findings to rounds along with the patient's perspective so that our plans reflected their experiences and were more successful.
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11 Sep
With in-person rotations back in full swing, it’s time for a thread about managing rough feedback. This is geared towards #MedStudentTwitter, but hopefully applicable to everyone whether you are giving or receiving feedback.

Here we go...
@HollandStanton @m3betch
Why I care: I got called “shy”, “unengaged”, a “passive learner”, & a “great pediatrician on my OB rotation”🙃. Critical feedback can hurt. I had to learn how to receive it and also how to change my actions so that the comments reflected my commitment. Thanks to mentors, I did.
First, I had to learn as a person who liked being liked and getting good grades to not take feedback personally, even when it sounds personal. Even though feedback is the basis of grading, people often get little training in it or uncomfortable giving/asking for it.
Read 14 tweets
17 Aug
Thinking about a theme in medicine. The same use of labels that define patients by conditions (CFers, sicklers, etc.) is also used in characterizing patient behavior (difficult, noncompliant, mistrusting of medicine, etc.)

Both are dehumanizing and miss the full story. Find it.
For the former, address patients by their names. Imagine the disruption of a hospitalization on their life. Sit with them and talk. Assess for barriers that led to their admission, esp if they occur repeatedly. Learn who they are and what matters to them beyond their condition.
For the latter, its both easy and lazy to label 1 person/family a “problem” than acknowledge or address systemic issues. Dont compare them to others. They have their own story. Do they have a marginalized identity that was historically mistreated? Personal trauma? Outside stress?
Read 5 tweets
4 Aug
Racist publications are the academic equivalent of “only people who say racist things are racist”. We could spend forever reacting to racist articles, getting retractions, and “I’m sorry but I’m not a racist” apologies OR we could dismantle the system that creates them.
Want to know what is also racist?
- boards of journals & healthcare institutions w/o marginalized group representation
- “community-based” researchers disappearing after the data is collected
- Marginalized groups not being represented in research because “they’re hard to reach”
- institutions spending more time conducting research in marginalized communities than providing clinical care
- Journals & healthcare orgs only talking about racism after May 2020 because it’s “trendy” or they fear looking regressive
- Hostile environments for BIPOC in academia
Read 4 tweets
18 Jul
I’m a pediatrician and Adolescent fellow at Lurie Children’s Hospital in Chicago (I don’t share this info in my bio for personal reasons) and I am speaking out against the practice of cosmetic and medically unnecessary surgeries on intersex people w/o their consent 1/
I first learned about @Pidgejen and @IntersexJustice thru @mrhealthteacher who brought it to my attention prior to the start of my fellowship. When I arrived, I asked questions and didn’t get satisfying answers. Most of our work doesnt overlap w the clinic, but that’s no excuse 2
Medical education teaches little about being intersex, except a focus on body parts, chromosomes, and inappropriate pathologization. I’m grateful to @howardbrownhc for showing me stories of intersex folks and the physical/emotional damage of intervention 3
Read 6 tweets
29 Jun
It clicked today that one reason I say “yes” to so much outside of work (even if it overwhelms me) is because my skills don’t feel affirmed in medicine. Curious how many others’ minority tax efforts are motivated to use and share skillsets that our institutions don’t value 🤔
When did I learn this? First year of med school. My background was in a biopsychosocial model of health and the traditional curriculum taught medicine in a vacuum. I realized I don’t actually care for science without its its interrelation to individuals and communities
On rotations, I thought, “this is my moment!” My 1st resident said, “you have lots of strengths, unfortunately they’re not valued in medicine” then said all I was doing wrong. An attg said, “excels in the art of medicine. Needs work in the science.” They werent separate for me
Read 5 tweets

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