Stop blaming patients for not doing enough to stay healthy

“Discrimination against heavy people, by the general public and medical professionals, might be a greater health and social problem than any extra pounds they may be carrying” argues UCLA Professor Abigal Saguy, PhD, in a provocative essay in the Washington Post.

“Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have” she writes, comparing such “size profiling” to “racial profiling.”

“Both types of profiling” she continues “lead to false positives (people wrongfully accused or medically overtreated) and false negatives (people who get away or are medically undertreated).”

I think comparing “size profiling” to the horrible continued legacy of racism is a stretch, but Dr. Saguy has a point–some clinicians seem quick to blame their patients for being overweight.  And also for smoking, for abusing drugs and alcohol, for eating unhealthful diets, for not exercising enough, for not taking their prescribed medications and for not following their physician’s advice.  I have heard some internists rail against patients who are “not taking responsibility” for their own health, demanding to know what the ACP is doing to make people accept more responsibility.

I can sympathize with physicians who are doing everything they can to help their patients improve their health, only to encounter patients who continue to do bad things to their health.  Especially, if the physician is subjected to performance measures that penalize them when their patients don’t have the desired outcomes.  No one wants to be blamed for things outside of their own control!

But this is true of patients as well.

The “blame the patient” attitude assumes that how much we weigh or how sick or well we are is mostly a matter of will power. Sure, there are things that each of us can do (and don’t do) that can help make us less or more healthy.  But many of these things–eating better, exercising more, not smoking, not drinking to excess–may be very difficult or even impossible for some people to achieve because of genetics (family history of alcoholism and other substance abuse), culture and community (the diet your grew up with, the food choices available to you in your community, exposure to crime and violence), stress, literacy, physical and emotional abuse, how you were raised by your parents, the quality of your schools–the list goes on and on.  And even if you do everything right, it may not work–eating well and exercising does not guarantee that someone won’t be overweight.  And being overweight doesn’t guarantee you will get sick.

The “blame the patient” philosophy also shows up in public policy proposals: high deductible health plans that by definition mean that the sick will pay more out-of-pocket (because they need and use more health services) than the well (because they need and use fewer health care services); higher co-payments for receiving non-emergency care in emergency rooms (which disproportionately affect poor people in poor health who may not have good access to community-based primary care); and proposed regulations that allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status.

House Democrats recently sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish “health-contingent wellness programs” that “allow differential rewards based on health status factors, including a person’s cholesterol, blood pressure, weight or body mass index.”   The lawmakers argued that such programs would undermine the ACA’s prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm “certain population groups, including racial and ethnic minorities, such as  Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels.”

ACP, in a comment letter on the same proposed rule, similarly stated “that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals.”

And ACP’s ethics policy, developed by its Committee on Ethics, Professionalism and Human Rights, states that “Incentives to promote behavior change should be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control. Incentives to encourage healthy behaviors should be appropriate for the target population. The American College of Physicians supports the use of positive incentives for patients such as programs and services that effectively and justly promote physical and mental health and well-being.”

Objecting to stigmatizing and punishing patients because of their body weight, health status, genetics, and personal choices is not the same as arguing that patients shouldn’t be engaged in, and responsible for, making contributions to their own health.  Physicians can and should engage patients in shared decision-making about their health.  They should engage patients in helping them understand their risk factors and how they might help reduce their risks.  They should help them succeed and also support them if they fail.

Physicians can also advocate for public policies to engage and empower patients in healthcare decision-making–such as for reimbursement changes to allow physicians to spend the time required for effective shared decision-making and creating positive incentives to help people access effective weight-loss or other wellness programs. While advocating against policies to stigmatize and punish people for their health status.

As my mother might say, no one likes a scold.  Let’s stop scolding people for supposedly not doing enough to stay healthy.  And instead, lets start helping them be as healthy as they can and make sure they are cared for when they are sick, no matter what they did or didn’t do when it comes to taking care of their own health or the genes they inherited from their parents.

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

Comments are moderated before they are published. Please read the comment policy.

  • Hospice_Auspice

    Okay, I’ll “stop scolding people for supposedly not doing enough to stay healthy” as soon as Medicare stops withholding their reimbursement for the hospital bills for those re-admitted within 30 days.

    • Kobukvolbane

      Trouble is, scolding people makes them resist our advice, most of the time.

      • azmd

        Funny, just like docking someone’s pay for events that they have no control over doesn’t really change their behavior either.

        • Suzi Q 38

          What do you mean by this?
          Could you give me an example?

          • N N

            He’s talking about “pay for performance” for doctors.

          • Suzi Q 38

            Thanks for the explanation.
            This stuff is new to me.

      • Suzi Q 38

        Yes and no. It depends on the person.
        Have you ever looked them in the eye and said that you care about them enough to e direct with them about the state of their health? That you want only good things for their long life?
        That you are a professional that is different; you are not afraid to say what needs to be done to safeguard their health.

        • Kobukvolbane

          It’s not fear. It’s saying things in such a way to motivate people and not promote resistance. Giving them information and then asking them if, knowing that information, they might see it as worthwhile to make goals. And if you encounter resistance, knowing how you will handle that. If a patient doesn’t come back to your practice, or stops listening to you because they feel judged, you won’t get anywhere. That’s all I’m saying. I talk to people about stopping opiates, alcohol, and tobacco all the time.

          • Suzi Q 38

            Good thoughts.
            I agree that if they are the sensitive type(s) and don’t come back, you have lost them.
            I remember being more sensitive in my youth.
            Now, I am much more understanding of the role the doctor has in deciding my medical care.
            My doctor getting exasperated and telling me that I was “Waaay too fat.” was a relief of sorts.
            I not only came back, but I returned to his office 15 pounds lighter, 3 months later. I repeated this scenario 6 months later. Within 10 months, I was about 40 pounds lighter.

            After 10 months, all he could say was: “How did you do it???”
            My point is that you sound like you know how to say what you need to say to help your patient(s). You probably know how to say it in the right way(s).

            My doctor was not PC, but what he said was direct and meaningful, after being so nice for a decade.

            It worked.

    • Suzi Q 38

      Keep on scolding them.
      I am not saying that you have to be rude.
      It takes time to care enough to warn people with direct talk about how bad it can be within a few short years if they keep eating the wrong foods, not exercising and getting fatter.

  • Joan Marie Verba

    Thank you for this. You’re right, there are a lot of reasons that people have difficulty maintaining a healthy lifestyle. In this economy, people are overwhelmed already, struggling to pay their bills (and lack of funds may be a reason for not purchasing expensive medications), assisting family members (especially if they’re caretakers for other relatives), and so forth.

  • azmd

    Turning blame back on the consumer of services and assigning unreasonable tasks to them is something we see in systems where the service provider is being held to an unrealistic and arbitrary level of performance. It has been going on for quite a while in the education world, where teachers are seeing available resources shrink while at the same time they are being micromanaged to achieve ever higher levels of “productivity.”

    Sound familiar? Doctors’ blaming of bad medical outcomes on misbehavior by the patient is analogous to teachers’ shifting their teaching responsibilities into the home via ever more burdensome homework loads, and blaming families for not providing a home environment which is perfectly conducive to learning.

    The solution lies in having providers who are not stressed beyond their limits, whether they are providing medical services or educational ones. If you have unreasonable expectations of your teachers and doctors, they will respond by having unreasonable expectations of their students and patients. Treat workers fairly, and they will do the same to those they serve. If you don’t want doctors who scold their patients, don’t create a system where they are regularly scolded.

    • Shirie Leng

      nicely balanced reply

    • SBornfeld


  • NewMexicoRam

    Murderers can’t help themselves; they feel better to kill someone.
    Pathologic gamblers can’t help it; they keep gambling no matter how much they destroy their lives.
    Pornographers only look at images on a computer screen; where’s the harm?

    Look. Don’t tell me that obese, overweight, smokers are the only ones affected. Bad lifestyles do harm others, if only through our pocketbooks when healthy people pay their insurance premiums.

    In a society that is being more socialist, we all need to do our parts in staying as healthy as we can.

    • Jewel Markess

      Smokers harm others via secondhand smoke, not by “costing more”. In fact, there’s been study after study that showed that in terms of cost, smokers cost less because they die younger. So don’t complain about your pocketbook because from your pocketbook perspective smokers, obese, etc. cost less over the lifetime.

      E.g. a smoker can die at lung cancer at 60 whereas a healthy person can get dementia or Alzheimer later on. Also, arthritis, and some other cancer. Healthy lifestyle doesn’t guarantee or even helps insure that one dies instantly in one’s sleep. An obese person can get heart disease at 60 and you can get it at 70. Or arthritis or osteoporosis.

      Really, in order to blame someone’s lifestyle for the cost of health care, you should find a single study that you with your healthy lifestyle will end up costing less.

      • NewMexicoRam

        If people with bad health habits save the system money, then why are we even treating them in the first place? Let them die even earlier! In fact, it should be everyone’s patriotic duty to eat a lot, smoke, drink till you swim, party with as many partners as you can, and drag race someone every night.
        It’s hospitalizations and emergency care that costs money, and people with bad health habits add to those kind of costs big time.

    • Suzi Q 38

      How about the patients that play on 3 sports teams at once?
      Skiing? Football? Soccer? Baseball? Wrestling? Running marathon after marathon? weight lifting?
      Can we blame them for the costs of arthritis treatment?
      Broken bones? orthopedic surgeries?
      How about back injuries? These are chronic conditions.

      Just like eating, can we tell them since they are harming their bodies?
      Or are these activities more socially acceptable?

      Better than smoking, drinking, and eating.

  • kjindal

    If you define “blame” as pointing out that someone is overweight, I think we need more, not less. I have had several patients (and even nurses) over 250 lbs insist that they’re not overweight. Then they wonder why they have HTN, diabetes, and back pain.
    And as far as higher ER copays affecting poor people, in NY those on medicaid have NO copayments in ERs or offices. Those in medicaid HMOs have a $0-$5 copay in outpatient offices that those HMOs prohibit the provider from billing for if the patient claims to not have it (despite the iphone and $140 Nike Hyperdunks).

    Also the pricing of insurance is designed by actuaries TO MAKE MONEY. That is how ALL business works in America. Just like car insurance- at higher risk for an accident? the insurance is priced accordingly. Anything else is just more redistribution a la Obama, ie. SOCIALISM.

    • SBornfeld

      “If the fans don’t come out to the ball park, you can’t stop them”
      —Yogi Berra

      • Kristy Sokoloski

        I love the quote. :)

    • Jewel Markess

      “Healthy people” cost more over the lifetime, so unless you can proof that an obese person with diabetes would end up costing less than a “healthy” person who gets some kind of cancer later on or arthritis or Alzheimer, you have no business blaming lifestyle habits for the cost of healthcare.

      You cannot eliminate death, nor can you ensure with ANY lifestyle means that one would die quietly at home in one’s sleep and not over the years form some chronic illness. Also, take statins to reduce cholesterol – how many people are on it in order to prevent this one heart attack? Learn to multiply. A lot of people over the age of 50 even those with great lifestyle are on multiple medications. I suggest multiplying them by number of years.

      From the insurance perspective, the best thing for them is that everyone over 50 or 60 goes to a tall building in Manhattan and jumps. But obviously neither of us wants to do it.

      • kjindal

        well then, in that case we should ENCOURAGE our fat diabetics to keep destroying themselves!
        I don’t dispute your cost analysis (I, for one, have read the literature about prevention NOT saving money), but I would postulate that the unhealthy fat diabetics & smokers likely contribute much less to society in terms of productivity than healthy adults who live longer but develop cancer / alzheimer’s in their 80s instead of diabetes in their 40s-50s.

        • Suzi Q 38

          What is sad is that I think patients are not aware of all that can happen with having a chronic condition like diabetes.
          I would probably show them pictures of a purple and black leg and foot that necessitated amputation. I would also let them know that the subsequent illness and death was not a fast one. That the patient was also on dialysis 3 times a week for 3 hours a day, and eventually needed a kidney transplant.

          At least with a heart attack, there is the sad reality fo a quick death. On the other hand, a stroke is not quick.

          Chronic arthritis is very painful.

          • Kristy Sokoloski

            Suzi Q, I agree that it is sad that there are patients that are not aware of all that can happen with having a chronic condition like Diabetes. However, if someone truly does not care about the impact that these kind of diseases can have on the body then showing them pictures of limbs that had to be amputated because the wounds can’t heal right, or explaining that the subsequent illnesses and death were not fast ones is not going to make a difference in the world. Now does that mean that they are in strong denial about it? Probably, but no one can do anything to change their mind. I know this because one of my relatives died young thanks to complications from diabetes.

          • querywoman

            Studies have shown that diabetics who gain a little weight may actually do better, because they are taking their meds. Amputations are most likely to be caused from medication noncompliance! I know, my brother was in denial about his diabetes and had three amputations over 10 years!

    • Suzi Q 38

      I am glad that you mentioned the nurses as well as patients.
      Is it “PC” if me to mention the overweight doctors and other medical personnel?
      My diabetic NP looked like she weighed about 235 or 250 at about 5’5.” Thank goodness the dietitian “practiced what she preached” a bit. She looked like she weighed about 145 on a 5’8″ frame.

      I am about 149 and 5’6.” I have gained 6 pounds since I am still not allowed to exercise regularly, only walk slowly. Who burns calories walking this slow? Maybe the doctor will allow me to ride the recumbent bicycle, which is better than nothing.

      Some doctors, male or female, look fairly overweight. Maybe they don’t have time to exercise.

      I think that some of you would like to tell us that it is better for us to lose weight, but hesitate to judge. Part of the reason may be that it works two ways.

      i admit that I kind of want to tell my doctor that he is overweight too, but that would be really rude. After all, he is only doing his job, and if telling me that I am “WAAAY TOO FAT” gets to me, maybe that is a good thing.


    Personal accountability in our society is becoming more scarce every day. There are definitely people that have medical conditions which cause weight gain and certainly people that can not afford to eat better. However, suggesting that most people fall into this category is a farce. People need to take personal accountability for their actions. If your sporting an iPhone or Nike Hyperdunks and claiming that you can not afford to eat better, you’re only fooling yourself.. and maybe the author of the above Washington Post article . Cheers!

    • JannyPi

      Pretty shallow to judge someone, and their “priorities” by their toys. Maybe the sneakers were purchased at the thrift store, or are being shared by someone else?

    • SBornfeld

      There’s a fine line between advocating sound health choices and making moral judgments on these choices. There are many reasons people choose unwisely.
      These poor choices cost us all, of course. Some directly hurt others (second-hand smoke, failure to vaccinate ). But even stupidity is not illegal, last time I checked.
      So do we make separate insurance classes for fat people? People who love butter? People who race motorcycles? (They do this with life insurance, of course–but how many risk categories should we make with health insurance?).
      BTW, how effective is “scolding” patients?

      • Suzi Q 38

        Sometimes scolding works. It worked for me.
        I lost 40 pounds, and the doctor was shocked, to say the least.
        I had accepted his crude scolding because his heart was in the right place and he cared. He also had been my physician for over 10 years.

    • Suzi Q 38

      So true. I get vegetables fairly cheaply at the Farmer’s Market.
      I also go to the local university that has a “Farm Store” of fresh produce grown on the university campus.
      If you lack funds, go vegetarian for about a week or two a month and see how much further your food budget goes.
      If they are poor, there are local churches that help out too.
      It is frustrating to see people wear expensive clothing and shoes, but live on medical and have no money for healthy food.

  • Shirie Leng

    Ok, fine, some people can’t help it. That’s fine. Just don’t judge the doctor’s quality of care and the amount of money he should get paid on things over which she has no control.

    • Suzi Q 38

      I went to a diabetes class at a teaching hospital. I guess the insurance was supposed to pay for me, but I didn’t want to turn it into the insurance company. I called the director of the program and asked heer if I could pay what the insurance pays her hospital, rather than the regular $400.00 charge for the all day event.
      I remember calling her twice to see if she asked their billing department if that was O.K.
      Next thing I knew, I got a packet in the mail for the upcoming, 6 hour event.
      I called her to ask if I could mail her a check, and if so, for how much.
      Well, she told me that she had enough people sign up, so NOT to sign in at all, just go.
      That class taught me a lot about foods and what to eat.
      I taught them about how to use the internet to track foods on sites like “My FitnessPal don com.”

      After that, I lost even more weight. I wish I could go again, as it was so motivating to see people have post meal blood sugars over over 300.
      Most were really obese, complaining about asthma and arthritis.
      These other ailments were reasons that they couldn’t exercise at all.
      I asked them if they ever tried walking back and forth in a swimming pool, for a feeling of lightness while walking…less impact on their already strained joints.

      To make a long story short. Several wanted to do what they were doing before. Just eating and resting…. making excuses.

  • Jay B. Ham

    So what would an ethically balanced incentive program look like? $500/year bonus for maintenance in a healthy BMI range, $1000/year for dropping 5 points off your BMI, $0 for not improving BMI?
    As for the genetic argument for obesity, it seems largely flawed as an explanatory tool for the obesity surge particularly when you look at the BMI of prior generations. Genetics haven’t changed, socioeconomics have.

    • Suzi Q 38

      Familial food choices, cultural and social norms rarely change from generation to generation. This is a very hard cycle to break.
      Telling a Latino or Asian that rice or beans everyday is not a good thing, may come with some resistance. Tell a Hawaiian or Pacific Islander that lau lau and poi should not be eaten on a regular basis.
      Almost every ethnicity has it’s “bad for you” foods. This many times is associated with love, acceptance, celebration of events and reward.

      Restaurants are laden with horribly prepared foods, and in large quantities. Yet, people go out to eat and spend a lot of money doing so every day. We celebrate milestones and events at restaurants.
      The sizes of the portions have almost doubled since the 1960′s.

  • Sunny

    I understand that many disease dont allow the patient much sense of control. That said, it’s hard to take the “patient is without fault” approach when our reimbursements are directly affected by what can only be interpreted as a lack of effort on the part of some patients. How can I appropriately modify a patients HTN risk factors if they refuse to adhere to a diet, exercise regimen and quit smoking? Should I be the one that takes a financial hit for every burger they order and every cigarette the smoke?

    When my mechanic tells me that my car needs a tuneup, and I ought not to drive on my spare tire for a coast-to-coast road trip, who is responsible when I ignore them get stranded at roadside?

    There are many very basic requests that my colleagues and I have made that get ignored – something as simple as bringing in blood glucose logs to adjust insulin regimens. At somepoint we have to accept that the persons sitting on the exam table is an adult (ignoring the pediatrician and pediatrics population) and they need to have a reasonable amount of responsibility for their own health care.

  • PoliticallyIncorrectMD

    Great example of pseudoscience. Lets keep it simple: less calories you take in and more calories you burn – less you weight. That is conservation of energy – high school physics. I thought it was a part of PhD curriculum. May be it ought to be. Genetic makeup and social environment are plain excuses.

    • querywoman

      And all weight loss programs fail 97% of the time in 2 years, because a hunger returns that causes the person to want food very badly, in spite of the kudos he or she has received for weight loss. The person gains back every single pound and more!

      • PoliticallyIncorrectMD

        I did not say it was easy… I said it was possible …

  • SBornfeld


  • Suzi Q 38

    I think that losing 40 pounds was the start of my back problems.

    I was 190, my BS was 6.8, my cholesterol over 225, and my BP was 160/85.

    My PCP did not have a good “beside manner.” After treating me for a decade he changed. In the past, he was always polite and would look at the floor when telling me that i should exercise more and lose some weight.

    He talked about a better diet, you know the speech.

    This time my BS A1c as at 6.8, and my BP was still high.

    He just threw my folder down on the counter and said, “YOU are WAAAY TOO FAT!” I was shocked. He then described me in 10 years, as a diabetic. Instead to taking offense, I “embraced” his honesty.

    I decided to start exercising, and losing weight.

    I started slow, then worked up to 5 times a week for an hour each day. I would get up at 5:00 AM and get to the gym by 6:00AM in order to do this during the week.

    I sometimes would swim at night when my husband came home from work and wanted company to go to the gym. I thought that exercising twice a day for 2 nights a week (swimming) was overkill.

    I dropped 40 pounds in a year, along with eating better. I still would “back slide occasionally and eat a bit of candy here and there, but nothing like before.

    I went from a size 14-16 to a size 6.

    Since my C spine surgery (back problems exacerbated by exercising),
    I have not been able to exercise. I have not exercised for almost 3 months (since October 2012).
    I have gained 6 pounds. I WISH I could go back to exercise.
    I eat just because I am home resting all day and I am bored.
    In the past, the doctors kept saying: “Oh, you have neuropathies in both hands and feet? Keep exercising. You have a burning sensation on your lower back? Keep exercising…Your urinary and bowel function have changed? Keep exercising. Your thighs and legs are weak…Keep exercising, as it is good for you. ”

    I had to make my own decision to stop. Turns out that their advice was making my C spine problems worse.

    I miss exercising, but I now realize that it made a bad condition worse, and everyone, including me was oblivious to the fact that it could be part of a huge problem. Only the teaching hospital physical therapist, back in December of 2011, made the connection and asked me to stop exercising. When I told the doctors what he said, they all scoffed at his concerns. They told me that could not be causing to problem; that I didn’t need an MRI, I already had the Lumbar MRI and it showed nothing.

    I liked exercising because if I exercised, I didn’t eat
    I still miss it, but I am not crazy. I have to heal myself first.
    My neurosurgeon has told me that I can walk 10 miles if I want to.

    Can you believe it????

  • querywoman

    I have been a social worker. There is a staggering amount of irresponsibility among the poor. A lot of them don’t know how to budget and bargain shop.
    $180 a month can be used to eat well.
    I often hear the excuse that the poor can’t cook or lack appliances? Oh yeah? Most people, even the poor in the US, live in homes with running water, refrigerators, and stoves. Cooking is a basic skill! Am I being naive? I’ve been cooking all my life.
    I helped a poor woman from church get her food stamps fixed. I got them raised from $83 to $180 per month. I managed to get her a back benefit also, and in one month she had a total of $483 food stamps put on her card.
    The $483 was gone in 2 weeks.
    I could not get this woman to pay attention to sales, to look at stuff that came in her mail with coupons. After she got the generous stamp allotment, we went on a shopping spree at Target. I showed her that Target butter was on sale. She picked up 2 packs. When we paid, I realized she had picked up 1 pack of Target butter and 1 pack of Land Of Lakes (not on sale). Not paying attention!
    I was astonished when a former minister at that church told me that people were buying at a convenience store and paying more because they could not afford bus fare. I thought the reverend had a few screws missing. I wanted him to teach people more on how to buy and prepare food. He’s since been reassigned.
    There are stores that accept food stamps within 1/2 to 1 mile walking distance of the church. I walk with a cane, and can make it. I used to work in a poorer urban part of town where lots of people walked and carried stuff. Even people like me who can afford bus fare!
    Groceries can be carried in a luggage carrier, bought at a thrift store, or even wheeled in a baby carriage.
    I know a young man with HIV who does not always eat well. He takes his meds and complies with treatment, but I have come to believe he is spending too much on alcohol, and he’s quite an intelligent man.
    I am a picky eater with food allergies. But, if I wanted to, I could live quite well on rice, potatoes, some veggies, homemade yogurt, with some meat tossed in. And throw in real butter and olive oil, a few luxuries. It comes out relatively cheap!
    In Pompeii, few kitchens were found. There were eating stations, restaurants. Slaves often ate there. I am started to think that eating stations might be better than food stamps.

    • Kristy Sokoloski

      I find your reply very interesting. The reason is because this post indicates to me what I often think about situations like this in many if not “most” cases: the person doesn’t want to do the things necessary to help themselves stay healthy.

      • Suzi Q 38

        Yes, I found it interesting, too.
        I am not sure if it is that they don’t want to.
        It may be more of a lack of awareness or skill as to what is available.

        • querywoman

          I think people are addicted to chemicalized food. American has plentiful food, but much of what is in grocery stores is engineered to make it last longer
          Just yesterday, I was discussing organic meat with a man on the bus. He orders it from HSN and says it’s good.
          I told him that, in what I read, organic food is not better for us, but I find it tastes better. He agreed that it’s not better. Some organics are risky with natural contagions.
          Then I said I like more natural bread, but sometimes junky white bread satisfies me in a way nothing else does since I was raised on it. He agreed.
          The woman I helped with food stamps could cook and walk. She’d rather buy prepared chocolate milk than mix cocoa with sugar and add it to cheaper white milk.
          Dr. Sara Stein could use some referrals to places that teach about food.
          I make yogurt without a yogurt maker. Just warm some milk and put a tad of any commercial yogurt in it and leave it alone for hours. I found I don’t even have to keep it warm.
          I learned to make bread without needing and without using a whole packet of yeast. Just mix up a tad of yeast with some flour and water and leave it alone till it starts rising. Then after about 4 hours, mix in more flour, water, and salt, and leave it alone a day.
          Water can be carbonated with a tad of yeast and some sugar. In the early process, it makes a lot of bubbles – that’s carbonation. More sugar and much more time make alcohol.
          I suggested this stuff to that minister. He was an ambitious type who was looking to justify a community garden. Yes, we could use that but the people he talked about buying at the convenience store were just lazy.

          • Kristy Sokoloski

            Querywoman, some of these ideas are great and while it could be true what the gentleman said about some those who go to the convenience store instead, there are people that just truly do not have the time of day or the money to be able to do it. Any other suggestions? If someone does not want to do the work that it takes to get better like the people Suzi Q mentioned that she talked to in the Diabetes education classes then that is their choice. Just like it’s their right to refuse to be treated for their medical conditions.

          • querywoman

            Kristy, of course, I don’t know the exact circumstances of those who go to the convenience store. But, the way the minister talked, he was talking about the poor “who can’t afford bus fare.”
            Luckily, this guy has left my neighborhood now. He always thought it was poorer than it really is. I used to work in a much poorer neighborhood. There are expensive homes in my neighborhood, and plenty of apartments. All these apartments around here require legal papers to rent. I used to work in an area that rented to undocumented aliens. We may have undocumented aliens here, but they are probably living with legal residents.
            I don’t even know how many people the minister saw buying bread and milk at the convenience store across from the church. Sometimes people dramatize what they tell ministers, hoping they will get rides. The nearest churches don’t give out food, but refer to a food bank. It’s not in walking distance, but, if they make it there, they will get a complementary bus pass for their next trip. I went to the food bank with that woman once, and she got lots of food, including farm fresh produce.
            Most of the poor have expensive TV’s in their homes. I almost never turn on my older TV. Each weekend at my own complex, the dumpsters fill with empty beer cases.
            Because I ride the bus, I know a lot of the habits around here. A lot of the apartment folks are on disability and get SS checks and food stamps. Yet, they manage to spend most of their discretionary income, which is their right. I see them selling bus vouchers, etc., and going to hock CD’s to put minutes on cell phones.
            They can make it to the county hospital, for which they must have a bus pass, maybe 18 miles away.

          • querywoman

            And I really like the idea of “feeding stations.” I wish the churches nearby could do that. They would be surprised, a lot of the locals would bring food.
            Now, if we had “feeding stations,” how would that we work? Should we give meal vouchers? Would the poor sell them? Probably!

          • Kristy Sokoloski

            Querywoman, you are right about what could possibly happen to those vouchers if given out.

          • querywoman

            Dr. Stein talks about people who are motivated! They could learn some techniques to make their food money stretch.
            At the same time I was a social worker, I taught 2nd grade Sunday School at a large downtown church. I taught the children of the upper middle class: doctors, lawyers, CIA employee, city professionals, etc.
            Many of my children had parents who worked 80-90 weeks. My children did not mention maids or cooks, but they talked of eating meals at home!
            Where did their parents find time to shop and cook? I do not envy those people!

          • Kristy Sokoloski

            Querywoman, interesting question. I don’t know where the find the time to do that, but that’s good that they did. Too bad more people don’t.

          • querywoman

            Kristy, the professional parents are responsible people who got education and hold down jobs! But, the kids needed more time alone with them. If they didn’t have household help, I would have encouraged them to get it if it were my place! It really doesn’t wash with me that the lower classes can’t find time to shop and cook appropriately, since not that many of them hold down 3 jobs!

          • Kristy Sokoloski

            How it is that those in the lower classes can’t find the time to shop and cook appropriately I don’t know either. Unfortunately, that is a situation that is going to be very difficult for others to comprehend. The reason? It’s more complicated than most of us realize. The other reason has to do with choice which leads right back in to the discussion that is going on within the blog entry about trying to hold patients accountable for their actions. As has also been discussed in that thread it’s their choice if they wish not to comply with treatment regimens. The same kind of principle applies. If those in the lower classes don’t want to take the time to shop and cook appropriately so that they have better health then that is their choice. No one can make them do this.

          • Kristy Sokoloski

            Querywoman, that’s a good point about the things people will say to ministers to get what they want. I know that several years ago there was a blog entry posted here about the issue of those on disability benefits that shouldn’t be. It really shed a lot of light on how messed up that system is. The whole thing is a mess.

          • Suzi Q 38

            I appreciate your reply, full of good, direct ideas for food.

            “I make yogurt without a yogurt maker. Just warm some milk and put a tad of any commercial yogurt in it and leave it alone for hours. I found I don’t even have to keep it warm.”

            How do you do this???
            What is the recipe?
            A “tad..” is that a teaspoon or tablespoon?
            …Warm some milk (low fat or whole, boiling or barely simmering? a cup of mild with a teaspoon of yogurt?
            do you mix this and then leave it on the counter for how long? How long until you can eat it? Can you store it in the refrigerator for a day?
            For the tad of yogurt to add to the milk, is it flavored with fruit?
            Now I know we are really off topic, but I am interested, LOL. Thank you.

          • querywoman

            Yes, off topic,but good for health.
            I had cellulitis of the legs five years ago. I finally asked for and got yogurt at every hospital meal, even though they don’t know the meaning of plain yogurt – it’s always some “lite” version with fake sugar and chemicals. I never got a yeast infection, in spite of all the antibiotics dripped into me.
            A “tad” of yogurt for me is just a spoonful or even a knife dipped in yogurt. It’s hard to find plain yogurt, but I usually manage. I have also started it with different brands and yogurt that had fruit in it. If the yogurt is slightly fruit-colored, it doesn’t even show in my final yogurt.
            I want my young friend with HIV to do this to make his money last longer and eat better.
            Then you can stir in fresh fruit or a quality jam.
            These are the kind of things that would help people, but most are hooked on buying stuff with chemicals and in lots of little packages!

        • Kristy Sokoloski

          Suzi Q, I could see where the lack of awareness or skill might be an issue for some people. This would then fall under the category of educating about health literacy. But for the rest, from what I can tell any way, they know what to do but they don’t want to do it. So what then?

    • Suzi Q 38

      You are so right.
      With the sad economy, money is a problem for many people.
      Recognizing that changes have to be made is an understatement.
      I started being more frugal about food about 9 years ago.
      I mean, really frugal about it.
      Why? It was healthier, for one thing. Another reason was that it was wasteful. I would rather put the money in savings for the future.
      Processed foods are NOT always the cheapest foods.
      Most are fairly expensive.
      The grocery stores are designed so that you have to work harder to get to the fresh foods and the dairy and meat sections.
      What is in front and the middle? The processed foods..bagged, frozen, refrigerated, and boxed.
      A lot of candy and cigarettes are in front, so that there is maximum visual exposure.
      I am careful to look in my refrigerator and food cabinet and make meals from what I have.

      I go to the Farmer’s Market at the local swap meet once a month and get really good veggies and fruit that probably last about 2 weeks. If you go at 1:00 PM, they mark everything down so that they don’t have to take it all back with them.
      I fill in with local market sales, and the local university farm produce.

      I probably spend about $200.00 a month (2) for food, and I am NOT on food stamps.
      If I was, I would qualify for some of the local churches that give out free food every week.
      Some of it is dairy, bread, and odd stuff that I am not sure that I want for health reasons. On the other hand, some of it is really good…like a 2 lb bag of carrots, a head of lettuce, a splurge in the form of a pound of cheese or butter.
      If you have to walk or take the bus, so be it. There are also neighbors, family members, and friends that can help out with rides.
      Walking is a cheap form of exercise. It is good and costs nothing.

    • Kobukvolbane

      That is harsh. I’m glad you are not a social worker anymore.

      • querywoman

        Think harsh if you want. It’s just observations. I have discovered that the food stamp program is not politically popular. A lot of the populace thinks food stamps are being sold and squandered. Some sell them, some don’t. And then some people can’t resist on commenting on what people buy with their stamps. Food stamps can be used on candy, steak, or lobster. The choice is there.
        But, if we fed people, in eating stations or restaurants, we’d know that they were eating. The school lunch program is a feeding station.

    • Sara Stein MD

      I’m really glad you’re not a social worker anymore. Your post indicates a complete lack of empathy and rush to judgment. It must be nice to generalize the experience of one client to millions. In terms of your assumption that I need to find someone to do dietary counseling with my patients, I am an obesity specialist, we have a coach in office that is free, and still, the limitations of poverty overwhelm healthy eating.

      • querywoman

        I use the term “social worker” loosely. Specifically, I certified people for food stamps, and it was none of my business what they ate!
        My coworkers always said the clients sat around and watched TV and bought frozen food, and also sold their stamps. Some do, some don’t. I didn’t waste my time on those kind of observations.
        I was there to give out financial benefits to whomever was eligible. At the time, however, I attended a large church that I could occasionally get to give out some food on a day that was not the normal food bank day. Then when the church moved in with another charity, I could not longer break rules like that. Gosh, I’m so insensitive that I spent a lot of time trying to get my clients other services in the city! While my coworkers laughed and played!
        I do not care if someone spends all their food allotment on candy or expensive meat, as it is not abuse of the food stamp system. To me, it is being nosy to pay attention to what someone else busy in the grocery store line.
        Food stamps or SNAP may be used to be food or seeds to grow food, and choice built is in the program!
        As for the limits of poverty, I am really not certain. Some people make their food benefits last, some don’t. The food stamp recipients with school age children usually get free school breakfast and lunches for their children.
        Oh, and I could tell you a lot about medical insensitivity. I used to certify children and pregnant women for Medicaid.
        Shortly before I left, a semi-public clinic called me to ask if I was going to put someone who was very pregnant on Medicaid. Yes, I intended to do it, can’t remember the situation, but I learned not to promise anything. Has to go up in the computer, ya know!
        Then the clinic caller asked me, “Is it safe to deliver health care to her?”
        I replied, “Only you can decide if it is safe to deliver health care,” while I’m thinking is it safe not to deliver health care? Medicaid is only a payment system, and many patients at that clinic are not eligible for Medicaid!
        Most of my lower income clients, if not on Medicaid, got local tax supported health care.
        I don’t know the specifics, but I cannot think that dietary counseling was routine.
        Most poor people in this country have a refrigerator an a stove. Much of what I meant is I wished they would learn techniques to make their food last longer.
        At the time, we had to get pregnancy verification forms to put pregnant women on Medicaid. The local hospital clinic nurses would not complete the forms if the woman said she was going to deliver at another hospital! It took as much time to argue as it did to fill out a form!
        A peculiar quality of the medical profession is that it does not like to handle internal complaints. Local public hospital supervisors should have had to take complaints and talk to patients just like any other government supervisor! You can talk to a supervisor in any other publicly funded institution, including the IRS!
        I reserve most of my insensitivity and criticism for certain publicly funded medical institutions in Texas, who are now in serious trouble for their behavior!
        I heard from my clients that a public clinic would turn people away for money on the days they were too busy! And that they would take the phone off the hook!

      • querywoman

        I’ll keep typing. I last worked in an urban area where lots of people did a lot of walking, and there were rich mixed in with the poor. I saw many people walk home with their laundry baskets over there. School crossing guards helped adults cross, even those without children. Near the big hospital in the area, I saw people in walkers and wheelchairs in the big middle of the street. The staff at the hospital said it was awful trying to drive around the disabled in the streets.
        And where I live now, the former minister claimed that the locals bought bread and milk at the convenience store, when there are food stampable stores with plenty of variety in a half mile to a mile distance. As I said, he has been reassigned.
        In my own city, and I stopped working over 10 years, I’m always trying to help the uninsured find medical clinics. Texas is at the bottom of the barrel in social services, but there are many resources, even here!
        My deceased mama would tell people to ask me for help on that, and you think I lack empathy!
        I really don’t care what you think!
        I care for the downtrodden! Still, in so many ways. And I’ve watched my young friend with HIV, and finally decided he blows his disposable income on alcohol and then has nothing left for food. I’m not that close to most situations!

      • querywoman

        Sara Stein, “dietary counseling” is not even my subject. How to make existing food money stretch longer is my subject.
        How about some developing your reading comprehension skills? Sorry for being tacky, yes, tacky like you!. I shouldn’t generalize either that all doctors lacks reading comprehension skills either based on so many I’ve seen who do!
        Rereading your original post, I see you mention $180 a month for food. How far that goes depends on how many people are in the home.
        If they buy a whole bunch of items in small individualized packets, etc., it’s normally more costly than larger sizes divided at home!
        And I’m longing for churches to teach stuff like yogurt making and natural bread baking, which can be done inexpensively and easily.
        Feeding stations might help.
        Perhaps the WIC voucher program could be expanded for the elderly and disabled.

  • Suzi Q 38

    Do you know about the farmer’s markets in your area?
    How about the churches that supply free or low cost food?
    I agree, that finding organic chicken would be expensive.
    Maybe you can find out if the organic market ever marks down their food. Some markdown food is still good the next day.

  • poisonalice

    I agree that there’s rampant, open, “acceptable” discrimination against the obese, in all parts of society. I’m currently 240lbs, I was about 290 at my heaviest. I’ve always been overweight, but I was always a very physically active person, too. In high school, I was on the swim team, and in the off season, I spent 2 hours a day a few days a week swimming, and 2 hours a day 5 days a week in the gym. I ate healthy, I did everything that I was supposed to do, and I never lost a pound. I lost about 40 pounds in college in the course of just a few months, but I literally never ate, maybe one salad a day on average, and walked 5-10 miles a day. I gained all that back over time, first when I broke my leg in 2 places and had surgery to repair it a few years later, and then I gained the rest back over some time after I had an accident a year and a half or so after that injured my spine and knee. When that happened, for years doctors said that the back injury was just muscle and from my weight and exercise would fix it, and my knee pain was from my weight and exercise would fix it. Despite the intense pain, and the fact I failed convincing them that I had no pain from my weight previously and I know my body enough to know that there’s something serious wrong with me, I followed all instructions, went to PT despite the incredible pain it caused me, exercised, dieted even more, etc. I finally found a doctor for my knee who looked past my knee and said there’s something very wrong there. I finally had an MRI and there was broken fat pockets and cartilage and such, and the tendon on the inside of my knee was torn clean in half so there was nothing anchoring my kneecap to the inside of my leg. The PT ordered for the “jammed and shifted knee” no doubt made the injury worse. After having surgery to repair it, I finally began fighting to find out what was wrong with my back. After another period of PT and such to supposedly fix the “muscle injury” to my back, I finally had MRIs on my spine and it found that I have degenerative disc disease and herniated discs up and down my spine, and sciatica due to breaking my tailbone several times. The last MRI discovered a newly herniated disc. Because of my combination of ailments (I also have fibromyalgia that the accident triggered, and it also runs in the family) and where the bad discs are located, I’m not a candidate for a fusion. But because of where this new disc is and the problems it’s causing me, my spine doctor told me I should have a microdiscectomy, which he said would help me regain use in my legs. Since he didn’t have the right piece of equipment to do it myself (because of the location, they’d have to go through the opening in the pelvis, requiring a specific piece of equipment), he referred me to a spine surgeon who he knew would have it. I saw this surgeon, who told me that there’s no surgery that he would do, and for me to lose weight and my back pain would, according to him, decrease immensely and possibly disappear. I had told him that I had lost 80 lbs and the pain increased quite a bit since (the weight I lost is unexplained. If I was an average weight and lost a significant amount of weight without explanation doctors would worry and run tests. But because of my weight, they were only glad I lost the weight, ignoring how much weight I’d lost in such a short period), and he made some contradicting comment that I can’t recall. I have 2 doctors agreeing I should have this surgery, and that my pain is caused by my injuries and illnesses, and NOT due to my weight, but they know me and my history very well. But every time I see a new doctor, it seems they believe all my pain is due to my weight and psychological. I am very discriminated against by doctors. Like I said, I tried for my entire life to lose weight. The only way it seems it can happen is either starve myself or just weight for an unexplained weight loss. Weight problems run in my family, both immediate and extended. And we’re not a lazy bunch that overeats junk food all day, either. So don’t tell me that genetics and personal biology are just excuses. Also, I’ve always had a lot of muscle mass beneath it all, that add pounds. And yes, a large skeletal system, which yes, truly exists. I don’t understand how people think that it’s possible for a person to have a petite skeletal build, and an average skeletal build, but when someone says they’re “big boned”,oh, it’s just a poor excuse for their weight. And I also have chronic severe fatigue, which I’ve been fighting since my early teens. I was physically active, but in my down time I always fought fatigue, and many times I would sleep the entire time that I wasn’t either at school or at swim practice or working out at the gym. These days I can’t even go out for a simple 20 minute walk because of the amount of pain it causes, which disappoints me because I actually enjoy going for walks. Even going to the store for more than just a quick in and out trip causes a lot of pain, and sometimes it can lead to being virtually bedridden for a day or two afterwards. I try to fight against it, but I also have to avoid working beyond my limits. I know that there are people out there that are obese who are that way due to poor eating habits and inactivity, but there are also people out there that really are just born that way and remain that way despite healthy life choices, and people need to realize this and stop with this thinking that all “fat” people are lazy overeaters. Granted, people like myself are the minority among the overweight population, but we exist, and we’re sick of people assuming that we caused this problem for ourselves. It’s kind of like people with heart conditions, or with diabetes. Sure, some people developed those conditions due to unhealthy lifestyle choices, but there are also plenty of people with those conditions who developed them despite their healthy living, due to genetics and/or personal biology, but you don’t see the entire population of the country openly discriminating against all people with those health conditions, do you? If people think obesity is such an issue, quit with the discrimination, and start being understanding and accepting, and offer support and all the education available, and perhaps only then people will start worrying about their health and start losing weight, and perhaps then people will stop gaining weight in the first place. And by the way, my blood pressure is normal, my cholesterol is fine, and my blood sugar is average.

  • sandra miller

    Good article! Fat shaming doesn’t work. If it did, we’d be a svelte nation. Recently Daniel Callahan, a senior research scholar and president emeritus of The Hastings Center publicly advocated vigorous, purposeful fat shaming. Said he: “Safe and slow incrementalism that strives never to stigmatize obesity has not and cannot do the necessary work.

    To which a California psychologist replied “For him to argue that we need more stigma, I don’t know what world he’s living in – he must not have any contact with actual free-range fat people.” Well said.

    Callahan cited shaming of smokers as effective in getting smoking rates down – but I’d argue that smokers didn’t stop smoking because of shame. They stopped smoking because tobacco advertisers had to stop advertising. Then a poison label, in effect, was put on the product. Then lung cancer was linked to smoking. Then smoking was linked to heart attack and stroke. Then someone started displaying black smokers lungs in schools. Then research showed smoking hurt nonsmokers – we weren’t just being whiny babies as the can’t-smell-anymore-anyway tobacco addicts assumed. Then public places started banning smoking to protect the health of the innocent bystander. Then, smoking rates began to decline.

    Obesity is a complex problem. Schools eliminating recess and PC, electronics as the primary form of sedentary entertainment, highly processed food, a diet loaded not just with too much fast food but too much salt, fat, too much dairy and meat and almost no fruits and vegetables — these all combine to cause obesity. The shame/blame game is not designed to help, and so, not surprisingly, it doesn’t.

  • Lisa Cunningham

    I like this. Some of us eat healthy and watch our weight but get cancer or something out of the blue anyway. I’m tired of being vigilant about my cholesterol, blood pressure and so forth but having a random illness strike me, then listening to all the accusatory B.S. questions. Sometimes we don’t know the reasons for a disease. My cancer came from HPV, the human papilloma virus. Am I to blame for something that will probably affect 80 percent of the population and about which little was known until the last 20 years?

    • Suzi Q 38

      “My cancer came from HPV, the human papilloma virus. Am I to blame for something that will probably affect 80 percent of the population and about which little was known until the last 20 years?”

      My threat was uterine cancer, and I had a borderline proliferating tumor (which was doing nothing) in my left ovary, covered with cysts.
      I remember being home from the hospital after my hysterectomy (2 years ago) and my sister saying: “Your surgery was probably due to HPV, you had too many boyfriends in you life.” Kind of insulting; like I asked for it….I showed her the door.

      First of all, it wasn’t due to HPV. Second of all, who cares if it was due to HPV? Prior to the seventies, little was known about HPV. At the same time, the “sexual revolution” and the women’s movement was raging. HIV was a rumor and a dirty little secret. People were highly concerned about herpes. By the 80′s one of my doctors said that his patients no longer got concerned when he told them they had herpes….they were just happy that they didn’t have AIDS.

      Yes, most people have been exposed to HPV, but can “clear” it.
      There are the minority that have been similarly exposed but can not.
      This is not your or anyone else’s fault.
      I had to tell my sister that she could have HPV, even though she had only slept with two men in her life. She still made out with a few more boyfriends, and her two partners had sexual experiences in their age 50 something lives. In other words: “You have slept with everyone that they have slept with.” The men may be “carriers.”

      I finished off with this: “Do your adult children have the Garadisil series of shots?’ I made sure mine did.

  • Steven Reznick

    There is a difference between discussing unhealthy lifestyles and educating your patients on how to reduce their risks of getting ill and scolding and blaming. There is no accountability in society for your individual actions anymore. It is always someone else’s fault. Unfortunately poor choices regarding tobacco, alcohol and drug use, and nutritional choices increase the risk of developing many diseases that are costly to care for on a chronic basis.
    The process of self improvement needs to begin with education. We have raped and plundered our public health and education budgets over the last few decades and the result is few are taught in home economics type class how to shop , prepare and store healthy meals. This curriculum needs to be offered in the upper elementary levels and throughout middle school and high school. Community based nutrition programs and incentives for participating will save far more money than it will cost. If the concern is the chemicals in the foods then maybe we need to restore teaching how to grow fruits and vegetables in community and private gardens. Some of the impetus must come from individuals and community based groups themselves. Serving nutritionally sound meals in school meal programs and involving the students in growing and preparing the meals will once again save more in the long run than it will cost.
    Physical education classes and budgets for them have been eliminated from many school systems. We need to restore them and teach the kids how to get fit with the resources they have. Kids like free play. They seem to figure out how to stay active and have fun and use their imagination. Encourage it.
    Benchmarking age appropriate checkups are needed as well so children and adults can gauge where they are and compare it to where they wish to be while receiving sound advice on how to accomplish that. That implies that instead of reducing the time spent in medical and nursing education, we will enrich those programs with material that teaches our future health care providers how to teach healthy living both the basic knowledge and the approaches and encouragement that actually works.
    We are talking about comprehensive programs which will provide savings in the long run not the short term. The key is to set up the reimbursement for the team and comprehensive approach to reward the long term positives. It will take years of effort and education to make a dent in the cultural unhealthy lifestyles that exist. We will still have to deal with those who throw all caution to the wind and choose to engage in significantly adverse health activities despite sufficient instruction and education BEFORE they even began making the poor choices.

    • Homeless

      While I don’t disagree with our suggestions, how do programs make people individually accountable? If individuals are to blame, the answer is for each individual to do better. Once you introduce a “program,” the individual no longer has accountability for individual actions.

      Which one is it? Am I accountable for my food choices or do taxpayers need to fund a program so I can make good food choices?

      I looked up how to grow food on the internet. I learned about nutrition from a book. I’ve taught my children that they need to be active…without a PE class.

      • Suzi Q 38

        You are ultimately accountable for your food choices.
        It is your body.
        To wait for the day that the government finally implements a fully funded food choice program may take months and years.
        Maybe there is such a thing already in certain states, but none in my area.
        I am not waiting.
        Your suggestions about how you have learned about food on the internet have been good. There is so much information on the internet. Teaching your children about exercise is so good.

  • drjoekosterich

    Blame is the wrong word. It is about choices and consequences. If people make certain choices about how they live their lives they will end up with certain consequences. Pointing this out is not about blame- it is about reality.

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