So says Jesus of Nazareth to the crowds in the Sermon on the Mount. Judging other people must be a problem. We hear the requirement to not judge anyone based on sex, religion, disability, etc. But whom DO we judge, without apology?
The overweight. They're almost as bad as smokers. There are proposals to charge the obese more for health insurance. And why not? These lazy, will-power-challenged fat slobs are causing all of us to pay more for our insurance, right?
Why do we make the judgement that they are lazy and have no character strength? Have you ever questioned that assumption? If not, why not?
We have biases, that's why.
First, we have been taught that obesity is a simple matter of too many calories in and not enough burned. Humans are really very simple machines, like locomotives or something, and if you shovel more coal in and don't' burn it you get fat. Very few of us, in or out of medicine, every question this assumption.
Second, those of us who are not obese take the first assumption and make an even deeper assumption: "I am better than those FAT people. I have the strength of character to not stuff my face like a sausage, and I exercise while they are too lazy to move their butts off the couch." How do I know this? Because it was me, saying and thinking those things. And I was not alone; most doctors are built like me and are HIGHLY susceptible to the temptation to think that because we were disciplined enough to get into Medical School, that discipline MUST explain why I'm not overweight.
In high school and college, on the swim team, here was an average days' food:
Breakfast: Bacon and eggs, two coconut donuts, hash browns, milk and OJ.
Lunch: whatever hot lunch Saga health service at Colorado College served.
Dinner (after swimming 6K yards): two to three full dinners followed by a PB and J on whole wheat for dessert. During swim season, I went from 145# to 138# eating everything that didn't actually run away from me. Meanwhile my younger brother was not swimming and was getting heavier.
Conclusion? Obvious. I am a superior person with willpower and self control. The Food Pyramid, Aerobics, and the McGovern report were all coming out. Low fat made sense to me! Less calories.
Somewhere along the way, though, some disturbing things started happening.
I met some overweight people with drive, decisiveness, intelligence, and, yes, tremendous willpower in all ways except food. But my ego overcame that in a moment; they were still weak when it came to food and exercise and if they would only be as virtuous as me all would be well.
But then I hurtled into my fifties. I did a couple of amazing hundred mile bike rides: the Stonewall Century and the Triple Bypass. These are outrageous rides with many thousands of feet of climbing, at altitude in Colorado. I biked many, many miles training for these and thought I was doing a good job eating. I know that the more weight you lose, the better your "power to weight ratio" is for hill climbing on your bike. Guess what? Weight was slowly coming on...155...160...165...170.
And then I went on Atkins. Biked less, ate a lot of fat, very low carbohydrate. 170...165...160...155...150. Bottomed out at 149.2. Not particularly hungry.
So what do I think is going on? In short, we judge fat people to be weak and shut off our brains. We don't look any further (we in medicine, we elsewhere.)
But what if...
What if I was thin and athletic as a kid because my body responded a bit less to blood sugar? What if my body handled it a bit better due to some genetic accident? What if (gasp) it wasn't my superior character? What if it was that the islet cells in my pancreas dumped a bit less insulin in response to a coca cola?
And on the other side...
What if the obese just happen to dump more insulin, overshooting, in response to the same Coke? The insulin forces the blood sugar out of the blood stream into muscles, liver, and fat, and blood glucose falls. Their brains start to scream, "Famine! I need sugar NOW! The long Neanderthal ice age winter is coming and we need to store FAT to survive. No, slow down, don't move so much, you are burning the calories that you will need to get past February."
What if they feel more urgent hunger than I, and feel a deeply alarming reluctance coming from their bodies to exercise? Remember what it was like to be REALLY hungry? What if our overweight friends and family feel that way all the time? How long do you think YOUR willpower would hold out? Hours, days, maybe even a few weeks?
I can tell you that the same bias that I mentioned above, that getting through All Those Years of Medical School, working hard, whispers to me that all I need to do is use my incredible willpower to muscle through. And when it fails, as sooner or later it always does, it's easy to beat myself up as a loser and just try again.
If you are interested, there are a couple of terrific books on willpower. Willpower: Rediscovering the Greatest Human Strength and The Willpower Instinct both tell us that willpower is somewhat like a muscle: it can be strengthened some, but it ALSO just runs out if you rely on it too much. There is a finite daily supply of willpower. If your body is screaming "FAMINE!!!" sooner or later your willpower will fail and look out, chocolate bars. I've been there.
In modern medicine we are always being told to be "outcomes based" and "evidence based." We as a culture have decreased our fat and increased our carbs just like the nice folks in the government told us. (Governments don't have to be outcome based; have you noticed? They don't have to be evidence based. They just have to convince enough people to vote them back in.) The outcome has, basically, been a disaster. And yet we just keep slavishly thinking that if we just try harder, ban large drinks, cut fat and eat HealthyWholeGrains (notice how it's now one word) a miracle will happen and it will all start working. We won't be fat and ugly any more.
Judge not, folks. Instead, be like CSI and Follow the Evidence.
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