Perspective
My Fat ass
A miniature donkey teaches lessons on helping patients fight obesity.
By Therese Zink, M.D., M.P.H.
My ass has an obesity problem. I am not speaking of my derriere, although over the years my own weight challenges have given me empathy for the trials of my patients. Rather, I am talking about my miniature donkey, Jimmy.
Jimmy’s back reaches my waist. (I’m 5 feet 2 inches tall.) Twig-like legs support his big-bellied body, like a pregnant woman wearing high heels. His tan, fuzzy ears edged in black are about four times the size of a horse’s. When I talk to him, they stand at attention and turn in my direction. When he’s angry, they lay flat against his head. His spiky mane, as black and upright as a punk rocker’s hair, marches down his neck. Liquid brown eyes outlined in black, like Charlie Chaplin’s Little Tramp’s, track my movements.
Jimmy’s lot in life is eating and hanging out with his pal Indy, a quarter horse. Food gives both of them pleasure; they graze in their three-acre grassy pasture all day. Each morning, they receive a measure of oats. Jimmy nibbles a mouthful, then meanders to the stable door and chews as he gazes out at the bucolic Midwestern scene. The morning sunrise bathes the pasture with its stand of maple and poplar trees in a rosy light. Beyond the three-strand electric fence, a patchwork of soybean and corn fields stretch to the hem of the sky.
In other countries, Jimmy’s relatives enjoy the same vibrant sky, but their pastures are less ample, and they expend more calories pulling carts and lugging packs. As a result, they are much thinner than Jimmy. Clearly, like many Americans, Jimmy’s obesity problem is attributable to his lifestyle—too much food and too little exercise. Because he is unable to restrain himself or increase his activity on his own, I muzzle him. A muzzle ensures portion control: A two-inch hole at the bottom of a rubber basket that attaches to his halter limits the size of a bite of grass to nibbles only, no super-size servings.
If I happen to leave the gate open, he bounds out of his pasture like a racehorse, bucking and kicking his hooves in glee. The escape artist gallops into the yard with unusual speed and makes a bee-line for the farthest corner. There, he settles in for a good chew; as the saying goes—the grass is always greener. If I approach, he skirts away. Herding him back into the barn is impossible, even with the help of my dog. However, if I leave the door open and ignore him, he eventually wanders inside the barn to be near to Indy.
Of course, as physicians, we can’t muzzle our overweight patients. So we try to encourage them to change their behavior. Research tells us that mentioning concerns about weight does make a difference, and sometimes it does.
Joanne came to see me for a follow-up visit regarding her blood pressure. “Did you see how much weight I’ve lost?” she asked, looking for my approval. I pulled up a chart on the computer that mapped her weight and oooed and aahhed at her 50-pound success. She’d even stopped by the clinic a month earlier for a weight check to document her progress. The line angled sharply downward; she was now under the 200-pound mark.
“What motivated you?” I asked.
“Well, you told me that it would help my blood pressure if I lost some weight.”
That’s all? I thought, how uninspiring.
“I went home and thought and prayed about it. I decided to join TOPS (Take Off Pounds Sensibly). Now I run the group.”
Adam, a 20-year-old patient, came to see me after his father was diagnosed with diabetes. “I don’t want to be like Dad,” he told me, his stomach concealing his belt. We talked about healthful foods and exercise. When he returned a month later, he’d lost almost 20 pounds. He had stopped eating fast food and started going to the local gym after work. For the next year, he checked in with me monthly, and we watched the line of the weight graph in the electronic health record trend downward. He dropped 100 pounds. I cheered him on and even asked the hospital to tell his story in the quarterly newsletter. In both cases, I only mentioned the issue of weight.
Despite me mentioning my concerns, more of my overweight patients retain their obese status than change it. I often feel I am fighting an uphill battle and lose steam when talking about it. I wish I could simply muzzle those patients. There is a fine line between inspiring and shaming patients. If I push too hard, they won’t return. Some patients refuse to stand on the scale in my office; some avoid the clinic altogether because they don’t want to face the scale.
Encouraging behavior change is one of the toughest challenges we face as physicians. Exploring the barriers to change takes time, which is a precious commodity when you’re on today’s health care treadmill.
Jimmy has taught me lessons about doing this that translate to patient care. A moody fellow, some days I approach to pat him, offer him a treat, and he darts away, turning his rear end toward me. Other times, he can’t wait for the carrot or apple I have to offer. At those times, he approaches with caution, sticks out his muzzled nose, and nudges my arm.
Like Jimmy, my patients are receptive to me only some of the time. Persistence and leading by example are crucial. When patients see me running during my lunch hour, they know that I am serious about my suggestion that they exercise. It’s hard for me to talk about healthful eating and exercise if I am not doing those things myself. Although it took a number of years, I’ve figured out how to manage stress without food and how to incorporate exercise into my daily routine. An overweight colleague who eventually lost 50 pounds told me that patients used to laugh at him when he brought up the issue of weight. Doctor heal thyself. Attend to your own ass.
As leaders in our communities, we physicians need to be strong voices for environmental change. We can support community efforts that address the obesity epidemic. We can raise questions about what is served in our school cafeterias and work to ensure that gym class is part of the school day and is fun for all kids, even those with little athletic talent. We can work to ensure that children have options after school besides watching television and playing video games and encourage parents to limit children’s access to sugary beverages and fast food. We can ask important environmental questions: Can urban areas support gardens to grow fresh produce? Is affordable, healthful food available in grocery stores in poor parts of town? How can we make our neighborhoods safer for exercise?
But on the individual level, we need to meet our patients where they are and gently encourage them to make healthier choices. Jimmy knows that I care for him because I meet him where he is each day. My patients are not so different. MM
Therese Zink is a family physician in Zumbrota, Minnesota, and a professor in the department of family medicine and community health at the University of Minnesota.