Voodoo Medicine Man got me thinking about this, and instead of posting pages upon pages of my comments on his blog, I've come out of hiding to make this post here.
I, as a fat girl, find it disturbing that it's more than appropriate to laugh about someone's weight than it is comment on the color of their skin, or the religion they follow. Despite the fact that the majority of overweight people (myself included) are where they are because of poor personal choices, doesn't make it any better, in fact, it makes it worse. But, is the individual solely to blame? Or does society hold some of it; as you suggested. I believe it does. You can't go more than a minute on any television channel without coming across a food ad; either for take-out, or something else. I live in Canada, so I'll give my thoughts on this from a Canadian perspective. Every time I go to the US, which is just a few minutes away from me, I am astounded by the food products you have that we, in Canada, don't. The amount of pre-packaged, pre-cooked meals just floors me. In some stores, there's enough of them that you could devote a whole 2 or 3 aisles to and still have some left over. Your fast food is ridiculously cheap and you have way more chains than we have in Canada. The ones we have are Arbys, Wendys, Taco Time, Taco Bell, McDonalds, A&W, KFC, and Burger King. I might be missing one, but I don't think I am. Going just across the border in to Bellingham and there's most of those I listed plus so many more I can't list them due to forgetting some of them. Different parts of the US have different fast food outlets, too - in Canada, we have the ones I listed.
Healthy food, as you suggested, is more expensive than the prepackaged variety, and even in Canada this is true. Despite this, I rarely buy the prepackaged food, in fact, if you saw my shopping cart most times, I'm sure it confuses people as to why a fat chick is pushing it around. Lots of vegetables, lean meats, no bread products, no sugary products, low fat dairy products, etc. But I know that if I gave up on that, I could buy my whole week's worth of meals in the frozen, re-heatable kind and safe myself a lot of money and time.
Do I think people should intervene? Yes. I do. I've had several physicians (walk-in clinic doctors, mostly and one gynecologist who I really wouldn't want anywhere near my vajayjay) tell me I have to lose weight. My problem is when I tell them what I'm doing to lose it, they poo-poo it and suggest something ridiculous like aquasize. The gynecologist I saw a few years ago wouldn't even let me finish my sentence before he started brushing my comments aside and telling me the benefits of swimming. I tried to explain to him the "Fitness Fantasy" contest I had just completed that summer (and won, by the way) but I barely got the words out before he made a snap judgement that it was crap and I should be doing aquasize and swimming, oh and yoga. I'm all for doctors giving me tools to further the knowledge I gained from that "Fitness Fantasy" contest and for encouraging me - but when I tell them that I lost damn near 30 pounds in 3 months, gained 10 pounds of muscle and lost 20 inches of my body and they brush it aside as though it were nothing even remotely beneficial: I get a little rankled.
I think, though, the WAY you intervene and how you speak to a person is very important. I, for example, am far more receptive to a physician telling me that I am over weight, that they're concerned for my future health, and they're going to help me find the resources I need (whether it's a nutritionist consult, or maybe a thyroid check, etc) to get healthy than to have a physician tell me "you're overweight, go swimming". I'm less likely to take them serious than someone who's being genuine and really reaching a hand out.
If you're the PCP for a patient who's overweight - moderately or morbidly, I think you have the responsibility and obligation to help them. Don't assume they DON'T know they're fat: we do have mirrors and society makes sure we're constantly aware of our behemouth size. Maybe they just don't have the education about what they're doing to their body. Maybe they DO have the education, and the knowledge and the awareness of what foods are bad but they don't know where to start with turning their habits around. Compulsive over eating is an addiction and a habit. I liken it to smoking. I was never addicted to smoking, but the habit would always get me. The need to do something with my hands, etc. I didn't crave the nicotine, I craved the action. Eating is the same. I can eat healthy (and I really do try), but you fall in to the habit of eating nonstop and it's incredibly hard to break. You feel like you always have to have something to chew on; gum works for only so long before you need something more substantial. So you eat. And usually when these cravings for the action of eating hit, you're no where near a salad bar.
For some morbidly obese people, there is a very deep-rooted psychological issue that they are medicating with food. It may not be classic emotional eater behavior, but there is something they are trying to drown out with food. My mother is this way, and only recently do I think she's realized it after I mentioned it to her. She was a gorgeous 120 pound 5'1 woman, with wicked curves, when she married my father over 34 years ago but when she had me 10 years later, she never lost the pregnancy weight. When my sister came along, she didn't lose that pregnancy weight either and since then, she's ballooned up to her current size. While she knows far more about nutrition and what's good than I do, she's still overweight. Granted, I don't think she really takes the information on exercise to heart and because I don't have a degree in it, she won't listen to me, but in her case I do believe there's more going on than simply bad personal choices. I know for a fact that she can't stop eating. She knows she's full, she feels full, but she still needs to eat. She'll be full from dinner and an hour later will be looking for something to eat. Not because she's hungry, but because she's just craving food. I have encouraged her to talk to her doctor about this, maybe get a referral to a psychiatrist - but in the meantime utilize the psychologist visits she can have through my dad's employee and family assistance program, or through mine (since dad and I are both unionized, different unions though) to maybe help her start to understand why she over eats. I have an idea about it, but the possibility may be too painful for her to hear.
Back on track though, obesity is such a complex issue that you really can't blame it all on one factor or another: either personal choices or society. There are so many reasons why there are far more overweight people today than 30 years ago and I don't see that changing in the near future. We've become a generation of instant gratification; we want our food and we want it NOW. We don't want to have to be in the kitchen preparing it. Over the years, we've killed our tastebuds and acclimated ourselves to the taste of McDonald's, to sugary drinks and treats, fattening foods, and chemicals in prepared/pre-packaged foods than home made stuff tastes "different" and "odd". Bad food is addicting, and I wonder at times if enough research has been done on the chemicals that are pumped in to it: could that, too, be a reason for our addiction? Is the aspartame in our soda the cousin to the nicotine in our cigarettes?
I really applaud your post and while it may not have been prudent for you to approach this woman with your concerns, feeling guilty about not approaching her is a start. Whether you're an ER doc or a family doc, I think physicians can have a lot of influence on patients whether they've known them for 5 minutes, or 5 years. Sometimes, hearing about a problem from someone with a degree is more of a wake up call than just admitting it to yourself.
Not to sound cliche, either, but change starts with the first step. If we, as a society, are going to change the obesity issue - we need to make that first step. Whether it's by educating people about nutrition and exercise, or starting off with a clean slate by way of our children, change isn't going to happen unless you take that first step. Likewise, changing someone's own personal battle of the bulge won't happen until they make that first step to a healthier future: whether that step is from you addressing the issue in a kind and concerned manner, or by their own personal revelation doesn't matter. Someone needs to make it in order to help direct them to a better track.
And now, I'm taking my fat ass out for a run. Thanks for the great post!