Archive for June, 2011
Weight and Obesity: Discrimination from Doctors
By Harriet Brown
When Anna Guest-Jelley–26 years old at the time–badly twisted her ankle, the Nashville native went to see her doctor. “Your ankle’s probably swollen,” she said, “because you’re carrying extra weight.”
Guest-Jelley, a yoga teacher, went along with her diagnosis. When the doctor reported that Guest-Jelley’s x-ray didn’t show any fractures, she returned home with instructions to ice her foot–and an all-too-familiar feeling of humiliation at the physician’s focus on her size. “Almost every time I’ve ever gone to a doctor’s appointment, I’ve experienced some level of shaming because of my weight,” she says.
Her experience is shockingly common. Weight stigma is on the rise in America, according to the Rudd Center for Food Policy and Obesity at Yale University, and, ironically, nowhere is it more deeply rooted than among health care providers. Multiple studies have found that doctors, med students, nurses, dietitians, and other health care professionals routinely stereotype their heavy patients. In landmark 2003 research from the University of Pennsylvania, for instance, more than half of the 620 primary-care doctors surveyed characterized their obese patients as “awkward,” “unattractive,” “ugly,” and “noncompliant”–the latter meaning that they wouldn’t follow recommendations. More than one-third of the physicians regarded obese individuals as “weak willed,” “sloppy,” and “lazy.”
And it’s women who bear the brunt of this characterization–even when they’re not obese. Doctors’ weight prejudices start when a female patient is as little as 13 pounds overweight–meaning her body mass index would likely be around 27–found a 2007 study from Yale University. (BMI is a measurement that uses a ratio of height to weight to categorize people as being of normal weight [18.5 to 24.9], overweight [25 to 29.9], or obese [30+].) “For men, the bias doesn’t kick in until around a BMI of thirty-five, approximately seventy-five pounds overweight,” says Rebecca Puhl, PhD, director of Research and Weight Initiatives at the Rudd Center. “That’s a definite gender difference.”
This bias can have a dramatic effect on women’s health, resulting in incorrect assessments of a patient’s condition and questionable recommendations. It’s impossible to know today whether Guest-Jelley’s doctor, presuming that her patient’s BMI (which was then 38.6) was responsible for her ankle pain, did not read the x-ray as carefully as she might have. But after a few weeks of icing her ankle, Guest-Jelley returned to the doctor because her condition was getting worse. Once more, the doctor focused on the scale. “She told me about how her friend had gone on Weight Watchers and had lost all this weight,” remembers Guest-Jelley. “And I said to her, ‘I’ve been on Weight Watchers five times.’ ”
At Guest-Jelley’s request, the doctor reluctantly referred her to an orthopedic specialist–who took another x-ray and told her that her ankle had been broken all along. Since the fracture hadn’t been recognized and properly treated for so many weeks, Guest-Jelley’s ankle never properly healed.
“I hear so many stories of doctors making assumptions about patients’ health and lifestyles based on their appearance,” says Arya Sharma, MD, PhD, chair of obesity research and management at the University of Alberta. “One of the key factors underlying this stereotyping is the notion that nobody would be obese if they were eating healthy and exercising,” Dr. Sharma says. “But for every obese person I see who doesn’t exercise two hours a day or who’s drinking gallons of soda pop, I’ll treat ten thin people doing exactly the same thing.”
Many women find that, no matter what their symptoms are, their physicians blame their weight. Take Parker Ross, 21, an avid walker and bicyclist who’s had asthma since childhood. Last year Ross, who weighs about 300 pounds, lost her health insurance and went without medication for a year. When her asthma got so bad that she couldn’t walk around the block, she saw a doctor. “I found myself being told that ‘obviously’ my weight was the big problem, and I should try to get some exercise,” says Ross. Although she explained that she couldn’t breathe well enough to exercise, the doctor refused to prescribe new asthma medication and instead wrote a prescription for Zoloft–surmising that she must be too depressed to focus on weight loss or exercise. “Everything I was trying to say to her was being just completely erased by her perception of my fat,” says Ross. “Who I was simply got erased.”
Fortunately, Ross has since found another doctor to treat her asthma.
Mary Tretola, 52, a CPA and a mother of two who lives in Seaford, NY, had a similar experience with her doctor. Since her mid-20s, she’s had a circulation condition that makes her legs swell. “Maybe being overweight does strain my legs, but even back when I weighed sixty pounds less than I do now, I still had this problem,” points out Tretola.
In some cases, overweight women may be refused medical treatment altogether. Liv Linhares, now a 350-pound 35-year-old social worker in Portland, OR, vividly remembers going to her student health center in college for a routine pelvic exam. At the end, the doctor said, “Because of your obesity, I can’t accurately feel your ovaries, so I can’t tell if there are any concerns.” He asked the then-20-year-old Linhares to sign a waiver saying that if she did turn out to have cancer, the health center wasn’t responsible. Linhares was mortified–and terror stricken. “I thought, Oh my God, I could have cancer and not know it!” she remembers. “He didn’t ask me anything about my life, how I ate, whether I exercised, if I smoked or had unprotected sex–no other questions about my overall health.” Too unsure of herself to speak up, she simply never returned to her health center.
This reluctance to seek medical care is an understandable response, but it can be deadly. “Obese women go less frequently for Pap tests than their thinner counterparts because of the prejudice they run into,” says Joseph Majdan, MD, a cardiologist at Jefferson Medical College who has written about how he himself was stigmatized by fellow doctors before he lost 100 pounds. Research shows that obese women typically get fewer screenings for breast and colorectal cancer too. This finding is especially chilling given the fact that women with BMIs of 30-plus are more likely to die from certain cancers–endometrial, esophageal, and kidney, among them–according to a study of more than 1 million women in the United Kingdom.
Doctors, of course, are expected to rise above social prejudices and treat all their patients with compassion. But physicians’ behavior often mirrors the broader culture’s attitudes. “As a society, we value thinness and hard work, so we equate being fat with being lazy,” says Mary Margaret Huizinga, MD, an assistant professor of medicine at Johns Hopkins University. Although most doctors say they show consideration for everyone they treat, no matter what, her research has found that physicians’ respect clearly diminishes as a patient’s BMI goes up. “Till society changes, the medical profession won’t either,” she says.
Many doctors argue that, overall, they do a good job of attending to all their patients equally. Indeed, a 2010 University of Pennsylvania study established that despite the clear weight bias among doctors, they recommended the same treatments for a specific list of conditions–including diabetes and certain cancer screenings–regardless of a patient’s size or BMI. However, the study didn’t consider other complaints associated with obesity (such as joint pain and shortness of breath), and it looked mostly at older men, who are less likely to experience weight bias.
What’s more, the study didn’t examine whether there was any difference in the way physicians communicated medical recommendations to their patients of different weights–and that may be just as key. “One of the most important parts of the medical relationship is the patient feeling able to ask questions and being comfortable with the doctor’s advice,” notes Dr. Huizinga.
Treating obesity, however, is uniquely challenging. Ninety-five percent of people who lose weight gain it back within 3 to 5 years–which may leave physicians feeling frustrated and helpless and perhaps inclined to blame patients. “When a person has cancer that recurs, the physician is so empathetic,” Dr. Sharma says. “But when a person regains weight, the response is disgust. And that’s morally and professionally abhorrent.”
When doctors take courses that emphasize “uncontrollable” causes of obesity, such as genetics or certain medications, their weight bias diminishes. But, although medical school curricula are expanding, most physicians who are practicing today received little training on weight issues.
Patient advocacy groups such as the Association for Size Diversity and Health and the National Association to Advance Fat Acceptance argue that since obesity has been so stigmatized and is so difficult to treat, doctors should be taught to focus less on weight itself and more on other indicators of health, pointing out that even overweight people can be otherwise healthy. They cite studies like the one published in the Journal of the American Medical Association in 2005 that found that people considered overweight (with BMIs of 25 to 29.9) actually had lower mortality rates than those viewed as being of normal weight. And some advocates also feel that whether weight is mentioned at all should be up to the patient.
But there are also doctors who are strongly committed to avoiding the pitfalls of obesity prejudice–while still addressing weight head-on. “The first thing that comes out of your mouth when you meet a patient can’t be ‘You’re obese,’ ” says Juan Rivera, MD, a preventive cardiologist and an assistant professor at Miami School of Medicine.
“You have to wait for the right moment, and be prepared to work together for a long time. Fighting obesity is a marathon, not a sprint.” Above all, Dr. Rivera says, it takes sensitive, honest communication.
For women who feel that their doctors treat them with less dignity due to their weight, experts, including Dr. Rivera, advise telling the physicians, calmly, what they perceive as biased behavior and how they feel about it. “Ultimately, both parties will benefit,” says Dr. Rivera. “And if your physician doesn’t take the criticism well, it might be a good time to switch doctors.”
Finding a new provider can make a world of difference. After Tretola’s doctor dismissed her swollen legs, she scheduled a physical with a new practitioner. “The doctor asked if I wanted to be weighed, and I said, ‘I’d prefer not to today,’ ” Tretola reports. “That was fine with him. We did talk about weight, but he was very welcoming, not judgmental, and he discussed problems–such as my high cholesterol–without blaming my weight.
“It was so refreshing.”
[Trigger warning: Binge eating/eating disorders.]
I suspect the very reason surgeons think it’s a good idea to inflict stomach amputation or stomach binding on humans — the assumption that people need to be “controlled” around eating — is part of the reason *not* to do such surgeries!
Weight-loss surgery was supposed to be Chevese Turner’s salvation — a last resort in her battle against obesity and binge eating. Instead, her 2007 lap band procedure catapulted her into full-blown bulimia.
“I had always struggled with binge eating, and my relationships with food didn’t change just because of the lap band. Even though binging is really painful when your stomach is restricted like that, I would still binge knowing that I would throw it up. I felt like finally I could be bulimic, like this was what I wanted all along,” says Turner, 43, of Soverna Park, Md.
Turner knew she had a binge eating disorder going into surgery, but after experiencing cardiac complications attributed to a lifetime of yo-yo dieting, she was desperate to lose weight. Instead of solving her overeating problem, however, the surgery only changed its form: for 18 months following the surgery Turner regularly binged and purged.
Only after going into intensive therapy to cope with the binging behavior she had experienced since age 5 did Turner, who now runs the Binge Eating Disorder Association, build a healthy relationship with food and her body.
Sixty percent of individuals seeking treatment for obesity have some kind of eating disorder, usually binge eating, according to a 2007 Harvard study. It is these individuals, who already have an unhealthy relationship with food and their bodies, who are at most risk of developing further eating disorders post-surgery, says Lisa Lilenfeld, a psychologist and president of the Eating Disorders Coalition at Argosy University in Washington, D.C.
Lap band or gastric bypass surgery is not likely to create an eating disorder where there wasn’t one, she explains, but “the most likely thing is that people had untreated or unsuccessfully treated binge eating disorders before surgery will continue to have problems after surgery. The problem is, it becomes physically challenging and potentially dangerous to binge like this because of the structural changes in the stomach,” she says.
On the other end of the spectrum, patients who used to overeat now overshoot with their weight loss, severely limiting their caloric intake to the point of malnutrition and anorexia.
“I’ve had a number of patients go from very obese to very underweight, so much so that they need to be rehabilitated with intravenous nutrition,” says Dr. Donald Kirby, a gastroenterologist at the Cleveland Clinic who treats patients undergoing bariatric weight-loss surgery.
Because there are so no statistics on how many of these patients experience eating disorders post-op, it’s difficult to gauge the scope of this issue and there is much debate over its prevalence between the surgeons who perform the procedures and the therapists who treat eating disorders down the line. Dr. Mitch Roslin, a bariatric surgeon at Lenox Hill Hospital in New York, has performed thousands of bariatric surgeries and he says he only sees one or two cases a year of eating disorders, but psychologist Lilenfeld believes it’s much more common than that.
Binge Eating: Hiding an Eating Disorder
Technically, those with diagnosable eating disorders are not advised to undergo weight-loss procedures, but because each hospital and insurance company has different psychological screening requirements, many patients with mental health problems slip through the cracks.
In some cases, psychological screenings consist of asking only a couple of basic questions that don’t even address eating disorders or mental health concerns, says Dr. Leslie Seppinni, a therapist who specializes in treating obesity. “Then after the surgery, most doctors fail their patients in terms of follow-up. There are some group sessions with other patients, but that’s about it.”
In Turner’s case, however, her health insurance had relatively rigorous requirements for surgery approval, including an eating disorder screening and a letter from her therapist. But for those who are desperate to get the surgery at all costs, she says it’s relatively easy to get around these requirements by answering the questions “right,” as she did.
Because of insufficient screening or deception, Lilenfeld says about a third of all patients who undergo weight-loss procedures are believed to have “severe binge eating disorder” going into surgery, though not all of these patients will go on to develop other eating disorders post-op.
Anorexia/Bulimia After Surgery: Medical or Emotional?
One of the reasons that true anorexia and bulimia may not be recognized after bariatric surgery is that the symptoms of these eating disorders can mimic some of the expected adverse affects of the surgery.
In the months following surgery, the stomach has to heal and slowly expand, which makes eating difficult and sometimes painful. Patients who eat too much will sometimes throw up because it’s the only way to relieve the pain in their stomach, not because they are compulsively trying to get rid of calories. Similarly, the indigestion, diarrhea and acid reflux that can occur post-op leads some patients to avoid eating altogether just because eating becomes an unpleasant experience. These patients will become malnourished and resemble anorexics, but the psychological aspect of the disorder is not there.
It is important to distinguish between these medical reasons for anorexic/bulimic behavior and true, psychological cases of eating disorders, says Seppinni, who has traveled the country interviewing people about their experience with obesity, weight loss and bariatric surgery. In true cases of eating disorders, it’s about the addiction to overeating getting transmuted into another addiction. For some, they become compulsive exercisers, for others, alcoholics, for still others, anorexics. “You take away the coping strategy they’ve been using all their lives, and the addiction has to go somewhere else,” she says.
The “loss” of binging as a coping strategy was palpable for Turner following her surgery. “I lay in bed and cried for a week because I couldn’t eat. Eating was the way I soothed myself my whole life. As soon as I could binge again, even though it was extremely painful, I did,” she says.
Getting bariatric surgery will not decrease mortality several years after the surgery,according to a study published in JAMA.
Although the weight-loss surgery has been shown to decrease weight and diminish diabetes, the older, severely obese male patients in the study were not living longer because of the procedure.
The study was to be presented Sunday at the Academy Health Annual Research Meeting.
For the severely obese, bariatric surgery is one of the most effective ways to reduce weight. The most common bariatric surgery is gastric bypass, which creates a small stomach pouch that restricts food intake.
The study conducted at Veteran Affairs medical centers followed 850 veterans who had bariatric surgery from January 2000 to December 2006.
When study authors compared the raw rates, patients who had surgery had lower mortality rates with 6.8 percent versus 15.2 percent after six years.
But when researchers compared the 850 veterans to 1,694 similar patients who did not have bariatric surgery, they found that surgery was not significantly associated with reducing mortality.
Matthew Maciejewski, of Durham VA Medical Center and colleagues concluded that “bariatric surgery does not appear to be associated with survival during a mean of 6.7 years of follow-up.”