A couple of years ago, blogger Barbara Benesch-Granberg, aka Thorn, wrote about her mother’s death in a post baldly titled, "Fat Hatred Kills."
It’s a deeply personal story about her mother’s struggles with being fat and her negative experiences with the medical system that ultimately led to avoidance of care. Benesch writes:
…With all that shame, and with so little support from her family or her husband, once Mom got hurt, she had a hard time healing from it. So when I was about 11 years old, and Mom went to see her doctor because of some problem she was having, and he scathingly told her that her problem was she was fat, and not to come back to him until she’d lost 50 pounds? Yeah. It hurt her. It hurt her bad.
The post sent an enormous ripple through the blogosphere. Two years later, people were still reading it and adding to the comment thread. It struck such a nerve that it led to the creation of First Do No Harm, a blog that catalogues fat prejudice – and its consequences – within the medical system.
The individual stories make for compelling reading. (Warning: Be prepared for salty language.)
There’s Adrienne, who went to see a neurologist to discuss the medication she was taking for epilepsy, and was urged to try a different medication because it would help her lose weight. The doctor tells Adrienne, "You’ll like that."
Adrienne recounts being "speechless with rage."
I’m not sure what to attack first: the assumption that weight loss is something I want, or his obviously cavalier attitude toward my health. I came to him because I’m having seizures, not because I’m fat. I want him to prescribe a medication because it is the most effective available medication for stopping seizures, not because it’ll make me thinner – and hey, maybe if I’m lucky, I’ll stop having seizures, too.
There’s Suzy, age 33, who was diagnosed with kidney cancer. She needed an MRI scan but no facility would take her because of her size; one imaging center suggested she call a zoo. Then a consulting doctor refused to do surgery, saying her weight made it too risky.
There’s J.C., a depressed college student who is told that losing weight will make her depression go away. There are stories about patients feeling berated and disbelieved. Some of them were pressured to undergo weight-loss surgery.
Critics might dismiss these people (they’re not all women, by the way; some of the stories were submitted by men) as demanding and overly sensitive. But in fact a significant number of studies have found the general stigma towards obesity is echoed among health care professionals.
This study, published just two months ago, found that negative attitudes towards obese patients were quite prevalent among doctors, especially younger doctors or those who didn’t see as many patients. Another study, from June of this year, documented negative reactions to obese patients among 40 percent of the physicians who were surveyed.
It’s not just doctors. These attitudes also can be found among medical students, nurses, dietitians and even dentists. When undergraduates in the food and nutrition sciences were surveyed a couple of years ago about weight bias, they displayed moderate fat phobia. They also tended to view obese patients as less healthy and less likely to follow treatment recommendations. Yet another study found that although physicians weren’t as biased about obesity as the general public, they still carried fairly strong attitudes and stereotypes about fat patients.
Ironically, many of the studies found that doctors also are often ill-prepared or lacking in knowledge for how to help patients who want to lose weight.
This doesn’t, and shouldn’t, mean health care professionals are the villains here. Similar attitudes are widespread throughout society.
And to be fair, the patient experiences recounted at First Do No Harm are anecdotal and represent only one side of the story.
It’s clear, though, that this is a significant issue for patients who are overweight or obese. More than anything else, what stalks through the personal stories at First Do No Harm is a sense of outrage and humiliation, of being judged – and treated – solely as a number on the scale.
What happens when these patients leave the doctor’s office? As one person wrote at First Do No Harm, "we just don’t go back."
I don’t know why anyone would be surprised by this. The clinic environment alone – chairs that are too small, gowns that don’t cover, blood pressure cuffs that don’t fit - can be daunting and discouraging. And it doesn’t help when obese patients are continually assailed by commentaries such as this, suggesting they be charged more to be transported by an ambulance because of their size.
So, does fat hatred kill, as Benesch-Granberg maintains in her story about her mother? If fat patients stop going to the doctor because it’s frustrating and humiliating, it’s hard to see how this would benefit their health. If all their health issues are blamed on their weight, as many of the stories at First Do No Harm recount, it’s hard to imagine that they’re receiving quality care. Indeed, more than a few of the stories submitted to the First Do No Harm blog involve misdiagnoses or delays in care by health care professionals who may have been too fixated on the patient’s weight to see anything else.
Bias and stigma toward obesity may in fact have more implications than anyone realizes, suggests the latest study to explore this topic. The study, conducted by researchers at Johns Hopkins and published in the November issue of the Journal of General Internal Medicine, found that doctors have less respect for obese patients and raised questions about whether this might affect the care these patients receive. (You can read the study in more detail here.)
It’s known, for example, that patients who are extremely obese and in need of a kidney transplant are less likely to receive an organ compared to patients who are not obese, even when other medical factors are adjusted for. You might argue that it’s because transplants are riskier among these patients – but how much of this is supported by the evidence and how much is based on perception or stereotyping?
A couple of key points from the Johns Hopkins study:
Previous studies have shown that when physicians respect their patients, patients get more information from their doctors. Some patients who don’t feel respected may avoid the health care system altogether, surveys and focus groups have shown. One limitation of the new study, [author Mary Margaret] Huizinga says, is that it was unable to link low physician respect directly to poor health outcomes.
"The next step is to really understand how physician attitudes toward obesity affect quality of care for those patients, to really understand how this affects outcomes," she said. "If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening? We need to understand these things better."
I would be remiss if I failed to point out there are health care organizations that do understand this issue and who work at being respectful and sensitive toward their patients regardless of the numbers on the scale. It’s worth noting that Affiliated Community Medical Centers has a bariatrics and weight control center offering support and medical guidance for people who want to lose weight. It’s hardly fair, after all, to nag and scold patients for being obese – but offer nothing to help them do something about it.
It’s not easy to untangle perception and facts. No one can deny there are inherent physical aspects of obesity that have to be taken into consideration when caring for these patients. But there are specific challenges in caring for tiny newborns too, or for frail elderly patients or for patients who use a wheelchair. Why should obesity be any different?
When the medical world buys into the negative stereotypes about fat patients and can’t look past their weight to see the individual patient, is this really helping these people? Or is this adding to their health burden? It’s a question that needs to be asked, and one that deserves some hard, honest examination.
Update, Nov. 23: This week’s edition of American Medical News takes its own look at this issue.
West Central Tribune file photo by Bill Zimmer