Oh Please.

I stumbled across an article describing the 'dangers' of the new Wii video game system from Nintendo. Finally, by inventing a video game that requires players to get their asses off the couch, there might be some hope for a generation whose main form of exercise is walking from the TV to the fridge.

Instead, people are overdoing it. And as a result, giving themselves the kind of injuries you'd expect to see when sedentary people suddenly spend hours on end doing things their body isn't accustomed to. Not to mention the damage that flailing limbs are doing to nearby lamps, pets and people.

So the litigation-savvy people at Nintendo are doing just what you'd expect-- warning people that it's safer to play the Wii from a seated position on the couch.

Don't worry, childhood obesity. The Wii won't be a threat for long.

My Newest Patient

So in the town where I work, the hospital is GP-run. That means that all family doctors are the most responsible physician for their patients when they're admitted to hospital. If someone is admitted to hospital and doesn't have a family doc, or if their family doc doesn't have priviliges at our particular hospital, they get assigned to a family doc who will look after them while they're in hospital.

We got an assigned patient over the weekend. Well, we actually got about 5 of them. And she wasn't really ours... she was assigned to another family doctor in our call group. There are 4 physicians in our call group, so on the weekends the doctor on call rounds on everybody's patients. We ended up rounding on about 35 patients. It was a long weekend.

The patient I'm referring to was transferred from another larger hospital to us for rehabilitation. She had been admitted with respiratory failure, which in someone her age (in her early 50's, relatively young) usually means underlying asthma or COPD brought on by a lifetime of heavy smoking. But since I'm telling this story, it's obvious that it wasn't straightforward.

The patient in question was 650lbs. It required the fire department to transfer her from the big city hospital. She was being transfered to us rather than the hospital in the town where she lived because, quite simply, they didn't have the resources to manage her. She required a double-sized bed, which then required a two-person room to become a private room. The nursing staff required for her care was staggering... she is an EIGHT person transfer. Just to roll her over to change her position or put a bedpan under her required a call for assistance to be made to the two adjoining units. Nurses had to be pulled away from the care of their own patients to assist in the care of this one. The nurses told us that it took three of them to move one of her legs when she wanted to shift onto her side. The patient had to be kept on an incline as the pressure of her pannus (apron of abdominal fat that hangs down over the groin) against her diaphragm made her increasingly breathless.

Walking into the room, I struggled to keep my expression neutral. Her facial features were seemingly concentrated in the center of her face, dwarfed by a large roll of fat under her chin. I spoke to her, feeling overwhelming guilt at my own reaction. I'll admit it... I was disgusted. Her hygiene wasn't good... rashes were evident in the areas between skin folds and it was obvious that the extra flesh severely limited the range-of-motion in her arms and legs. All I could wonder was how on earth anyone could let themselves get this big. As someone who has battled their weight all of their life, I understand that is probably not a fair thing to assume-- that she had 'let herself' get that big. But she had no disability before she put on the weight (which was apparently put on gradually though her 20's and 30's, according to her medical record) and here she was, disabled by it now.

I know my reaction was wrong. And I made sure that I treated her the same way I treat everyone else. And I felt very uncomfortable when I overheard some of the nurses making comments about her afterwards-- not that I said anything to them about how inappropriate their harsh judgements of her were. But I knew that deep down, I agreed with them.

And for that, I still feel guilty.

Because "FAT" is a Four-Letter Word

For people carrying extra pounds, the word "fat" is often like the elephant in the room that everyone is pretending not to notice. In the case of medicine, this is a very bad thing. The fact is, being overweight (and I won't get mired down in the definition of overweight vs obese vs morbidly obese or whether or not BMI is an appropriate measurement instrument) is a medical condition. It is a significant risk factor for everything from heart disease to pregnancy complications. But no one wants to talk about it. And worse yet, people get offended when their doctor brings it up.

I have been known to spend time on a certain internet message board or two... the majority of the women on these boards are 20-35 years old and married, and are looking to start a family. A surprising number of those (as I mentioned in my last post) have had trouble conceiving. Of course, every healthy young person who wants to have a baby and can't get pregnant in a reasonable amount of time wants to know why. Fair enough.

What I'm seeing, though, are women who are coming back from their doctor's office steaming mad. Why? Because the doctor told them to lose weight, and in some cases, refused to perform invasive investigations until they did. They call their doctors 'insensitive', and 'ignorant' and insist that they know many women heavier than themselves who have gotten pregnant without problems. They demand hysterosalpingographs, exploratory laparoscopy and want to be put on drugs like Clomid. And they're very angry at the suggestion that their weight might be a contributing factor.

Part of the problem is that when someone, even a medical professional, suggests that someone is overweight (I prefer to use the terminology "carrying a few extra pounds"), women don't hear it as medical advice. It doesn't come out the same as 'your cholesterol is high' or 'your thyroid is low'. It comes out wrapped in a lifetime of insecurities and issues. It suddenly comes out in the voice of your mother, telling you at 6 years old that your sundress is 'slimming'. It comes out in the voice of your father, asking you at the age of 15 if you'd put on weight recently. If comes out in the voice of your ex-boyfriend, telling you that you'd have a 'rockin' bikini body' if you just lost a few more pounds. Worst of all, it comes out in the voice that has always shouted in the back of your head that you'd be prettier/happier/more successful if you were skinny. It's hard to separate the 'issue' from the 'issues'. And so the suggestion that losing weight is integral to your health comes out as a social judgement, rather than as medical advice.

Which is too bad. Medical research has shown that patients are more likely to lose weight if their doctor addresses the issue and supports their efforts. And in the situation I mentioned of trying to conceive, a weight loss of as little as 10% of your body weight may be enough to overcome the Unopposed Estrogen Syndrome that is most likely to be the root cause of anovulatory cycles and failure to conceive in women with a BMI over 30. And even if the problem is NOT as straightforward as losing a few pounds, wouldn't you want to try that before resorting to invasive measures that carry risks and side effects?

I wonder-- is the reluctance to accept this advice stemming from the fact that it suggests that it's the womans own fault that she can't conceive? Or is it even deeper than that? Is it because she feels that answer is "too easy" and wants medical intervention to feel that something is actually being done?

In a roundabout way, this leads us to the issue of PCOS (polycystic ovarian syndrome), a complex problem which encompasses benign ovarian cysts, irregular menstrual cycles and insulin resistance. More women are being diagnosed with this today than ever before. It's still unclear if being overweight predisposes you to developing PCOS or if PCOS causes obesity secondary to insulin resistance. But it's the same insulin resistance that is a precursor to adult-onset diabetes, a condition that is known to be caused in part by being overweight. Which came first... Chicken? Egg?

I'll get off my soapbox now. But I'm always hesitant to address the issue of weight with a patient, unless it's directly related to their reason for coming into the office (high cholesterol, knee trouble, diabetes). Maybe I'll get braver as time goes on, because I fear that continuing to ignore the elephant in the room isn't doing my patient any favours.