The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Monday, March 06, 2006

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.

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Blogger Gym Girl said...

Being overweight myself (I hate the word fat) I would have to say that issue is the fact that the patient themselves is the cause of the problem. We are a society of high tech medicine that can cure all sorts of things. Something hurts and there's an over the counter medicine that can relieve the pain. But to insinuate that you, A DOCTOR cannot prescribe something to fix this problem is unthinkable! How dare you put it back on me! Accepting the fact that you are to blame for your problems is hard for anyone to swallow. I don't envy your position at all. I think that until the patient realizes that they have a weight problem and it may be the cause of other problems there is nothing you can do. I had to hit rock bottom before I finally started losing weight... maybe I'm not the only one who needs a swift kick in the behind to finally acknowledge the problem.

2:43 PM

Blogger Gabbergirl said...

I am overweight, and I am also struggling with PCOS. I was doing really well losing the weight, and then something happened and I've gained some of it back. It's making it really hard for me to get going again. Even though I KNOW it would increase our chances of getting pregnant if I did. It feels like so much pressure.

And it is hard to hear you have a weight problem, even from a doctor. I totally hear my mom getting after me all the time to lose weight, which really makes me want to stop at the next drve thru. So when I got to my fertility doctor next Monday, I am going to try really hard to take his advice to lose weight if that's what he thinks I should do before any invasive tests are performed.

Thanks for reminding me about this though... it helps to hear it put so eloquently and it really helps me to put things into perspective.

5:50 PM

Blogger Ada said...

It's sad that we live in a society where "overweight" is synonymous with "ugly" or "imperfect" as opposed to the more accurate "unhealthy". However I think that as a female doctor, you'll be able to better connect with your patients than a male doctor dispensing the same advice would. Good luck on speaking up more!

11:31 PM

Blogger Carina said...

Weight issues suck. They just do.

I had a different problem when I was ttc the first time around--I had to gain weight. I was on a special diet for my endometriosis, and I was having trouble keeping my weight at a normal level (I don't know why, as now the pounds are sticking around *sigh*). Once I finally gained a few extra pounds, I got pregnant--on my hubby's surgery rotation in med school on the one time we had sex that whole month that we thought was too late for me to get preggers.

Of course, now I have the opposite problem after more treatments post children for my endo and all, but even Hubby, the internist, is carrying a few extra pounds and is nice about it.

I think if it comes from a doctor who looks too perfect, then it's too hard to hear. If I hear that they're having trouble too and understand that I'm trying, I'm more likely to listen and keep working on it. That's just me, though.

5:52 PM

Anonymous Anonymous said...

As someone who wants to be be very healthy when I decide to have children, I have been bugging and asking my physician for anything that I should do to have the best pregnancy possible. I will be trying for children in a year or two (WBer here) and I want to do what's best for myself and my children.
She told me to lose weight (I was 59kg - 152 cm) and she's been watching my blood sugar for 6 years (tendancy for hypoglycemia). I have full confidence in her abilities to help me take care of myself. She's refered me to a nutitionist and encouraged me to work out (a lot). I'm so much healthier now.
She told me I'm overweight, and I listened and it was great.
Keep up the great work because some of us appreciate it.

9:16 PM

Anonymous Sandra said...

Of course you knew I would have something to say about this.

I've lived it. Having irregular menstrual cycles since I first got my period (I wasn't overweight at the time), being over weight now and for the last 12 years, having been tested when I was younger for polycystic ovarian syndrome. I am the patient you are talking about.

When we were first trying, we wanted to do it right. I got the best books on being healthy and getting pregnant. I knew my "extra pounds" were an issue and wanted to speak to an OB to be certain even though I was overweight I could have a baby. First doctor we saw said absolutely nothing. Everything a-okay and told us we would be pregnant before the year was over.

Took us a year and a half to conceive our son. And we only did so because we saw another doctor who was amazing enough to be honest. Looked at me said I was overweight, said if I didn't lose I wouldn't get pregnant and that if I did get pregnant it would cause complications. That he also wanted me to be there for my son after he arrived.

I lost 40lbs and got pregnant right after. I walked into his office for an update and I told him I was pregnant. He screamed out "Hoorray!!!!!". I loved that doctor and wish others could follow in his way of practicing.

Find the courage, because out of every person who gets pissed from being told the truth there is another who will listen. There is another who's life will be changed forever because you had the courage.

6:43 PM

Blogger doctor T said...

My doctor never told me to lose weight, and even when I started losing weight and asking questions about weight loss had no advice or answers for me. I was clearly overweight/obese and I have joint problems. I knew I needed to lose the weight, but it's sad that my doctor never said anything. Then again, she's generally a pretty shitty doctor, so I don't think it was fear of saying FAT that was the problem. I think it was more because of her constant overbooking and insistence on 5 minute appointments.

8:56 PM

Anonymous Anonymous said...

Okay, so because a women is overweight she doesn't have a right to medical tests and treatments like a thin women?

What is an overweight women does have a blocked tube, but the doctor refused to treat her because of her weight??? That is just wrong, wrong, wrong!

If my doctor dismissed all my health concerns because I'm overweight, I would be one sick girl.

I'm grateful there are "fat" friendly doctor's out there.

11:25 AM

Blogger Couz said...

The last anonymous comment has completely missed my point. It has nothing to do with anyone's 'right' to medical investigations. It's a question of people wanting to rush to invasive investigations and treatments when many of these cases would likely resolve with weight loss. Wouldn't you want to try the noninvasive thing first? Unless you suffered from PID in the past or have a known congenital malformation, the chances of any woman having a blocked tube are a lot slimmer than the chances of her having a hormonal imbalance secondary to excess adipose tissue.

But if the problem were as simple as a blocked tube you wouldn't be likely to suffer from irregular cycles anyway. A blocked tube is asymptomatic.

9:16 PM

Blogger Leah said...

This comment has been removed by a blog administrator.

2:40 PM

Blogger Ms.Teacher said...

I've been wondering about this myself. Last year, my world came crashing down, health wise. I needed to see a cardiologist and a rhuematologist. I am overweight, but neither doctor told me that losing weight would help. Now, logically I know that losing weight would dramatically help in many ways. Why would they not tell me this? I have been very successful at using this as an excuse NOT to lose weight. I'm not blaming my doctors per se, but I wish I had them pushing me to lose weight to help decide that I need to for once and for all.

3:12 PM

Blogger MustangSally said...

I had never heard of PCOS until I was diagnosed with it myself. Insulin resistance is not fun at all, but it was sort of a relief to know why I was gaining about 10 pounds a year and couldn't lose it no matter how much I exercised or didn't eat.

Something to keep in mind is that I wasn't offended by my doctor mentioning my being overweight. I was relieved when I found out I wasn't just fat because I was lazy. Even though having insulin resistance or metabolic syndrome isn't much fun, it still helped to have a name to the problem I was having.

And a bit more food for thought: I've lost over 20 pounds since I started eating on a diabetic diet. I don't starve myself, I have just changed the type of foods I eat. I bet a lot of women would love to hear that they could still eat a lot of the foods they liked and still lose weight. Of course, there's no guarantee, but hope is hope. Glucophage has helped me a lot too. The most important thing is to let the patient know you are supportive. It's easier to take advice that way.

9:28 PM

Blogger Couz said...

Sorry, Daisie. I had to remove your comment because you used my real name. Anonymous blog, remember? ;-)

Too bad, too. It was a very eloquent comment.

9:40 PM

Blogger mrbunsrocks said...

The world needs more doctors like you!

Sometimes, the issue stems from the size of a patient - too small, too large, etc. It sucks because it's such a sensitive topic, but when someone is able to address it in a constructive way, a lot of headway can be made. :)

4:03 PM

Anonymous Anonymous said...

I work in administration for a healthcare system (hospitals, physicians' offices, home health, the whole 9 yards for comprehensive patient care) and once a year we are given the opportunity to have a free "wellness profile". Of course I take it because it's free basic metabolic labs that I can take back to my m.d. and we work on any problems. Just before my wellness profile last year I was discovered to have arthritis in my hip (I'm mid thirties, this is not fun) and the wellness profile came back with hyperlipidemia. So, my md told me to lose 15lbs because my hip would hurt less and my cholesterol would go down. (Eventually, I'll need to lose 40 from where I was, and I know that, but fifteen was a start.) I lost ten of those pounds and have become pregnant with baby #4, but the cholesterol is down to an acceptable ratio and I'm just now - 10 weeks from delivery beginning to have daily hip pain from putting back the 10 lbs plus 4 more.
I am overweight. I knew that before, and I know that heart disease and diabetes are my family's killers. Now, my doctor is helping me to work toward manageable weight loss goals, or will be after baby comes. Working with her, just knowing she might ask me on any given day that I see her, has helped me to be better about trying to lose the weight.
By the way, I have not shown any signs of diabetes since Baby #3, but eating an ADA diet was helping me lose the weight and has kept me from getting gestational diabetes again. I'll be sticking with that (at least mostly) for the rest of my life because I feel better eating this way.

11:03 AM

Anonymous Anonymous said...

As a 'fat' nurse, my own doctors avoided the subject of my weight. It was frustrating for me as I was doing all I knew how to do to loose weight and just kept ballooning. I read an article on PCOS in the popular press and began delving into the medical literature about the subject. When I brought up the possibility to my own GYN, he admitted he didn't know much about it. I gave him my printout from the lit review and we agreed to meet a few weeks later. In the meantime, I passed one of the endocrine/GYNs in the hall and asked for a 'hallway' consult :) Gotta love us nurses, eh? My only question for him initially was, "Look at me like a patient, not a peer, and think PCOS. What do you think?" He did a good up and down in Dr mode, and said, "You could be a poster child for PCOS!" He agreed to consult w/ my MD. With collaboration between my GYN and IM docs, 4 years later I am 150# lighter and doing great.

So, despite the topic being tough and full of emotional overtones, don't give up. If my healthcare team and I had been able to get past the judgemental aspects of discussing my weight, we might have discovered this disorder sooner.

You already have a communication style at work (we all do), with practise and time you will find a way to really TALK w/ your patients about this topic in the same way you discuss smoking, sexual activity, and drug use.

12:17 AM

Blogger Alison Cummins said...

I think you missed the point of Anonymous 11:25 AM.

When a doctor says “you’re fat,” yes of course a woman hears this as a moral and social judgement like all the moral and social judgements she’s heard and made over the years. Just like you said. So when a doctor adresses a health complaint with “lose weight and then get back to me,” she hears it as “the only people I treat medically are thin people” or “prove that you meet my standards for self-care and I’ll think about it” or “your fat is the most important thing about you” or “you might be worried about your fertility/joint problems today, but I’m going to punish you for being fat by deferring help until you lose 20/100/200 lbs.” And sometimes this is exactly what they mean. A fat friend was told by a doctor “I like my women thin.” Well, she doesn’t care how he likes his women. She’s not his woman, and her body doesn’t exist to please him.

Add to this the fact that many fat women have spent their lives dieting and have actually gained weight as a result: the yo-yo syndrome. One woman calculated that if she had never dieted she would weigh 150 lbs instead of the 275 she weighs now. Being told to “just lose weight” doesn’t instil confidence in these women or make them feel heard or respected.

Some fat people have psychiatric problems. Anxiety or compulsive disorders or psychiatric problems or neurological impairments. Telling them to come back when they’ve lost weight doesn’t address the reality of their lives.

This is not to say that doctors should ignore the elephant in the living room. But they need to be able to hear Anonymous 11:25 AM to be able to do this effectively.

One way is to do a thorough physical workup to reassure the woman that she is being treated as a whole person and not as a piece of fat. Then present a diagnosis: PCOS, for instance. Being fat is a risk factor for PCOS, but PCOS is also a risk factor for being fat. Work on a plan for treating the PCOS that can be monitored. Of course it needs to include weight loss, but the problem should be identified as PCOS, not fatness.

Another way of addressing fatness with a patient is referring to it as “gaining weight easily.” There are lots of reasons someone might “gain weight easily” that have nothing to do with moral or social judgements. But if someone gains weight easily and they have PCOS, then losing weight is going to require more vigilance than for a “naturally thin” person. Acknowledge this. That doesn’t mean the effort shouldn’t be made, but that you will be there for the bi-weekly weigh-ins at your clinic and for ongoing advice and support.

11:20 AM

Anonymous Anonymous said...

I too had the menstrual issues spoken of by the other posters and while I was treated medically some of the time (with great reluctance, I might add), I was always told I needed to lose weight.

I knew that, of course, but at that moment, it didn't help the immediate problem which was, to put it quite delicately, a serious problem. (A little love affair with megadoses of iron solved the immediate problem--after 5 years of having the immediate problem.)

All in all, it took me 20 years to find a way of eating that worked wonderfully well for me. So well, in fact, I lost 150 pounds in 2 years and felt fabulous, with good labs.

However, whenever I mentioned the name of this wonderfully magical eating plan to my doctors, I was met with sneers and jeers.

The fact is that the doctors who *will* tell you to lose weight have no idea how you should go about doing so and are not receptive to alternative theories of nutrition.

After my experience and education with my eating plan (ah, Atkins--is that a dirty word here, too?), I have come to the conclusion that generally, docs are woefully uneducated about diet in general, much less targeted diets for certain results.

7:19 PM

Anonymous Alexandra Lynch said...

Not only is the problem that the phrase "you need to lose weight" heard in the voice of everyone who ever made fun of her over the years, she may be in the position I was, in which I could eat a ridiculously small amount a day and maintain weight, if not gain. (I had no trouble getting pregnant, however. Quite the reverse problem.)

In the end, I was diagnosed with a thyroid tumor, had that removed, and went on thyroid hormone replacement therapy. And now the weight's coming off, though slowly.

I'm still working through anger that I spent a third of my life so far trying desperately to cut calories or fat or carbs or whatever and the problem could be solved with a small pill.

11:20 PM

Anonymous Anonymous said...

The message that REALLY comes through is "I KNEW I NEEDED TO LOSE WEIGHT" why wait for the doc to tell you that? And how does he/she get to be the monster for telling you that, however he/she words it?

The cultural message is that we aren't responsible for ourselves, that whatever is wrong in us is someone else's fault and another someone ought to fix it without much discomfort to us.

Grownups look around, see what needs to be done, figure out how it can be done and gets to work on it.

My health is my responsibility and only I have any real power to improve it or to destroy it. To me, that rocks! Why on earth would I give up such power?

12:11 PM

Anonymous Anonymous said...

Alright, fair enough. But what about someone with PCOS who isn't overweight? When I was diagnosed my BMI was 23.5, was told that losing a little weight may help with the symptoms. Easily lost 20 pounds through healthy eating and exercise, now BMI 20 and I'm having more problems than ever. Med's haven't helped, weight loss hasn't helped; my androgen levels are up, progesterone through the roof, menstrual cycles have stopped entirely, and my docs just shrug it off like it's no big deal since I'm not overweight and not trying to conceive atm. What's a girl to do??

2:52 AM

Blogger Irishdoc said...

I agrre that docs run into alot of problems when we tell people that it's time to lose some weight. People often aay that they "know" they need to lose weight, but I don't think people can understand the effects we see on a daily basis. The guy in sepsis that were terified to RSI because he has a difficult airway, the lumbar puncture we can't get because the needle isn't long enough or in extreme cases the pt we have to send to the zoo because they won't fit in the scanner. It's a real problem

3:52 PM

Blogger Alison Cummins said...

And then of course there’s this woman who wondered why she kept dieting but never lost weight:

5:31 PM

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7:17 AM


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