From The Wards: How We View Obesity

Obesity is not a new problem to the everyday American. Over the last few decades, we have been bombarded with news of overwhelming obesity and of the alarming childhood obesity running rampant. In the hospital, we see countless patients coming in with obesity as a direct cause of their acute presentation or obesity as an inseparable compounding factor. Sensational television and Internet series highlighting the lives of obese patients suffer through have created more awareness of this complex issue.

Unfortunately, by and large, public opinion of obesity perceives these individuals as slovenly, lazy and intentionally ignorant about their life choices. To many, obesity is viewed as a largely preventable and reversible condition. Even in the world of medicine, it is not uncommon for negative bias to be assumed when treating obese patients. More often than not, I have heard snickers about patients’ weights, lack of sympathy to the patients’ difficulties, and even complaints about their “extra” complications that have to be accounted for simply because of their size.

It is fact that obesity adds a layer of complexity in health care. It is fact that these patients tend to have more problems at clinical presentation and throughout their hospital course; their past medical history lists are longer, and they have less effective responses to certain therapies. It is also fact that these patients are set up for more complications during or after their stay at the hospital compared to their non-obese counterparts, and they are at higher risk of recurrence of disease.

It is not fact that these patients are doing this intentionally.

It is not fact that these patients want this and don’t care for their circumstances. It is not fact that these patients deserve whatever ailments they suffer. It is not fact that everything is within their control and these patients simply chose inactivity.

The problem of obesity is a multifaceted one; it is deeply embedded in the fabric of socioeconomic and emotional contexts. For many of us, the act of eating is an emotionally charged event carrying social and even familial weights. For some, it is a method of comfort — who isn’t familiar with the phrase “eating your feelings away”? — or a way to establish control in one’s life. For others, weight loss may be obstructed by significant barriers: physical disability, mental illness, financial obstacles, comorbid medical conditions, and so on. Risk factors such as smoking, alcohol and substance abuse also play integral parts in exacerbating this already morbidly dangerous condition.

At the heart of this problem, it is painfully obvious to me that most people do not have a good understanding of a healthy diet and appropriate lifestyle modifications.

During my third-year rotation, I worked at the bariatric surgery clinic for a week. Looking through the shelves of protocols and paperwork, it was immediately clear to me that weight-loss surgery was an extremely arduous procedure. As a medical student, I wasn’t immune to the notion that such procedures were performed out of a personal failure to achieve weight loss instead of a necessity before this rotation.

The requirements to qualify for bariatric surgery are exceedingly long. At my institution, patients must first complete a full course of educational material with checkpoints and exams to verify their understanding. After that, patients must be signed off by a general physician, a nutritionist and a psychiatrist. Patients must also go through extensive dietary modifications with calorie-guided diets to ensure continued success of the surgery. Finally, they must lose a certain percentage of weight prior to their surgery date to be given the green light. Even after surgery, there are regular follow-up appointments in place to track progress and monitor adherence to diet and various lifestyle modifications.

After sitting in on several parent-child obesity appointments, I realized for most obese patients, the problem starts very early on in their lives. The lack of education on what’s healthy and balanced living is a very pervasive and repetitive theme. Many of these patients start as extremely picky eaters, and their lack of portion control is often compounded by parents’ fear of denying their children. It’s astonishing how Super-Size America (bigger is always better, right?) permeates so deeply into our minds. The team showed real-life portion sizes of different foods to both the parents and child to educate on appropriate meal time sizes. Sitting in the small, pediatric chair watching the conversations, I take account of my own shame when I realized I definitely eat more than one serving of pasta easily at a time.

On the wards, I’ve witnessed our teams academically account for obesity as risk factors for complications and make specific accommodations. Extra precautions are taken to maximize patient outcome — just like any disease process with compounding risk factor such as hypertension or chronic liver disease. For the most part, the team never discounts the patient’s obesity as a lesser factor in their patient care.

What’s lacking is the education piece. In the inpatient setting, the team often assigns this part as an outpatient task. A nutritionist is contacted, and the patient is often instructed to follow up upon discharge. The disconnect is that most patients don’t know why they have to follow up. Sure, it is common knowledge that obesity is an unhealthy condition, but many patients don’t understand the vast medical ramifications their obesity has. What’s more, many of them don’t realize that their obesity can be attacked in a stepwise manner, chipped off one fragment at a time. It doesn’t have to be an extreme upheaval of lifestyle or a complete sacrifice of all things that ever tasted good to mankind. Like any chronic disease, it’s a compromise and a work in progress that should be a continuing conversation with the patient’s healthcare team.

Perhaps part of patients’ hesitance in taking action is the fear of judgment. The accusation of being lazy and unwilling to change is a hurtful one. What’s more, because for many patients, obesity is not simply an issue of eating and weight loss, they often don’t feel comfortable facing this behemoth. What they need is a supportive team that not only provides patients with good lifestyle modifications, but also addresses the elements that fuel unhealthy choices whether that be counseling, smoking cessation, financial support, family conferences and so forth.

At the end of the day, I believe that obesity is just as important as any other item on the patient’s problem list; it is a complex problem that needs an open dialogue between physicians and patient. And until we stop laying all the blame at the patients’ inaction, and unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.