By Susan Levine
Washington Post Staff Writer
Tuesday, January 3, 2006

When Irish researchers recently reported that many people's rear ends are too fat for regular-length needles to reach their target, the finding immediately made the opening monologues of late-night TV shows on this side of the Atlantic. The wisecracks were an easy laugh, but for the one in three American adults who is obese or close to it, they were no joke.

Because of this country's expanding heft, blood-pressure cuffs now come in "large adult X long" for arms that don't fit smaller circumferences. Patient gowns can be ordered in size 5X, providing "comfortable, comprehensive coverage," according to the ad for one product. There are wheelchairs with seats up to four feet wide, scales that measure many hundreds of pounds and hospital beds built sturdy enough to handle excessive loads.

Drug injections in the derriere are merely the latest example of how extreme weight complicates the delivery of routine care, often with adverse effects.

An industry has sprung up to make and sell larger supplies and equipment. "It's been a developing problem, and we've watched the manufacturers adjust," said Scott Hanna, whose company, QuickMedical in Washington state, offers "AmpleWear" gowns and "high-capacity" home scales that go up to 660 pounds. Customers include more than medical providers, and Hanna especially remembers the entreaties he has gotten from the general public.

"People call and say they had to go down to the boatyard or the post office to get weighed, and it was humiliating," he said. "Until you speak with these people heart to heart, you don't understand what they're going through."

Susan Yanovski, an obesity expert with the National Institutes of Health, has studied the facility changes required for larger patients and the physician approaches that she thinks need to evolve, too. The bias against obese people is "systemic and institutionalized," she has written.

"We're really just getting started in looking at how this impacts care," she said in an interview. From accessibility to attitudes, "we're really doing people a disservice if we don't find better ways to do diagnosis and provide treatment."

The percentage of obese Americans has more than doubled since 1960, with the most gain occurring in the last two decades. Given that change, it's not only the specialists who are having to adjust.

In Manassas, family practitioner Philip Peacock and his colleagues at Prince William Family Medicine soon may plan a new office. And it makes sense, Peacock said, to consider the dimensions needed for their increasingly heavy clientele. One architect recommended adding a love seat to the waiting room. Like so many doctors' waiting rooms, theirs is filled with standard-issue chairs -- with arms.

"A love seat would fit a larger patient without them having to look around the room" for a feasible alternative, Peacock said.

That might be just the start. Perhaps a specially designed exam room: "We've had patients who couldn't lay down on our standard table," he said. There also have been patients whose weight precluded certain diagnostic tests at area hospitals; for one man several years ago, Peacock even made calls to veterinary schools.

Sophisticated imaging machines such as MRIs now are being super-sized. "They don't have to stuff people in there," said David Boleyn, an attorney for a venture capital group that unsuccessfully sought regulatory approval for three such machines for Northern Virginia clinics.

The issue goes beyond girth to medical efficacy. Although an open MRI machine can accommodate an obese person, its penetration and focus often suffer. A higher energy level is required to bore through all that tissue and "produce a clear, clinical image with a diagnostic value," Boleyn said.

Obese people may face similar problems with ultrasound, mammography and electrocardiogram tests. They may avoid regular health care because of embarrassment, caustic physician comments or transportation difficulties. No matter the reason, the implications can be serious.

Even with comprehensive care, extreme weight heightens the risk of diseases and disabilities, including diabetes, hypertension, osteoarthritis and sleep apnea.

Two years ago, Duke University's medical school became one of the first in the country to start an "obesity management course" for its aspiring physicians. The professor who created the month-long rotation said the traditional medical curriculum offered little exposure to obesity or its treatment.

Much continues to lag, however. The Irish study released in late November may have determined that participants were getting inadequate drug doses because needles could not reach the buttocks muscles, but it did not look at whether the drug quantities being administered were adequate for people's weight.

Clinical trials are rarely conducted with severely heavy people, and extrapolating and adjusting dosages can be difficult, noted Morgan Downey, executive director of the American Obesity Association. "There's just a lot of uncertainty as to what to do," he said.

For most of his 66 years, Washington lawyer Michael Berman has confronted weight and medicine -- as a patient. He has been as much as 332 pounds fat, the word he always uses, though he's currently in the slimmer 230s. "I've never trucked with doctors who were the least bit put off with my size," said Berman, whose soon-to-be-published autobiography, "Living Large," likely will make that clear. Still, he has had to put up with health care along the way.

There was the knee surgery when he had to be bent over the edge of the operating table and "stretched" so the anesthesiologist could locate the right spot for an epidural needle. A kidney biopsy nearly didn't happen because of concerns that his adipose would keep a crucial line from its destination. To this day, any time a nurse takes out a regular blood-pressure cuff, Berman takes charge.

"The problems," he said, "are real."