Weighty Assumptions

"It's like they make the diagnosis as soon as they see you walk through the door." -- Miki Merritt, Vice President of the local chapter of the National Association to Advance Fat Acceptance. (By Katherine Frey -- The Washington Post)
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By Roni Caryn Rabin
Special to The Washington Post
Tuesday, January 29, 2008

After a car accident mangled her right foot, requiring five operations and a bone graft from her hip, Lynn Behnke was in so much pain that she had a hard time sitting or sleeping and often had to call in sick. But when she went back to her surgeon, his advice surprised her.

He told her to go on a diet.

Behnke was livid. "If a skinny person came in with that kind of pain, they would have been given pain medication," said the 44-year-old Fairfax resident, who then weighed 200 pounds -- enough, at 5 feet 6 inches tall, to be considered obese.

Overweight and obese patients have long complained that doctors treat them insensitively and are too quick to attribute health problems to their weight. But their claims of bias were often met with skepticism -- until recently. Now research from such academic powerhouses as Yale University and the University of Pennsylvania is adding to evidence that the problem may be real and may affect patients' quality of care. And actions by the giant health maintenance organization Kaiser Permanente show the medical establishment is beginning to respond.

Two studies in the journal Obesity Research in 2003 found that many physicians harbor negative attitudes toward fat people: A University of Pennsylvania study of 620 primary care physicians found that more than half reported viewing obese patients as "awkward," "unattractive," "ugly" and "noncompliant"; a Yale study reported that health professionals strongly associated being overweight with being "lazy" and "stupid."

Such negative views, some experts charge, may be helping to drive patients away: These experts point to a 2000 study of 11,425 women, which found heavy women less likely to obtain cancer screenings such as Pap smears and mammograms even though they're at higher risk of dying from cervical cancer and breast cancer. Newer research has produced similar findings: A 2006 study of 498 women, published in the International Journal of Obesity, found that obese women delayed cancer screenings more than other women. Negative attitudes of health-care providers and disrespectful treatment were among the reasons cited for postponing care.

"What's concerning is that people who are overweight and obese should probably be seeing their physicians more often, not less, because of their increased health risks," said Rebecca Puhl, director of research and anti-stigma initiatives at Yale University's Rudd Center for Food Policy and Obesity.

Working with Kaiser Permanente, Puhl last year developed a training program to educate health providers about weight bias; the program went online in December.

Puhl said she is concerned that physician attitudes may be harming patients' emotional well-being as well as their physical health, undermining self-esteem and possibly triggering the very destructive behaviors doctors want to discourage, such as binge eating.

Several obese patients said in interviews that they went to see a doctor only when it was unavoidable and often left feeling that they hadn't gotten the help they needed.

"It's like they make the diagnosis as soon as they see you walk through the door," said Miki Merritt, 42, of Grasonville, Md., vice president of the local chapter of the National Association to Advance Fat Acceptance ( http://www.naafa.org). In her case, she said, doctors incorrectly ascribed a painful rash to poor circulation they blamed on her weight. (At 5-3 and 220 pounds, she has a body mass index of 39; 30 or higher qualifies as obese.)

A Johns Hopkins-trained dermatologist later diagnosed the rash as a symptom of sarcoidosis, an inflammatory disease that can affect multiple organs and is believed to be an autoimmune disorder. He treated Merritt with steroids, which suppress the immune system, and, Merritt said, she has not had a flare-up since.

Behnke, the woman whose car accident left her with chronic pain, said she "fired" the doctor who kept harping on her weight and found a new primary care physician who took a different approach, prescribing physical therapy and acknowledging that her pain was real.

"I told my new doctor, 'I suppose this will get better if I lose weight.' He said, 'Not necessarily,' " Behnke said. "He said, 'You've had nerve damage, joint damage, tissue damage and muscle damage; it's not necessarily going to go away.' "

A Yale study of 2,449 overweight and obese women, published in 2006 in the journal Obesity, found that they identified doctors as one of the top sources of negative comments about their weight.

Online complaints about physician attitudes toward fat people have grown louder since a Wisconsin woman posted a blog a few months ago titled "Fat Hatred Kills," about the death of her 53-year-old mother. Barbara Benesch-Granberg, who identified herself in the post only as "Thorn," said her mother, a short woman who weighed about 280 pounds most of her adult life, had avoided physicians for years after a doctor told her "not to come back" until she lost 50 pounds.

The three-part post touched a nerve, and now obese patients are chronicling their experiences with the medical establishment on a new blog, called First, Do No Harm ("Real Stories of Fat Prejudice in Health Care"; http://www.fathealth.wordpress.com).

Some patients relay disparaging comments made by their doctors; others contend they were misdiagnosed because a physician was so preoccupied with their weight. There are also links to blogs recommending "fat-friendly" physicians throughout the country.

One patient, Becky Johnson, 34, of Westerville, Ohio, described her experience with a specialist who told her that all she needed to do to resolve a painful hip condition was lose 100 pounds. He wrote her a prescription that said "Potatoes, rice, sugar, pop -- No!"

"The whole thing -- from the time I walked into this office to the time I walked out -- took 10 minutes, and he never even looked at my hip," Johnson said in a phone interview. She later sought help from another doctor, who diagnosed bursitis and treated her with cortisone.

But doctors are in a quandary: If they tell a person to lose weight, they risk alienating that patient. But if they sidestep the subject, they're possibly jeopardizing the patient's health, since being overweight is a risk factor for serious conditions including hypertension, diabetes and heart disease.

"Part of the problem is that primary care physicians don't really have a lot to offer [to obese] patients," said Arthur Frank, medical director of George Washington University's Weight Management Program. The standard advice to eat less and exercise more isn't very helpful to obese individuals, some of whom are increasingly believed to suffer from a metabolic disorder rather than a failure of will, he said.

So, many physicians feel frustrated. They may make assumptions about an obese patient's lifestyle and may, rightly or wrongly, hold the patient responsible for the weight problem, said Lorenzo Norris, a psychiatrist who is director of the Medical Wellness Program at George Washington University Hospital and screens patients for bariatric surgery. Patients, meanwhile, feel chastised, blamed and judged.

Keith Bachman, a Kaiser Permanente internist who collaborated with Puhl on the weight-bias training program, said physicians can put obese patients at ease by asking them if they want to discuss their weight before initiating a conversation and focusing on concrete behavioral changes -- such as walking four times a week instead of twice -- rather than on weight goals.

"Just acknowledging that weight loss is difficult can go a long way with patients -- and acknowledging that they've tried many, many times before," Bachman said.

The training program asks doctors to question their own assumptions and ask themselves, "Do I consider all of the patients' presenting problems, in addition to weight?"

"It's not a black-and-white issue," said Cathy Grinels, a 55-year-old teacher from Alexandria who is obese. "I don't want a doctor who is going to ignore my size. But if I come in with an ear infection, I don't want it attributed to my weight."

Roni Caryn Rabin is a freelance writer based in New York. Comments:health@washpost.com.

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