In treating obese patients, too often doctors can’t see past weight

The persistent cough started when Rebecca Hiles was 16. She was an active high school senior, though, at 180 pounds, overweight for her height. She was diagnosed with airway irritation, given medicine, and advised to lose weight. But she was unprepared for how much those extra pounds would dog her over the course of the next seven years — overshadowing her doctors’ visits while a tumor grew undetected in her lung.

Her symptoms persisted through college and beyond, and she put on weight. At every visit, with each of 11 different doctors, she was diagnosed with something different — acid reflux, allergies, bronchitis, pneumonia — and advised to lose weight. Tired of hearing the same advice over and over, she started skipping appointments.

“I was telling my doctors that there is something wrong with my body and they were not listening,” she said.

When she returned to the ER in 2012 with more severe respiratory symptoms and a fever, she was referred to a pulmonologist. A CT scan there detected her cancer, which had progressed to take over half of her left lung.

She had surgery to remove the entire lung in November of 2012. Fat shaming, she said, cost her a lung, and it could have cost her her life.

Hiles’s medical odyssey was unfortunately not unique. Our cultural obsession with appearance may bleed over into the exam room, leading doctors to disproportionately focus on weight and to interact with fat patients differently from thin ones. It’s a stigma that can bring sometimes life-and-death consequences.

“This is not about somebody’s feelings being hurt,” said Dr. Michelle May, a family medicine physician and proponent of Health At Every Size, a group advocating for a weight-inclusive approach to health. “This is about people receiving inadequate health care, and preventative advice, and counseling, and support, and treatment — because the focus is on weight instead of managing risk factors.”

Risks missed

Obesity is a health risk, and its growing prevalence a cause of concern. Excess weight increases the risk of a variety of health conditions including high blood pressure, diabetes, heart disease, and stroke.

But medical professionals disagree about how they should address weight management with patients, or whether they should address weight loss at all. Diets may be effective for losing weight temporarily, but they rarely work for overweight and obese people in the long term, and the health gains are likewise fleeting. And by focusing on weight loss, doctors may harm their relationship with a patient or miss a chance to discuss other, more pressing health issues.

Take for instance the findings of a recent survey on heart disease. Of 700-plus women who had a heart disease risk factor — things like high blood pressure, high cholesterol, or diabetes — only 16 percent reported being informed of this risk by their doctors. Much more commonly, those at risk were told to lose weight, even though weight is not factored into risk predictions for heart disease. Half of the women said they had cancelled or delayed a doctor’s appointment until they could lose weight.

An earlier survey of primary care physicians and cardiologists showed a similar pattern. Though heart disease is the leading cause of death among women, the study found only 39 percent of physicians were “extremely concerned” about this issue, whereas 48 percent of physicians were “extremely concerned” about women’s weight.

“We haven’t really thought about this before” but we need to explore the issue “because women are dying,” said study leader Dr. Noel Bairey Merz, medical director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Heart Institute.

It’s not just heart disease. Another study has found that other types of preventative care, including breast exams and pap smears, are often delayed by obese women. While obesity is associated with a variety of health conditions, if the medical profession fails to provide a safe space for patient care, these missed opportunities for intervention may be partly to blame.

To avoid feeling shamed, some patients will let “things exacerbate to a huge degree before they seek medical care because this stigmatizing interaction has set them up to mistrust any sort of medical interaction,” said Dr. Sayantani DasGupta, a pediatrician and faculty member at Columbia University.

Bias is an insidious thing, though, and doctors may not even be aware of it. Studies of so-called implicit bias have found that even medical professionals who work specifically in the area of obesity harbor biases toward fat individuals, associating them with being more lazy, stupid, and worthless than thin people.

That can show through in doctors’ relationships with patients. Physicians are much less likely to offer statements of empathy, concern, or reassurance to overweight and obese patients — things like, “I can see how frustrated you are by your slow progress — anyone would be,” or, “I can see this is very distressing for you.” That connection can matter to their care in larger ways. Studies show that patients with less empathetic doctors are less likely to be satisfied with their care and to follow their doctor’s advice.

A way around weight

Evidence from randomized controlled trials points toward another solution — that physicians can set aside weight loss and still make headway on other health risks, such as lowering cholesterol and high blood pressure. For instance, the Dietary Approach to Stop Hypertension (DASH) nutrition plan has been shown to lower blood pressure in people with obesity by promoting healthy foods, without aiming for weight loss. Aerobic exercise programs for obese women have successfully lowered their risk of heart disease, regardless of whether the women lost or gained weight.

But other doctors contend that removing weight from the equation is ultimately a disservice to their patients.

“We should look at [obesity] as a chronic disease, and treat it as such, but definitely not ignore the benefits of weight loss or even dumb it down or simplify it,” said Dr. Ian Neeland, assistant professor at UT Southwestern Medical Center. Patients deserve compassionate care, but for those most at risk, watching weight is important, he explained.

Close monitoring of weight can alert physicians to illnesses that patients themselves may miss, things like viral infections, thyroid disorders, heart failure, and even cancer.

But it’s a delicate balance.

As humans it is impossible to eliminate the instinct to judge others, but by recognizing that these judgements exist, physicians can consciously work to overcome them.

Physicians should avoid attribution bias, or blaming a health condition on a patient’s weight because it is low-hanging fruit. Patients across the weight continuum develop a variety of diseases. Obesity does not make patients immune to conditions smaller patients develop and vice versa, and this fallacy can be fatal to patients. Weight-based stigma shouldn’t be allowed to stand in the way of doctors giving care and patients seeking it.

“We can have the best science in the world, but if we can’t deliver the practice that will improve health, then what’s the point of the science?” said Merz.

As for Hiles, she finally found that practice, in the form of a team of doctors who tackle her health in a more holistic manner not tied to the numbers on the scale. “I’m in a really good place when it comes to physicians,” she said. And she remains cancer-free.