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.

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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.

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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.

  • Let be realistic. Obesity is not a chronic disease. Obesity is costing the insurance companies billions of dollars each year and doctors need to start addressing obesity. People who are obese are literally crushing their lower extremities, and I see this on a daily basis. On a personal note my Cardiologist looked at me and said your fat and I see you for a heart attack in the next five years. That was 40 pounds ago. Sometimes a little tough love does a body good. We have tried to become so politically correct that were afraid to offend people. Let be honest, your fat and if you do things right you can look and feel better. Its my choice and my choice only on what I put in my mouth. Start making dinners at home that are healthy and stay out of the buffets.

  • I appreciate this article. Another problem diagnosis is chronic pain. for years i was prescribed low dose narcotics without being tested for what was causing the pain. My belief is that physicians prefer to prescribe pills and have the patient return rate boost their income. The other factor in not diagnosing the cause of pain is their belief that the patient especially of female has an emotional component and likes to take narcotics. It seems to me that doctors prefer to prescribe drugs than look for the root problem? Perhaps the drug companies encourage them to prescribe their drugs.

    • I have been dealing with the exact same thing! I don’t understand why it is so hard to get my doctor to actually believe me or care what I’m saying. Here is two vicodins a day please leave now. I’m only 35 – he has never even run any tests other than blood work on me. Sucks

  • It’s not just about weight. It’s a bias to the most obvious. In many ways it is an understandable response–many times it *is* the obvious. But not 100% of the time. Maybe not even 75%. And those patients are forced to cycle through various “obvious” diagnoses until the doctors realize there’s actually a problem.

    I also don’t envy the doctor, having to sort through the imperfect and often confusing maze of symptoms that patients may report in trying to understand what is happening to them.

  • Unfortunately, obesity IS directly correlated with a host of modern diseases. Obese patients and at much higher risk for metabolic syndrome (combination of insulin resistance, high blood pressure, high triglyceride/oxidised LDL cholesterol, and often elevated C-reactive protein showing chronic inflammation) and full-blown diabetes. Which puts them in the risk category for the most important modern killer – cardiovascular disease. Osteoarthritis, vascular insufficiency, pulmonary and renal complications, damage to the nervous system, and some types of cancers are directly related to obesity as well. Maintaining healthy weight, in addition to not smoking, is the best thing people can do for their health.

    • when I go to the doctor for pneumonia I do not want to be lectured about my weight. I am not stupid, nor lazy. I want to be respected. When I have an allergic reaction I do not want a lecture on my weight, when I have fallen and dislocated my knee I do not want a lecture about my weight. I want the proper treatment for my illness and injury FIRST and foremost, then you may say the knee will heal better if….I am not just an unfeeling ball of fat I am a human being with feelings who has been treated poorly by every doctor I have had to see…..

    • I am overweight my cholster old is perfect, my blood pressure is good I am not insulin resistant. I do have asthma. If I go to the Dr with shortness of breath and he tells me I am at higher risk for heart disease because I am fat. Though I have no risk factors for that instead of treating the asthma I DO have. He is not doing what is best for me and I am goin to have to find a Dr that treats all of me. Instead of seeing a fat lady and giving me a standard answer.

  • This article made me want to cry. When my daughter was 19 years old, she had spent the summer working very hard cleaning out my mother-in-law’s house. My mother-in-law was moving after the death of her husband. This work was very strenuous as well as emotional.
    My daughter developed pain in her shoulder because she was the only one tall enough and strong enough to lift much of the furniture and boxes. The pain became excruciating and we made an appointment with a orthopedist; concerned that she may have torn her rotator cuff from all of the lifting. My daughter is 5 ft. 10 in. tall and weighs over 250 lbs. The doctor walked in, took on look at her and said “I think that you have tendonitis. This is due to misalignment of your shoulder due to your weight. You can take over-the-counter medications to relieve the pain and inflammation. Also, you can try ice packs. But you will continue to have problems because you are overweight.”
    Needless to say, she has not lost weight and refuses to go to the doctor. And she still get pain in her shoulder and we still do not know if she tore her rotator cuff.

  • There IS an answer to those that need help losing weight, that want to lose weight, and can’t. The government, along with state government and health insurance companies, spend Billions of dollars every year, to treat people not only for obesity, but all the health problems that go along with it, and you need to include the heavily used Durable Medical Equipment program with that as well.

    Why not offer, through your medical provider, gym memberships. The gym’s would have to be specific, not these fly by night places. They would need to have specific exercise equipment that can hold the morbidly obese. Most go to around 200-250 lbs. They would need to have a free nutritionist and exercise intructors, for those on the program. And they should have free open mental health classes with a qualified mental health professional to address the mental health aspects of not only over eating but food addiction. Paying $30 to $50 per month, beats paying thousands of dollars per month on doctors, tests, diabetic medicines, diabetic supplies. The membership would be monitored, so if the person does not go for 30 days it auto cancels, so gyms could not bilk the government. This also motivates the gyms to keep their customers happy and coming back.

    Seriosuly, this could work, and save the government a LOT of money for those that successfully lost weight, and might even motivate some people to get off their duffs and get back into society and get a job, once they have lost the weight. While I am not a proponent of government getting into every facet of our lives, sometimes there IS a greater good.

    * Obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs in the United States. Currently, estimates for these costs range from $147 billion to nearly $210 billion per year

    * Moderately obese (BMI between 30 and 35) individuals are more than twice as likely as healthy weight individuals to be prescribed prescription pharmaceuticals to manage medical conditions

    * Costs for patients presenting at emergency rooms with chest pains are 41 percent higher for severely obese patients, 28 percent higher for obese patients and 22 percent higher for overweight patients than for healthy- weight patients

    * Obese adults spend 42 percent more on direct healthcare costs than adults who are a healthy weight

    And for those of you who would say, screw the obese, we’re not going to pay for them going to the damn gym!!! You are ALREADY paying MILLIONS more for them to go to the doctors and get medicines, diabetic supplies and durable medical equipment. So, why not be logical and save some money, and lives at the same time.

  • I do not see any references listed to the studies you quote. As far as I can tell, this is not a scientific/academic article, but rather an opinion piece. Too bad, as it’s an area of extreme importance.

  • What is most frustrating to me, as a medical provider, is the excessive focus on BMI, which doesn’t taking into account such things as fitness level, or body fat percentage, or pre- vs post menopausal status. CMS (which sets rules, regulations and reimbursement by Medicare) added a BMI Screening to be done for all Medicare patients as part of a “quality care” initiative, but I believe all it does is put too much focus on size and not enough focus on overall wellness. Anyone who thinks one can’t be fat, as well as fit and healthy, just isn’t paying attention: football linebackers, shot-putters, triathletes and marathoners and cyclists who are successful and healthy as well as in the “plus size” category.

  • Very similar thing happened to me. My weight slowly ballooned upward from the time I hit puberty. Every single doctor told me to “eat healthier and exercise more,” without even asking how much I ate or exercised. I have mastered half a dozen musical instruments, graduated from an Ivy League school, and gotten a black belt; yet every single doctor took one look at my body and decided I was lazy and lacked self-discipline. Sometimes when I was very insistent they might grudgingly test my thyroid. Most of the time they gave me a prescription to treat the symptoms, rather than digging down to find a root cause: lipitor, phentermine, paxil, you name it. It took 15 years and my seventh doctor before I was *finally* diagnosed with hypoglycemia and hyperinsulinemia. Turns out all I had to do was start eating a low-carb, high-protein diet and eating every 3 hours to keep my blood sugar steady. And my cholesterol and blood pressure dropped to normal levels, my mood swings stopped, my weight dropped by 80 lbs. I am still bitter that I wasn’t diagnosed way back in college; my self-esteem suffered horribly during those 15 years, and there was a period of 5 years where I refused to even go see a doctor, it was such a humiliating experience. Now I practice Health At Every Size, and I refuse to see any doctor who won’t respect that.

  • also, there is no evidence that any combination of diet and exercise work for more than 5% of people at 5 years out, so if the sole focus is on weight loss, doctors are choosing to recommend a treatment plan that simply does not work, and also has known negative side effects. There are many peer-reviewed articles on this, here is one: http://www.ncbi.nlm.nih.gov/pubmed/10449014

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