DebraSY

I Have Good News, and . . .

In Weight-Loss Maintenance on February 21, 2011 at 7:23 am

The year is 2050.   Two women with a BMI of 40 sit waiting to meet with their General Practitioner, Doctor Pense.  The nurse calls the first patient, and does not take height and weight.  The appointment takes place in the doctor’s office, not the exam room.  The initial exam and lab tests are done.  The Doctor speaks first.

“Well, Donna, I have good news for you, mostly, and some bad news.  The good news is that your type of obesity is one that is medically insignificant.  Your fat does not compromise your health.  You may, in the future, have some joint issues, arthritis.  You may need new knees or hips.  However, for now, there’s nothing medically indicated.  That means the bad news is that insurance won’t pay for further treatment at this time, and I know you were hoping for some help with weight loss.  Insurance will pay for those joints as you need them.” 

“Medically insignificant?” 

“Yes, your fat composition, disposition is not likely to create any more medical problems for you than if you were naturally trim.  Your life expectancy is the same as a naturally trim person’s of your age.  Your fat is cosmetic.  Did you find that pamphlet I gave you on hygiene and special care of the fat body helpful?”

“Sure, Doc.  It’s helpful.  Uh . . . I’m still . . .  Do you know why I’m fat?”

“That would require more testing.  All I can tell you now is that it’s benign.”

“So, you’re saying I have to live with this enormous butt?”

“Oh, Silly, you . . .”

“No, seriously, I’ve had to buy special furniture for my house.  This isn’t funny.  The trend recently has been for stick furniture, and it’s been a nightmare trying to find good, sturdy stuff.  And that’s just the beginning of . . .” 

“Yes, yes.  I’m sorry.  That’s an unfortunate trend.  But it is only fashion.  You know, back at the turn of the century, some doctors’ offices didn’t even have chairs to accommodate people of different sizes.   That wasn’t a fashion statement, it was ignorance.”

“That was a judgment!  It must have made fat people feel horrible.  If even their doctors . . .”

“Oh, yes.  I’m sure it did.”

“That still goes on, you know.  Fat people feel awful . . . sometimes . . . at least I do.  There’s so much pressure to be thin.” 

“I know, prejudice dies hard, and fashion can be relentlessly narrow.  But that kind of nonsense no longer carries the imprimatur of the medical or scientific community, and public policy is changing too.  Things are getting better.  You know, if you can believe this, even doctors commonly used to promote the notion that anyone could manage his or her weight just by eating less and exercising more.”

“No!”

“I know.  It was ridiculous.  And 97 percent of people failed at it, of course.  It was horribly demoralizing.  Nevertheless, doctors didn’t even talk about “the obesities.”  They talked about obesity, as though there was only one way to get fat, one way to be fat.” 

“Oh, good Lord.  And that wasn’t so long ago.”

“Maybe two generations.  And our treatments were horribly limited, barbaric even.  With your BMI, even though your fat is medically insignificant, your doctor might have encouraged you to have your gut mutilated – your stomach clipped down to the size of a chicken egg and great lengths of intestine removed permanently, followed by a very difficult life in terms of eating.  Just . . .”

“Oh, I’ve read all about that. Horrifying.”

“And, if you didn’t want to be so extreme, a doctor could surgically insert a little corset around your stomach.”

 “Now, you’re cracking me up.”

“But it’s true.”

“Doctor Pense, I know you think you’ve given me good news, but I just hate my big butt!  I have trouble buying clothes and I just don’t . . . Isn’t there anything I can do?  I’m not asking to be thin; I just want to be more proportional.  Can’t you help me?”

“I hear your frustration, and you have good reason to be frustrated.” 

“Thank you.”

“The obesities, however, create a much more complex and time-consuming puzzle than a GP can solve in a visit or two.  I’m happy to give you a referral and send your lab results to an obesities management center.  The doctors there will evaluate your genetics and your endocrine profile, run more precise tests.  They’ll be able to pinpoint what caused your type of obesity – whether it was a chemical exposure or virus that you had, or an exposure that one of your parents encountered and passed on to you, whether your gut flora are fighting you, or you are sensitive to certain foods or additives, or whether it is simply genetic predetermination.  They may find something partially reversible, with dietary adjustment and individualized exercise, or medication.  They may suggest cosmetic surgery options — but NO stomach mutilation!  On the other hand, they may tell you that you’re one of those people who would have been destined for the fat side of the bell curve, regardless, and little you can do will budge your weight much.  But if you want to continue with treatment, dieticians and fitness professionals will work with you on being the healthiest you that you can be, for a price, of course.  And, meanwhile, you just keep shopping for good strong furniture, and come visit me when you think it’s time for new knees.”

“Yeah, Doc, go ahead and write me a referral.  Do you have any idea what they’ll charge me?”

“I understand the initial lab work and evaluation are reasonable.  Call them and they’ll give you the particulars.  No harm in exploring.”

“Thanks.”

After some small talk, Donna departs and the nurse brings in the second patient, and, again, the conversation begins with Doctor Pense.

“Hello, Mary Jane.  I have mixed news.  The good news is that your prognosis is strong and your insurance will pay for whatever treatments you need.  The bad news is that your type of obesity is medically significant.  You’re not in any immediate danger. . .”

“I’m not going to keel over?”

“Oh, no, no.  But you are at increased risk for developing a number of health conditions, and they are related to your obesity.   I’m going to write you a referral . . .”

“Whoa!  I hate going to new doctors.  Can’t you just help me?”

“Funny, I was just talking about this.  The one-word answer is “no.”  GPs haven’t even pretended to be experts on the obesities since roughly 2025.  You know, at the turn of the century, GPs were expected to help people manage their weight with Ouija-board medicine.  I’m not lying.  They’d just pull plastic BMI calculators out of their lab coat pockets – pharmaceutical companies provided these ditties free – and they’d spin the calculator (they kind of looked like Aztec calendars) and they’d tell you your BMI.  That’s about all they’d do.  They’d probably give your thyroid a cursory check, but very few labs.  And then they’d just advise you to eat less and exercise more, maybe 30 minutes a day.  They called it a “lifestyle.”  And if you didn’t get trim, in addition to healthy, well, shame on you.  Maybe you should just go get your gut mutilated.  There were specialists to do that.”

“Oh, I’ve read all about that.  Primitive.” 

“Thank God we’ve grown a little more sophisticated, eh?”

“Yes.”

“So, I’m writing you a referral to an obesities management center that specializes in medically significant obesities and related conditions.  They’ll do additional lab work and evaluate your type of obesity with more precision than I can to devote to it.  The good news is that all the obesities have a good prognosis.  Most people can get their medical risks under control, even if they don’t lose significant weight.”

“Thanks, Doc.”

“Now, let’s look at what my lab numbers indicate, so you’ll be prepared for your meeting with the specialists.  Your Freedhoff ratio, of course, is the first thing they’re going note . . .”

***

Sigh.  Being treated like individuals.  If we can envision it, it can happen.  I tip my hat to Dr. Arya Sharma and his colleague Yoni Freedhoff.  Thanks for visiting, Dr. Freedhoff; it’s courageous to expose yourself to raw emotions about something so close to you.  I hope you find benefit in it, and I hope other doctors emulate you.

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  1. Cool! I think you have the beginning of an excellent science fiction novel. Can there be spaceships with people of a variety of sizes working on them, without the fat people being used as some kind of negative symbol or cautionary tale? Can I have a cameo in the film? 😀

  2. That was just delicious, Debra. I hope it comes to pass one day.

    Sadly, it’s too late for our generation, which still lives in the Dark Ages of weight management. I think what disturbs me the most is how so many people–both lay and medical–think they know the solution (usually ELMM) and treat those who don’t follow the party line with contempt and disgust, not to mention the effects of improper medical treatment (“if you’d just lose weight, your life would be medically perfect”) or non-access to medical services (the barbaric “pre-existing condition” clause in the States).

    In the good old days, we just burnt witches at the stake. Nowadays, people suffering from one type or another of obesity (I love the concept of “obesities” in the plural)and who fail to lose the weight (i.e. almost everyone) are just shamed into silence, self-hate, self-mutitlation…

  3. I’ve sort of stumbled upon doctors who treat me like an individual, fortunately. My GP and I have come to a sort of detente about my weight — he’s a bit bemused by me but defers to my being in charge of things related to weight.
    I loved this. I will re-read it.
    And, I have a very small butt, as it turns out, with a BMI of more than 40. I carry my weight in, uh, other places.

  4. Thanks for the kind words and the great post.

    One thing’s for certain, the field of obesity medicine is in its infancy. I do believe there’s hope, at the very least for changing medical attitudes.

    For that to happen, closed-minded doctors and disgruntled patients alike are going to need to find venues to interact safely with mutual respect. Thanks DebraSY for providing one.

  5. Ah, and thank you too, Dr. Freedhoff. Visit often. (Oh, and I’m giving you five years to develop that telling ratio, which doctors will come to rely on to determine the medical significance of adiposity.)

  6. Arya’s already beaten me to the punch: http://www.drsharma.ca/edmonton-obesity-staging-system.html

    He did take some flak for it from some circles.

    Of course you can’t please everyone.

  7. I have a score of Stage 2, according to the EOSS.
    Just trying out how that sounds.

    • Depending on how “physical limitations” and “sleep apnea” are included, I’m likely Stage 2. At the moment the asthma is affecting my daily activity more than the fat. 😛

      Re: sleep apnea – I know some people get it when they gain weight. In my case, I’ve snored my whole life, same as my thin father and his brothers. I have trouble seeing it as a side effect of my size when I was snoring long before I was this size, y’know?

  8. I love this post. We can hope.

  9. You’ve said your BMI exceeds 40, AW, so that would make you a Class III, Stage 2. I, on the other hand, am classless (and I have friends who will attest to that), so the fact that I am also stage 2 is immaterial, I suppose.

    While I think this EOSS probably is an invaluable tool to help doctors communicate with one another and patients, and to determine the appropriateness for admission to a particular program, it’s just a start. I think you’re right, Dr. Freedhoff, that the field of obesity is in its infancy. Plenty of room for growth.

    Perhaps the Freedhoff ratio will have something to do with fat composition/distribution indicative of impending trouble or the relationship of two endocrine numbers that signal the need for further testing.

    One thing I really like about the EOSS is that the stage 1 case example is a 38-year-old female with a BMI of 59.2. Currently, for most US doctors, that BMI alone would set off all their alarms and have them prescribing gut mutilation. It’s nice to see it set in a different, more reasonable, perspective. And, DeeLeigh, isn’t the Stage 0 case example you? Physically active female, BMI of 32, no symptoms, no self-esteem issues, no functional limitations? A First-class, Stage 0.

    • I guess for me, I see that there are thing I can and cannot control with regard to my health.
      I can control my eating patterns and what I eat. I can control how much exercise I get. I can’t control my genetic inheritance, my psychological baseline, and the overall environment in which I live. So, I make the best choices I can. Class III, Stage 2 — I can probably live a full and fruitful life, however long it may be, right there.

      My fantasy (and yours above encourages me to explore mine) for 40 years into the future includes a bit more of an impact of the acceptance of fatness in the culture as a whole. I would be dreaming that a woman with a BMI of 40 with medically insignificant obesity would find plenty of support (furniture, clothing, etc.) and role models in pop culture and beyond for self-esteem and acceptance.
      Just as people with bodies that respond differently to a myriad of environmental inputs (food allergies, sensitivity to sunlight, vulnerable immune systems, to name a few) — I would hope that we come to a place of understanding about the relationship between choices and environment to a more accepting place overall.

      • I’m with you, AW, that culture SHOULD evolve with medicine and science, and my first draft was a bit more utopic than the final, but I was possessed to make a different point. I think culture will lag because as long as there is a benefit to be accrued by one set of people for oppressing another, then prejudice, discrimination and other forms of oppression will continue. (Who am I quoting/paraphrasing? I know I didn’t come up with this one on my own.)

    • Hi again Debra.
      I think that you are “Stage 2” isn’t immaterial — it points out that even with all that you do to maintain your health and your weight, it doesn’t mean that the health issues you manage go away — they still require attention. And you’ve already “lost the weight” — so you are treated the way a person without a BMI over 25 is treated.
      And, even if there’s no obesity classification for you, according to WHO (according to who?), I think you have plenty of class.

  10. I’ve been stage 0 for 35 years, although maybe they’d classify me as stage 1 based on the fact that my blood pressure sometimes tests as borderline high. Also, I’m class 2, not class 1 right now. I gained 20 pounds because of having to stop exercising before and after the hip replacement and my BMI is now 36 or so. Also, I drink more than is recommended for optimum health, so that complicates things. However, yeah. If obesity is so deadly, then why am I not sick yet? Maybe some of those health problem track to dieting or yo-yoing rather than to obesity?

  11. Don’t know if I’ll be around in 2050, but if I am: I hope I will be working in my commune’s herb garden while the local shaman comes round to talk about…whatever…then we’ll laugh about the old days when people fetishized communication by leaving notes for strangers while hunched over keypads alone in their rooms…

  12. Oh, what a great fantasy – if only! I like the class/stage system – if only more doctors used it. I’m a Class II, Stage 1, barely – my blood pressure / cholesterol / blood sugar / etc. are all within healthy ranges. But I do get out of breath when doing heavy exercise easier than I used to, and still fight some residual body image issues. Though, interestingly, I would have been considered a Stage 2 despite being classless (heh) or Class 1 a few years ago, prior to discovering FA, when I was far more disordered and depressed/anxious re: my weight than I am today. Yet many doctors still believe that fat-shaming, which only worsens the psychological symptoms included in the EOSS tool, is perfectly acceptable. I’m glad to see that mental health is also taken into consideration in this tool.

  13. DebraSY, it would be a wonderful thing if this becomes reality.

    But okay, that staging system. So if a fat person with major depression/suicidal ideation, that’s considered an “obesity-related mental health condition,” and thus an automatic stage III, even if I had it when I was so-called “normal” weight (for about five minutes) and didn’t actually become “morbidly obese” (or uh, class 3) OR get the depression into total remission until I went on meds for it? (I go off the meds, the weight goes down, and I wind up in the bell jar. Can’t win that one for losing, I guess.)

    I also had symptoms PCOS (automatic stage II) even at my very lowest weight. Shit, I had them when I was NINE YEARS OLD, and no more than a little chubby, so I doubt that would go into remission even with serious weight loss.

    • I agree there’s some “is it the chicken or the egg?” things. When I told my parents I’d been prescribed a CPAP my Mom tsk-tsked, after all, I was snoring and having breaks in my breathing when I was 12 and only a little chubby, my Dad’s been snoring and having breaks in his breathing since he was a teen, why is it a problem now? And I read research on how getting less sleep correlates to weight gain over time … and I wonder.

      And yes, I’m a depressive too, and usually gain weight when I’m in a depressive episode.

    • Ah, Meowser, it is, indeed, so stinking complicated. You are the poster child for “complex,” and I would be wrenched if I were to learn that a doctor offered you an inappropriate, simplistic (or, in the case of gut mutilation, violent) obesity-related treatment, simply because you are both fat and depressed.

      I do give Drs. Sharma and Freedhoff credit for not diminishing the complexity of this issue themselves, in their personal musings (and likely in their personal medical practices). As for the EOSS, since it does not suggest specific treatment (and instead suggests when a referral is in order) it’s a tool. It’s as useful as the person handling it is skillful. I’m not so enthusiastic about their 100-page guidebook, which does offer specifics (such as the 30-minute test) and may provide enough information to make GPs more dangerous. In complex situations such as obesity and depression, GPs need to be referring, not treating. Some recognize that depression is complex. They need to acknowledge that obesity is too. And, with regard to an obesity referral, that’s mostly only in order when the patient requests help. The EOSS could be a helpful tool for the patient as well as the doctor, to know when requesting a referral might be useful.

  14. I admit, I’d like the fantasy even better if in the second case, the doctor says “[m]ost people can get their medical risks under control” and stops right there. Weight loss shouldn’t even be mentioned in a society that does not look at size as an indicator of health.

    Good for you for also pointing out that BMI is a population measure that follows a bell curve, so some people will naturally be at the ends of that curve, with no significant effect on their health.

  15. “Weight loss shouldn’t even be mentioned in a society that does not look at size as an indicator of health.”

    From your lips, Attack-Laurel . . .

  16. If I had a dime for every weight loss blogger who mentions in all her (and occasionally his) posts that weight loss equates automatically perfect health, I’d be a very wealthy woman.

    As we–dare I say, the enlightened and embattled minority–know, good health and a “normal” BMI often have nothing to do with each other. Overweight may play a decisive role in bringing on condition X in patient Y, while it may have absolutely nothing to do with the health (good or bad) of patient Z. Yet this equation (health = “correct” weight) is rife in the weight loss community. In fact, in the past two years, I have seen it getting worse and worse.

    A successful weight-loss blogger whom I really like recently wrote that (this is not a quote) she felt between a rock and a hard place: eat real food (like peanut butter, for instance) and gain weight (apparently due to binge eating) and be *unhealthy* or eat frankenfoods (like Splenda, for instance) and maintain the significant weight loss she accomplished and be *unhealthy*. It makes me sad for her and for many others.

    I think a lot of the acceptable weight = good health meme comes from people’s need to find simple explanations for what ails them (lol). Telling someone that they may not find nirvana in a BMI of 22 is tantamount to telling them to give up on life. An easy answer (even if it’s far from completely or even somewhat true) seems to win hands down over the complexity of reality.

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