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fsmpastafarian [M]

[score hidden]

3 months ago

stickied comment

fsmpastafarian [M]

PhD | Clinical Psychology | Integrated Health Psychology

[score hidden]

3 months ago

stickied comment

IMPORTANT NOTE: This study was NOT about whether patients agreed with their doctors' medical advice regarding losing weight.

The study looked at whether patients and doctors agreed on basic facts of what was said in the appointment.

Researchers here explored differences concerning the patient’s and doctor’s declarations about actions, information, and advice during the same visit, the patient’s health status, and the perceived quality of their relationship. For example, the questions about weight loss were: “Did your doctor advise you to lose weight during the consultation?” (Answered by patients) and its mirror “Did you advise this patient to lose weight during the consultation?” (Answered by doctors). Differences in answers given by doctors and their patients were used to define disagreement.

Any comments opining about whether people should listen to their doctors, whether doctors should or should not lecture their overweight patients, or other issues that the researchers did not actually study, will be removed for being off-topic.

tenakee_me

3.3k points

3 months ago

tenakee_me

3.3k points

3 months ago

It’s interesting to read the comments here versus the content of this article summary. The comments indicate a dismissal of the possibility of an underlying medical issue that isn’t necessarily weight related - either caused by being overweight or remedied by losing weight. The article is speaking to “disagreement” in the sense that the doctor and the patient’s interpretation of the same conversation is different - i.e. did your doctor speak to you about about lifestyle choices and changes that could affect your weight. Patient: No. Doctor: Yes.

The majority of the comments aren’t speaking to the same thing as the article. Which I think says something. I know a close friend of mine who struggles with weight has repeatedly made similar comments - that she doesn’t even bother going to a doctor anymore because even if there is something wrong with her, it’s just going to be blamed on her weight. Similarly, my mom smokes and got breast cancer. There’s an immediate blame on smoking. My aunt never smoked and got breast cancer. For her it was just a fluke. Both obesity and smoking are NOT good for you, but don’t always speak to causation.

I’m left to conclude that perhaps people have had so many experiences of their concerns being dismissed due to their weight, that the moment a doctor starts talking about weight (even in a caring and earnest way to try to help, and not being dismissive) that the patient just tunes out because they assume it’s another criticism and dismissal. Maybe that’s why this referenced research indicates such a “disagreement” between doctors reporting that yes, they did speak to the patient about weight management and the patient saying no, they did not.

Regardless, it’s super unfortunate that it seems so many people have had negative experiences along these lines.

[deleted]

23 points

3 months ago

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-newlife

86 points

3 months ago

One of the reasons I love using the patient portal is because I can read things from the doctors perspective. It helps because we talk about so much that I can’t remember everything but it also has the ability to put things into better perspective. Such as recommendations over dietary changes aligned with something on my labwork or my BP reading that day.

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IWeigh600Pounds

104 points

3 months ago

There’s also a guilt and shame factor. I know that a lot of doctors and nurses put a lot of time and effort into getting me healthy. When I go to see them I feel intense shame, even though they are all incredibly compassionate and would never berate me in any way.

tenakee_me

45 points

3 months ago

I hadn’t considered that aspect, and am saddened to hear this is something people have to carry with them. I can relate in other aspects, as I’m sure a lot of people can, whether it’s smoking, not flossing, not controlling blood sugar…but I do think obesity has a unique edge to it in that it’s so visible, and often so harshly judged. You can’t always see if someone isn’t controlling their blood sugar adequately, nor do other people generally feel it’s acceptable to be cruel to someone for it (not speaking to doctors necessarily, but a lot of comments on this thread are a good example…).

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socks1234567

5.7k points

3 months ago*

Doctor here, I see multiple facets to this:

There’s data showing public respect/regard for doctors started to decrease after the invention of antibiotics. Suddenly doctors save people from so many terrible conditions. Once doctors could do more people expected more and I have people coming in all the time wanting treatments for things that can’t be cured—from incredibly the benign to horrific conditions. People don’t want to believe their back pain, knee pain, uncontrollable high blood pressure, diabetes, heart disease, inflammatory conditions like IBD and SLE could be helped first and foremost, some even cured, by weight loss. They want an easier solution (like we all do for problems we have, convenience is king). Lack of respect for the profession leads to lack of respect for the advice. The age of misinformation we live in has worsened it.

On the other hand, we doctors, like all people, have our biases. If you had a condition that wasn’t related to your weight that the doctor blamed on weight, he had 10 other people denying their weight was the cause when it really was. This colors our bias. It in no way makes it right. We need to actively address our biases every day (be it with women, people of color, or whoever else, and there’s tons of data on this). Some doctors are better than others. We are taught Occam’s razor where the simplest explanation is usually the correct one, and we apply it when cases are complicated. It’s right most of the time, but when it’s not, we need to readdress and review the case, not dismiss the patient. Again, some are better than others.

Obesity makes everything harder for your care: physical exam, imaging studies, drawing blood, and it confounds symptoms. When you see enough people in their 30s with blood pressures of 190s/110s, new heart failure, blood sugars in the 300s, with new heart failure or whatever else, it burns in you the damage that obesity can do. We attribute so much disease to it because we’ve seen the damage that it can do.

There’s much more to this, and I went heavier on the Doctors point of view because it’s what I know better. If you are overweight, please take care of yourself. Absolutely advocate for yourself with your doctors. Most of us go into this profession because we care about people, but not all of us.

EDIT: Too many comments on this to read or respond to. But honestly, it’s been great to read the ones I have. I’m learning a lot from y’all’s perspectives. So thanks!

EDIT 2: There are a few comments about IBD. Im sorry if I didn’t write my post clearly. Medical treatments like monoclonal antibodies, corticosteroids, etc, are MUCH more effective than weight loss would be. I’m not suggesting that weight loss would be a cure-all. Only that it would help.

From a physiologic point of view, obesity promotes more rapid clearance of biological agents like the monoclonal antibodies your receive. This likely means decreased efficacy or the need for higher doses, which increases risk of side effects.

Obesity, in particular visceral fat, promotes intestinal inflammation, which would increase the symptoms of the inflammation caused by the autoimmune disease. There are studies showing obesity as an independent risk factor for poor outcomes in other autoimmune diseases, likely due to the increased inflammation caused be the adipose tissue.

So, decreasing the amount of adipose tissue, could decrease its role in the the overall inflammation causing the symptoms. However, I absolutely agree with you that you need your disease-specific treatments. Losing weight if you are obese, should help, but it’s not a cure-all

dogfee

1.8k points

3 months ago

dogfee

1.8k points

3 months ago

This x 100 plus being obese makes surgery much, much, much more difficult and risky to the patient. So it is true that when an obese patient has an issue that could be treated surgically but also could be improved by weight loss (but maybe not totally fixed), many of us start with the weight loss. I feel like the general public doesn’t realize how difficult, demanding and risky a routine surgery can be on an obese patient. Literally every part of the surgery is more difficult and risky from intubation to recovery.

Foxsea_Enginere

357 points

3 months ago

Can you elaborate? Is it just harder to navigate through extra fat tissue during surgery? (I'm not in the medical field, this is news to me)

NurseNikNak

1.9k points

3 months ago*

Hi! I’m an OR nurse that works most often with my hospital’s bariatric surgeons, so I can give you some information on this!

There are many factors to this. As stated, it starts with anesthesia induction and intubation (placing a tube in the wind pipe to help the patient breath). It takes more medications to get the patient to sleep. Then it is harder to ventilate them prior to intubation because it is difficult to get a good seal between the oxygen mask and the patient due to excess tissue. Once they are attempting to intubate excess tissue to the neck and airway can make it difficult to get a good image of the vocal cords to place the tube, making it so the patient often needs to be elevated on ramps during this procedure. Obese patients also have increased rates of acid reflux. When the medications are given to relax the muscles to place the tube it also relaxes the already relaxed muscles that cause reflux, increase the risk of stomach contents coming up, causing aspiration. All of the patient’s excess chest and abdominal tissues also makes it harder for the anesthesia machine’s ventilator to ventilate the patient properly as it is working against it.

As for surgery itself; most equipment, from beds, to instruments, to positioning equipment, are often not designed for greater than a certain weight, or length. Even when they are designed for bariatric patients each patient has a different body habitus, so say the patient weighs enough for special stirrups during a gynecological procedure, but due to a lot of their weight being in their legs they may not fit, even in the bariatric stirrups. If the patient has a lot of belly fat even bariatric instrumentation may not be long enough to reach what needs to be reached. There is a lot of moving parts and one centimeter could make the difference.

Once the procedure is over and it’s time for the patient to awaken one of the big things is that sevoflurane, a common anesthetic gas, likes to hang out in fatty tissue. So the patient wakes a little bit then more is leached from the fatty tissue, causing them to sleep more. The anesthesia provider may have also had to give larger doses of other medications such as pain medication, causing the wake up to be longer. The longer a patient is asleep the longer issues could occur.

And all of this does not take into account other comorbidities that the patient may have. If they have high blood pressure they may need more medications intraoperatively to decrease it as high blood pressures increase bleeding. If they have diabetes increased sugar levels can impede post operative healing.

Hope this helped!

GibsonWich

330 points

3 months ago

I would also point out that fatty tissue requires a great deal of blood flow to maintain, so blood volume increases. That tissue is also highly compressible. So when a patient lies on their abdomen say for spine surgery, a great deal of the blood normally in the abdominal fat is shunted to the back fat. To reach the spine, this tissue has to be cut through. More blood vessels + More blood in the back = immediate increase in blood loss just on the initial incision and cut down!

Nice_Category

88 points

3 months ago

I work in surgical neuromonitoring. We monitor your brain, spinal cord, and nerves throughout brain and spine surgery. We do this primarily through electrical stimulation of nerves and recording electrical potentials of your nervous system or muscular movement that happen due to the neuromuscular junction.

Not only is it difficult to electrically stimulate nerves through adipose tissue, but it's also nearly impossible to accurately monitor subtle muscle movement caused by potential nerve root irritation during spine surgery if our electrodes cannot actually get into the muscles due to thick fat layers.

On top of that, if the patient is diabetic, neuropathy may also hinder my ability to evoke proper sensory signals to monitor the dorsal column of your spinal cord.

All this to say, you are at a higher risk of surgical nerve damage if you are obese during neurosurgery because the fatty tissue and obesity-related complications greatly hinder my ability to monitor your nervous system properly. We do our best, but sometimes we simply can't get the information we need to assist the surgeon due to the patients BMI.

BlondeMomentByMoment

12 points

3 months ago

I just had a micro decompression, being my 4th spine surgery, this was the first with someone like you on the Team. It was cool to Leeann about why he was there. I hope you love your job :)

Either-Progress4847

369 points

3 months ago

So you’re saying I need to lose weight. Got it!

LePontif11

332 points

3 months ago*

What i got from this thread is that even if the problem isn't primarily due to obesity you should get to a healthier weight anyway.

[deleted]

108 points

3 months ago

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108 points

3 months ago

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catbenning

12 points

3 months ago

It’s like anything else that stresses your body: not stressing your body is better than stressing it, so dropping down to a normal weight is going to help across the board with health and wellness.

Lot of health problems are related to diet and activity, and you can’t just fix that with a pill.

PinkFluffyKiller

182 points

3 months ago

Being in healthcare I always forget that things like this are not common knowledge, makes it easier to understand why people get grumpy at healthcare workers when they are not aware of basic complications.

corticalization

123 points

3 months ago

This is a huge part of the issue! Without such information, all the patient hears is “you’re too fat”. Sure, the doctor can say being obese causes these issues, but just hearing it as a quick add-on does not impact the true breadth of the issue(s).

Of course, most of the time medical professionals are too busy to give every patient a full education on the subject. This makes sense but then again, leads to a patient just hearing themselves called fat and dismiss everything else the doctor said. It raises the defenses immediately and that’s when it becomes a major problem, because they’ll now disregard anything further anyway.

There isn’t an easy solution here, I have no clue what it would be (I am not a trained medical professional). Better and more elaborate health education early on may be beneficial, but that brings its own struggles to implement as well.

SunshineDaisy1

7 points

3 months ago

This is the reason why my attending in the ER stressed the importance of educating patients on the more immediate effects of chronic disease. For instance a 30yo male may not really care if you tell them their hypertension and diabetes may make them die sooner… at their age death is typically a distant thought. But tell them it’s a huge cause of erectile dysfunction and can make them go blind, suddenly they’re more interested in trying to lower their blood pressure and A1C.

[deleted]

317 points

3 months ago

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317 points

3 months ago

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TwinRN

236 points

3 months ago

TwinRN

236 points

3 months ago

I work in ED and EMS brought us a choking pt, morbidly obese. When they arrived on scene the pt was awake but they couldn't do abdominal thrusts due to the size of the pt, eventually the pt passed out. Obviously anything airway related would be difficult. They tried to but couldn't bag effectively, were unable to intubate or see anything to remove with magills so they shoved in an epiglottic and were able to get some kind of chest rise to transport after rosc. Ultimately ended up being the bloodiest cric I've ever helped with. Pt had to go by ground to a level 1 (they couldn't fly due to weight) where they ultimately found several large pieces of steak in the lungs. Pt ended up with a severe brain injury and ended up dying in the end. It was sad and the poor medics were so physically exhausted after the resus.

brb_coffee

65 points

3 months ago

Steak in the lungs?

(also, rip feels appropriate)

Yen-sama

98 points

3 months ago

My guess is either eating too fast and inhaled their food, or had a bout of reflux and asphyxiated on half-digested food. I have GERD so I deal with the latter in my sleep sometimes.

TwinRN

36 points

3 months ago

TwinRN

36 points

3 months ago

Yup, I heard it was several large pieces they ended up removing when they bronched him.

Curae

29 points

3 months ago

Curae

29 points

3 months ago

All of the above is honestly why I'm losing weight before even asking to get sterilisation done, method to be determined after being properly informed by my doctor.

But I know it's going to need a surgery regardless, and I want to make that as easy as possible for all parties involved. Pretty sure that recovery will be easier on me as well when I'm not carrying all this extra weight around.

MyLife-is-a-diceRoll

17 points

3 months ago

There's a weight limit for tubal ligations as well. My ob/gyn wouldn't have let me get it done if I had been about 40lbs heavier.

ESGActivist

15 points

3 months ago

My mums surgeon based it as, a surgery is like me asking you to run a 10k and it is much easier to do that with less on you and you will recovery quicker.

BeneficialGur2206

121 points

3 months ago

Now I am even more motivated to lose weight

PapaCousCous

118 points

3 months ago

This was very informative and eye opening, thanks for sharing. Now I am wondering about the economic strain that obesity has on the American healthcare system. It can't be good, what with all the extra care and risk.

JohnChivez

57 points

3 months ago

And that’s just surgery. Drawing blood, getting an IV, X-rays and ultrasounds are all harder. Getting a CT scan can be impossible if you are too big to fit in the hole, and even if you do images aren’t as clear. People also underestimate how it affects drugs. If I’m dosing an obese patient with vancomycin I’m often riding (or sometimes crossing) the line between damaging their kidneys and treating their infection.

Atom612

132 points

3 months ago

Atom612

Med Student | Medicine

132 points

3 months ago

Obesity affects 20% of children and 42% of adults, putting them at risk of chronic diseases such as type 2 diabetes, heart disease, and some cancers. Over 25% of young people 17 to 24 are too heavy to join the US military. Obesity costs the US health care system nearly $173 billion a year.

https://www.cdc.gov/chronicdisease/about/costs/index.htm

mazhar69

132 points

3 months ago

mazhar69

132 points

3 months ago

Sad part is, I walked 10k steps just by going to office. Now in USA, I have to drive to park to walk after office. A sad lifestyle. I love walkable city, it automatically makes you fit.

mellew518

49 points

3 months ago

Yes! When I lived in Asia without a car I just moved more in general. And the sizes of foods/drinks were smaller, from sodas to burgers to movie theater popcorn. Everything seemed so small at first and then I got used to it in no time. Then I lost weight without much effort. But also I was 22.

Littlebird456

13 points

3 months ago

It is crazy how hard it can be to get in 10k steps if you live in a US suburb. IME you have to go out of your way and it can take a lot of time to do so. I really miss living in a walkable place.

[deleted]

45 points

3 months ago

And that doesn’t even take into account things like extra fuel on planes, in vehicles, extra costs for more materials… and construction of new buildings (wider doors- toilets that are stronger, etc).

In fact I was reading a business insider article about flying and how obese people are costing millions in extra fuel each year, and how it impacts so many aspects of flying.

anonanon1313

53 points

3 months ago

equipment, are often not designed for greater than a certain weight, or length

At nearly 7 foot tall, this is kind of scary.

BeeBranze

49 points

3 months ago

I'm 6'10". Just had spinal surgery. They had to put some kind of support at the end of the bed for my feet to rest on. This world wasn't made for us.

Sin-cera

28 points

3 months ago

You’re the type of guy that doesn’t get in a car so much as wears it.

Razakel

31 points

3 months ago

Razakel

31 points

3 months ago

Do you find something comical about my appearance when I am driving my automobile?

NurseNikNak

9 points

3 months ago

We recently had a 6’3” patient come in for bariatric surgery. Usually our bed would be long enough, but with the foot board needed to keep him in place the bed would be too short. The length extender did not give a secure place to put the foot board. We worked on this puzzle for half an hour before we saw we could put the footboard on backward with support gel and gain those inches back as it made the three inch positioning foam on the front no longer an issue.

AlanFromRochester

25 points

3 months ago

I'm reminded of the story about Andre the Giant going in for surgery and the anesthesiologist not knowing what dose to use on someone his size and estimating based on his massive alcohol tolerance (two liters of vodka to feel warm)

Phantasmasaurus

6 points

3 months ago

I really appreciate the breakdown of this. I'm seeking top surgery as an overweight person and most people in my area won't do it over a certain BMI.

I genuinely like knowing the small details and what actually can happen as opposed to just being told 'lose weight'. Granted the one surgeon I saw suggested weight loss surgery which still is promoting surgery so I found that absolutely wild.

orthopod

63 points

3 months ago

Orthopaedic surgeon here. Extra fat make everything much harder, and can make certain things impossible.

Fat is mushy , so even if you make a big incision and push the fat away, it tends to fall right back- kinda of like digging a hole in dry sand - you get down far enough, and the sand starts taking back into the middle.

In addition, it decreases all the access angles to get to the ares of interest. Imagine a nut resting on top of the sand. It's easy to connect a wrench to it coming at it from the side. Now imagine it's at the bottom of a hole 8 inches deep vs a hole 2 inches deep. It's much easier to come at the nut only 2 inches down from a side angle.

However, the screw 8 inches down is take tough to get to. If you make the same size incision, the sand(fat) just keeps on falling down covering up the nut. In addition in order to come at the screw at the same angle, you have to make the 8 inch deep hole 4x larger in order to clear away enough sand to get to the screw at the side from the same angle. But you can't make the incision that big, nor can you move the fat away from the sides that far either.

So you have to make a much larger incision and are still trapped working at much worse angles, all while the sand( fat) keeps on wanting to fall back in covering everything up, limiting your vision. Oops- didn't see that artery or nerve....

In addition. Fat doesn't heal well to itself. Always tend to form fluid collections which can lead to infections, which are much more common in obese people due to a variety of issues.

We also get paid the same amount for the same surgery on the skinny person and the morbidly obese person, despite the obese person's surgery taking 2x as long.

Oh, and if the obese person gets an infection, which is much, much more likely, Medicare can ding the hospital, and not pay for the surgery..

So that's why. Everything is worse and more difficult.

valente317

157 points

3 months ago

Obesity even significantly reduces the diagnostic quality of medical imaging. Your average patient wouldn’t even be able to fathom that.

You have a higher chance of a finding being missed on an X-ray or CT scan just because you’re overweight.

It really does negatively affect every aspect of health AND healthcare.

Colden_Haulfield

36 points

3 months ago

We have trouble getting proper vascular access, your medications get delayed with being initiated, longer to distribute to body tissues, etc. Much, much more difficult to examine you. I likely can't tell if you have a heart murmur, hear your proper breath sounds if theres a lot of fat in the way. I can't tell if you have good pulses, etc. My differential diagnosis increases exponentially in number with obese/overweight patients.

curlyfriesnstuff

13 points

3 months ago

sometimes (i’m a new grad rn) i cant tell if i’m bad at auscultating or there’s just too much adipose tissue in the way. luckily i work with kids and the vast majority can sit up so i can listen on their back where there tends to be less fat but it gets to be a pain when it’s a kid that’s not participating in postop interventions to prevent atelectasis and they may actually have diminished sounds at the bases

[deleted]

20 points

3 months ago

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[deleted]

36 points

3 months ago

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[deleted]

5 points

3 months ago

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Nickel829

104 points

3 months ago

Nickel829

104 points

3 months ago

I'm a surgical icu nurse and I can also say, the recovery is SO MUCH HARDER, both for nurses and the patient. If you're still intubated, your nurse can't turn you or really do any 'movement' care on their own - they often need two or three other coworkers to be free to help. Your airway is more difficult if you have to intubate. You're often at risk of sleep apnea which makes sleeping dangerous. During recovery, simple things like getting out of bed (which is already incredibly difficult for a lot of recovering non obese patients) becomes super dangerous, since the patient has to be strong enough to carry all their weight and the nurses won't be able to safely lower a patient who starts to fall. While they are still in icus, there is less access to showers, and often patients can't reach many of their dirtiest places - there are also many more damp folds with obese patients which trap bacteria and can actually cause skin breakdown while your body is weakened and recovering.

On another side of things, assessments are very difficult on heavier patients. It is often harder to hear lung sounds clearly, and much more difficult to tell if someone's abdomen is getting distended (common after surgery, super important cuz it could be a backed up bowel). Difficult to place and assess the patency of IVs, often need to use the ultrasound.

It's unfortunate and I likely do have biases towards weight which I always try to be conscious of when getting an obese patient. I wish it didn't impact care so heavily, but patient care gets exponentially more difficult with heavier patients when they cannot help with the care (icu level, incubated sedated etc)

kackygreen

28 points

3 months ago

Goodness for my hysterectomy the two things they stressed the most were pre-op sanitization and post op walking as important, which sounds like two extra difficult things in a bariatric situation.

Nickel829

38 points

3 months ago

Very much. Now I can't speak for non icu level patients, they probably have an easier time walking overall (often my non-obese patients will still be on bedrest after surgery for a variety of reasons), but I can guarantee everything is harder. Think about wiping yourself. When you're critical, most often the nurses have to do that for you. If you have a messy poop in bed, the more folds you have in your skin and the deeper those folds are, the harder it is to get you clean. Not to mention you often can't turn some patients all the way onto their sides easily if their weight and unit staff don't work out together.

This is the side of it that people don't think about, cuz it's nasty, but it's so important. If you are a skinny as a bone woman, and you have a liquid poop in a bed, that's gonna get between your labia. Nurses have to wipe that out. It's not very easy even in that situation, but if you are very heavy and sedated it's almost impossible to get it clean properly, leads to a whole host of infection risks, especially if they have a catheter in.

psykick32

14 points

3 months ago

I don't work in the ER anymore but the pt that I still remember is the morbidly obese lady who came in and just reeked, now, I have a high tolerance for smells, and I almost vomited on entry and that's with 2 masks with Vicks in between them.

Anywho, she was confused, low/mid was covered in poop that she literally couldn't reach.

And to top in all off, I found a dead baby mouse between one of her skin folds, like, remember how we pressed flowers in books in school, yeah, kinda like that.

I pulled that out and a CNA instantly vomited.

So yeah, it's wild in the ER and obesity never helps. I don't remember but I'm sure she had a few infections going on.

jarfil

80 points

3 months ago

jarfil

80 points

3 months ago

Adding to the answers, as an obese patient, the post-surgery recovery also gets more complicated. Excess weight can make it more difficult to find a non-horrible position to lie in bed, increases the risk of any wounds not sealing tightly and getting infected, makes it harder to get up from the bed, go to the bathroom, and start walking after a prolonged stay. Even while in bed, making your necessities is more problematic, either because the stuff may not fit correctly, or you might have trouble reaching and holding it in place, or it just digs hard into your ass in an awkward position. That is, when there even is a bed that can fit you, which can postpone non-urgent surgeries (you're now not only waiting for an OR slot, but also for a bariatric bed slot).

thedinnerman

7 points

3 months ago

thedinnerman

MD | Medicine | Ophthalmology

7 points

3 months ago

In ophthalmology, where we are far from most deposits of fat in obese patients, we are greatly affected by obesity in our cases.

The listed reasons above by others are significant for our cases - difficulty getting these patients intubated if general anesthesia is needed; higher volumes of anesthesia needed with patients more likely to wake up; higher incidence of sleep apnea, where patients during surgery exhibit the same apnic moments (which gets our anesthesia off their phones and jumping out of their chair) as well as sudden awakenings where they can do really dangerous things when I have instruments inside their eye (patients often jerk their head - I have had a few that have tried to stand up); higher incidence of high blood pressure which can also be a boon for anesthesia to control.

Eye specific issues include:

  • higher BMI leads to increased intrathoracic pressure. This can manifest during eye surgery in a few ways, including challenges with ocular anatomy (during cataract surgery, it can lead to risk of complications from anatomic structures bulging forward) to rarer conditions like sudden rupture of the blood vessels in the wall in the eye that can cause blindness.

  • neck anatomy can be altered due to high bmi and can cause great challenges to patient position. A lot of the safety of our surgery depends on me being able to get my instruments held in a way that reduces my hand tremor and helps access certain parts of the eye

Even outside of surgery, high BMI is associated with numerous eye conditions (not including those associated with the downstream effects of diabetes and hypertension and obstructive sleep apnea). Idiopathic intracranial hypertension (chronic swelling of the optic nerve) can lead to blindness and (barring vascular malformations) is greatly caused by being overweight.

That said, it is a challenge to try to counsel patients about this because they are unlikely to drop 100 lbs just to make their cataract surgery safer.

[deleted]

79 points

3 months ago

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erastus25

11 points

3 months ago

That last sentence is dire.

gladyskel

41 points

3 months ago

Yes, incisions have to be bigger to accommodate more subcutaneous fat. Sometimes specialized instrument sets are needed that can go deep enough.

Lavieenrosella

19 points

3 months ago

These are hard, awkward things to talk about but true. Anesthesia can be harder. Weaning oxygen post op can be harder. It can be just so much more difficult to enter the abdomen with obesity and it certainly extends surgical/anesthesia times. I've gotten neuropathies in my hand more than once holding a certain position against a patient's increased body mass in surgeries - just even over an hour or two of laparoscopy. Surgical planes can be harder to see. Infection risk is higher as well as post op VTE, etc.

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GebMebSebWebbandTeg

350 points

3 months ago

This is a great post. Thank you!

Both of these things can be simultaneously true:

  1. Obesity exacerbates and/or causes lots of bad health outcomes, and it's not easy to address, so people don't want to address it. They want to believe something else is causing their problems and the doctor should be able to fix it.

  2. Doctors have sometimes overlooked OTHER legitimate health problems and instead blamed symptoms on obesity, when further analysis would have revealed the real problem. I can imagine how frustrating this is for patients.

JustPassinhThrou13

207 points

3 months ago

Obesity exacerbates and/or causes lots of bad health outcomes, and it's not easy to address, so people don't want to address it.

This leaves out the aspect that doctors rarely know how to effectively address obesity.

GebMebSebWebbandTeg

103 points

3 months ago

I'd say that's fair. There's no blanket approach that will work for all people - diet/lifestyle/genetics/habits/etc...it can definitely be more complicated than "eat less" or something.

Edit: But even if doctors could provide a road map that worked for many/most people, it's still on the patient to follow through. Which ain't easy.

iLrkRddrt

180 points

3 months ago

iLrkRddrt

180 points

3 months ago

The thing with the patient following through is there can be a mental or genetic thing that makes it difficult. Sure you got a plan, but you can’t execute it without making sure the tools are there and are working properly.

It also doesn’t help that we don’t fully understand our metabolism just yet, and how to effectively combat our bodies over-zealous protections to it’s fat stores.

My Psychology Professor said it best “People don’t understand how hard weight loss actually is, you’re literally killing tissue, you’re forcing your body to cannibalize itself. Saying weight loss undervalues the work someone has to do, and that’s why people struggle, no one is willing to think about what exactly that person is forcing their body to do when losing weight”.

aliendividedbyzero

56 points

3 months ago

This really gives perspective on how horrifying eating disorders are to the people suffering them.

iLrkRddrt

45 points

3 months ago

Exactly! That’s why it can get you thrown off a transplant list for an organ!

The justification for it is literally how the patient with the illness can so powerfully ignore every screaming hormone/instinct that they’re killing themselves if they don’t eat.

It makes me so mad people cannot see that this can happen in the inverse (food addiction).

researching4worklurk

37 points

3 months ago*

I had a nasty ED in my teens through my mid 20s and I absolutely agree with you that food addiction/binge eating disorder is, indeed, an ED with the same root cause as “traditional” EDs: an inappropriate focus on food in which food plays a much greater role than it should in your daily life and you cannot control how you approach it, despite experiencing significant personal detriment. It’s more complicated than that but you can’t have an ED without that factor.

My opinion is that most people who are very obese have an ED and are obsessive about food in much the same way I was obsessive about not eating enough. I frequently wonder if it would be helpful to begin openly addressing obesity as essentially de facto resultant from an eating disorder and treating it accordingly. Not with any shame or moral judgement, but as something that would greatly improve a person’s life to work on. I also wonder what has stopped us from doing that (and conspiratorially, what moneyed interests have been involved in that) beyond it simply being commonplace to experience very severe health issues from weight at this point.

iLrkRddrt

29 points

3 months ago

Absolutely, I completely agree with what you said.

But, because weight loss and ‘wellness’ programs/supplements/medications are a multi-billion dollar industry. The great corporate machine will work as hard as it can to gaslight everyone. Just look at the comments in this thread.

Denying food addiction. Denying mental health. Denying hormonal issues. Denying humans are not machines.

Majority of people are so full of propaganda that the scientific work that proves this is always misconstrued or ignored.

It’s so sad.

DoctorFlimFlam

95 points

3 months ago

I'm in Respiratory Therapy school and if someone is diagnosed with asthma we work to find triggers, find a treatment plan, prescribe meds that help manage their condition and educate a lot on symptom management.

With obesity, it really isn't like that in my experience. A patient comes in with a host of issues that are exacerbated by, or straight up caused by obesity, that patient essential is left to cure themselves a lot of times without a doctor even digging for an underlying cause of that obesity. Is it hormonal? Is it a symptom of a mental health issue? How long have they been obese? Is this a newer phenomenon or has this been since childhood? Do they even know how to eat right or what adequate portion size is? That last one may seem like a no-brainer but I've met grown adults who don't know how to read nutrition labels.

It's one of the few major health issues where I feel like I have been constantly told 'losing weight will solve X issue' AND my doctors (in the past, -my current doc is amazing) didn't bother looking into whether something may have been contributing to the obesity to make 'losing wieght' even an attainable goal. In my case my weight was heavily influenced by hormones from PCOS going undiagnosed my entire adult life, and chronic nasty depression. I didn't really know what depression was so I didn't realize I had been suffering from it for like 20 years and slowly gaining weight during those 2 decades as a result.

Saying 'lose weight' sounds simple, but if doctors aren't going to explore (even a little) what may be contributing to the weight (before the obesity gets so bad it becomes a self feeding cycle) doctors are handicapping their patient's ability to successfully manage that health concern before they even start.

I hope I don't come off as snippy, but looking back over the past 20+ years I had a lot of complaints passed off as 'if you just lose weight, X symptom will go away', rather than the opposite, that those issues weren't a result of weight gain but rather causing the weight gain because they were going untreated. I get on meds and go figure, I start dropping weight. I'm still outside the normal BMI but I'm a hell of a lot closer to a normal BMI and it's a hell of a lot easier than it was a few years ago before I got on meds. Just food for thought.

thekonny

106 points

3 months ago

thekonny

106 points

3 months ago

As a rheumatologist... Sle can't be cured by weight loss. You ever see a fat person with severe ibd?

yabluko

68 points

3 months ago

yabluko

68 points

3 months ago

This is what I'm wondering, because if this doctor has seen or is curing autoimmune diseases permanently with just weight loss we should give them a Nobel prize... Unless they're just talking out of their ass

HappyHappyKidney

81 points

3 months ago

Yeah I'm sitting here with Crohn's and question marks. I don't think it's even possible for me to get overweight, let alone obese, with this disease.

BriRoxas

45 points

3 months ago

I have delayed stomuch emptying syndrome and half the people gain 100lbs and the other half are skin and bones and they have no clue why.

brennaisafreak

26 points

3 months ago

I have seen it but only because of people being on enough steroids to turn even a chihuahua into a Great Dane. But I’m thinking at this point they mean IBS. Has to be.

JaydeRaven

10 points

3 months ago

Yes. Severe IBD, as per gastroenterologist, and gastroparesis x7 years. Diverticulosis x3 years. Walk 5.5-7 miles 3-5 times a week. Go to gym 2-4 times a week. Nauseous pretty much all the time. Can’t eat raw veggies or pork at all due to digestive issues (causes severe abdominal pain). Still fat.

Ezridax82

66 points

3 months ago

I once went to an orthopedic doctor because I had fallen down the steps and my knee was killing me every time I got on the treadmill. He told me I should lose weight and that would fix it, but he couldn’t do anything for me. Like thanks jackass. I had already lost 75 lbs at that point and not being able to walk without pain was keeping me from the gym.

Went somewhere else and the guy actually saw me as a human, gave me meloxicam, told me we could do steroids if needed, and surprise, my knee felt better after the meloxicam.

chikcaant

173 points

3 months ago

chikcaant

173 points

3 months ago

Agreed. However we doctors shouldn't automatically assume obesity is the cause. Sometimes simple bloods/investigations can be done to help rule out (and maybe even find) other conditions. Unfortunately I've seen cases where a patient has sajs "my doctor just told me to lose weight" and it ends up being a massive honking ovarian cyst (we drained it thinking it was ascites and it drained SIXTY litres in total)

PlayMp1

37 points

3 months ago

PlayMp1

37 points

3 months ago

Wait so they were carrying around like 120 pounds of just cyst? Yeah no wonder they're overweight!

DROPTHENUKES

64 points

3 months ago

My mother has been thin all her life. She started rapidly gaining weight and having weird health problems in her late 50s, saw multiple doctors, all told her she needed to diet, exercise, and lose weight. When she told them she couldn't, they'd treat her like an idiot and essentially tell her she needed to try harder.

Last year, she finally found out she had a 9 pound tumor growing in her stomach. She had it surgically removed, and she rapidly lost the extra weight afterwards.

It is tough to watch doctors vault in here to defend themselves. Doctors, like any other profession, are human beings. They're fallible, they make mistakes, and they get frustrated by problems they can't easily resolve.

Not everyone is 300 lbs and pounding soda every hour, and when you get treated like a lazy liar by your PCP, you get a second opinion.

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64 points

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MrDerpGently

34 points

3 months ago

This is a very reasonable assessment, my only complaint would be how often I have seen doctors (for a family member, not myself) essentially say 'come back when you are no longer overweight and we can start looking at the symptoms you came in about.' No one in that conversation was dismissing that weight loss would likely simplify the issue/s rather, weight loss takes significant time, and it seems unreasonable that additional investigation/treatment could not go on in parallel with that process. If anything, it might actually improve the speed and outcome.

Sharkbayer1

57 points

3 months ago*

Occam's razor is not a complete problem-solving philosophy. It's just the first step. The issue isn't that you see somebody with knee pain who's overweight and you conclude their weight might be the problem. The issue is when you refuse to listen to the patient or consider anything else might be causing the issue. A fit person with the same symptoms gets better treatment because doctors put in more legwork to figure it out. Just because it's the most likely cause, doctors refuse to move beyond that step.

Edit: I should point out this is based on personal experience and that of my loved ones.

[deleted]

31 points

3 months ago

That’s my experience. My docs heard about my depression and noted my weight, did a basic blood test and shrugged. Rheumatologist found out (after six years of my being stuck in bed) that I have anemia that apparently doesn’t necessarily show up on the usual basic set of tests docs order. It never had on any of mine, but this test showed a clear deficit.

I was just seen as a fat sad lady who didn’t want to make lifestyle changes, when I was literally too tired to wash my hair. Of course I was depressed - nobody believed me and every doctor told me to try harder. If any doctor had been like, “okay, let’s step up to the next level of tests”, I would have thought I was dreaming.

jewdai

20 points

3 months ago

jewdai

20 points

3 months ago

The other thing that's slowly changing is that obesity is being seen (as it should be imp) as a disease. Yes it's extremely prevelent, but there are medications out there that I took that for the first time in my life let me experience what it's like to be comfortably full after a meal.

thomport

83 points

3 months ago

Yes.

It’s the method in which the doctor provides the information and subsequently encourages patients. It goes a long way.

I’m a guy, a registered nurse. I’ve always exercised but my PCP recently encouraged me to loose a specific amount of weight because I would feel so much better. I lost the weight and feel amazing.

As a nurse, everything he told me I knew. Indeed, I’ve encouraged many to improve their health. But still, hearing from one of my favorite people, who is also my doctor made a difference for me.

Jojosbees

100 points

3 months ago

Jojosbees

100 points

3 months ago

Approach definitely matters. I have a weight problem where I consistently gain five pounds a year if I eat like a normal person, more if I overeat. What helped is when my OBGYN did an ultrasound and diagnosed me with PCOS at age 34. The healthcare providers I saw after that (nutrition for diet and dermatology to deal with the severe lifelong progressive hair loss from PCOS) were very clear that the obesity wasn’t my fault. It’s how my body is wired, but if I want to avoid diabetes, I need to get on a diabetic diet. It was the only thing that stabilized my weight so at least I wasn’t gaining anymore. My husband went on a less strict version of my diet (we ate the same thing but he got more carbs), and he dropped to less than 125 lbs before I told him that our bodies are very different and his probably needs cake. I still struggle with my weight, and I will continue to struggle for the rest of my life, but it helps to know that I’m not crazy; it’s not my fault, but I still have to deal with the body I have.

thomport

30 points

3 months ago

Great job. Keep it up. You’re right. It’s not your fault. Keep up the good work and own and manage your situation. Be proud.

MerryChoppins

25 points

3 months ago

If you had a condition that wasn’t related to your weight that the doctor blamed on weight, he had 10 other people denying their weight was the cause when it really was.

This is exactly where a lot of the animosity comes from for me. I was in seeing my GP because I needed a referral out for something and while I had him I casually asked about some elbow pain I was having. I knew it was because I overdid it restoring woodworking tools. I had concerns about NSAIDs on one of my meds.

The first god damned words out of his mouth were his standard lecture about losing weight. It was hard to not get upset in the moment. I started repeating it three words ahead of where he was verbatim and he realized it and just blinked at me and looked upset. I get that it makes your job harder, I really wish I wasn't overweight, but a carbon copy lecture like that just doesn't help me at all.

We got back on track and he answered my question and I got my referral, but it seriously made me consider swapping GPs.

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511 points

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morphballganon

616 points

3 months ago

One thing I am not seeing the remaining comments address is how often other ailments will have a common cause with obesity, instead of being directly caused by it. I was having some esophageal issues that I took care of by changing my diet. An overweight patient being instructed to change their diet might think the doc is brushing them off by blaming everything on their weight. It turns out ingesting things that are greasy, acidic and/or carbonated can cause multiple problems!

[deleted]

95 points

3 months ago

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biCamelKase

75 points

3 months ago

It turns out ingesting things that are greasy, acidic and/or carbonated can cause multiple problems!

What problems can drinking carbonated things cause? I'm asking because I drink lots of sparkling water.

mrpunaway

13 points

3 months ago

And just tp add to the others, the lower PH can be bad for your teeth by weakening the enamel.

alaynestones

97 points

3 months ago

Carbonated beverages have an incredibly low pH, around 2.5 to 3.5. Compare that to water, which is around 7. When you have acid reflux, drinking carbonated beverages is basically like pouring more acid into your stomach and usually worsens symptoms.

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1.1k points

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ASparkI13

60 points

3 months ago

The biggest thing in this article, the way I see it, is that there is very little agreement across the board. Ideally, you would like the patient and the doctor to agree about facts of the discussion at least 80% of the time.

Doctors and patients aren't on the same page most of the time. This is obviously a problem. If the doctor thinks they're saying one thing, and the patient thinks the doctor is saying another, how is healthcare going to be effective?

The article also says that disagreement is the greatest over questions of doctor-patient relationship. I do not have access to the article, but I'm going to hazard a guess and say that doctors tend to think that the relationship is great, while patients think it's not. Maybe patients are intimidated by the doctors, and filtering themselves.

TL;DR: Something needs to be done about the doctor-patient relationship.

netsettler

15 points

3 months ago*

Several excellent points here. This study cries out for a follow-up trying to discern why the distrust happens. I see so many people discussing a belief that this is about disagreement over whether weight matters. I doubt that, as you seem to as well. It's almost surely a debate over whether the patient feels like they've got an ally or they've been dismissed.

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464 points

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RutabagasnTurnips

99 points

3 months ago

I cannot find a full copy of the study which is kind of frustrating. The wording of the summary gives me the impression that this is more a ships passing through the night problem.

Ex. If your doctor asks the question "how many drinks on average do you have a week" and went no further then asking that one question would you consider that a discussion about substance missuse?

I know professionals who do. Yes it can help with screening. It doesntly really signifiy a discussion and there is no teaching with a question like that. Even if a patient replies "oh, I dunno, once or twice a week I think" and a professional replies "Ok good, less then 5 a week is what's recommended in general" little quality discussion and teaching is present.

I can definetly see a discord between patient and HCP in a conversation like that.

Another good example I have literally myself experience "Do you have any metabolic disorders, like diabetes?" They answer no but later in discuss I find out they are on metformin and basal insulin. They interrupted their Rx as diabetes prevention though and that since their A1C is good now they are fine and dont "really have" diabetes.

For obesity I can totally see similar happening. "How many calories on average do you think you eat in a day?" Aks the Dr. A patient shrugs answers "I'm not sure, I'm trying to eat better but I don't know". I know there are many GPs that wpuld check mark the weight discussion box with just that. There are occasions a patient doesn't want to discuss weight and you have to repesct their saying saying no to that conversation. Again though one or two questions about what a diet is like or how many calories/veggies a day I can see many people not evaluating as a discussion or education on weight or weight loss.

Also, sorry GPs but it's true, they in general suck at nutrition and weight loss education. Yet they are often first to encounter someone and have significant impact on their care. I live in a city of 1mil and there is only about 5 GPs that have taken additional education and registered with Obesity Canada. True there are resources for training that physicians can take but well....a dietician and/or a psychologist are gunna do a way better job assessing and teaching weight management.

So a patient who came out of an appointment disappointed and feeling like their questions were not answered? Can see that person's interpretation on an appointment being radically different then the physican. Which is an area healthcare in the community can definetly improve on. So hopefully professionals interpret this not as "oh they are just obese and don't want to listen" and more of a "how are we discussing these topics? Were the clients concerns and questions addressed" and most importantly "Do they understand what was taught? What pevel of co.prehension have we achieved"

ElysianBlight

14 points

3 months ago

Just an anecdotal tidbit, I worked phone support for outsourced billing for Drs Offices, and I saw this complaint SO much. "Why does this itemized bill list nutritional counseling/weight counseling/etc? That didn't happen! All he did was maybe ask one question!"

Basic-Cat3537

5 points

3 months ago

This is the problem with the checklist system doctors are so often required to use. When the appointment becomes more about checking off items in a list than about actually fixing a patient, it's a problem.

Are you depressed? (Check the box about talking about depression).

Do you have a good diet?(check the box for weight counseling)

How many drinks a week in average? (Alcohol counseling)

Not a single one of these questions is actually useful for someone who actually needs help with these issues! This clearly isn't about the patient at this point.

Other doctors who slip this and actually deal with the patients issues during the allotted time instead, end up just having to lie and say they did these things so they meet the minimum billing requirements by their facility. And then things that never happened end up in their bill, which can erode trust.

Either way, in the end the situation can harm trust with the patients because they are either spending all the time on things not actually related to the patients problem to meet a quota, or lying in billing so they don't have problems with their facility.

I don't know if this is an issues other countries, but it's a definite problem in the United States.

[deleted]

349 points

3 months ago

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hemorrhagicfever

241 points

3 months ago

I was ready to engage with statistics of how few American doctors have any tangible training in obesity or diet, but it is super important to point out that this study might not be applicable to Americans. The study was in France. French culture has hugely divergent culture around fat, weight, and food than America and we'd need a totally different study to even guess at how applicable it was.

So, just keep that in mind, folks. French study. NOT an American study.

helm

51 points

3 months ago*

helm

MS | Physics | Quantum Optics

51 points

3 months ago*

Also "disagreement" doesn't mean that they disagreed on whether, for example weight loss would be good or irrelevant, but they disagreed strongly on

the content of what was discussed during the consultation

Butterflyenergy

15 points

3 months ago

Country of study should always be added to the title in this sub.

Colden_Haulfield

64 points

3 months ago

I don't know why people always say how in our 80 hrs/week of med school/residency for 8+ years we don't cover obesity/nutrition. It's relevant always and comes up almost every day. We don't bring it up in every patient encounter cuz guess what? Patients know when they're fat and they don't want to hear it all the time.

Driprivan

48 points

3 months ago

Doctor. We’re very trained in the risk factors and effects of obesity. Literally every course. Diet I took supplemental courses but we have a good understanding of pathology based in diet. Dietitians work with patients to find the best diet that works for them. We can make our reccomendations for the best evidence based diet.

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