Larger Patients: Fewer Lectures, Better Health Care

Written By HBNS Staff

If you're a heavy person, you probably dread medical visits that seem to center on weight, regardless of whether you come in for an unrelated complaint or a routine screening. Even so, don't let that stop you from getting the health care you deserve.

Larger patients can take control of their health care experience through communication, planning, assertiveness and even a bit of attitude.

Hanne Blank, a 39 year-old Baltimore writer, describes herself as larger or fat, not obese or overweight. "Overweight? Over what weight? Over whose weight?"

Some doctors suffer from "fat distraction," Blank says. "They get excitable about fat and overweight and find it hard to pay attention to anything else. You have to take pity on doctors if they're getting fixated on fat when it isn't pertinent. You have to help them get past this; they're stuck."

Blank is a former long-term vegan and "passionate whole-foods cook" who already knows about diet and exercise. Her interview took place by cell phone while she walked her Akita.

Redirect their attention, she suggests. "It's perfectly fine to say, 'Hi, I'm here because of my elbow.'"

Thirty-year-old Jeani lives in the Chicago area. She also rejects the overweight or obese labels as clinical terms that "medicalize" body size. Being fat definitely has affected her health care, says Jeani, who asks that her last name remain anonymous.

She has a chronic health condition that is not related to her weight. When she went to a specialist to pinpoint the problem, she says that he spent most of the appointment "discussing size: I had to get bypass surgery, take weight-loss medicine or follow a strict diet. Otherwise, he said, I would be dead before I reached 30."

The bias can also be less obvious, Jeani says."I can tell when somebody is not happy to be around me. Some doctors were uncomfortable touching me. Sometimes it's the way they look at me, or avoid looking at me." Is she right?

"Multiple groups of health care providers have demonstrated biases and prejudices against overweight adults," says Rebecca Puhl, Ph.D. She is the director of research and anti-stigma initiatives at the Rudd Center for Food Policy & Obesity at Yale University.

Younger doctors, dietitians and nurses might have stronger "anti-fat bias" than older practitioners, research suggests. Why are these attitudes so important?

Although larger patients visit the doctor more often, they get less preventive care than normal-weight patients. Fewer clinically obese women undergo screening for colon and cervical cancer. New evidence suggests that these women are also more likely to delay breast exams and mammograms.

Pat Lyons, RN, was one of the developers of the "Big Woman's Passport to Best Health," intended to reduce barriers to care.

One barrier was wrong-sized medical equipment; for instance, speculums that do not fit. One woman told Lyons, "The doctor said I was too fat for a proper exam and to 'come back when you lose 50 pounds.'"

"If it happens once, I tend not to go back," to that provider, Jeani says. "I wouldn't let a dry cleaner tell me that I had to lose weight before they would clean my clothes, so why would I let doctors say they wouldn't treat me until I lose 20 or 40 pounds?"

"Don't accept 'lose weight' as an answer when in need of any medical procedure." Lyons says. "There are skilled clinicians that can provide the service."

Fear of disrobing can be part of the reason for avoiding certain procedures, Puhl says.

"Those 'charming' paper gowns come in one-size fits no one," Blank says. She brings her own bathrobes for office visits, along with a pair of slippers. Nobody has complained, and she has even gotten compliments on her robe.

Most doctors want every patient to feel welcome and a supportive environment can help.

The ideal office has "large blood pressure cuffs, large examination gowns and a sturdy examining table," according to the National Association to Advance Fat Acceptance (NAAFA).

"A lot of doctors don't think about the physical realities of their waiting room," Jeanie says. "When waiting rooms have comfortable chairs, fat people just sigh in relief."

How do you find a fat-friendly doctor?

"Use word of mouth; ask around," Blank suggests. "In cities where they exist, consider clinics or providers that serve GLBT [gay/lesbian/bisexual/transgender], where they're used to serving a very diverse population and understand what diversity really means."

Dr. Paul Wertsch relates to large patients as people, not weight problems. Wertsch is on a "fat-friendly health professional" Web site list built from patient recommendations.

In his Madison family medicine practice, he and his staff "try to treat everyone nicely." he says. "This is Wisconsin. We have a large middle-European population. Yes, we do make accommodations. We try to have appropriate chairs. We've always tried to be considerate of people."

When he meets larger patients, he says, "I just know that they've been talked to about their weight many times. I don't dwell on it. I build up a relationship. Without hounding, I might say, 'Now let's talk about exercise.'"

For some people, weight is no longer open to discussion. When choosing a doctor, "the bottom line is whether the professional preaches weight loss if you have stated that this is not an option for you," the NAAFA Web site says.

Puhl says the question is not whether doctors should bring up the subject, but how.

"Providers can have productive conversations about weight with their patients — they are agents of change. Still, sensitive communication is key. They could ask, 'Would it be OK if we discussed your weight today?' The way that they approach the issue will influence the patient's motivation."

"I recognize at times that weight might have a correlation with certain medical problems," Jeani says. "A doctor could bring it up respectfully: 'You have diabetes. Your weight could be a factor, but let's focus on other things you can work on.'"

And if a patient is not ready take off an ounce? "Even if a person is not going to lose weight, if they come in for regular care and manage their blood pressure, they'll do better," Wertsch says.

"Recognize the patient's frustration," Puhl says. "Instead of emphasizing the number on the scale, focus on behavior changes, like eating more fruits and vegetables, drinking more water and less soda and walking more."

Patients can help pave the way for smoother visits, Blank says. "Call in advance and say you're overweight and be honest: 'I weigh this many pounds (give them a ballpark figure). I need to go in there and know that your equipment can handle me. For the purpose of you and my liability, I need to know that you have equipment that can hold me safely,' and safely is the money word."

You can't always plan ahead or pick and choose your providers, if you're an HMO member or in need of emergency care.

If you're in the hospital and "you get inappropriate or fat-negative care, go to the hospital ombudsman," Blank says. "Tell them what you want: a written apology, a referral to another doctor in the same hospital. If a stress test was compromised because of verbal abuse, say, 'I want the test run under better circumstances.'"

"I don't care what you weigh: Everybody has to learn to be assertive or they're not going to get adequate health care."



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