should lose weight, a doctor told Sara Bramblette, advise a diet of 5020 kilojoules a day. But Bramblette had a basic question: How heavy
scale up to 160 kilograms doctor, and she was heavier than that. If the number is not known, how was I to know if the diet was working?
The doctor had no answer. So Bramblette, 39, used a solution that made him burn with shame. She went to a nearby scrap yard that had a weighing scale on it. She was 227 kilograms.
Almost two in three Australians are overweight or obese, a rate that has been growing for more than two decades, but the system of health care – in their attitudes, equipment and common practices – is bad prepared, and its practitioners are often willing to try increasing obese population.
Difficulties range from scales and scanners such as MRI machines that are not built large enough for heavy people, surgeons who categorically refuse to give knee replacements or hip to obesity, to doses of drugs that have not been calibrated for obese patients. The situation is particularly thorny for those with extreme obesity – body mass index of 40 or higher -. And they face a wide range of health problems
Part of the problem, patients and doctors say, is the reluctance to look beyond the weight of a fat person. Patty Nece, 58, went to an orthopedist, because his hip hurt. He had lost nearly 30 kilos and, although it still had a way to go, felt good about herself. Until I saw the doctor.
“came to the door of the examination room, and I began to tell my symptoms,” Nece said. “He said, ‘Let me get to the point you need to lose weight..” “
The doctor said, never examined. But he made a diagnosis, “the pain of obesity” and transmitted it to his internist. In fact, it was learned later, she had progressive scoliosis, a condition not caused by obesity.
Dr. Louis J. Aronne, an obesity specialist at Weill Cornell Medical, helped found the American Council of Medicine of obesity to treat this type of problem. The goal is to help doctors determine how to treat obesity and serve as a resource for patients seeking doctors who can see beyond their weight when they have a medical problem.
Aronne says patients tell stories as Nece him all the time.
“Our patients say, ‘. No one has ever treated me as if I had a serious problem and remove They tell me to go to Weight Watchers,'” Aronne said.
“Physicians need better education, and they need a different attitude towards people with obesity,” he said. “They have to recognize that this is a disease like diabetes or any other disease they are treating people for.”
The problems that obese people face follow them through the medical system, starting with the physical examination.
Research has shown that doctors can spend less time with obese patients and not to refer them for diagnostic tests. In a study of 122 primary care physicians affiliated with one of the three hospitals about their attitudes toward obese patients he was asked. Doctors “reported that serve patients had a greater loss of the heaviest time was that doctors would like their jobs unless their patients increased in size, the heavier patients were seen to be more annoying and less patience doctors heaviest felt that the patient was “the researchers wrote.
At other times, doctors may unknowingly influenced by unsubstantiated assumptions, attributing symptoms such as breathlessness the weight of the person without investigating other possible causes.
That happened to a patient who finally went to see Dr. Scott Kahan of an obesity specialist at Georgetown University. The patient, a 46-year-old suddenly found it almost impossible to walk from your room to the kitchen. Those few steps left breathless. Frightened, he went to a center for local urgent care where the doctor said I had a lot of weight pressing on her lungs. The only thing wrong with it, the doctor said, was that she was fat.
“I began to mourn,” said the woman, who asked not to be identified to protect their privacy. “He said.. ‘I have not a sudden weight pressure in my lungs I’m really scared
” That’s the problem with obesity, “the doctor said.” Have you thought about going on a diet “?
It turned out that the woman had several small blood clots in his lungs, a life-threatening condition, Kahan said.
For many, the next step in the diagnosis involves a scan, like a CT or MRI. However, many extremely heavy people can not fit into scanners, which, depending on the model, generally have weight limits of 160 to 200 kilograms.
scanners that can handle very heavy people made, but a national survey found that at least 90 percent of emergency rooms did not have them. Even four out of five community hospitals that bariatric surgery centers of excellence were considered lacked scanners that could handle very heavy people. However, you need to scan or magnetic resonance imaging to evaluate patients with a variety of ailments, including trauma, acute abdominal pain, pulmonary blood clots and strokes.
When an obese patient can not fit in a scanner, doctors can simply give up. Some use X-rays to scan, hoping for the best. Others resort to more extreme measures. Kahan said another doctor had sent one of his patients to a zoo for a scan. I was so humiliated that she declined requests for an interview.
The problems do not end with a diagnosis. With treatments, many uncertainties remain.
In cancer, for example, obese patients tend to have worse outcomes and increased risk of death -. One difference is maintained for all cancers
The disease of obesity may exacerbate cancer, said Dr. Clifford Hudis, executive director of the American Society of Clinical Oncology.
However, he added, another reason for the poor results in patients with obesity cancer is almost certainly compromised the health care. Drug doses are usually based on standard body sizes or surface areas. The definition of a standard size, Hudis said, often based on data involving people from decades ago, when the average person was thinner.
For the fat, which could lead to underdosing for some drugs, but it is difficult to know without studying the specific effects of drugs on heavier people, and such studies are generally not made. Without such data, if someone does not respond to a cancer drug, it is impossible to know whether the dosage was wrong patient or tumor was resisting the drug.
One of the most common medical problems in obese patients is arthritis of the hip or knee. So common, in fact, that most patients who come to the offices orthopedists’ agonizing pain in hip or knee arthritis are obese. However, many orthopedists not offer the surgery unless patients lose weight first, said Dr. Adolph J. Yates Jr., professor of orthopedics at the University of Pittsburgh School of Medicine.
“There are offices to be screened over the phone,” Yates said. “You will be asked for weight, height and tell patients before they see that they can not help them.”
But how well are grounded weight limits?
“There is a perception among some surgeons is more difficult, and certainly some felt it was an added risk,” to operate in the very obese, Yates said. He was a member of a committee that reviewed the risks and benefits of joint replacement in obese patients for the American Association of Hip and Knee Surgeons. The group concluded that heavy patients first should be advised to lose weight because lower weight reduces stress on joints and can relieve pain without surgery.
But there should be no blanket to operate in obese people rejections, the committee wrote. Those with an index above 40 body mass – as a woman of 5 feet 5 inches with a weight of 113 kilograms or a man of 6 feet weighing 136 – and can not lose weight should be informed that their risks are greater, but there should be categorically ruled out, the group concluded.
Yates said he had worked successfully in people with BMI of up to 45. What is behind the refusal to operate, he said, is that doctors and hospitals have become risk averse, and who fear that their qualifications will fall if too many patients have complications.
A lower score can mean reductions in Medicare reimbursements. Poor results may also lead to penalties for hospitals and, eventually, doctors.
A recent survey of more than 700 hip and knee surgeons confirmed impressions Yates. Sixty-two percent said they had used body mass index cutoffs results as to require weight loss before offering surgery. But there was no consistency in the numbers they chose.
“The numbers were all over the map,” Yates said. And 42 percent chose a body mass index cut, said they had done so because they were worried about their performance score or your hospital.
“It is very common to pick an arbitrary number BMI and say, ‘That’s the number we will not go over,'” Yates said. However, a person with an index of, say, 41 could be healthy and active, he said, but in terrible pain of arthritis. A knee replacement could be transformative life.
“It’s a zero-sum game, with everyone trying to have the lowest risk patient,” Yates said. “Patients who may be at a slightly higher risk can be treated as a class rather than individuals. That is the definition of discrimination.”
Surgery involves anesthesia, of course, leading to another topic.
There are no requirements for drug manufacturers to determine appropriate doses for obese patients. Only a few medical experts, like Dr. Hendrikus Lemmens, a professor at Stanford University aneasthesiology have tried to give answers.
His group analyzed several drugs: propofol, which puts people to sleep before general anesthesia; succinylcholine, used to relax muscles in the trachea when to insert a breathing tube; and anesthetic gases.
The doses of propofol, Lemmens found, should be based on lean body weight – body weight minus your fat. The use of total body weight, as is routine for people of normal weight, would lead to an overdose for obese patients, he said. But succinylcholine doses should be based on the total body weight, which determines, and the dosage of anesthetic gases is not significantly affected by obesity.
Regarding regional anesthesia, said: “There are very few data, but it is likely that the dose should be in accordance with the lean body weight.”
“bad results because of inappropriate dosing does not occur,” Lemmens, who added that 20 to 30 percent of all obese patients in intensive care after surgery were there because of complications aneasthetic said. Given the uncertainties about the anesthetic dose for the obese, said Lemmens, who suspects that a significant number of them had inadequate dosage.
However, for many obese people, questions about proper medical care are irrelevant as they stay away from doctors.
“I avoided going to a doctor at all,” said Sara Walker, the author of “Dietland,” a novel. “This is very common with fat people. No matter what the problem, the doctor blame fat and lose weight will tell.”
“Do you think I do not know I’m fat?” He added.
The New York Times
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