NOTE: This article has been recommended by Heather Bell from the New England Center for Health Education, and is being referred to the Center for Obesity Research and Education for distribution to interested U.S. doctors.
I AM SURE that this letter comes as a surprise to you since I rarely make medical appointments (except when uncomfortably ill) and patients rarely write their doctors before seeing them. I am not an exceedingly resistant patient yet have unique concerns that are rarely recognized or taken seriously by health professionals. The problem is that I have a health condition that literally overshadows and obscures the true state of my well being.
While my dilemma is intensely personal, I think that the issues I raise may characterize the feelings of many of your patients facing similar circumstances. My intention is to aid you in your understanding and treatment of me as an obese person. There is a barrier between myself and health professionals. My weight is a message from me to the doctors to keep their distance. Distance is created by the moral, social, and psychological values that prevent you and I from diagnosing my ailments and enabling me to live a more healthy life.
Here are four principles I would like to discuss with you as groundwork for working together on my health problems.
a) Obesity is a medical condition, not a moral failure.
b) Obese people and health professionals need to recognize the detrimental effects of yo-yo dieting.
c) Obesity obscures diagnosis through generalization and shame.
d) The establishment of respectful, trusting relationships with non-prejudiced doctors are of utmost importance.
OBESITY IS A MEDICAL CONDITION, NOT A MORAL FAILURE
It can be argued historically that when a health concern is not thoroughly understood and amenable to therapy, it tends to be approached from a moral perspective. The definitive example of this today is AIDS but, since that may be too explosive and close to us right now, I suggest that we think of cholera. Cholera was painted with the brush of moralism in the early decades of this century. The health care professionals of that day observed that it was the poor who became infected. Cholera was therefore considered a result of uncleanliness, laziness and even moral degradation. When the medical view of the disease shifted as more "hard facts" became available, the attitude and feelings about who got the disease and why altered. Who has obesity and why are questions which are only now coming slowly into focus.
With continued research chronic obesity will be better understood, controlled, and perhaps even cured. But until the research is completed, we struggle with the temptation to think of obese people in outdated, stereotypical ways - as undisciplined gluttons who wilfully give in to their urges to eat. If breakthroughs are to be made then both patients and health care consultants must break the habit of moralism. This will require the humility to say we don't have a cure for morbid obesity but while we are waiting we will not blame patients or do anything that makes the situation more unbearable than it already is for many. This is the first prerequisite for our doctor-patient partnership.
OBESE PEOPLE AND HEALTH PROFESSIONALS NEED TO RECOGNIZE THE DETRIMENTAL EFFECTS OF YO-YO DIETING.
Until recently, the recommended way to treat obesity was through restrictive dieting. Sometimes behavioral modification and drug treatment augmented this approach. With the discovery of the yo-yo effect (that is, when weight is taken off quickly and in great amounts the set point rises and the patients gain even more weight), there is an understandable and legitimate resistance in obese persons to any form of dieting.
Obesity may contribute to a shortened life but dieting can kill you quickly! Recently there have been studies, sponsored by weight loss organizations, which suggest that yo-yo dieting is not as much a health risk as purported. Such a claim must be examined in light of the motives of these organizations who financially benefit from this form of therapy.
I have pledged to give up quick weight loss strategies because of the effects of yo-yo dieting on my health. I have lost tremendous amounts of weight through restrictive dieting, up to 175 pounds at a time. Upon completing one cycle of such dieting I had my gall bladder removed and now I have an even harder time moderating my weight than before. As if it were a great medical secret, the surgeon took me aside and told me jokingly that he called gall bladder procedures "the diet operation". Unfortunately, it was a doctor who recommended a radical weight loss in the first place. The entire experience was demoralizing.
Restriction and the so-called use of willpower does not address the felt problem of obese people. If for many, but not all obese patients, food is a substitute for a lack of nurturance, then the withdrawal of the food leaves the primal need for love unanswered. Restriction in diet is not about taking control of your health but, consciously or unconsciously, will be identified with punishment and the withdrawal of comfort.
The realistic statistic of a greater than 95% failure rate in permanent weight loss due to dieting does nothing to promote it as the therapy of choice for obesity, yet doctors, patients and the exploitive weight loss industry collude in recommending restrictive dieting as a way of dealing with weight difficulties. Even when this ineffective treatment is abandoned another problem often complicates it. Recently, when I decided that I would no longer diet restrictively, I found myself eating voraciously. As a result, I gained 50 more unneeded pounds. Complications in mobility and a sleep disorder set in. It was tremendously humiliating to have to admit that I couldn't stand to do the dishes or walk to the corner store without excruciating pain in my back. The anger and frustration that my "disciplined" approach didn't pay off and couldn't be sustained contributed to this reaction.
When a cure seems hopeless a rage reaction results for many patients. This may take the form of indiscriminate eating. To avoid the pitfalls of either restrictive dieting or rage I would suggest that as health partners we develop a strategy that incorporates the eating of - and enjoyment of - healthy food and reasonable mobility. Right now for myself, unfortunately, most movement is painful and a moderate loss of weight over a long time period coupled with a slow strengthening of my muscles to carry my weight may be what the doctor and patient ordered.
OBESITY OBSCURES DIAGNOSIS THROUGH GENERALIZATION AND SHAME.
Before directly addressing the issue of weight, I would like to evaluate my current health. This is difficult since obesity can mask real health problems. I am not quick to discuss my health due to shame. Lifting layers of fat to examine body orifices is a humiliating procedure for some fat people. I call this the "untouchability" factor. The social shame coupled with the body image issues of obese people are not unlike the leper whose disease keeps people well away. I have a psychodynamic theory as to why this might be the case. Many, but not all, obese people have developed obesity as a response to abuse or denigration by their family. The necessary medical examination may bring back the body's memory of abuse, real or symbolic. This factor would be doubly relevant if the sexual organs are part of the problem. If the demeanor of physicians is perceived as uncaring, detached, or in a hurry, this unconsciously cues patients that they are being treated inhumanely.
The most obvious thing about me health-wise is my size but weight may not be what brings me to the doctor's office on every occasion. For instance, if my ankle hurts it may be the tremendous weight I carry on my feet, or it might be anything from a small fracture to a sprain. The usual response to an obese person complaining of sore ankles is the stern admonition to lose weight and the pain will go away. However, any foot doctor will have to acknowledge that even thin people can have foot problems. Another example is genetic heart disease. Although obesity is a contributing factor to heart problems, if several members of the family have died of a heart attack then there is at least one reason beyond obesity for causation.
This is true in my case. Three people in my family have had heart problems, yet I have been given the impression by many doctors that any heart pain I sense is the result of obesity alone. If a doctor is distracted by my weight they are not likely to search for other explanations. Obesity obscures diagnosis. Often the overall effect of patient shame is concealment of important medical data needed for thorough examinations. For instance, if under one of those layers of fat lies a mole or some other growth, it may go undetected. Haemorrhoids in many people go unreported, but in the obese, due to the physical and psychological discomfort, they are more often unacknowledged.
THE ESTABLISHMENT OF RESPECTFUL, TRUSTING RELATIONSHIPS WITH NON-PREJUDICED DOCTORS ARE OF UTMOST IMPORTANCE.
A key to health partnerships involves respectful, trusting relationships between non-prejudiced doctors and non-defensive patients. As much as I would like to enter with you in a partnership toward health, the principles above must be respected, discussed and acknowledged. If you have read this far, I am confident that you have goodwill and are concerned with my well being. It is central to my view that the relationship that we establish for the betterment of my health is characterized by mutual respect. The day when patients, obese or otherwise, are passive in their health care is over. So I look forward in improving my health along with you, and enabling you to deal more effectively with me as your patient. Undoubtedly, my weight will be a contributing factor to many of the ailments I come to you with, but with the above principles in mind I think we have made a great first step toward partnership.
Respectfully Yours, Arthur P. Patterson
Recommended site for further research: BodyPositive
|
Watershed Home Page