Hindsight: Managing Weighty Issues on Lean Evidence
Saturday, August 25, 2012
In 2005, I wrote an article for the Canadian Medical Association Journal (CMAJ), in which I highlighted that fact that in light of the obesity epidemic, physicians and other health care workers will be delivering health care to a growing number of obese and severely obese patients.
“Diagnosing many common medical conditions, although straightforward in nonobese patients, can be fraught with difficulty in morbidly obese people because little is known about the sensitivity and specificity of diagnostic tests in this population. …obtaining imaging studies such as CT or MRI is often impossible for morbidly obese patients because of the size and weight limitations of the machines. Oversized equipment is unavailable in most hospitals. These limitations call for more research into diagnostic algorithms, tests and reference ranges for morbidly obese patients, to avoid misdiagnoses and to ensure optimal care.”
I also noted that with the exception of ‘weight-loss studies’, people with obesity are generally underrepresented in clinical trials.
“As a result, the majority of clinical practice guidelines, even for conditions commonly found in obese patients (e.g., hypertension, diabetes mellitus, asthma, ischemic heart disease, venous thrombosis and neuropsychiatric disorders) fail to make specific recommendations for patients with morbid obesity that go beyond a rather general appeal for weight loss. This issue is far from trivial, as obesity significantly affects the pathophysiology and pharmacodynamic response in a multitude of medical conditions. For example….gastroesophageal reflux disease, where the pathophysiology in obese patients (increased intra-abdominal pressure, hiatal hernia, vagal abnormalities) may be distinctly different from that in nonobese patients. Responses to medications may be different, as metoclopramide may fail to decrease gastric volume or raise pH in obese patients. Similarly, although self-reported asthma is more frequent at higher BMI levels, obese individuals paradoxically are at lowest risk for significant airflow obstruction, and much of the respiratory symptoms may indeed be due to nocturnal aspiration of gastric reflux. Thus, asthma not only may be overdiagnosed in the obese population but, if present, may require a different approach to management.”
I also commented on the need for studies that examine the effects of excess weight on pharmacokinetics and pharmacodynamics of medications commonly used in obese patients.
“Virtually all existing diagnostic criteria and algorithms will need to be revalidated in the obese population, and where physical limitations hinder the use of diagnostic imaging technology, new strategies will have to be developed to deal with very obese people…. In short, most of what we know about medicine will need to be re-evaluated to ensure optimal medical care of obese patients.”
In the seven years that have passed since I wrote this article, we have seen a vast increase in the study of obesity, including studies specifically addressing many of the issues I highlighted in this commentary.
However, we are still far from fully appreciating the impact of the obesity epidemic on medical practice and in many instances, managing obese patients can be better likened to ‘muddling through’ than to a sound evidence-based approach to medical practice.
Training in obesity management or bariatric care is still not a mandatory requirement for graduating from medical school or obtaining your medical license. We are still graduating health professionals, who know more about calcium homeostasis than about energy homeostasis.
If you have experienced problems with diagnostic procedures or treatments because of your size, I’d certainly love to hear about them.
AMS
Vancouver, BC
Saturday, August 25, 2012
MRI scanners are an issue – even the open MRIs cannot accomodate some patients. This is unacceptable, as it limits my ability to provide the appropriate diagnostic testing.
Saturday, August 25, 2012
Over the past year I’ve had to go several times to Emergency at two different local hospitals. At both places it was impossible for them to find a blood pressure cuff to fit my arm. Before they even started, I would suggest they find a thigh cuff, but they would always go ahead and put on the largest size, the automatic machine would start to inflate, get to where it was starting to be painful, then the velcro would pop off. At that point, they would just give up. In a city with a population of over 300,000 people, I – at 350 lbs – am hardly the only or fattest person in town. I am glad that they do have available large-sized hospital gowns, but most of the waiting area chairs have arms which dig into my sides and are hard which is really painful on my arthritic hip. For visits to my family doctor I bring my own thigh blood pressure cuff, which I have offered to the staff in the ER but which they declined to use. On the positive side, I have only had one medical professional give me a hard time about my weight. That was several years ago when I had a pre-surgery interview with an anesthetist who said in a nasty tone that “it’s people like you who make my job really hard”. Thankfully he wasn’t on duty when I had the actual surgery.
Sunday, August 26, 2012
Over the years, medical studies have concentrated on the group that our society values most: men of northern European ancestry. Women, and people whose background is different – anyone who’s considered non-standard in any way – has been underrepresented. Is it any wonder that fat people have been neglected? It’s good that you’re posting about this, because it’s been a huge problem. If it’s starting to improve, that’s a relief.
The attitude in the medical establishment often seems to be that if fat people aren’t able to lose weight permanently, then our lives have no value. The treatment for every medical problem we have is the same: weight loss. Many doctors and other medical professionals look on us as wilfully non-compliant and as an inconvenience, not as people whose bodies work a little differently than others’, but who still deserve competent medical care.
It’s all part of a larger pattern. I was reading a post on the mechanistic model of the human body as the dominant paradigm in western medicine, and I think that one thing that comes out of it is this: a lot of medical people would like to deal with standardised human bodies. Ethnic differences; differences between women and men; non-standard bodies, whether they’re larger, disabled, or in any way unusual; it just complicates things too much. It forces medical people to look at patients’ bodies as individual and unique, and it’s easier to see them as sets of interchangeable parts.
I don’t know what the solution is, because the mechanistic model does work to some extent. It’s surely a way to look at bodies that has built western medicine up to a certain level of effectiveness. But, it has its disadvantages, and it is fails in some respects. Maybe it’s time to get more sophisticated.