Obesity and healthcare

[anxious_101]

food for thought: http://www.kevinmd.com/blog/2011/06/hospitals-treat-obese-patients.html

 

Btw, that blog is fantastic and full of lively posts and discussions.

[limoncello]

Thanks for the link!

[Jochi1543]

Marie June 17, 2011 at 4:43 pm

 

Dear me, I don’t know quite where to start.

 

Ok, how about with some word substitution. How about we substitute the words “morbidly obese” with the words “HUMAN BEING”!! Or maybe “the disabled”? Because human beings and the disabled are so inconveniently imperfect, they should be lumped in with those undisciplined, slobbering morbidly obese freaks. Why should the rest of us, the Perfect Ones, have to go to any lengths to accommodate them? Everyone knows that someone who is morbidly obese deserves to die. After all, they did it to themselves. It doesn’t matter if they developed an eating disorder because they were sexually abused or they have a co-morbidity that keeps them from getting any exercise. They are disgusting parasites.

 

“What should be a rational method of dealing with morbidly obese patients?” Hmmm. That is a good question. I suppose an answer like “With dignity and compassion” never occurred to you? Right, me either. Just because we have the technology and awareness of the needs of the morbidly obese, why should we use them? They have nothing to offer society, after all, no value, so investing in equipment that might accommodate them, help them heal and perhaps develop a healthier lifestyle is clearly not worth it.

 

Thank you for opening our eyes! I can’t wait to see who is next on the Unworthy of Accommodation List.

 

Best comment ever - I've got nothing to add.

[Erk]

Best comment ever - I've got nothing to add.

 

I disagree with both the original article, and with the spirit of that comment. Obesity should be treated as a medical condition not dissimilar from (though not identical to) smoking or alcoholism. Presently it's handled as a taboo, and there are many reports of medical personnel being persecuted as "unfair" for criticising patients' obesity, especially in the US.

 

On the other hand, I don't think people should be denied treatment because of a predisposition to certain conditions, even if it's due to a voluntary habit. It's too difficult to draw the line: should we deny treatment to people who go skydiving? Who drive sports cars? There are countless behaviours that could get blanketed this way.

 

Instead, we need to fight the cultural attitude that makes it acceptable to be obese. When doctors can advice against obesity-forming behaviours as candidly as they can against smoking or drinking in excess, the problem will be much easier to address.

[Rebencer]

I disagree with both the original article, and with the spirit of that comment. Obesity should be treated as a medical condition not dissimilar from (though not identical to) smoking or alcoholism. Presently it's handled as a taboo, and there are many reports of medical personnel being persecuted as "unfair" for criticising patients' obesity, especially in the US.

 

On the other hand, I don't think people should be denied treatment because of a predisposition to certain conditions, even if it's due to a voluntary habit. It's too difficult to draw the line: should we deny treatment to people who go skydiving? Who drive sports cars? There are countless behaviours that could get blanketed this way.

 

Instead, we need to fight the cultural attitude that makes it acceptable to be obese. When doctors can advice against obesity-forming behaviours as candidly as they can against smoking or drinking in excess, the problem will be much easier to address.

 

I agree completely Erk, they made that same comment on 'Supersize Me' which I saw for the first time a couple weeks ago.

 

I also think there is a big difference between these costs in public and private systems. In a public system everyone is paying your medical bill, so (I believe) it is your responsibility to try and reduce unneccessary costs. That doesn't mean everyone has to devote their lives to being in great shape, but there should be evidence of them trying to be healthy once a problem has been brought to their attention.

[anxious_101]

From today's paper: http://www.healthzone.ca/health/dietfitness/article/1012290--it-s-time-to-fight-obesity-opposition-parties-say

[<abstract>]

I agree completely Erk, they made that same comment on 'Supersize Me' which I saw for the first time a couple weeks ago.

 

I also think there is a big difference between these costs in public and private systems. In a public system everyone is paying your medical bill, so (I believe) it is your responsibility to try and reduce unneccessary costs. That doesn't mean everyone has to devote their lives to being in great shape, but there should be evidence of them trying to be healthy once a problem has been brought to their attention.

 

 

My family doc speaks very candidly to her patients about their weight, but she does it in a nice way. Most people who are obese, know they are obese and are not in denial about it. The best way to approach this issue is to obviously bring it up (ignoring the issue will not solve anything), inform patients of the risk of being obese and to provide resources to help them.

 

With obese patients the amount of weight they should loose to be in a healthy zone is very daunting to attain and people get discouraged if they don't get results. Sometimes recommending small changes and easy attainable goals are the best way to help the problem. A 5-10% reduction in weight will give tremendous benefits and it is easily doable with small changes in diet and exercise.

 

Cheers

[naspec]

As trusted medical professionals we should also be careful to steer our patients away from bogus diets and so-called "supplements" that prey on their situation.

[Zarza]

A 5-10% reduction in weight will give tremendous benefits and it is easily doable with small changes in diet and exercise.

 

Careful here.. if it was easy, they we wouldn't have a problem. If you start telling obese patients it's easy to lose weight, when they've been trying their whole lives without success, you're likely going to damage your trust and rapport with them.

 

Another point to remember is that research is showing that healthy lifestyle habits (i.e. regular physical activity, healthy diet) will reduce risk of chronic disease independently of weight. You can't just look at a person and assume you know their story. Weight and obesity have so much stigma and emotion attached to them. Overweight/obese patients often have huge self-esteem and mental health issues related to their weight and health professionals need to be careful not to get sucked in. We should be promote healthy lifestyle habits and promote self worth.

[TheCat'sMeow]

Careful here.. if it was easy, they we wouldn't have a problem. If you start telling obese patients it's easy to lose weight, when they've been trying their whole lives without success, you're likely going to damage your trust and rapport with them.

 

Another point to remember is that research is showing that healthy lifestyle habits (i.e. regular physical activity, healthy diet) will reduce risk of chronic disease independently of weight. You can't just look at a person and assume you know their story. Weight and obesity have so much stigma and emotion attached to them. Overweight/obese patients often have huge self-esteem and mental health issues related to their weight and health professionals need to be careful not to get sucked in. We should be promote healthy lifestyle habits and promote self worth.

 

 

By all means address the issue tactfully but there is always a role for a discussing weight reduction, much like the discussion on smoking cessation. It's you're job as their physician to get their history, find out what they've tried, and help them to come up with strategies for weight reduction.

[aaronjw]

By all means address the issue tactfully but there is always a role for a discussing weight reduction' date=' much like the discussion on smoking cessation. It's you're job as their physician to get their history, find out what they've tried, and help them to come up with strategies for weight reduction.[/quote']

 

The strategy for a Doctor is to refer them to a professional who can properly help them. Doctors are not trained to be nutritionally competent.

 

In additional to a referral to someone who can help them nutritionally, they should also refer said person to someone who can address psychological issues because when it comes to people who are grossly overweight, I contend that's the one of the BIGGEST problems - their mental state.

[Zarza]

The strategy for a Doctor is to refer them to a professional who can properly help them. Doctors are not trained to be nutritionally competent.

 

In additional to a referral to someone who can help them nutritionally, they should also refer said person to someone who can address psychological issues because when it comes to people who are grossly overweight, I contend that's the one of the BIGGEST problems - their mental state.

 

Amen! 10char

[EBDOC15]

It's amazing how underutilized dietitians are in our health care system. I can see how an evidence based medical system is reluctant to prescribe supplements etc.. but there's no reason not to refer to a dietitian for weight loss advice etc...

 

Reminds me how physicians should also be willing to refer to exercise specialists. I guess part of the problem is that there are few highly trained specialists out there and the qualifications/ knowledge of workers in this field varies considerably. Maybe if trainers certified by the CSEP as exercise physiologists were able to provide government subsidized workouts?

[Jochi1543]

It's amazing how underutilized dietitians are in our health care system. I can see how an evidence based medical system is reluctant to prescribe supplements etc.. but there's no reason not to refer to a dietitian for weight loss advice etc...

 

Like aaronjw said earlier, for most people, it's not about not knowing what to eat. It's about emotional eating, lack of time to make meals, lack of access to healthy options, ADHD, an above average interest in food (see Kate Moss saying "Nothing tastes as good as being thin feels" - I personally beg to differ), and just plain greater appetite. I just wrapped up a family med elective and after bringing up the issue of weightloss with a number of patients, no one was terribly interested in seeing a dietitian. One person had already seen one and said the plan she received was boring and unappetizing and she simply couldn't bring herself to stick to it. There are people who eat to live - for those types, it's not as hard to stick to a plan - and people who live to eat - for them, it's difficult to give up gourmet foods. Then you have the reality that most dietitians are not able to provide culturally appropriate advice. We saw a person from Fiji who had poor diabetic control with diet alone. They had already seen a dietitian before, but as we considered sending them to the dietitian again, we realized it was pointless - someone from Fiji eats a completely different diet from what the Canadian-trained dietitian is familiar with. Someone who has been eating duck and goat curries all their life won't suddenly switch to a diet of deli turkey sandwiches.

[MarathonRunner]

Actually, from what I understand from my friends who studied dietetics (and from my own research), they HAVE to take a course on giving culturally appropriate advice in order to become Registered Dietitians. So you will see courses like "Cultural Ecology of Food and Health" at U of A, or "Cultural Aspects of Food" at U of Guelph because dietitians need to be aware of different cultural practices when it comes to food.

 

Dietitians of Canada is well aware that Canada is a multicultural country and that dietitians need to give culturally-appropriate advice to individuals. Certainly all my dietitian friends know that it is very important to tailor their advice to the needs of their clients, and if they don't have the skills necessary, they aren't afraid to refer them to a dietitian that has more knowledge of the client's particular cultural heritage. Now obviously in some areas of Canada there won't be a lot of options for referrals, but in major cities, they can refer someone from South East Asia to a dietitian with that background or from that cultural group.

 

I daresay, like any profession, there are dietitians that don't try to tailor their advice, or make appropriate referrals, and there are probably some that become RDs before cultural sensitivity was a significant issue. But for my friends who are fairly recent grads, it was hammered into them that they need to be culturally aware. It is pretty useless to give people advice that they can't or won't follow because of their cultural beliefs and background. I remember one of my dietitian friends saying that for new immigrants from India, for instance, it is practically impossible to get them to switch to skim milk. So instead, you try to get them to try 2%, which is better than whole milk, but not as drastic a change as going to skim.

 

(I know a lot about this subject because I was seriously considering dietetics as a second degree if I did not make it into medicine, so grilled my dietitian friends extensively on their programs and their practice, and did a lot of research into what was required to become an RD.)

[Zarza]

Well, as an RD who has been practicing for a while, I have to agree. If the RDs you refer to are not being culturally appropriate in their interventions, then they are not meeting minimum competency for practice within our College (at least in Alberta). Beyond cultural classes in university, there are many continuing education opportunities hosted dietitians who are of particular background or otherwise intimately familiar with ethnic eating patterns. Sounds like your RD ought to look into this.

 

There are bad and ineffective dietitians just like there are bad and ineffective nurses, doctors, social workers, etc. To paint the whole profession as per your experiences with an individual isn't accurate, or going to lead to your patients getting the best possible care. An effective dietitian should be looking holistically at the client and working WITH them to work towards a healthier lifestyle and making mental health referrals when needed.

 

My experience with people sent to me because their doctor told them they need to lose weight is that the vast majority do not lose much weight. With repeat visits most do, however, find ways to improve their diets/activity patterns to bring down their HbA1Cs, lipid panel, blood pressure, etc to help control whatever disease state they're fighting. These successes can sometimes help people realize they are more than the number on the scale.

[mavrik13]

While I don't agree 100% with the author, s/he brings up some good points. I think the question the author poses is not 'should we accomodate morbidly obese people in the healthcare system?' but rather 'how far should we go to accomodate morbidly obese people in the healthcare system?'.

 

Should we retrofit ambulances with $12,000 worth of cranes to transport the morbidly obese, or require major cities to have 'XXXL' sized CT/MRI scanners? What if we could buy two, three, or four regular sized scanners for the price of one 'XXXL' scanner? Is retrofitting our healthcare system to accomodate the morbidly obese the most justified area to receive the limited healthcare dollars we have? Since we live and work in a cost-limited environment, it is our responsibility to try to strike the best possible balance for the good of the population, not just the patient in front of us (or the lawyer beside him).

 

The question is not whether these people should receive the best and most compassionate healthcare we can provide (of course they do), but rather what is the most efficient and equitable manner of rationing the limited healthcare dollars in our system. I am not saying we should exclude them or any other marginalized population, but we have to look at the big picture here - is this sort of spending justifiable? I don't have the answer.

[D.K.]

We should absolutely NOT accomodate the morbidly obese. It is THEIR fault that they got that way. We all have urges, for example the urge to eat. Some people have stronger urges that others. But in the end, acting on those urges is a CHOICE.

 

Here's my suggestion: if you are too big to use existing medical equipment, you don't get to use it. Period.

 

The money is better spent helping people who didn't CHOOSE their suffering. IE: cancer research.

[aaronjw]

Dopamine.

 

Lets see if you understand what that means and why its not a simple matter of will power as to why people with addictions do what they do.

 

But playing your argument out, how about people who smoke or drink? What about athletes that play sports who get injured?

 

In general i dont disagree with your thought process but unfortunately issues like obesity and other issues above extend far beyond will power. Its difficult to tell people thy shouldmt do x or y when gov't makes it easy amd convenient for people to indulge. How about a premium or higher tax on junk food, alcohol or cigarettes? Maybe that would help some of the desire for these products?

 

We should absolutely NOT accomodate the morbidly obese. It is THEIR fault that they got that way. We all have urges, for example the urge to eat. Some people have stronger urges that others. But in the end, acting on those urges is a CHOICE.

 

Here's my suggestion: if you are too big to use existing medical equipment, you don't get to use it. Period.

 

The money is better spent helping people who didn't CHOOSE their suffering. IE: cancer research.

[D.K.]

Dopamine.

 

Lets see if you understand what that means and why its not a simple matter of will power as to why people with addictions do what they do.

 

But playing your argument out, how about people who smoke or drink? What about athletes that play sports who get injured?

 

In general i dont disagree with your thought process but unfortunately issues like obesity and other issues above extend far beyond will power. Its difficult to tell people thy shouldmt do x or y when gov't makes it easy amd convenient for people to indulge. How about a premium or higher tax on junk food, alcohol or cigarettes? Maybe that would help some of the desire for these products?

 

No, **** that. The free market has to be let out of the cage. No more public healthcare - privatization is the only sustainable future of healthcare. That means fat people pay more.

 

That's the only fair thing here. I think it's complete bull**** how I treat my body well, and I am punished by having to subsidize some cheeto-munching, Oprah-watching fatass.

[aaronjw]

No, **** that. The free market has to be let out of the cage. No more public healthcare - privatization is the only sustainable future of healthcare. That means fat people pay more.

 

That's the only fair thing here. I think it's complete bull**** how I treat my body well, and I am punished by having to subsidize some cheeto-munching, Oprah-watching fatass.

 

Do you drink? Do you smoke? Do you play sports?

[Rebencer]

I'm with Aaron on this one, these issues aren't black and white. Perhaps a few years out of high school will give you some perspective DK.

[D.K.]

I don't drink (much), I don't smoke, I don't use drugs, I eat healthy, and I exercise everyday. Give me my tax money back, and take your healthcare, and shove it up your ass. I don't want it. I'll pay on a case-by-case basis thank you.

[preppy038]

I don't drink (at all), I don't smoke, I don't use drugs, I eat healthy, and I exercise everyday. Give me my tax money back, and take your healthcare, and shove it up your ass. I don't want it. I'll pay on a case-by-case basis thank you.

 

Hope your selfishness pays you well.

Why don't you go live in the States where your opinion is the majority?

[D.K.]

I could just as easily say "go move to Sweden if you think collectivistic social policy is a good idea." A view being alternative to the predominant one does not intrinsically discredit it.

 

As a general rule, the free market is the answer to everything. The only people against it are the feeble who can't compete.

 

It's not selfish - I believe in equal opportunity. That way, if you find yourself in a bad situation, you have nobody to blame but yourself. Personal responsibility needs to make a comeback.