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Dr. Suzanne Koven, When obesity is given too much weight in a diagnosis

28/Mar/2011

Monday, March 28, 2011

(The Boston Globe)

When obesity is given too much weight in a diagnosis

Joanne went to the Grand Canyon, but she never saw the view. In her 40s at the time, and a patient of mine, she flew from Boston to Phoenix to visit an old friend who had moved out West. The two drove 230 miles north to a lodge near the South Rim. As Joanne was getting out of the car, she suddenly experienced a severe headache, nausea, and vomiting. Her friend called an ambulance and Joanne was taken to a local clinic, where she was diagnosed with altitude sickness, a reasonable conclusion since the South Rim is at 7,000 feet and Joanne weighed more than 300 pounds. The diagnosis was reasonable, but was it right?

Obesity increases the chances of getting altitude sickness, but it also can color physicians’ attitudes about their patients and cloud their thinking about the causes of illnesses. Since obesity can underlie many medical problems, it’s not surprising clinicians sometimes have trouble seeing past a patient’s fat. Excess weight puts people at risk for heart disease, high cholesterol, high blood pressure, diabetes, arthritis, gall bladder and liver disease, skin infections, sleep apnea, infertility, depression, and certain types of cancer including breast, uterine, prostate, and colon.

Most people would not think of altitude sickness as a complication of obesity, but in the Rocky Mountains, where up to a quarter of all visitors develop some form of this condition, physicians and emergency responders are very aware that heavier people may be at increased risk. Mountain sickness occurs when people ascend to or descend from altitudes over roughly 7,000 feet, where air pressures and oxygen concentrations are lower than at sea level. Taking medications such as acetazolamide (Diamox) and allowing time for acclimatization when ascending or descending can prevent symptoms, which include headache, nausea, and vomiting — just what Joanne had — but some people develop altitude sickness anyway.

At the clinic, Joanne was given an oxygen compressor and told to travel slowly back down to Phoenix. She did as instructed, and even felt well enough to sightsee for a couple of days before flying home to Boston. When she arrived at her apartment, though, she had another sudden headache, even worse than the one she had had in the mountains. She called 911 and went to an emergency room, where a CAT scan of her brain and a spinal tap were both normal. Joanne was told she had migraines (which she had never had before) and sent home with pain medicine. A few days later, when the headache was still intense and the pain medication ran out, she went to a walk-in clinic and asked to be admitted to the hospital. An unsympathetic doctor responded, “What would I write as a reason for admission: vacation?’’

Bias against fat, well documented in the workplace and other settings, definitely exists in clinics and hospitals. A 2003 survey of more than 600 primary care physicians revealed that more than half shared the general public’s negative perception of obese people. Over 50 percent responded that they considered obese patients unattractive and less likely to comply with medical advice. No doubt many obese patients sense this disapproval and avoid medical care because of it. Some may stay away from doctors offices because they dread the skimpy gowns, narrow examination tables, and embarrassing weigh-ins. These factors are likely to contribute to the markedly lower rates of screening for cervical and breast cancer among obese women.

A more subtle kind of discrimination exists in the contradictory attitudes many doctors have toward obesity: The complications of obesity are serious medical problems, while obesity itself is not a medical matter but an issue of willpower, maybe even a character flaw. Joanne had experienced this attitude before. In her 20s she had gone to a doctor who told her to “just lose 25 pounds.’’ When she returned for her next visit, after having struggled to achieve that difficult goal, her doctor didn’t acknowledge her accomplishment. Instead, he again told her that she should “just lose 25 pounds.’’

Several days after returning to Boston, when her headaches had not resolved, Joanne went to a neurologist who found that she did not have altitude sickness at all. She had had a series of small strokes brought on by a rare lung tumor called a carcinoid, which releases chemicals that can cause blood vessels to constrict. Her weight played little or no part in what had happened to her on her trip.

Joanne’s lung tumor was removed and her headaches disappeared. A few years later she had weight loss surgery and she now has normal blood pressure and blood sugar — those had been high when she was heavier — and she is able to exercise without getting short of breath.

I happened to be on vacation, too, when Joanne went out West and became ill. Later, when we discussed her medical care, she told me that it had been excellent, for the most part, except for a few doctors and nurses who had treated her as if her only health problem were her obesity and, therefore, her own fault. She said, “It would be nice if they experienced lives as fat people for about a month. They might get a clue!’’

I asked if she wanted to go back to the Grand Canyon, thinking the trip was important to her as a symbol of her triumph over obesity. But perhaps I, too, had misjudged the role of weight in my patient’s life. She told me she had no such trip in mind. “I never really went to see the Grand Canyon,’’ she explained. “I went to see my friend.’’

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. In this new monthly column she will write about the uncertainties, dilemmas, and stories that patients and doctors share in practice. She can be reached at inpracticemd@gmail.com.

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