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Large Patients and Lack of Preventive Health Care
Physician or Patient Driven?
Arch Fam Med. 1998;7:385.
DURING THE past several years, physicians have become increasingly aware of the epidemic of obesity in the United States. The alarming increase in its prevalence, both in adults and children, has led to the development of initiatives geared to the recognition of obesity as a complex disorder of energy balance requiring long-term treatment. The change in our view of obesity from a shameful social problem to a medical disorder worthy of attention is to be commended. The treatment of obesity, however, is not necessarily synonymous with the treatment of patients who are obese. Are large patients well served by their clinicians?
In this issue of the ARCHIVES, Fontaine et al1 provide evidence that overweight patients are less likely than those of normal weight to receive important preventive health care services, particularly those that involve disrobing and clinical examination. This study, which has the advantage of being large and population based, adds to the evidence from smaller studies that overweight women do not receive adequate health care.2 Although the data from this study are correlational, and we cannot determine whether the reasons for this failure were physician or patient driven, it is most likely that both were important.
Physicians' attitudes toward obese patients reflect those of society in general. Clinicians tend to view obese patients as lazy, sad, and lacking in self-control.3 Examining obese patients is more difficult, and the attitude of "why bother, I'm not going to be able to detect an abnormality anyway" may be more prevalent than we suspect. Concomitant health problems such as diabetes mellitus or hypertension that are more frequent in obese persons may push preventive services to a lower priority. From a patient perspective, large patients report being treated by physicians and other medical personnel with disdain and disrespect. From examination gowns that do not fit to insensitive and public comments about weight, it is no wonder that, as one overweight patient has said, "I've gone to the doctor for a sprained wrist and been lectured [about my weight]. I postpone my yearly Pap smears for the same reason."4 Interestingly, the one preventive care service that was not significantly less likely to be performed in obese women is mammography. This is not fully explained, but it may be because obtaining mammography merely requires a prescription by the referring physician and does not require disrobing and hands-on examination in the physician's office.
According to the most recent data from the Third National Health and Nutrition Survey,5 overweight (defined as a body mass index of >27.3 kg/m2) is present in 33% of non-Hispanic white women, 52% of non-Hispanic black women, and 50% of Mexican American women. What is a physician to do? Awareness of the possibility that health care professionals may be disenfranchising a substantial proportion of their patients is a good first step. Educating office staff to be sensitive to the needs of large patients; providing armless chairs, large blood pressure cuffs, and examination gowns; and generally improving the comfort and accessibility of one's office for these patients are others. While not negating the importance of obesity as a health problem, physicians need to remember that not every health problem is obesity related. Overweight patients also need and deserve the same age-appropriate preventive health care services recommended for all patients.
Above all, overweight patients deserve to be treated with the same degree of care and compassion as those of normal weight. For some patients, it will be the first positive experience with a physician that the patient has had in years. Rarely do physicians have an opportunity to have as much effect on a patient's psychological, as well as physical, well-being as by evaluating and changing the ways in which they and their staff interact with overweight patients. As Albert Stunkard, MD, a pioneer in obesity treatment, has said,6 "the experience [of being treated by a physician with respect] may be the greatest gift that a doctor can give an obese patient."
Susan Zelitch Yanovski, MD
Obesity and Eating Disorders Program
National Institute of Diabetes and Digestive and Kidney Diseases
Building 45, Room 6AN-18
Bethesda, MD 20982-6600
REFERENCES
1. Fontaine KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med. 1998;7:381-384.
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2. Olson CL, Schumaker HD, Yawn BP. Overweight women delay medical care. Arch Fam Med. 1994;3:888-892.
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3. Price JH, Desmond SM, Krol RA, Snyder FF, O'Connell JK. Family practice physicians' beliefs, attitudes, and practices regarding obesity. Am J Prev Med. 1987;3:339-345.
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4. McAffe L. Discrimination in medical care. Healthy Weight J. 1997;11:96-97.
5. Centers for Disease Control and Prevention. Update: prevalence of overweight among children, adolescents, and adults—United States, 1988-1994. MMWR Morb Mortal Wkly Rep. 1997;45:198-202.
6. Stunkard AJ. Talking with patients. In: Stunkard AJ, Wadden TA, eds. Obesity. 2nd ed. New York, NY: Raven Press; 1993:353-363.
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