Weight and See

 

Obesity and dietary issues have been seen as major contributors to diabetes and cardiovascular health for some time now. No longer regarded as outward manifestations of status or wealth in most societies, they are now often subjects of disparagement, and those carrying extra weight frequently stigmatized and derided. As if the very fact of being overweight was an act of moral depravity, or at the very least, a manifestation of weakness. Self-neglect.

Smoking –especially in North America- suffered a similar fall from grace when it became evident that it was a cause of major health problems. But it is much easier to hide a smoking habit than an overweight or frankly obese body. And whereas public measures to stigmatize smoking and outline the health risks may have some effect on smoking behaviours or smoking persistence, they seem to be counterproductive in successfully encouraging exercise for weight loss according to a large study from Britain: http://bmjopen.bmj.com/content/7/3/e014592

This was a long term study starting in 2002 of 5480 participants of both sexes, all at or over 50 years of age, and carried out by Dr. Sarah Jackson from University College London. ‘In summary, these results provide evidence that weight discrimination may be associated with lower participation in regular physical activity and higher rates of sedentary behaviour. Through this mechanism, weight discrimination may be implicated in the perpetuation of weight gain, onset of obesity related comorbidities and even premature mortality.’

The BBC News also reported a perhaps more easily assimilable summary of the study: http://www.bbc.com/news/health-39191100. The point being, evidently, that shaming or drawing attention to the weight a person is carrying is less likely to get them to exercise than a welcoming and supportive attitude. And environment -‘Exercising when you are overweight can be daunting, and the fat-shaming attitudes of others do not help.’

I suppose this study is much like carrying coal to Newcastle, but nonetheless it is important to hold a mirror to societal attitudes and prejudices. It’s often not so much that we mean to denigrate people who hold different values, or who do not seem to espouse the image we find attractive but rather that we hold ourselves apart. Withholding approval can be as devastating as active discrimination and, at least in this case, seldom leads to positive changes.

Unfortunately the problem of excessive weight sometimes slips by in a gynaecology office as well –noticed, but unmentioned- because of fear of upsetting the patient. Occasionally, an opportunity will present itself, however. One has to be alert –and sensitive.

Janina was a new patient to me. I first saw her in the waiting room sitting in the corner seat which was partially obscured by a large, leafy Areca palm. Her head and face were further hidden behind a magazine whose pages never seemed to turn. A large lady by any estimation, she attempted to camouflage it as best she could with an extra-large, loose fitting brightly patterned sweat shirt and bulky jeans. The effect was really quite beautiful –and so was Janina when she finally lowered the magazine. Her large, brown eyes were captive birds that fluttered delicately behind the bars of exquisite eyelashes. Her face was soft and her smile, although timid and infrequently offered, was captivating. She wore her hair long and auburn waves flowed slowly and gently over her shoulders like water on a beach whenever she moved.

She made a show of being nice in the waiting room, but I could tell that she was uncomfortable as she followed behind me to my office. She closed the door quietly behind her but before she sat she moved the chair as far away from the desk as the room allowed.

I smiled at her in an attempt to put her at her ease, but she had already dropped her eyes onto her lap and refused to retrieve them.

“Dr. Blackstock says you are having some problems with your birth control pills,” I said, when it became evident that she was not going to volunteer any information.

She sat perfectly still, her hands clasped motionlessly where her eyes still lay. Finally, she took a long, slow breath, looked at me, then slowly nodded her head. It was a sad movement, and for a moment, I wondered if she was going to break into tears. But she remained silent.

“What kind of problem are you having, Janina?” I asked, after another sepulchral moment.

She sighed again, but her face changed. “Isn’t it obvious, doctor?”

I raised an eyebrow to indicate that it wasn’t.

“Ever since I started on the pill, I’ve continued to gain weight,” she started. “I was never this heavy before…” She paused briefly to let that sink in. “Never…” She let her eyes drift around the room for a moment, finally settling them on a terra cotta statuette of a seated woman with a begging bowl that I’d placed on a little oak stand in the corner. “I don’t want to end up like her,” she said, pointing at the woman. She sent her eyes back to perch briefly on my face. “But even she isn’t as fat as me…”

As the words sank slowly into silence, a tear began to run down her now quivering cheek. I rose from my desk and walked across the room to hand her some tissues. She seemed to appreciate the gesture and her face softened for a moment. In fact, she used the opportunity to examine me as I walked back to my desk.

“You have no idea how people look at a fat person like me…” she finally volunteered and then her eyes focused on a wooden figurine on my desk behind a plant; it was a woman holding a child and peering out as if she were hiding. “I feel like that woman,” she said, nodding at the plant with her eyes.

I must have let a worried expression escape onto my face, because Janina seemed to focus on it. “It’s a different world when you’re fat, doctor. That’s all people see…”

I sighed. I couldn’t help it; she seemed so sad. “I see beauty,” I said –it just escaped from my lips. I hadn’t planned it…

Suddenly she smiled, and her hair danced once again over her shoulders. She straightened herself on the chair, and then with a gentle shrug stood and moved it closer to the desk.

 

 

 

 

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”