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Medicine is failing obese people

We need more than diet and exercise pep talks to save people suffering from morbid obesity.

Health care providers are generally ill-equipped to deal with obese patients and their complex health needs.
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Watching a person die from cardiac arrest in an intensive care unit is devastating. It’s especially so when the person is a woman in her 40s who has been smothered to death by her own weight — and we doctors can do nothing to save her.

This 500-pound patient, who was at a county hospital in Georgia where I was working, had respiratory failure caused by obesity hypoventilation syndrome, a breathing disorder. It was just the tip of the iceberg of her medical problems. Her obesity had contributed to the development of heart failure, which led to kidney failure that necessitated dialysis. Her respiratory failure required mechanical ventilation, which placed her lungs at increased risk for infection. And so she developed pneumonia not too long after being placed on the ventilator.

While we "saved" her after the initial cardiac arrest, her weakened heart and body arrested again. Unable to overcome all of these odds, this patient died in the hospital’s ICU.

I cannot help but wonder what would have happened if we had managed to intervene long before her obesity sent her down this fatal path.

Patients with obesity often can’t even get standard medical procedures

We’ve long known that a body mass index over 25 can increase health risks like heart disease, stroke, diabetes, hypertension, and more. And as a huge meta-analysis in the Lancet showed, incremental increases in BMI lead to rising mortality rates. The risk for premature death was highest in those with the highest BMIs. Preliminary results from the Cleveland Clinic and New York University released in April reveal that obesity is the leading preventable cause of life-years-lost, 47 percent higher even than tobacco.

Yet health care providers are generally ill-equipped to deal with patients with obesity and their complex health needs. Over the years of my medical training, I’ve seen more and more examples of these patients unable to get the care they need.

Consider the challenges of something as simple as diagnostic testing. In medical school, we had a patient who was transferred to our academic tertiary care facility because she could not fit in the CT scanner at her local community hospital.

Occasionally, there are stories of patients having to be transported to the local zoo to have certain imaging tests done, where fitting in the machine is possible but the images are much poorer quality than what you’d get in a hospital. So after suffering from this incredibly humiliating experience, the patients are left with subpar diagnostic studies.

Weight limits are not reserved for MRI and CT scanners alone, which typically cannot handle people weighing more than about 400 pounds. Most nuclear medicine stress test tables have weight limits around 300 pounds, and cardiac catheterization tables have similar limits. After surveying more than 90 hospitals, a study in 2008 found that on average, cardiac catheterization tables can only accommodate around 450 pounds.

So for a nearly 600-pound patient with chest pain who could not do an exercise stress test due to knee problems and could not fit on either a nuclear medicine stress table or a cardiac catheterization table, what could we even do to investigate the possibility of underlying coronary artery disease? Nothing. Which is why this patient was discharged after being given a bariatric surgery referral and lots of counseling on ways to lose weight.

The burden of weight compromises the body — and makes obesity hard to treat

Most of my overweight and obese patients have been battling their weight their whole lives. And not surprisingly, the figurative and literal burden of their weight has gradually accumulated over the years. When these patients present with crippling knee pain and ask how they can ease their discomfort, it is often very hard to tell them their knee pain is likely due to wear and tear over the years.

Physiologically speaking, it makes sense that obesity and its associated weight load alone can damage joints. Rheumatologists have tracked the effect of obesity on the development of knee osteoarthritis, including the impact of increased mechanical loading and the fatty tissue–fueled inflammatory storm that can damage joints over time. Similarly, due to the increased load on the spine, increased body mass is responsible for the higher incidence of back disorders in patients with overweight and obesity.

Joints are not the only parts of the body that are literally squeezed by the burden of excess body mass. Patients, like the woman I saw, can suffocate, or experience shortness of breath as their chest wall and respiratory muscles become unable to efficiently do the work of breathing. Studies have found that even with a BMI less than 30, there can be a detrimental effect on respiratory function. So compromised respiratory function is not reserved just for the severely and morbidly obese but also the mildly overweight.

Patients with obesity deserve better care. But how?

The obvious advice for patients suffering from chronic joint pain, compromised respiratory function, and other problems linked to their obesity is this: Lose weight. And we tell patients to do so by monitoring their diet and exercising regularly. But what can we do when their shortness of breath, joint pain, and back pain precludes their exercise efforts and this frustration leads them to abandon their healthy diet habits as well?

If we want to try to curb any of the future devastating health complications our patients with obesity will face without weight loss, then we have to try to offer them something other than diet and exercise pep talks.

Despite current research efforts, there are only a handful of drug therapies available to assist with weight loss. And many insurance providers require six to 12 months of documented weight loss efforts before they will approve bariatric surgery as an option.

The medical field is working toward non-drug therapies and non-surgical interventions that can help our morbidly obese patients, with the recently approved AspireAssist being the first of many potential advances in weight management. As controversial as this device is, there is no doubt that some of our patients may need just this kind of assistance to at least start the weight loss process.

There have also been short-term studies looking at the impact of cognitive behavioral therapy as a way to approach obesity treatment from a psychological perspective. Unfortunately, these studies have not shown long-term success and have only affirmed the need for longer studies to better assess whether psychological interventions could help patients adapt better eating habits in an effort to lose weight.

With ongoing funding and research efforts focused on improving therapeutic interventions and increasing access to diagnostic modalities, perhaps our patients with obesity will actually stand a fighting chance in the battle for their health.

Farah Naz Khan is a doctor and a writer in Atlanta, Georgia. Find her on Twitter @farah287 or via her website FarahNazKhan.com.