In Practice: Reflections from NPs and PAs

Scott Cuyjet, RN, MSN, FNP-C, practices adolescent medicine in the San Francisco Bay area.

 

Consider the following case:

An 18-year-old female patient with a body-mass index (BMI) of 43 and no other health issues is referred for gastric sleeve surgery. She has tried multiple diets in conjunction with being moderately active and at best has paused or slowed her weight gain. Her parents and one sibling are not overweight, but her other sibling is. She is told she needs to lose 10% of her body weight over the next four months in order to qualify for the surgery, which seems to be a realistic goal based on this article from the Mayo Clinic. The patient weighs 260 pounds, so that makes 26 divided by four, which is 6.5 pounds a month or 1.625 pounds a week. The problem is that she has already tried multiple diets, is moderately active, and has still been gaining 10 to 30 pounds a year. When she returns for her pre-surgery appointment, she is chastised by the surgeon for not losing all of the weight. The surgeon states that it must be because she did not cut back on her already low 1100-calorie diet. The patient wants to say, “That is why I am resorting to this extreme as my last hope, you idiot,” but instead, tears just flow down her face. The surgeon says he will do the procedure anyway.

The problem my patient and I had with this case is that many healthcare providers are stuck in an antiquated metabolic model for weight gain, and patients are experiencing discrimination and harassment because of it. According to this model, any calories taken in that are not burned off by one’s basal metabolism or exercise are stored in one’s fat cells and weight is gained. Conversely, if you take in fewer calories than are used, your fat cells should get smaller and you should lose weight. This model does not explain how most of this patient’s adolescent friends can consume 3,000-4,000+ calories a day of junk food, often do very little activity, and still do not gain any weight. A critique of this model can be found in this article in Digg entitled, “The Calorie Is Broken.” As a provider dealing with overweight patients, I have been frustrated with the lack of data about why people gain weight if it is not because they eat too much and don’t exercise. I feel as though I have nothing to offer these patients to help them other than medications that are minimally effective with intolerable side effects, or surgery, which is extreme and has not been an option long enough to know about its potential long-term side effects. Ultimately though, people should not have to lose weight if it is not affecting their physical or mental health. I have patients who are overweight and have no negative health problems who are perfectly content with their weight.

People who are obese have gained a majority of their stigma from data that suggest that the simple fact that someone is overweight or obese makes them unhealthy. The authors of the Digg article state, “[The] inability to curb the extraordinary prevalence of obesity costs the United States more than $147 billion in healthcare, as well as $4.3 billion in job absenteeism and yet more in lost productivity.” Lately there have been some emerging research studies that are questioning the theory that being overweight alone makes one unhealthy. In a recent UCLA study, researchers concluded that, “Close to half of Americans who are considered overweight by virtue of their BMIs (47.4 percent, or 34.4 million people) are healthy, as are 19.8 million who are considered obese.’” They also found that “More than 30 percent of those with BMIs in the normal range — about 20.7 million people — are actually unhealthy based on their other health data.” The health markers used in this study included blood pressure, glucose, cholesterol, and triglyceride levels.

As medical practitioners, we need to educate ourselves to think outside the box, or in this case, outside the scale, in regard to the causes of obesity versus the causes of hypertension, diabetes, hypercholesterolemia, and other markers of poor health. Other current obesity research points to gene-environment interactions as drivers of obesity — as in this article in the New England Journal of Medicine, which states: “There is good evidence indicating that although obesity may start as a lifestyle-driven problem, it can rapidly lead to disturbed energy-balance regulation as a result of impaired hypothalamic signaling, which leads to a higher body-weight set point. Thus, obesity may be considered a disease initiated by a complex interaction of genetics and the environment.” Some possible environmental culprits of this disruption include chemicals. A recent article in the New York Times Magazine about a chemical called PFOA highlights the dangers of such endocrine-disrupting chemicals that can “interfere with human reproduction and metabolism and cause cancer, thyroid problems and nervous-system disorders.”’ According to the same article, “There are 60,000 unregulated chemicals out there right now.”

Another theory among providers is that their overweight patients are just not moving enough. Yet according to this study in the journal Cell Biology (conducted in non-overweight/obese people), people with moderate activity levels only burned an average of 200 calories more a day than sedentary people did and that increasing exercise did not increase calories burned.

Yet another possible cause of obesity may be our gut bacteria. There are emerging theories and data about their possible effect on many health conditions including weight gain. As stated in an article in Scientific American, “New evidence indicates that gut bacteria alter the way we store fat, how we balance levels of glucose in the blood, and how we respond to hormones that make us feel hungry or full. The wrong mix of microbes, it seems, can help set the stage for obesity and diabetes from the moment of birth.” This article from the journal Open Forum Infectious Disease shows potential evidence for weight gain from a change in gut bacteria, although it is only a case study. It is a study of a 32-year-old woman who gained 34 pounds over 16 months after receiving a fecal transplant for C. difficile from her 16-year-old daughter, after which, “She had been unable to lose [the] weight despite a medically supervised liquid protein diet and exercise program.”

Finally, the biggest problem with not knowing more than we do is that the current explanations blame the patient. This can lead to discrimination and shame, which can negatively affect other aspects of patients’ lives. With regard to discrimination based on weight, this article in Psychology Today underscores that it comes from all directions, including healthcare providers. Its findings included:

• More than half of doctors described their overweight patients as ugly, awkward and non-compliant with treatment.
• Nearly one-quarter of nurses admitted to feeling repulsed by their obese patients.
• Nearly 30 percent of teachers said that becoming obese was “the worst thing that can happen to someone.”
• Defendants in lawsuits who are overweight are more likely to get slapped with a guilty verdict.
• More than 70 percent of obese people reported being ridiculed about their weight by a family member.
• Fifty-two percent of obese individuals believe they’ve been discriminated against when seeking employment or a promotion.
• Children as young as 4 are reluctant to make friends with an overweight child.

Other reports indicate that obese children are more likely to be bullied (although this article from CNN is from 2010, the information is still relevant), and obese adults (especially women) make less money than their average-weight peers.

With regard to my patient, it has been a little over a year and she has lost 50 pounds even though her diet and activity are similar to what they were before surgery. She now finds it easier and less stressful to buy clothes, has more friends, and feels more confident. So again, it cannot just be about calories. The removal of part of her stomach changed something about the way she is digesting food and storing or burning calories.

In closing, remember that just because someone is overweight does not mean they are unhealthy. We need to test all patients regardless of weight for things that are actually affecting their health. And remember to be kind and think “outside the scale,” as these are people with feelings who are being bombarded from many directions with messages both overt and subtle about their weight and body image.