HAES in Medical School

Eating Disorders & HAES

2010-08-02T13:13:00.000-07:00

Right now I'm on an eating disorders rotation, mostly seeing girls who are very, very sick with Anorexia Nervosa. There are a number of things that make me think about HAES. Sometimes it's hearing about how these girls were affected by the health programs at their schools, that typically talk about "healthy eating". This Red Light, Green Light program seems pretty typical of what is taught -- some foods are bad, and should be eaten as little as possible. These kind of programs piss me off to no end. But one thing that I heard someone say this week was along the lines of "The problem with these programs is that the kids who don't need them end up taking them to heart and cutting out foods to the point of becoming unhealthy, and the program doesn't have an impact on the kids who do need to listen." Now this pisses me off even more. Yes, the programs are bad for the kids who, for whatever reason, build the false messages into the development of serious eating disorders. But they are also bad for the fat kids who get the message that they are bad, their bodies are bad, their eating is bad, and their fat is their fault. And I know that this is what I should expect at this point in my medical training ... but somehow I expected more of the folks who work in eating disorders.

The other part that really gets to me is that there's all this lip service to 'people come in all shapes and sizes', etc. But I get the distinct feeling that there's the hidden caveat of "except if you're REALLY fat" attached to it all. There are posters depicting women at a range of sizes, from thin to slightly chubby, but never with someone who is outright fat. It's hard for me to tell how much of this is me overreacting vs. what's really going on, but so far, there have been some tough moments for me working in this environment.

BMI and Stupid Assumptions

2009-10-03T06:45:00.000-07:00

Excessive exercise often accompanies eating disorders. You wouldn't think it would be necessary to point out that this is not healthy, but as the ED Bites blog says, it's often hard for people to grasp that exercise isn't automatically nor universally a healthy behaviour.

A few weeks ago, we had a seminar with a case study (an invented case) about a woman with a BMI of 20. The medical students presenting this case described this as a "normal, healthy BMI" and then recommended that she increase her exercise as part of a list of general recommendations for improving health. The seminar leader, Dr. P, a family physician who had written these cases as composites from real scenarios, did not disagree.

A friend of mine with background in eating disorders work did say to the group that a BMI of 20 is very often neither normal nor healthy. Any woman presenting to her family doctor with a BMI of 20 deserves a screening for eating disordered behaviours rather than a blanket recommendation to increase exercise.

Another case during the seminar described a patient with a BMI of 32. At one point there was a list of behaviours that were affecting his health. Obesity was listed. I pointed out to the group that obesity is not, in fact, a behaviour. Then, as the case continued, Dr. P said that the individual's obesity would limit his ability to do his job as a construction worker. I asked why, and was told that he would not be fit enough to do his job. Dr. P did not seem to buy the argument that fitness is not the same as obesity.

The whole thing was incredibly irritating. Note that we're talking about a BMI of 32 here. In fact, every obese person described in the seminar had a BMI of 32 or 33. Apparently people larger than that are too unbelievably enormous to even consider... Thanks to Dee for the photo below, an example of a man with a BMI of 32.

Edited to Add: A number of commenters objected to my statement above about a BMI of 20 triggering screening for an eating disorder. That is not the same as assuming this patient has an eating disorder. She probably doesn't. However, given that anorexia nervosa is a relatively prevalent (0.5 to 1% prevalence means all family practitioners will see several cases) and very severe illness, I do think that every woman with a BMI on the low or low-normal side deserves a screen for eating-disordered behaviours. Screening in this case would be a minute or two spent asking questions about weight loss, amenorrhea, eating patterns, and exercise patterns.

Similarly, I screen everybody with a sleep complaint for major depression, and anybody who has had a traumatic event for PTSD. The vast majority of patients won't have depression or PTSD. But if 1/100 has a good chance of it then these are serious enough risks that I think screening is warranted. One problem with eating disorders is that it's really difficult to find prevalence rates and the studies vary widely about how common these illnesses are. I'd rather err on the side of screening too many people than miss one.

An additional issue here, unique to eating disorders, is that physicians do a pretty poor job of identifying patients until they get really, really sick. Knowing that there's a good chance I am already missing a lot of patients with these illnesses tends to lower my threshold for screening for them.

Blood Pressure

2009-09-10T08:11:00.000-07:00

Recently, during my Obstetrics rotation, I saw a woman with very high blood pressure. She was 36 weeks pregnant. I wondered whether her blood pressure was elevated due to the cuff being too small. I asked around, and a few people vaguely remembered that there was once a large cuff but they weren't sure where it was. I eventually found a thigh-sized cuff which gave a much lower reading. It may have been inaccurate too, because the thigh cuffs tend to be too wide for fat arms (unless the fat arms happen to belong to a very tall person).

Nobody else really seemed to think the lack of an appropriate BP cuff was a big deal. I think it's not just a big deal, but totally unacceptable. There needs to be a large cuff available in every ward in every hospital that treats a general adult population. Too-small cuffs directly affect patient care.

Here's a pie-in-the-sky dream: I wish we (the fat acceptance & HAES communities) could raise money to send one-piece large-cuff sphygmomanometers (like the Welch-Allyn DS44-12) to hospitals and clinics, along with a letter discussing the importance of providing appropriate care to large patients!

Edited to add: Thanks to living400lbs for providing the link to Well-Rounded Mama's excellent series about the need for large blood pressure cuffs.

Weight Stability

2009-09-08T09:37:00.001-07:00

A while back, I attended a tutorial where we discussed a fictional patient case. In the introduction, the patient is described as having gained 45 lbs over the past three years. Most students seem to believe that this is a reasonable amount for someone to gain simply based on becoming more sedentary and adopting a worse eating style.

I strongly disagreed. I think that the vast majority of the time when someone has a stable weight for years and then suddenly gains a significant amount of weight (175 to 225 lbs, in this case) it's almost always going to have a medical cause. Our bodies cling to our setpoints quite voraciously. It's HARD to gain that much weight from a stable beginning. Of course, there are exceptions: chronic dieters, psychiatric illnesses such as depression, and individuals who happen to be unusual weight gainers or losers.

It took me a while to figure out why this was making me so angry. I think that this attitude that it's so easy to just gain 50 lbs if you 'let yourself go' is behind this idea that somebody who is thin is actively doing something right to maintain their weight. So if somebody is thin it follows that they are maintaining a 'good' lifestyle. If they adopted a 'bad' lifestyle, they would become fat. That is, naturally thin folks have a vested interest in believing that it is easy to gain weight because the conclusion drawn is that they have a good, virtuous lifestyle that has earned them the right to be thin.

Of course, if somebody unintentionally LOSES any weight (even 10 lbs lets say) we'd be all over a medical cause for it!

Vitamin D

2009-08-31T10:31:00.000-07:00

Vitamin D is a fat-soluble vitamin. When fat individuals get vitamin D (whether from skin, food, or supplements) much of it gets squirreled away into fat stores rather than in circulation. As a result, fat people are far more likely to be vitamin D deficient than smaller folks.

This makes the paper Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population (from September 2009's Pediatrics) particularly interesting. It concludes:

Low serum vitamin D in US adolescents is strongly associated with hypertension, hyperglycemia, and metabolic syndrome, independent of adiposity.

I wonder how much of the supposed metabolic risk of being fat is really a result of vitamin D deficiency? The evidence is just emerging, so nobody knows for sure yet. Still, fascinating stuff.

Small Victories

2009-08-20T15:16:00.001-07:00

It's nice to occasionally have a HAES victory, even when it's small. I'm doing a rotation in a psychiatric ward this month, and in their examination room there was a huge BMI poster on the door. It was the same kind of poster you see everywhere with a graph to see how fat you are, and a table explaining that anything over a BMI of 25 means you need to lose weight.

BMI posters are incredibly irritating no matter where they are, but in a psychiatric ward it makes even less sense: People are already feeling pretty badly about themselves, let's berate them about their weight! And if they are in the psychiatric ward to treat an eating disorder, even better to remind them that they might be fat! So, I asked the individual in charge if it could be removed, and she took a look, agreed with me, and pulled the poster down.

One BMI poster less in the world is one of those small but very satisfying victories.

Pediatrics

2009-05-01T09:26:00.000-07:00

I am currently finishing up my pediatrics rotation. While I absolutely love working with kids, the constant focus on The Obesity Epidemic has been infuriating and exhausting. I gave a presentation to the department today, and while I usually talk directly about HAES in these contexts, I just couldn't cope with that kind of hostility after over a month of it. So I spoke about a related topic -- treatment of Anorexia Nervosa.

I spoke about Family Based Treatment, and how it is the only treatment for AN that has reasonable evidence behind it. I discussed how FBT works. I talked about the absence of evidence that families of teens with AN are themselves pathologic. Many of the audience members had a big problem with this. The argument that most families have pathology, particularly if you put a big microscope under them, so you shouldn't use anecdotal evidence to villify families of teens with AN was not convincing apparently. Plus, you know, the lack of evidence.

Anyways, that was all fine. I can deal with that. But then, just as I'm finishing, one of the pediatricians says, "You know, I bet that this behavioural approach would work really well for obesity as well. You schedule meals at particular times, you watch the kids, and you force them to normalize their eating." An argument followed where I stated that there is no evidence that kids who are fat eat worse than their thin peers. The pediatrician and several others were simply like, "You're wrong." Fine. Even that I can deal with!

But just before the pediatrician left, I was making the point that there is a huge difference between AN -- a severe mental illness with a high mortality and even higher morbidity -- and obesity -- a supposed risk factor for illness that describes one end of the normal spectrum of human variation. And the pediatrician said, very confidently, that he didn't think AN was worse than obesity in the long run. Nobody else seemed to understand how profoundly offensive, never mind ridiculous, that statement is.

Sigh. There are so many days where I feel like I'm living in a parallel world, and I start wondering whether I really am the crazy one. I'm ready for pediatrics to end.

2009-02-10T16:33:00.001-08:00

Not much to report from medical school lately. There's an interesting study described in the NYTimes about how "health scares reduce smoking but not obesity": http://www.nytimes.com/2009/02/11/health/11smoking.html. It's interesting how they ignore the obvious conclusion: smoking is a modifiable behaviour; weight isn't.

Blobs of Fake Fat

2008-11-23T18:40:00.001-08:00

Doctors in the UK are getting plastic models of fat blobs to show their patients. (Yes, seriously).

When I was 10 or so, I recall my family doctor showing me one of these plastic models. It was very hurtful. I really don't understand how the message can be anything other than "This is disgusting. This is part of you. Thus, you are disgusting." I already wanted to lose weight; it had been my New Year's Resolution for years, and part of my daily life for even longer. This experience just added more shame and more pain to being a fat child.

Experiences like these with doctors are a big part of why I chose to study medicine. There are better ways to motivate people, and better ways to promote health. One of my dreams is to one day open a multidisciplinary primary care health clinic based around Health at Every Size principles. Fake fat won't be allowed on the premises. :-)

Obesity Guidelines

2008-11-05T21:17:00.000-08:00

I was recently looking through the Canadian Guidelines on Obesity Management. This is a monster of a document: 24 chapters and over 100 pages. It's also infuriating. A few choice quotes:

"In addition, the medical profession is failing to counsel young, disease-free adults and those in lower socioeconomic groups" [to lose weight]. Because if you haven't yelled at healthy fat people, you just aren't doing your job!

"Overweight and obese people, especially those with binge-eating disorder, lack self-efficacy. Self-efficacy refers to confidence in one's ability to do what is required to produce the desired outcome." I was pretty angry when I read this. Just because I'm fat doesn't mean I am lacking in the ability to Get Things Done. So I went and looked at the abstracts for the three articles they use to reference this statement (1, 2, 3).

The first two articles refer specifically and only to weight self-efficacy -- which, apparently, is confidence in one's ability to do what is required in order to get to a socially-sanctioned weight. That is, fat people are pretty sure that they can't diet to become permanently thin. I would describe that as "fat people have a good grasp on reality" rather than "fat people have low self-efficacy".

The third article is the only one that refers to self-efficacy in general, and it finds that fat individuals with binge-eating disorder have lower self-efficacy than fat individuals without binge-eating disorder. Which, obviously, says nothing about fat people as a group.

Good News, For Once!

2008-09-07T18:48:00.000-07:00

First, apologies to anybody who is still reading this blog for my several-month-hiatus! Over that period, I gave two talks about HAES topics: one to my medical student peers, and one to some philosophy grad students. Both went over very well! It was nice to find a receptive audience for these ideas.

Third Day Back

2008-09-07T18:39:00.000-07:00

We managed to get through two whole days of school this semester without mention of the Scary Obesity Epidemic. On the third day, our final lecture about health care spending and cost analysis was nearly over when the professor decided to use an example of how fat people are going to bankrupt us. After all, the obesity epidemic is no doubt going to cost a fortune because of diabetes and other necessary interventions. And just to make sure that our evidence-based-medicine week had some not-remotely-evidence-based comments, he added that exercise programs for kids that reduce obesity later are likely to have a great return on investment these days.

He really ought to read Junk Food Science occasionally, where he could learn things like childhood obesity prevention programs don't work, or that there's really no evidence that fat people are going to cost more, and being fat may actually save the health care system money.

Research about dieting never changes...

2008-03-11T15:43:00.000-07:00

Every few weeks, I get together with some friends who are also interested in fat acceptance and HAES and we discuss a relevant journal paper. The first paper we discussed was a meta-analysis of dieting studies. It's a good paper, published in 2007, in the Journal of the American Dietetic Association. It reviews what we all know: all diets work pretty well at first, then you gain the weight back. In the end, after a year or two, dieters in studies end up about 5 kg lower than they started. Given that this doesn't include the 1/3 to 1/2 of the people that drop out, and also given that initial weights tend to be inflated as people binge before their initial weigh-in, and given that this isn't nearly enough to make any fat person thin ... those 5 kg are pretty meaningless.

Still, this month's Journal of the American Medical Association published a paper called Comparison of Strategies for Sustaining Weight Loss. This study has -- I counted them -- 27 authors! It's published in a top medical journal! It involves over 1500 participants! And can you guess what it showed? Yup, they all lost weight at first, and then regained to end up about 5 kg below where they started.

I really don't get it. Why do they bother? Why does this stuff keep getting published? (And in major journals!) It's all the same.

Fat, Female, Forty, Fertile

2008-03-05T09:44:00.000-08:00

We had a lecture about gallbladder surgery this morning. The phrase "Fat, Female, Forty, Fertile" describes the patient most commonly affected by gallstones. The prof simply explained this without moralizing, and even mentioned that rapid weight loss is a substantial risk factor for gallstones. You can discuss fat as a risk factor for specific diseases in an inoffensive way.

Plastic Surgery

2008-03-05T09:34:00.000-08:00

This morning we had an hour lecture on plastic surgery. The cases shown were pretty amazing -- individuals recovering from burns, cancer and accidents whose lives have been dramatically improved by plastic surgery.

It was all well and good until the lecturer tells us we have five minutes left, and do we want to see a "really gross case" before the end of class. Of course, the class says yes. So he pulls up a slide that says "Morbid Obesity". He then described and showed images of a panniculectomy. That's an operation to remove a large pannus (basically extra tummy fat that can hang down over the pelvis in fat people). This was an unusually large pannus in an unusally large woman.

I jotted down a few comments, verbatim, from the lecturer:

"next time you go to the chip truck" (that is, remember this case, because if you eat too many chips you'll get like this)

"she works at the post office" (just to reinforce other random fat-person stereotypes, I guess)

"I'm not making fun of her, this is a horrible disease" ... but ... "this disease is from eating"

"she's still huge! look at the size of her!" (that is, she's still a giant fatty after we've removed the pannus)

This was a whole lecture of cases that could be considered 'gross'. It's gross to see someone's abdomen ripped open, it's gross to see someone with half their face missing, and it's gross to see a hand with no skin on it. Nevertheless, the panniculectomy was the only item in the lecture that was explicitly described as gross. The part that really gets me is that the prof wasn't describing the surgery as gross, rather, he was describing this woman's body as gross. That's the part that really is not okay.

Afterwards, I was pretty upset about this. Over the next couple of days I asked a few classmates for their impressions. The response was pretty uniform. Mostly, they didn't recall the panniculectomy slides at first. Then they agreed that there would have been a less offensive way to say it -- but on the other hand, there's a lot of black humour in medicine, and I'm being a overly sensitive.

I don't think I'm being overly sensitive. This matters. Fat people don't seek medical care because they worry that doctors will think their bodies are "gross".

References

2008-02-10T11:42:00.001-08:00

Some basic first resources to point people to when learning about HAES:

"Diets Don't Work" list of blog posts
Penn & Teller Video Clip
Gina Kolata on dieting
A good summary of dieting myths

The right way to talk about fat

2008-02-09T17:36:00.000-08:00

Recently we had a lecture about various gynecologic cancers. There were several mentions of weight as a risk factor and it was as simple as that. Not in a condescending way, not in a "they deserved it" kind of way, not in a "and by the way they need to diet NOW" kind of way. Just simply explaining. The lecturer also pointed out that women with ovarian cancer are often told that they're just getting fat when, in fact, they have tumors growing. Not surprising to me, but good to mention to our class, I think.

Smoking and sedentary means fat?

2008-02-05T13:13:00.001-08:00

Today in tutorial we considered the case of a post-menopausal woman and her risk for osteoporosis. The case described the woman as a sedentary smoker, but made no mention of her weight. The tutor then made a comment along the lines of "And is she also obese? Probably!" I responded, "Probably not, because obesity is protective for osteoporosis and this woman already has low bone density." I don't even know what the association was in this case, it seemed totally random. Is it simply because people assume that sedentary = fat?

Other than that, the gynecology resident who taught the session was an excellent tutor. He explained the material well, shared career advice, and was generally friendly and helpful. I'm adding this bit because I don't want to generally complain about this tutor -- he wasn't bad. The stereotypes about fat patients seem to hold for just about every physician I meet through school, no matter what they are like otherwise.

Another BMI Chart

2008-02-04T18:04:00.000-08:00

Today in tutorial we were handed another BMI chart. That's either my third or fourth since starting medical school. I can't quite remember, partly since I throw them out right away... The claim was made in this tutorial that a BMI of 27.3 increases the risk for endometrial carcinoma. I was pretty skeptical. Flegal's 2007 JAMA paper shows that in the BMI 25-30 range the risks of "obesity-related cancers" are not significantly different from the BMI 20-25 range.

I don't have time to look into this carefully right now, but I'll try to check out the following article when I have some time.

Authors Full Name	Chang, Shih-Chen. Lacey, James V Jr. Brinton, Louise A. Hartge, Patricia. Adams, Kenneth. Mouw, Traci. Carroll, Leslie. Hollenbeck, Albert. Schatzkin, Arthur. Leitzmann, Michael F.
Title	Lifetime weight history and endometrial cancer risk by type of menopausal hormone use in the NIH-AARP diet and health study.
Source	Cancer Epidemiology, Biomarkers & Prevention. 16(4):723-30, 2007 Apr.
Abstract	Obesity and menopausal estrogen therapy are established risk factors for endometrial cancer. However, the joint effects of obesity and menopausal hormone therapy on endometrial cancer risk are incompletely understood. We addressed this issue in a cohort of 103,882 women ages 50 to 71 years at baseline in 1995 to 1996. During a median of 4.6 years, which contributed to a total of 455,304 person-years of follow-up through 2000, 677 cases of endometrial cancer were ascertained. (...)
Date of Publication	2007 Apr

Balancing Evidence and HAES

2008-02-04T08:25:00.000-08:00

I am a second year medical student. I am fat. I believe strongly in Health at Every Size: the idea that everyone, regardless of size, can improve health through enjoying physical activity and eating well and pleasurably. I do not believe that dieting or intentional weight loss are healthy or desirable activities.

I started this blog because situations and school get me so angry when obesity is discussed. This is my space to vent.

My lecturers and tutors and classmates mean well. They are certain that encouraging patients to lose weight is positive and will improve health. And beyond that, I wouldn't deny that there is an association between (some) disease and weight. But it's not as strong as is commonly thought. And as Sandy and others point out repeatedly, correlation continues to be different from causation.

A Morning of Gynecology

2008-02-04T08:09:00.000-08:00

This morning, we had three gynecology lectures. The first two were about menopause and the third was about PCOS. The menopause lectures were bearable; the PCOS lecture was not.

Some points that bothered me:

An example used in lecture was, "This week, I am treating an 11-year-old girl with PCOS who weighs (pause for effect) TWO HUNDRED KILOGRAMS!" (The class responds "Ooooooohhh".) Yes, this child is unusually fat for her age. No, we don't have to present her as a freak. Let's keep in mind that the vast majority of 11-year-olds couldn't weigh that much no matter how hard they tried.

The oft-repeated statistic that "even a 5% reduction in body mass improves ovulation and fertility" was used. That always seems to me to be evidence that your behaviors matter more than your absolute body mass.

A slide quoted "Obese women (BMI > 27 kg/m2)" I guess this is a typo, but it seems to me that more often than not the typos classify people as fat when they are not. For the record, the current cutoffs define BMI of 30 as obese, and before the cutoffs were changed about ten years ago a BMI of 27 was considered the cutoff for overweight (ie BMI of 26.9 was considered normal.) So, in this slide we present a weight that a few years ago was on the cusp of normal as "obese". Sigh.

The part that bothered me most was when I spoke to her after class. I asked whether she uses metformin as a first-line treatment for PCOS. I was particularly curious about this given the recent NEJM review that recommends metformin as a first line treatment. The lecturer responded that she doesn't use it as first line treatment. She gave several good reasons: the evidence is unclear, there isn't yet a consensus, patients could end up taking the medication for decades, etc. I generally agree with all that.

Her last reason, though, was along the lines of: "If we give metformin to teens with PCOS, then we negate the importance of lifestyle changes." That really gets me. If the medication is effective at treating PCOS then teens should have access to it! The alternative, telling teens that their facial hair and acne is because they are fat, just leads to a lifetime of yo-yo dieting and self-loathing.

Background:

PCOS stands for Polycystic Ovarian Syndrome. It is a common condition where women have varying symptoms that might include irregular periods, excess facial and body hair, acne, and type II diabetes. Many women with PCOS are fat.

Metformin is a medication that is mostly used for diabetes that makes the body more sensitive to insulin. Insulin resistance is currently thought to be the main mechanism causing PCOS. Metformin, then, is often helpful in reducing symptoms for women with PCOS.