Antifatness in the Surgical Setting

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It was 6: 30 A.M., and I was getting ready to head down to the operating room (OR) for the first case of the day: an abdominal wall hernia repair. I prepared for the case by logging on to the electronic medical record portal and reading through the patient’s medical history as well as the preoperative notes. In many of the physician notes, the first line noted the patient’s body mass index (BMI) of 41. The patient’s ventral hernia was estimated to be 30 centimeters by 20 cm, one of the largest hernias ever repaired by the surgeon I was working with. A CT scan revealed large sections of the large intestinal protruding through this hernia. This poses a high risk of bowel twisting which can lead to tissue deoxygenation or necrosis, as well as perforation and sepsis. The patient was in critical condition.

I ventured down to an OR to locate the CT and MRI images. This was part of my role as a medical student, helping the nurses and scrub technicians prepare the OR for surgery. To help surgeons see the anatomy and their approach better, I projected the scans onto large-screen TVs in the OR. The room burst into shock when I pulled up the images. They wondered how anyone could allow a hernia to get so bad before seeking medical advice. Others couldn’t believe someone could live with such an extreme defect and not want it repaired for cosmetic reasons. After moving the patient to the OR, the team began to prepare the surgical site. As she fell asleep, the medical staff couldn’t stop talking about her BMI. Throughout the five-hour procedure, the comments were relentless as everyone took turns looking at the gaping hole in her abdomen. To repair the hernia, two of the largest pieces Strattice biologic mesh were sewn together. The estimated cost of the mesh alone was $30,000.

As the surgery was over, I couldn’t help but think about the obvious yet ironic connection between the weight comments made by the health care team, and the reason the patient procrastinated prior to the surgery. Why would anyone want to interact with a medical system that looked at them in such a derogatory way?

Antifatness is socially ingrained and virtually inescapable. Pop culture idolizes thinness. The Centers for Disease Control and Prevention has created an alarmist “obesity epidemic “, based on exaggerated statistics that haven’t held up. Clinicians are no different from everyone else who is socially conditioned to have this bias. In a recent study, 24 percent of physicians stated they were uncomfortable having friends in larger bodies, and 18 percent admitted they felt disgusted when treating a patient with a high BMI. This is a disturbing finding, but not surprising considering the fact that very few programs train health care professionals against cognitive bias.

Abundant research shows that obesity is not a choice but a result of systemic inequity. The crux of this research explores the multiple systems that underpin weight: food insecurity, housing insecurity, poverty-induced scarcity mindset, medications, diseases, lack of education, mental health issues and chronic stress among them.

Many researchers and scholars have exposed the pervasiveness of antifatness culture, but some of the most prominent actors in maintaining this culture have not been discussed. Surgeons are key to addressing the antifat bias in healthcare. This requires that we address aspects of surgeons’ training as well as their daily tasks that could make them more susceptible to this cognitive bias.

Weight bias is heightened and reinforced in the surgical setting, where surgeries on higher BMI individuals take more time, cost more money and have an increased risk of complications. Because of the lack of filters that patients may have, surgeons may have higher antifatness attitudes and behaviors. These cases can require more time and care, which can be difficult for surgeons whose care and time are already limited by staff shortages. These factors can lead surgeons to vent their frustration by making comments about the patient’s bodies.

Surgeons have a different professional culture and training. Primary care physicians’ training may focus more on upstream factors contributing to care, including being taught about social determinants of health and multifactorial causes of the patients’ conditions. In contrast, surgeons–who on average spend 3,963 hours of training honing a complex motor and visuospatial skill may naturally focus more on the procedural task at hand rather than the factors contributing to their patient’s condition. Surgeons may be less inclined to consider antifatness because of the demands of their job. Surgeons must also work against weight stigma in order to provide the best patient care.

Surgeons often spend the most time in the hospital. As such, surgeons are often the most prominent in shaping the culture of the OR and hospital. Their understanding of weight biases and the associated behaviors is crucial to counteracting the pervasive weight stigma among healthcare providers. Many patients with higher weights will need intensive care, ongoing follow-up, and strict treatment adherence after surgery. Patients with a higher weight are also 12 times more likely to have a complication requiring extended hospitalization and continued interface with their surgical team. To build positive relationships with patients, surgeons must confront their weight bias.

A culture of antifatness in surgeons can have a multiplicative effect on patients and the overall health system. Studies show weight bias from providers is palpable for patients. Patients can sense the lack in dignity and respect in providers’ attitudes, and may decide not to interact with the system that makes them feel inferior. Many doctors make weight loss a deadline for patients, rather than working with them to build trust, understand contributing factors, and work together to make lifestyle changes. This can lead to a loss of self-worth and a poor relationship with providers.

When providers alienate patients who first touch the health care system, through poor care or rapport, these patients are more likely to not resurface until reaching a critical health point, as with the hernia repair case discussed above. Research suggests that providers spend less time with larger patients, provide a lower quality of care and misdiagnose larger patients more frequently.

Antifatness is often a more socially acceptable masquerade for anti-Blackness. The Department of Health and Human Services reports that about four out of five African American women are overweight or obese, and Black Americans were 1.3 times more likely to be obese compared to white Americans. This intersection allows for covert ways to harm Black bodies and brown bodies.

In the end, antifatness behaviors and biases must change. There are many ways to change: systemwide education, amending medical documents, reframe patient conversations, and advocating for higher-level policies that increase access. The goal of a health provider should be to improve health–vital statistics and lab results, symptom relief, time spent exercising, mental well-being, and not thinness. Obesity can have serious health consequences. However, the current BMI-focused approach to assessing a person’s health is not the best. Lack of education among medical professionals is perpetuating antifatness. To educate health care professionals and shift unconscious and conscious attitudes, a health system-wide training program should be developed.

Providers need to make it a habit to note diet and exercise in their social history. This is a far better way than aggregating these factors into BMI. They could work with patients to connect them with resources in the community to help them achieve their health goals, such as lower blood pressure or better cardiovascular. Providers could also use evidence-based approaches, such as education, increasing access to food and exercise, discussing weight loss surgery or medication, and engaging in motivational interviewing. Patients will feel empowered and supported if they are able to understand the multifactorial nature and take a patient-centered approach from the beginning. Patients will be more inclined to return to their health care system and to invest in the relationship between provider and patient. Providers need to understand the complexity of weight and learn how to use alternative health markers. They also need to advocate for policies that reduce food deserts. These actions may be viewed by surgeons as tasks that are reserved for primary care physicians. It is possible to practice unbiased medicine. In one promising model, hospitals in Canada have recently launched a surgical prehabilitation program and toolkit that helps surgeons and their patients work on hypertension, hyperglycemia, hyperlipidemia and cardiovascular health.

Recent movements around self-love and body acceptance are important, but they cannot replace the work that needs to be done by the people who manifest antifatness bias. America doesn’t have an obesity epidemic, it has an unhealthiness epidemic. Yet the worse health outcomes compared to countries with similar economies are just as much a product of antifatness as they are of fatness. Antifatness can contribute to obesity and worsen poor health by causing shame and blame. Until surgeons and other healthcare providers decide to address antifatness, they will continue to be part of the problem.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily

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