“Just lose weight!”

A sensational medical story in the news this week was mostly seen as a curiosity, a lurid anomaly. The true significance of this story was missed both by mainstream media and healthcare professionals.

A woman in Oklahoma suffered for twelve years with a growing ovarian tumor that went undiagnosed. Everytime she went to the doctor, she was told she was just fat and needed to lose weight. After awhile she stopped going to the doctor. It wasn’t until she’d become so swollen that the circulation in her legs became compromised and they began to crack and ooze that a doctor finally took her seriously and admitted it wasn’t just a problem with “overeating.” During an exploratory surgery they discovered a 93 pound ovarian cyst. Yet even then, it was compared to a “big balloon, a big beach ball” and the news reports wrote mockingly of her walking around with a tumor she didn’t know was there.

Luckily, this woman’s tumor was benign. But “obese” women have higher death rates from many cancers than “normal” weight women. Several researchers have looked for reasons for this health disparity and have learned it isn’t because of their fat in the way that is popularly believed.

In the May 2000 issue of Annals of Internal Medicine, doctors reported on a survey of 11,435 women which learned that the heaviest women had received less preventive cancer screenings — screenings that might identify cancers early at more treatable stages. They found 78% of fat women had had a pap smear compared to 84% of “normal” weight women. These differences remained even when accounting for age, education, illness and health insurance. They couldn’t explain the barriers to appropriate preventive care.

A study published last October in Cancer Detection Prevention did a chart review of men and women in 22 primary care practices and found obese patients were 25% less likely to be screened for colorectal cancer than non-obese ones. They said research was needed to identify the possible barriers.

Two other observational studies controlled for recognized barriers to care, such as access, insurance and education, and found that obese women are still less likely than normal weight women to obtain preventive gynecological services (pap smears, gynecological exams, clinical breast exams and mammograms). The barriers to fat women receiving health care were unidentified.

Those possible barriers were identified in a renowned study led by Dr. Marlene B. Schwartz at the Department of Psychology at Yale University in 2003. They administered an Implicit Associations Test and questionnaire of explicit attitudes and personal experiences with obesity to 389 medical professionals who specialize in the treatment and study of obesity. They found, on both implicit and explicit measures, significant anti-fat bias among health professionals. These professionals saw obese people as lazy, stupid and worthless. Their findings confirmed other published studies, but this one was noteworthy, they said, because these were primarily professionals who knew “that obesity is caused by genetic and environmental factors and is not simply a function of individual behavior” or “lifestyle choice.” They wrote:

The stigma of obesity is so strong, that even those most knowledgeable about the condition infer that obese people have blameworthy behavioral characteristics that contribute to their problem. Furthermore, these biases extend to core characteristics of intelligence and personal worth.

Similar negative attitudes towards fat people had been documented among medical students, dietitians and nurses. In one study, 31-42% of nurses said they would prefer not to care for obese patients at all. In another study, 17% of doctors said they were reluctant to perform pelvic exams on obese women. And in this study, anti-fat bias was highest among younger medical professionals, indicating a need to address fat stigma in medical training.

Dr. Schwartz and her colleagues suggested several potential implications for adversely affecting the care obese people receive. Perceptions of laziness might lead to blaming a person for his/her obesity, “which may influence the professionals’ behavior in both overt and subtle ways,” they said. “Factors such as time spent with patients, empathy, quality of interactions, optimism about improvement and willingness to provide support might be affected.” It would be understandable that these patients would avoid seeking care if they felt uncomfortable in the health care setting.

A study led by Nancy K. Amy, Ph.D., at the University of California, Berkeley, specifically sought to better define these barriers to fat women seeking care by looking at gynecological cancer screening. Their study was published in October, 2005, in the International Journal of Obesity, but received little notice, perhaps because its findings are uncomfortable to confront.

These researchers surveyed 498 white and African-American women with body mass indexes of 25 to >55. Over 90% of the women had health insurance. This study was not about access to care, but low utilization of available services.

Unrelated to their education, employment or health insurance status, 83% reported their weight was a barrier to getting care and more than half delayed seeking care because of their weight. The problem was especially significant among the women at the highest weights, with 68% of them delaying primary and preventive health care. Among women with BMIs of 25-35, 86% had received regular pap smears compared to only 68% of women with BMIs >55. Similar numbers for found for mammograms.

In revealing what fat women experience in the healthcare environment that they said were barriers to them seeking care, the researchers found that barriers increased in prevalence and severity with the women’s size. A negative attitude from healthcare providers had been experienced by 59% of fat women, with 46% reporting they had been treated disrespectfully. Most of the women felt they had received a lower quality of care because of their weight. And nearly two-thirds reported that a barrier for them in seeking preventive care is that they had been told to lose weight even if they were seeking medical care for a condition unrelated to their weight. And like the dismissive care this Okalahoma woman had experienced for years, fat women are often told their health concerns are simply because they're fat and that they just need to lose weight.

A surprising number of fat women, for instance, report that they’ve been counseled to have bariatric surgery and told they are going to die unless they lose weight, even when they sought a doctor’s care for a totally separate issue, such as eczema or an ear infection.

These researchers also surveyed 129 healthcare providers and more than half admitted they had no education about caring for larger patients. Also cited as a concern was the unavailability of appropriate supplies and equipment for larger patients, a problem seen regardless of the medical setting.

Professor Amy and colleagues concluded that women could be helped by learning what is appropriate care and attitudes, and for each woman to choose a caring provider she is comfortable with and can communicate her concerns to. They added:

Obese women will need assurance that they will receive the same quality care and respect as other women. Second, the providers need to be aware of the effect of barriers on women of different sizes. Long-term solutions involve enhancing the patient-provider relationship through training for positive attitudes and mutual respect.

© 2007 Sandy Szwarc