Shunning The Obese.

Thin is "in." Obese people are shunned. The obese associate with each other, marry, and have obese children. Obesity is major national health concern.

What should we do? Is obesity a: discriminatory bias; an illness or eating disorder; an acceptable life style choice; or an irresponsible one? The proper answer depends on who is viewing.

Individual Viewpoint
Dr. Ben Kazie asserts the perspective of the individual provider: doctor, nurse, or social worker. That individual makes no value judgment regarding a patient. Whether the sick person is an injured terrorist captured while planting a bomb; a 450-pound woman with diabetes, bad joints and heart disease; or a serial killer, the care provider simply does her or his best. In as much as the provider is human and may have negative feelings and judgments about the patient, these are put aside to offer best possible care. The professional care provider is non-judgmental and considers only the welfare of the individual.

Whether obesity is an illness or a choice by individual is a non-issue to me. One must draw the line somewhere. Yes, there are people who have glandular and/or genetic conditions that force them to eat-to-obesity but they are a tiny fraction of the obese population that could choose to eat reasonably but does not.

From the provider perspective, whether obesity is an addiction or choice makes no difference. Either way the true healer offers care. The issue becomes muddy from the pediatrician's standpoint. Most children are not genetically predisposed to be obese. This is a learned behavior. When a child sees obese parents, their body type becomes the child's body image.

If a parent poisons a child with drugs, the pediatrician has a moral and legal responsibility to protect the child. What if the "poison" is food? Where do you draw the line between acceptable parenting practices and child abuse by facilitating over-eating?

Systems Viewpoint
From the viewpoint of the system, a person who decides to smoke and eat-to-obesity has chosen to consume over time more health care resources than someone who is an appropriate-weight non-smoker.

The distinction in viewpoint - provider versus system - is critical. The caregiver does whatever is best for the patient. The system does what is best for the system. The provider is (partly) responsible for the patient. The system is (partly) responsible for all patients, not one individual.

Questions: Can something be right for the individual and wrong for the system? Can something be wrong for the individual and right for the system? Yes to both. Most important: who is ultimately responsible for your health: you, your doctor, or the system? [I hope, I hope, this is rhetorical.]

For any (repeat any) system to be stable meaning that it will not collapse, there must be feedback. Feedback is the linkage between consequences and the one whose choice produced those consequences. Right now, our country is struggling to find a way to connect (link) the financial meltdown with those who caused it. For healthcare-the-system, the problem is connecting financial consequences (costs) with one who chooses to be more expensive. This leads to the conclusion that "fat people should pay more." Any system that lacks effective feedback risks bankruptcy and collapse. Such a system is also unfair to those who choose not to consume excessively.

(Beware of the converse rationale: if fatter is sicker and more expensive, then the thinner you are, the healthier and less costly. Not so. Just ask any physician or even the man-in-the-street looking at the ridges in the clavicles of otherwise beautiful Keira Knightley. Both extremes - fat and thin; obese and Lara Flynn Boyle camera-ready - are unhealthy for the person and costly for the system.)

What should be done about obesity depends on who you are.
• Individual providers should offer all appropriate care.
• Healthcare system should connect person who chooses with consequences of their choice.

Comments

[DrCharlesMartin]

A thought-provoking post, especially in the context of national policy discussions about health insurance and health care reform. In our experience, patient education is a key element. There is very little knowledge and understanding among the general populace about healthy eating and physical activity, which are vital if we are to make any progress in slowing the diabetes epidemic to which obesity contributes so significantly. We write extensively about related issues at http://dentistryfordiabetics.com/blog, especially the links between elevated blood sugar and gum disease that can interfere with diabetes control and significantly increase serious health risks such as heart attack, stroke and blindness.

- Charles Martin, DDS
Founder, Dentistry For Diabetics

[bowseat93]

In the last few weeks, the former head of the FDA, David Kessler, has been all over the airwaves and print media with some compelling evidence that the food industry is complicit in the fattening of Americans. Sounds like Katan (see Feb 26 NEJM) might concur. He writes "individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices."

Katan, the head of one of your more prestigious medical journals, also writes that "Like cholera, obesity may be a problem that cannot be solved by individual persons but that requires community action" in part because gastric bypass is the "only effective alternative that we have at present for halting the obesity epidemic."

On your blog, you write "People as patients should be responsible for personally controllable health risk factors, such as smoking, obesity and alcoholism."

Kessler's research and the study in the NEJM suggests that weight may not be as "personally controllable" as you seem to think it is.

[Sinick]

Yeah, and the execs who advertise happy meals on children's TV shows and the pols who allow unhealthy food in schools (and get a cut) should pay their fair share of taxes and be in the same health insurance pool as the rest of us. They drive us to consume and would also like to double tax us for it?

Not all of us can afford private health care, chauffeur driven to a posh gym, a gofer to shop at Whole Foods or an in-house chef to cook organic vegetarian meals for our family.