And it's not that they're trying to be disparaging or mean. It's very frustrating for doctors who have to explain to patients repeatedly the root cause of their issues, and that there is no "fast fix" or medicine that will fix their problems until they lose weight.
It's not simply based on BMI. It's based a lot of things, but at some point the BMI will be bad enough that the other things become irrelevant.
>asking a 500lbs person to lose 200+lbs before you're willing to treat their disease with actual evidence-based medicine—looking at symptoms, pathology, etc—is tantamount to outright denial of care.
It would be if that actually happened in any systemic manner. And even in the cases where it does happen, it has less to do with whether the doctor is willing and more to do with whether the doctor is able to diagnose.
> But just saying "we have a BMI cutoff" is pretty much discrimination masquerading as medicine.
It's discrimination in the same way that saying people under a certain height can't ride rollercoasters. There isn't some conspiracy amongst theme parks to alienate short people. It's dangerous, and it's nothing to do with prejudice against short people.
And in reality, it's not "we have a BMI cutoff" as the only criteria. It's "we have an extensive and exhaustive list of things we look for before we recommend surgery to patients, since surgery is a dangerous and often life threatening procedure. One of those criteria is a BMI that doesn't cause undue risk to the life of the patient".
It would be if this was actually happening, which is never. Maybe there's like a handful of shitheads out there doing it, but this isn't a wide-spread problem.
http://onlinelibrary.wiley.com/doi/10.1111/obr.12266/full
"Finally, physicians may over-attribute symptoms and problems to obesity, and fail to refer the patient for diagnostic testing or to consider treatment options beyond advising the patient to lose weight. In one study involving medical students, virtual patients with shortness of breath were more likely to receive lifestyle change recommendations if they were obese (54% vs. 13%), and more likely to receive medication to manage symptoms if they were normal weight (23% vs. 5%)."
> Comparisons of recommendation categories for shortness of breath by condition revealed that students were more likely to recommend lifestyle changes when the patient was obese than when she was not obese, χ2 (1, N =76) =14.6, p<.0001. They were less likely to recommend symptom management (i.e., bronchodilator prescription) for shortness of breath when the patient was obese, χ2 (1, N =76) =4.8, p<.05. There was, however, no significant difference in recommendation rates for diagnostic tests.
The article links to research showing that it is a wide-spread problem. There may be valid criticism of that research, but your flat unsupported denial is not that criticism.
That's for all patients. But it states the risk of knee fracture is higher for overweight patients.
http://www.zimmer.com/patients-caregivers/article/knee/knee-...
Here's a source specific to overweight patients. Obesity is often comorbid with conditions that make it harder to heal and increase the risk of infection, such as diabetes.
http://orthoinfo.org/topic.cfm?topic=A00745
Here's a crucial section:
"However, if you have obesity, you may never achieve the increased mobility and range of motion experienced by a patient of normal weight.
You may also experience more implant and prosthesis complications after surgery, including:
Component loosening and failure
Dislocation of the replacement joint, especially in the hip
That section would be based almost purely on weight. Certainly, BMI is a crude measure, and it doesn't work well for weight lifters and athletes. But that's mostly an issue an issue for people near the "overweight" cutoff at 25. The more obese someone gets, the less false positives BMI has.
There's clearly an issue where past a certain level of adiposity, knee surgery is not sensible: the risks become high, and the outcomes become poor.
What would you do instead? To operate with the expectation of poor outcomes is not good medicine.
"But there should not be blanket refusals to operate on fat people, the committee wrote. Those with a body mass index over 40 — like a 5-foot-5-inch woman weighing 250 pounds or a 6-foot man weighing 300 — and who cannot lose weight should be informed that their risks are greater, but they should not be categorically dismissed, the group concluded."
It's really simple. You can inform people of the increased risks and possible outcomes and let them make their own decisions about their bodies. The article here is not saying that doctors should ignore weight as a factor, but that they shouldn't make decisions to deny or provide care based solely on BMI.
Why would a doctor let his patient take on a risk that he isn't willing to perform? Patients should not get 100% say in their treatments. If there's a high mortality rate for something as trivial as knee pain, then the compassionate thing would be to refuse that operation and look at alternatives like pills or physical therapy. Having that person's family deal with 'suicide by doctor' is a non-starter here. This is like saying mechanics should respect the wishes of people who want to output their exhaust into the cabin. Afterall, the customer is always right!
Also, people in pain aren't terribly rational and don't make good decisions. Doctors should be the gatekeepers here on a certain level. I shouldn't be able to demand surgery willy-nilly and expect doctors and surgeons to act like a concierge service. Surgery is a serious risk and no one is going to casually perform malpractice here. Worse, knee repair is a tricky thing. If your knee can't support 300+lbs then a repair is only going to be a temporary solution until you damage it again, which will probably be soon after. We're not engineered to handle these kinds of loads, thus the weight loss recommendation.
I don't know anyone who would disagree with this sentiment. And the article doesn't present any evidence that there are blanket refusals. Sure, the article presents a few anecdotes, but that's not enough to show that blanket refusals are happening on a larger scale.
> You can inform people of the increased risks and possible outcomes and let them make their own decisions about their bodies.
It's really not that simple. A medical doctor's mission is to help people and very specifically to "do no harm". When the data suggests that they are more likely to do harm by operating, then the doctor is following their oath by not performing a surgery.
"A recent survey of more than 700 hip and knee surgeons confirmed Dr. Yates’s impressions. Sixty-two percent said they used body mass index scores as cutoffs for requiring weight loss before offering surgery."
It sounds to me like "cutoffs" and "requiring" would indicate a blanket refusal, and 62% seems like a fairly large scale to me. What evidence are you looking for?
Other common conditions can also increase risks of complications, and patients are routinely given opportunities to weigh those risks before deciding on surgeries. My suggestion isn't that the doctor throw his duties out the window, but that with high-BMI patients, those duties should not suddenly become more dictatorial than with other patients.
How did you conclude that BMI is non-scientific? Did you know that Centigrade was invented in the early 1800s, and the first realization of the metric system was in 1799?
BMI definitely isn't accurate for people with high lean body mass, but the patients in this article aren't bodybuilders whose muscle mass drives up their BMI--people with high lean body mass are less likely to need hip and knee surgery. Sure, BMI is an approximation with some well-known cases where it's inaccurate, but doctors are well aware of this fact.
> If you look at the statistics on weight loss success rates, asking a 500lbs person to lose 200+lbs before you're willing to treat their disease with actual evidence-based medicine—looking at symptoms, pathology, etc—is tantamount to outright denial of care.
I'd like to see those statistics.
> I'd like to see those statistics.
https://www.ncbi.nlm.nih.gov/pubmed/10449014
"Data from the scientific community indicate that a 15-wk diet or diet plus exercise program produces a weight loss of about 11 kg with a 60-80% maintenance after 1 yr. Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr."
And that's 11kg… the situation described above is 90kg. You're essentially telling someone to go away and come back after 2+years of dieting to get medical care. Don't you think that seems unrealistic?
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ind...
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ind...
> > > If you look at the statistics on weight loss success rates, asking a 500lbs person to lose 200+lbs before you're willing to treat their disease with actual evidence-based medicine—looking at symptoms, pathology, etc—is tantamount to outright denial of care.
> > I'd like to see those statistics.
> "Data from the scientific community indicate that a 15-wk diet or diet plus exercise program produces a weight loss of about 11 kg with a 60-80% maintenance after 1 yr. Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr."
This in no way indicates how many patients with knee and hip issues are able to solve those knee and hip issues simply by losing weight.
> And that's 11kg… the situation described above is 90kg. You're essentially telling someone to go away and come back after 2+years of dieting to get medical care. Don't you think that seems unrealistic?
No, I'm not telling someone to go away and come back after 2+ years to get medical care, I'm prescribing medical care that will take 2+ years.
Weight loss isn't denial of care; weight loss is the care.
There are plenty of forms of treatment that take a long time. If a doctor prescribes a course of medication that takes 2 years before trying surgery because it will solve the problem for most people and is lower-risk, you wouldn't complain about that, or call it denial of care. But in fact, weight loss is safer than most medicines--weight loss for an obese person has almost no negatives.
I posit that the only reason you're objecting to weight loss as treatment is that you've formed your opinion based on identity politics rather than medical efficacy.
Care is getting the obese person to lose weight. Which is hard, harder than dealing with hard drugs. Dieteticians, who are supposed to be specialists, fail hard at care. GP doesn't even know where to start.
So let's fix what is broken. If a person cannot eat, they are fed, right? That is a task for a properly trained nurse.
But I don't know of a doctor who wants to provide essentially more than daily care and effective one to begin with.
And doctors do not like to feel like failures.
However, that's not what most people here are arguing for. The specific case here is a complaint that people are denied surgery, and people feel that this is denial of care; that is, people are arguing that we should perform knee and hip surgeries on obese people, even though weight loss would be a much safer treatment.
The joints can and do regenerate except from chronic problems. Unfortunately, obesity is one, just losing weight does not fix joints as quite a few long time former weight lifters can attest.
I don't have any reason to disbelieve you about your friends, but your friends do not represent all obese people, and in losing weight does fix joints some percentage of the time. Given the alternative is surgery, which kills the patient some percentage of the time, I don't think there's a lot of debate to be had here.
Moreover, there are other issues to verify, say, a person born with hip dysplasia should be treated regardless of weight as weight loss will never fix the underlying problem.
Also aching hip joints quite effectively prevent many kinds of exercise, which does not help with weight loss at all.
Without an effective alternative course of action, the surgery may be the one remaining effective measure.
I disagree--in fact, I think a large part of the problem here might be this very conversation. It's unclear how much of the reason that counseling is ineffective is because obesity has become an identity politics issue. If you tell someone that it's okay to be fat, and go so far as to say that obesity isn't the cause of their problems, it's a lot easier for them to just cry "denial of care!" than to actually lose weight. The first step to solving the problem is admitting it is a problem, and fat acceptance is actively impeding that part of the recovery process.
I don't have personal knowledge to say which way the direction of causality goes: whether identity politics causes counseling to be ineffective, or whether counseling is inherently ineffective and therefore identity politics are right. But I think that doctors are the ones with the most information to decide that, not identity politics activists.
What I do know is that even if counseling is only 10% effective, it's far less dangerous than surgery, so it should always be the first choice. If someone tries weight loss programs for a few years and fails to lose weight, then maybe it makes less sense to deny surgery (this would be a situation I'd be interested in hearing medical opinions about). But I see no evidence that this is actually happening. What I'm seeing is people saying that demanding people try weight loss first is equivalent to denial of care, and that people should be allowed to get surgery without even trying to lose weight.
And while this firmly steps outside science, I think obesity makes sense to treat as an addiction problem. I've been treated successfully for alcoholism via a program which equally has very low success rates to weight loss programs. My personal experience with this is that, as identity politics say, it makes little sense to shame people for their addiction or to discriminate against people because of their addiction in cases where it doesn't affect their ability to perform. Blaming me for my addiction or punishing me for my addiction didn't work. However, what also didn't work was living in denial that I was an addict and that my addiction was a problem. I don't blame myself for my addiction, but I did need to take action and participate in my treatment.
You wouldn't give someone with alcoholic hepatitis a liver transplant unless they stopped drinking, and you shouldn't give an obese person a hip replacement unless they lose weight.
I know, anecdotes are not data, but there is essentially no data that supports the claims made about BMI, and there are known measurements that are more effective than this grossly ineffective ratio that is loved pretty much only by insurance underwriters.
I'm proposing that weight loss is an effective and reasonable treatment for hip or knee problems in obese people, so this observation is consistent with my proposition.
> I know, anecdotes are not data, but there is essentially no data that supports the claims made about BMI, and there are known measurements that are more effective than this grossly ineffective ratio that is loved pretty much only by insurance underwriters.
People are focusing in on BMI as being an inaccurate measurement of fatness, but notably all the cases noted where people treated with weight loss instead of surgery are people who are fat by any measurement you want to pick. Look at the pictures, or read how the person interviewed says, "Do you think I don't know I'm fat?" Can you point to cases where someone who isn't fat was denied surgery due to their BMI?
5 years later. I do about 3 hours of cardio a week, I weigh 185 and my waist is about 32. My BMI is 31.8. No doctor has ever looked at me and said I need to lose weight.
BMI is completely bunk in my case.
2. Caliper fat measurement is pretty accurate if done correctly, but it's also hard to do correctly.
3. In your own words, no doctor has ever looked at you and said you need to lose weight. This seems to indicate that while BMI isn't always an indicator of health, doctors are capable of identifying the exceptions.
As far as the caliper body fat test. It was done using 6 parts of the body.
And in my personal experience, my mother experienced precisely what you don't think ever happens. A sinus infection went untreated for weeks after repeated doctor visits.
It is not that the doctor won't treat a sinus infection, it's that he won't _diagnose_ a sinus infection because the level of care drops when a patient is obviously overweight.
What some docs seem not to have learned is to ask the first question you learn to consider in tech support (and medicine is, in a sense, tech support for the human body) -- "what's changed?".
Unless the patient had a sudden and rapid change of weight that corresponds to the symptoms occurring, even if it is something whose onset was brought on by weight over time (or just made more likely by weight), its probably not the weight itself directly causing the symptoms, and if you don't properly diagnose the cause, you have no idea if losing weight is an appropriate remedy, irrelevant to the symptoms at hand, or something likely to cause changes in the body which exacerbate those symptoms.
Failure to properly diagnose the actual problems makes it harder for the doctor to assist the patient in actually losing weight. "Lose weight" is an outcome, not a course of action, and choosing the most medically appropriate course of action to achieve that outcome is down to coincidence if you decide to skimp on proper diagnosis just because you think that the patient needs to lose weight.
This kind of language is part of the problem, shifting blame onto actual patients.
Already before you're obese it'll be difficult to give someone CPR. If someone is obese that's dangerous already. It's completely normal and logical response to tell them to lose weight.
> This survey doesn't confirm that surgeries are refused for the fear of lower ratings.
The articles says:
> And 42 percent who picked a body mass index cutoff said they had done so because they were worried about their performance score or that of their hospital.
The problem with this story isn't that it's facts are wrong or misrepresented, it's that they're only reporting one side of the debate in a situation which is very much not one-sided.
Ugh, you're just wrong, and I can only conclude you didn't read the article. They mentioned who conducted it and linked the actual survey, which has all the information you mention.
From the article:
> "There is a perception among some surgeons that it is more difficult, and certainly some felt it was an added risk,” to operate on very obese people, Dr. Yates said. He was a member of a committee that reviewed[1] the risks and benefits of joint replacement in obese patients for the American Association of Hip and Knee Surgeons. The group concluded that heavy patients should first be counseled to lose weight because a lower weight reduces stress on the joints and can alleviate pain without surgery."
> But there should not be blanket refusals to operate on fat people, the committee wrote. Those with a body mass index over 40 — like a 5-foot-5-inch woman weighing 250 pounds or a 6-foot man weighing 300 — and who cannot lose weight should be informed that their risks are greater, but they should not be categorically dismissed, the group concluded.
Again, I think that it's reasonable to have BMI cutoffs as a requirement for surgery, but let's make that argument based on facts, please.
[1] https://www.researchgate.net/publication/278060582_Obesity_a...
As a chronically 25-50lbs overweight person with knee problems, just dropping 10lbs was like night and day for me. Suddenly my feet and knees didn't hurt as much and I felt and slept so much better. There's an ugly narrative here that few press outlets want to sell because I imagine fat rights groups will be offended, but there's a real personal responsibility argument with weight that too often gets brushed under the carpet. Victimization naratives are popular now and get significant ad impressions. Consider the two headlines, which one will get you more clicks? "Doctors biased against the fat patients; thin patients treated better" or "Losing weight is your responsibility when it comes to your health." Obviously, the former will get all the clicks.
I really hope fat rights groups and the liberal media stop with these narratives. Losing weight isn't terribly difficult if you actually care about your health. Its a small investment that significantly pays off. Yes, I get a little offended when my doctor brings it up, but he's right every time. When my weight hits a certain number, my body just falls apart. Suddenly sleep apnea kicks in, I'm sore all the time, I get winded easily, and my back and knees hurt. We shouldn't be fighting against this kind of advice. Its still good and often life-changing advice.
Sadly, this forum being mostly millennials means the comment section is leftist victimization responses straight out of /r/fatlogic. I pity the generation growing up with a 'no one is ever at fault' and 'personal responsibility doesn't exist' philosophy. Its a disservice to them and ruins lives.
Calories-in vs. Calories-out is not helpful advice. A person's metabolism can slow to a crawl if the person is starving.
It's much better to fix the metabolism, and remove metabolism-destroying foods from the diet. Many common foods should not be eaten (tofu), or only eaten when well-cooked (kale) [1].
[1] https://en.wikipedia.org/wiki/Goitrogen#Goitrogenic_foods
"You don't need to exercise, you don't even need to eat healthy. Eat less than your BMR and you WILL lose weight."
Your claims of a metabolism slowing down "to a crawl" if a person is hungry isn't helpful in the slightest; comments like this demoralise people. They work out, eat kale, make sure to never feel hungry lest they "slow down their metabolism to a crawl" and still aren't losing weight. "why bother?"
Personally I have been through 6 different kinds of diet, calorie counting or not. The only thing to put in a dent long term was a very low carb high protein ketogenic diet (but it broke liver enzymes and cholesterol long term, took it 2 years. Exactly at the point where I achieved the right weight too. Yes, it was nutritionally verified.) and a hardcore CR diet which was terrible to adhere to. (essentially hungry all time after two weeks, preoccupied with food enough to be distracting at work. Also nutritionally verified.)
And in our culture you get to tell everyone you will not partake in their food which is extra torture on top.
So yes, the advice is garbage, does not work in general long term in my long and varied personal experience.
Also, obesity is a syndrome. There are many causes and diet is probably very ineffective for most. At best a symptomatic treatment.
To be at that level of starvation would require the person's body fat percentage to drop to essential levels. "Starvation mode" in normal weight and overweight people is a pernicious myth.
Metabolism control seems to be based of medium term intake rather than fat stores. Either that or there is a set point which is quite hard to move. Or both. Handling the fat does increase basal metabolic rate to an extent. But only so far. The abovementioned slowdown starts with mild thyroid suppression and shows up in bloodwork. This can cut BMR by up to half without starvation. (25% calorie cut from high levels is nowhere near enough)
The problem is, this reduces will to both diet and exercise and induces a low grade depression.
I only have my own metabolic panels taken at my expense weekly during a vegan diet (vetted by a dietician) attempt. A failed one to boot. From correct baseline to borderline hypothyroidism in a matter of weeks. Quick rebound when the attempt was stopped.
The study would have to be careful to exclude people with known preexisting conditions that cause obesity and only take in "idiopathic" subjects.
The most interesting related study I found is the Right Track long-term study of adolescent health related behaviour and total factors. It is currently in progress. Hopefully it won't disappear.
The complaint is that doctors tell fat people to lose weight when they come in with symptoms that match the symptoms of being very overweight. If you go to the doctor with knee pain and you are drastically overweight, the most likely answer is that the knee pain is from being overweight. The doctor is going to tell you to lose weight. This doesn't mean they're dismissing that it might be something else, which is evident by the example in the article where the root cause was also found.
I had to stop reading at the point where the quoted a doctor as saying
>doctors and hospitals have become risk-averse because they fear their ratings will fall if too many patients have complications
followed by
>A recent survey of more than 700 hip and knee surgeons confirmed Dr. Yates’s impressions. Sixty-two percent said they used body mass index scores as cutoffs for requiring weight loss before offering surgery.
This survey doesn't confirm that surgeries are refused for the fear of lower ratings. It confirms that doctors have a BMI cuttoff for surgery. Saying that there shouldn't be a limit somewhere is beyond stupid, meaning this survey is pointless. And it's frankly tremendously disrespectful towards doctors - they have BMI cutoffs for the sake of the patient's life. The risk of complications is extremely real and doctors don't want a high risk of literally killing someone to resolve a knee pain that, while crappy, is better than dying. And they're not even asking patients to live the rest of their life with that knee pain - only long enough they can lose weight and not have such drastically dangerous odds from the surgery.
This article is garbage.