“For someone with your breast size, the risk of a complication is pretty high. I would recommend against the surgery.”
I smiled at the 50-year-old woman who sat in front of me wearing a pink, paper gown and a crestfallen look. She had recently been diagnosed with breast cancer and was planning on undergoing a mastectomy as part of her cancer treatment. Her breast surgeon had referred her to me to discuss the possibility of beginning her breast reconstruction at the time of her mastectomy: an immediate breast reconstruction.
Prior to her arrival, I had reviewed her chart in the electronic medical record — the body mass index was lit up in a highlighted yellow: “42.” Morbidly obese. I glanced to see if this had been documented in the patient’s problem list — it was not. It appeared that no one, including her primary care physician, had listed her morbid obesity as a disease to be tracked and followed. Every other condition associated with it had been: type 2 diabetes, sleep apnea, and knee pain.
I went in to see her, reviewed her medical history, examined her, explained the various options and complications of breast reconstruction, all the while knowing that I would be ending our discussion by telling her she would not be a good candidate for surgery … but I hedged on the reason. Yes, she had large breasts, but it was her obesity that put her at high risk. Why? I did not want to make a person who had just received a cancer diagnosis feel even worse by telling her that her weight precluded her from a procedure.
Obesity, particularly, morbid obesity, is well known to lead to a higher risk of mortality and morbidity, including being a risk factor for certain types of cancers. And, yes, it is associated with a higher rate of complications in breast reconstruction, joint replacement, and coronary surgery. In 2013, the American Medical Association declared obesity a disease, and despite this, I think many physicians continue to be uncomfortable having frank discussions about it with their patients. I believe there are several reasons:
It is omnipresent. With obesity present in over 36 percent of the U.S. population, it may become to feel like a new norm rather than a public health crisis. As physicians, we learned to use the standard person as a reference in clinical scenarios and calculations. The standard person weighs 70 kilograms or 154 pounds. Most physicians would be hard pressed to find many standard persons in their clinic today. (Full disclosure: The author of this essay does not meet this definition either.)
Obesity is hard to treat. When one considers the numerous unhealthy, and inexpensive diet options facing Americans, trying to tell someone to simply “eat better” can be challenging. Moreover, a recent study points to what may be the Sisyphean challenge regarding weight loss: in a 2016 article in Obesity, the authors reported on how the vast majority of Season 8 contestants from the television show, the Biggest Loser, gained back much of the weight they had initially lost, and that their bodies showed a compensatory metabolic adaptation to counter the weight loss. Outside of bariatric surgery, weight loss strategies for patients are challenging.
The fear of fat-shaming. Just as I have described in my own experience, physicians are afraid of sounding like bullies when it comes to discussing obesity with their patients. Now, with patients having open access to their medical records, and the increasing financial consequences of patient satisfaction, doctors may feel that they cannot wade into an area that may cause an intense backlash. When I asked several physicians why they did not document obesity in a patient’s chart, they often responded with a variation on “why get them upset.”
If physicians are going to be able to truly prevent and manage obesity, we are going to have to learn to get out of our comfort zones and have honest conversations with our patients. Patients, however, will also have to understand that a discussion about their weight can no longer be considered a taboo subject.
Vik Reddy is a plastic surgeon.
Image credit: Shutterstock.com
