Anti-fatness in the Surgical Setting

I was getting ready to go to the operating room at 6:30 A.M. for the first case of the day: an abdominal wall hernia repair. I log on to the electronic health record portal and read through the patient's medical history and the surgical notes written by the team. The first line of the notes noted the patient's body mass index. One of the largest hernias ever repaired by the surgeon I was working with was the patient's ventral hernia, which was estimated to be 30 centimeters by 20 cm. A high risk for bowel twisting can be seen in the 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 888-666-1846 The patient had reached a critical point.

As part of my medical student role, I went down to the OR to locate the images of the computed tomographic and magnetic resonance images. I projected the scans onto the large screen TVs in the OR to help surgeons better visualize their approach. The team in the room was in shock as I pulled up the images. They wondered how someone could let a hernia get worse before seeking medical help. Some people couldn't believe that someone could live with a large defect and not want it fixed for aesthetic reasons. The team began to prepare the surgical site after rolling the patient into the OR. Medical staff in the room talked about her body mass index as she was drifting off into a state of sleep. The comments were constant throughout the five-hour procedure, as people looked at the gaping hole in the patient's abdomen. Two of the largest pieces of mesh were sewn together to repair a hernia. The cost of the mesh alone was $30,000.

I couldn't stop thinking about the connection between the weight comments from the health care team and why the patient didn't get the surgery. Why would anyone want to interact with a medical system that looked at them in a negative way?

Anti-fatness is ingrained in society. Pop culture glorifies thinness. The Centers for Disease Control and Prevention created an alarmist based on exaggerated data. Like everyone else in society, clinicians are conditioned to harbor anti-fatness. According to a recent study, 24 percent of physicians said they were uncomfortable having friends in larger bodies, and 18 percent said they were disgusted when treating a patient with a high body mass index. It's unsurprising that few programs train health care providers against this bias.

Studies show that obese people are often a product of systemic inequity. The research focuses on 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 anti-fatness culture, but some of the most prominent actors in maintaining this culture have not been discussed. Surgeons are central to dismantling the problems of anti-fat bias in health care, and that requires addressing aspects of surgeons that may make them more prone to this cognitive bias.

Weight bias is reinforced in the surgical setting, where surgeries on higher-weight individuals take longer, cost more money and have an increased risk of complications. Anti-fatness attitudes and behaviors may be higher among surgeons due to the lack of filter people have when the patient is snoozing. The increased time and care required in these cases can be difficult for surgeons, whose time and care is already strained. These factors may lead surgeons to make comments about the patient's body.

Professional culture and training are different for surgeons. Primary care physicians training may focus more on upstream factors contributing to care, such as being taught about social determinants of health and multifactorial causes of the patients' conditions. In contrast, surgeons who spend 3,962 hours of training honing a complex motor and visuospatial skill may focus more on the procedural task at hand rather than the factors contributing to their patient's condition. The demands of a surgeon's job may make them less likely to think critically about anti-fatness. To provide optimal patient care, surgeons need to work against weight stigma.

Doctors spend the most time in the hospital. They play a vital role in forming the culture in the OR and hospital at large, and their understanding of weight bias and its associated behaviors is critical to counteracting pervasive weight stigma among health care providers. Many higher-weight patients will need intensive care after surgery. Patients with a higher weight are 12 times more likely to have a complication. Surgeons need to confront their weight bias to build positive partnerships with patients.

A culture of anti-fatness among surgeons leads to negative impacts on patients and the health system. Studies show weight bias for patients. Patients can sense the lack of dignity and respect in providers and may choose not to interact with the system that degrades them. Many clinicians turn weight loss into an ultimatum for patients rather than focusing on building their trust, understanding contributing factors and partnering with them to makeIncremental lifestyle modifications possible. This can hurt patients and providers.

The hernia repair case is an example of a patient who is more likely to not come back until they reach a critical health point. According to research, providers spend less time with larger patients, provide a lower quality of care and misdiagnose larger patients more frequently.

Anti-fatness is a more accepted masquerade for anti-Blackness. Four out of five African American women are overweight or obese, and Black Americans are 1.3 times more likely to be obese than whites, according to the Department of Health and Human Services. Black and brown bodies can be harmed by this intersection.

The biases and behaviors that maintain anti-fatness need to change. Creating systemwide education, amending medical documentation, reframing patient conversations and advocating for upstream policies that increase access are some of the potential avenues for change. Vital statistics, lab results, symptom reduction, time spent exercising, mental health and not thinness should be the goal of a health provider. The current approach to capturing a person's current health status is not the best way to do so. Anti-fatness is perpetuated by lack of education among medical professionals. A health systemwide training should be developed to educate health care providers.

Diet and exercise should be noted in social history as opposed to being lumped into a body mass index. They could connect patients with community resources to help them meet their health goals. Providers can use evidence-based methods such as educating patients about nutrition, increasing access to food or exercise, discussing weight-loss surgery or medication, and employing motivational interviewing. Understanding the multifactorial nature of weight and taking a patient-centered approach early on can ensure patients feel supported and empower to achieve optimal health outcomes. Patients will return to the health care system if they invest in the provider-patient relationship and health goals. Providers need to internalize the complexity of weight, learn how to use alternative health markers, and even advocate for policies that reduce food deserts. The action items may be written off as tasks for primary care physicians. It is possible to practice unbiased medicine. Hospitals in Canada have recently launched a surgical prehabilitation program 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 anti-fatness bias. America has an unhealthiness epidemic. The worse health outcomes in countries with similar economies are just as much a result of anti-fatness as they are of fatness. Anti-fatness may be contributing to obesity and poor health through shame and blame. Surgeons and other health care providers will be part of the problem until they decide to be part of the solution to anti-fatness.