America spends as much as $147 billion annually on the direct and indirect costs of treating overweight and obese patients, according to a Centers for Disease Control and Prevention study published in 2009. That made up 9.1 percent of medical spending in 2006, the year on which the study was based. And the problem of obesity in America isn't subsiding. Joseph F. Majdan, M.D., director of professional development and assistant professor of medicine at Jefferson Medical College in Philadelphia, believes physicians can impact this situation positively. But first, he says, many providers must rid themselves of their prejudice toward obese patients. In an article he wrote late last year in the Annals of Internal Medicine, Majdan shared with colleagues the often-rough treatment he faced from fellow physicians regarding his former weight problem and why obese patients deserve respect. Majdan talked with H&HN Contributing Editor Bob Kehoe.
What led you to share your story on obesity with physicians?
As one who's been obese off and on throughout my life, I've had to face a great deal of animosity, both personally and professionally—sometimes subtle, sometimes overt. I believe that this prejudice toward obesity still exists in medicine and in society. But, I believe that the vast majority of physicians do not ascribe to this thinking and will take heed of this by addressing, discussing and remediating this ongoing problem.
Why is this an issue for physicians?
The literature suggests that physicians often have negative attitudes toward obese patients. Although there is nothing to suggest that obese patients receive less care, if physicians have negative attitudes toward these patients or look at them in a derogatory manner, their approach to these patients has to be impacted.
What's causing these attitudes?
I think it's an extension of society's negative views … the mantra of lack of self-control being the major reason of failure for obese patients, that they somehow have less of an aptitude or intellectual ability and that they are not equal in society. It's extended into medicine. We don't know the true cause of obesity. We know that it is a disease, but it is a multifactorial disease. This void, coupled with society's negative attitudes, has propelled a lot of medicine into maintaining this prejudicial view toward obesity.
Can this prejudice be overcome?
Yes. If you look 100 years ago, were we taking African-Americans into medical school? No, but we changed. Females couldn't go into medical school. Now more than 50 percent of the population in medical schools is female. Diseases sometimes were looked at as alien or a bad omen, but we changed.
If you have a patient who has a recurrent disease such as cancer or a mental illness like depression, we respect and treat that. But obesity itself is a disease and can recur; and if it recurs, why does recurrence create such a negative reaction? Society views it like that—the obese person is under attack. We have to be leaders, not followers, in eliminating this negative, prejudicial witchhunt that continues against obese people. Making derisive comments about them and saying we're going to tax you because you're overweight isn't right. It makes no sense.
Woodrow Wilson said if you want to make a few enemies, try to make effective change. Well, I'm willing to take this on and I think good men and women will listen and try to change this.
How can providers approach obese patients with more compassion?
It's interesting that the National Institute of Health and Nutrition and the World Health Organization classify obesity as a disease, but insurance programs don't cover weight-loss programs, only gastric bypass, and that's only when you get to a certain body mass index. We do not address or reward the preventive measures, only the effect. We have to allow for insurance coverage of weight-loss programs. We have to recognize that obesity first and foremost is a disease.
We physicians must recognize that weight loss is only accomplished through a positive and empathetic approach, and try to understand not only the physiology, but that these patients aren't abnormal. We have to give patients the freedom to be personally responsible and not just tell them to do something. If we do this, patients can recover when they do fall from losing weight.
More research is needed into the causes of obesity, and universities and medical schools have to teach this topic in a more logical, sensible manner. We can't simply say that these patients have to lose weight and put them on a diet. Every obese person knows how to lose weight—it's how to keep it off that's a major problem.
What can hospital leaders do to foster sensitivity on this issue?
People who make abusive, abrasive comments about their patients and their fellow colleagues should be brought before professionalism committees. The obese should have the same rights and privileges as any other person. That has to be made clear to the staff.
What do physicians need to be taught about how to treat obese patients?
One of the things we need to teach them is to recognize obesity as a disease and not as a form of weakness. We also have to teach them to be sensitive and not prejudge obese patients, to respect them and remove the judgmental attitude that is prevalent. Kindness and empathy are imperative if we're going to succeed in the treatment of obesity.
Did you learn anything from your weight-loss experience that helped you as a physician?
Yes, with obesity there is no magic bullet. We see people on television who say to eat whatever you want, but take this pill and you'll lose weight at night as you sleep, or follow this program and you are guaranteed to lose weight. There is not one standard approach; each patient is unique. As I've worked with obese people and experienced obesity myself, I found that certain programs and modalities work for certain people. The physician has to be cognizant of this.
What may happen if there isn't greater sensitivity from providers?
We must have greater sensitivity so that patients won't be afraid to come to physicians. Obese patients tend to stay away from health care providers because of their lack of self-esteem. They're embarrassed because of societal attitudes toward obesity. Removing that prejudice will allow better health care to be provided.
The other thing is that it doesn't cost much to get a greasy, cholesterol-laden meal. Try to eat well now—it's more expensive. After I lost weight, my food bill doubled. And that's fine because I want to be healthy, but what message does that send to the family that is struggling?
What are the ramifications if we don't do a better job?
If we just chastise people because of their obesity, we're going to see a rise in the risk factors for coronary artery disease, peripheral vascular disease and diabetes, and the health care system will be further burdened.
According to Judeo-Christian medical ethics, patients should never be a burden to society, no matter what their race, color, creed, sexual gender or body mass index. We have to address this. In a pragmatic world, the cost is becoming alarming.
We have to look at ways to give physicians financial rewards for taking care of the preventive components. Instead, we treat the end result of what has occurred, not the cause of the disease, which is lifestyle.
How are you keeping weight off?
I exercise every day, or six out of every seven days. I bicycle, I skull on the river or exercise in the gym. I weigh myself every day and I follow up with a nutritionist. I go to a class every two weeks where I meet with a dietician. I eat a lot of vegetables. I eat yogurt, fish and salad. If I limit the amount of stimuli I have, I find I can control my weight, and I've kept it within a five-pound level.