Preconceived Notions: Provider Bias, Young Patients, and Weight Loss Surgery

While surgery has shown to be the most effective tool in combating obesity, younger patients are not being offered this option. Providers need to re-evaluate their own biases when treating these patients in terms of how could improve various quality-of-life factors as well as the young patient’s health.  

Fatima Cody Stanford, MD, MPH, MPA, an instructor of medicine and pediatrics at Harvard Medical School and an obesity medicine physician at Massachusetts General Hospital, treats children and young adults with severe obesity – defined as having a body mass index (BMI) above 40. One of her young adult patients presented to her clinic with a BMI of 58. When this young woman first came to the clinic, she told Stanford about her struggles to find a job. She had gone to a local retailer to apply for a job and was quickly told she would not qualify for the position.

Severe obesity continues to trend upward, and along with the physical comorbidities like type 2 diabetes, obstructive sleep apnea, and heart disease, severe obesity carries with it other intangibles. There remains a significant bias against people with obesity and severe obesity. “Persons who have severe obesity are often overlooked or undervalued with regards to their working environment,” Stanford says. “And we do know that they have a lower likelihood of acceptance into advance degree programs.”

If a pediatric patient has severe obesity early in life, it means an earlier onset of comorbid conditions, which means they’re going to have a higher degree of morbidity and earlier mortality, not to mention an impacted socio-economic status, increased risk of depression, decreased quality of life, and so on.

Stanford and her collaborators Karen Campoverde-Reyes, MD, a research fellow at Harvard Medical School and Massachusetts General Hospital; and Madhusmita Misra, MD, MPH, a professor of pediatrics at Harvard Medical School and chief of pediatric endocrinology at Massachusetts General Hospital, at ENDO 2018 presented results from their study that found only a small percentage of teenagers and young adults with severe obesity undergo weight loss surgery even though it’s considered the most effective long-term weight loss therapy. The investigators concluded that a possible reason for the underutilization of weight loss surgery in this patient population is a lack of education and awareness among healthcare providers and the public regarding surgical treatment of obesity.

The results also speak to the bias against people with severe obesity, even among medical professionals.

“I have lost very young patients. I lost two patients, one at the age of 11, one at the age of 26 from obstructive sleep apnea, but they both had severe obesity. And I don’t like to go to funerals.” – Fatima Cody Stanford, MD, MPH, MPA, instructor of medicine and pediatrics, Harvard Medical School; obesity medicine physician, Massachusetts General Hospital, Boston

No Surprises

Stanford, Campoverde-Reyes, and Misra looked at the frequency of weight loss surgery in 14- to 25-year-olds treated at eight academic health systems that participate in a web-based clinical data research network called ARCH (Accessible Research Commons for Health). Four of the institutions are in Boston: Beth Israel Deaconess Medical Center, Boston Children’s Hospital; Boston Medical Center and Partners Healthcare, which comprises Massachusetts General and Brigham and Women’s Hospital. The others are Washington University School of Medicine in St. Louis, Morehouse School of Medicine in Atlanta, University of Texas Health Science Center at Houston, and Wake Forest Baptist Medical Center in Winston-Salem, N.C.

They identified people with severe obesity using the diagnostic billing code for a BMI of 40 or more. They found that about 0.7%, or 18,008, of the more than 2.5 million patients ages 14 to 25 had a diagnosis of severe obesity, the investigators reported. The percentage of patients with severe obesity who underwent weight loss surgery ranged from 0.4% at Boston Children’s Hospital to 21.5% at Partners Healthcare. The other percentages were 1.4% at Boston Medical Center, 2.3% at Beth Israel, and 2.5% at Washington University. The other institutions performed too few weight loss surgeries (fewer than 10) to report percentages.

“I wanted [the results] to surprise me, but [they] did not,” Stanford says.

She again points to a low level of education in the treatment of severe obesity among medical students, residents, and attending physicians as a reason for her team’s findings. But it’s not just that. Stanford also sees a continuing bias towards people with severe obesity, in which people tend to presume it’s just a “lifestyle choice,” that if they could just eat less and exercise more, the pounds would melt away. “That’s actually not founded on science that we know about obesity,” she says. “I think there’s a bias that plays a large role. When we look at patients who have lost weight through diet and exercise versus those who have lost weight with weight loss surgery, we see the person who’s lost weight with diet and exercise more favorably. Like, ooh, they deserve to lose the weight.”

“We’ve placed a moral judgment against that person that needed to utilize that tool, and I just see it as a tool, which is weight loss surgery,” she continues.

Weight loss surgery criteria for teenagers and young adults is the same as the criteria for the adult population. Patients with moderate obesity (BMI of 35 to 39.9) and a comorbid condition like type 2 diabetes or heart disease would be candidates and patients with a BMI of 40 or above would meet the criteria without a comorbid condition. Still, these patients would have to have tried lifestyle changes, but if everything has been exhausted, then physicians should consider weight loss surgery.

“I Don’t Like to Go to Funerals”

So there is this bias against individuals with severe obesity, but there also seems to be a bias against performing this major surgery on teenagers and young adults. But for Stanford the benefits of the surgery far outweigh the risks of worsening comorbid conditions. And for her, it’s personal. The week before Stanford spoke with Endocrine News, she was at a funeral for a 38-year-old man who passed away from a heart attack. He had obesity that led to cardiac disease. “This is the reality of what happens on the ground,” Stanford says. “I have lost very young patients. I lost two patients, one at the age of 11, one at the age of 26 from obstructive sleep apnea, but they both had severe obesity. And I don’t like to go to funerals.”

Of course, a lot of times children and teenagers with severe obesity are dealt that hand from the beginning. Their parents and grandparents suffered from obesity, but the medical community can’t change family histories. And these are deaths that could have been prevented. “There is a high likelihood that they’re going to have severe obesity, and they develop issues much like their parents and grandparents and suffering a sudden cardiac death at 38 is not out of the realm of normal,” Stanford says. “And so I would say it’s more hassle for us not to intervene.”

Working to Do Better

In the March issue of the journal Obesity, Turner et al. published a paper titled “Current Knowledge of Obesity Treatment Guidelines by Health Care Professionals,” that concludes “provider understanding of appropriate clinical care for obesity is inconsistent with evidence-based recommendations. As coverage for behavioral counseling services and pharmacotherapy expands, it is imperative that health care professionals understand how to effectively leverage these treatment modalities to optimize health outcomes for patients with obesity.”

“We think about the high impact diseases such as obesity, but we don’t think about the fact that it affects hiring. It affects socio-economic status. It affects quality of life. It affects depression. These things are all inter-related, and so treating that child or adolescent with severe obesity sooner really can play a large role in setting them on an upward trajectory pretty early in life.” – Fatima Cody Stanford, MD, MPH, MPA, instructor of medicine and pediatrics, Harvard Medical School; obesity medicine physician, Massachusetts General Hospital, Boston

The authors also write that the “impact of pervasive weight stigma on [health care provider] understanding of ideal approaches to obesity management should not be discounted when considering systematic drivers of suboptimal or absent obesity care.”

“I think that we can work to do better despite the level of training we have,” Stanford says. “Or we’re going to continue to fail our patients and our obesity rates are going continue to proliferate, and we’re going to start to see it earlier and younger. We see patients die much earlier than they need to of chronic diseases like heart disease associated with obesity.”

Stanford sent her patient with the BMI of 58 to surgery. Her BMI dropped to 28. She went back to the same retailer, the same hiring manager, with the same resume and was hired on the spot. It was kind of a bittersweet victory, but this patient was bold enough to address the issue with the hiring manager, saying, according to Stanford, “Look, I’m the same person. I came in before two and a half years ago, and you told me I wasn’t qualified. And you hired me, but there’s no difference, and I really think you should really look at your policies regarding hiring.”

“When we think about obesity in our large population, we only think about the disease process,” Stanford says. “We think about the high impact diseases such as obesity, but we don’t think about the fact that it affects hiring. It affects socio-economic status. It affects quality of life. It affects depression. These things are all inter-related, and so treating that child or adolescent with severe obesity sooner really can play a large role in setting them on an upward trajectory pretty early in life.”

  • Bagley is the senior editor of Endocrine News. He wrote about the use of telehealth methods and diabetes outcomes in the May issue.

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