Anti-fatness in the Surgical Setting

It was 6:30 A.M., and I was getting ready to head down to the operating room (OR) for the first case of the day: an abdominal wall hernia repair. In preparation for the case, I logged on to the electronic health record portal and read through the patient’s medical history and the preoperative notes written by the surgical team. In many of the physician notes, the first line noted the patient’s body mass index (BMI) of 41. The patient’s ventral hernia was estimated to be 30 centimeters by 20 cm, one of the largest hernias ever repaired by the surgeon I was working with. The CT scan showed sections of the large intestine protruding through the hernia, which posed a high risk for bowel twisting, which can lead to perforation and sepsis or tissue deoxygenation and necrosis. The patient’s condition had reached a critical point.

I ventured down to the OR and located the CT and MRI images, as part of my medical student role of assisting the nursing and scrub technicians in prepping the OR prior to surgery. I projected the scans onto the large screen TVs hanging in the OR to help the surgeons better visualize the anatomy and their approach. As I pulled up the images, the team in the room erupted in shock. How could someone let a hernia get this bad before seeking medical consultation, they wondered. And others couldn’t believe that someone could live with such a large defect and not want it fixed for cosmetic purposes. After rolling the patient into the OR and moving her onto the operating table, the team began to prep the surgical site. As she drifted off into a state of sedation, medical staff in the room could not stop talking about her BMI. The comments were unrelenting throughout the five-hour procedure, as people took turns gawking at the gaping hole in the patient’s abdomen. Two of the largest pieces of Strattice biologic mesh made by the supplier were sewn together to repair the hernia. The estimated cost of the mesh alone was $30,000.

As the surgery ended, I couldn’t stop thinking about the obvious, yet ironic, connection between the weight comments from the health care team and why the patient procrastinated before getting the surgery. Why would anyone want to interact with a medical system that looked at them in such a derogatory way?

Anti-fatness is socially ingrained and virtually inescapable. Pop culture idolizes thinness. The Centers for Disease Control and Prevention created an alarmist “obesity epidemic” based on exaggerated data that haven’t held up. Like everyone else in society who is socially conditioned to this bias, clinicians are not exempt from harboring anti-fatness. In a recent study, 24 percent of physicians stated they were uncomfortable having friends in larger bodies, and 18 percent admitted they felt disgusted when treating a patient with a high BMI. This is upsetting, yet unsurprising considering that few programs actively train health care providers against this cognitive bias.

Abundant research demonstrates that “obesity” is not really a choice and is often a product of systemic inequity. The crux of this research explores 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’ training and day-to-day tasks that may make them more prone to this cognitive bias.

Weight bias is heightened and reinforced in the surgical setting, where surgeries on higher BMI individuals take more time, cost more money and have an increased risk of complications. Anti-fatness attitudes and behaviors may be higher among surgeons partly as a result of the lack of filter people may have when the patient is sedated. The increased time and care required in these cases can be difficult for surgeons, whose time and care are already strained given staff shortages. Together, these factors may lead surgeons to express their frustration through comments about the patient’s body.

In addition, professional culture and training are different for surgeons. Primary care physicians’ training may focus more on upstream factors contributing to care, including being taught about social determinants of health and multifactorial causes of the patients’ conditions. In contrast, surgeons—who on average spend 3,963 hours of training honing a complex motor and visuospatial skill may naturally focus more on the procedural task at hand rather than the factors contributing to their patient’s condition. Ultimately, the everyday demands of a surgeon’s job may make them less likely to think critically about anti-fatness when providing their day-to-day care. Yet, to provide optimal patient care, it is equally important for surgeons to work against weight stigma.

Surgeons are often the physicians who spend the most time in the hospital. As such, 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. Post-surgery, many higher-weight patients will require intensive care, continual follow-up and long-term treatment adherence. Patients with a higher weight are also 12 times more likely to have a complication requiring extended hospitalization and continued interface with their surgical team. Surgeons must confront their own weight bias to build positive ongoing partnerships with patients.

A culture of anti-fatness among surgeons leads to compounding negative impacts on individual patients and the health system. Studies show weight bias from providers is palpable for patients. Patients can sense the lack of dignity and respect in providers’ attitudes and, in turn, 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 make incremental lifestyle modifications possible. Altogether this can harm patients’ self-worth and rapport with providers.

When providers alienate patients who first touch the health care system, through poor care or rapport, these patients are more likely to not resurface until reaching a critical health point, as with the hernia repair case discussed above. Research suggests that providers spend less time with larger patients, provide a lower quality of care and misdiagnose larger patients more frequently.

Anti-fatness is often a more socially acceptable masquerade for anti-Blackness. The Department of Health and Human Services reports that about four out of five African American women are overweight or obese, and Black Americans were 1.3 times more likely to be obese compared to white Americans. This intersection allows covert ways to harm Black and brown bodies.

Ultimately, the biases and behaviors that maintain anti-fatness need to change. Potential avenues for change include creating systemwide education, amending medical documentation, reframing patient conversations and advocating for upstream policies that increase access. A health provider’s goal should be health—vital statistics, lab results, symptom reduction, time spent exercising, mental health—not thinness. There are health consequences to obesity, but the current BMI-focused approach is not the best way to capture a person’s current health status. Lack of education among medical professionals is perpetuating anti-fatness. A health systemwide training should be developed to educate health care providers and shift conscious and unconscious attitudes.

Providers should also make a habit of noting diet and exercise in social history, as opposed to collapsing these factors into BMI. They could partner with patients and connect them with community resources to enable them to meet their health goals of lower blood pressure or better cardiovascular health. Providers can also focus on 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 empowered to achieve optimal health outcomes. This affirmative type of partnership will encourage patients to return to the health care system and invest in the provider-patient relationship and health goals. Providers must internalize the complexity of weight, learn how to utilize alternative health markers and even advocate for policies that reduce food deserts. Surgeons may read the above action items and write them off as tasks reserved for primary care physicians. But practicing unbiased medicine is possible. In one promising model, hospitals in Canada have recently launched a surgical prehabilitation program and toolkit 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 does not have an obesity epidemic; it has an unhealthiness epidemic. Yet the worse health outcomes compared to countries with similar economies are just as much a product of anti-fatness as they are of fatness. Through shame and blame, anti-fatness may be contributing to obesity and exacerbating poor health. Until surgeons and other health care providers choose to be a part of the solution to anti-fatness, then they will be part of the problem.