Global Doc: Heavy Matters

Author: Dr. Vincent DeGennaro Jr. ’02

Vincent DeGennaro

“I’m doing my part. I want to get better and go home,” Dorothy says as she looks up at me from the hospital bed. We talk about her family and work life, and she tears up several times during the conversation especially when she talks about how her mother died of cancer. “I’m afraid to go that way,” she divulges. Her 450-pound body fills the oversized bed entirely and the railings covered in padding prevent a hefty body part from falling out. Dorothy is so large that she is physically incapable of transferring herself from the bed to a chair without assistance, and once seated in the chair she is held in place by a safety strap so she doesn’t fall, her core muscles not strong enough to support the massive trunk in an upright position.

“I understand your fears completely, but you have lots of other problems to worry about that aren’t cancer,” I tell her. “Let’s focus on those now and do what we can to make them better.” We talk more about her immediate medical problems and attempt to address each one of them, but I’m left wrinkling my brow through a lot of the conversation.

Each pain or medical problem ends and begins with the excess weight. We can ease the pain with pills and control the infections with antibiotics, but the obesity complicates any treatment and prolongs every illness. “We can treat the pain in your knees, but the arthritis will continue to get worse and require narcotics to deal with the pain. Eventually you will need total knee replacement surgery.” I leave her room feeling helpless and empathetic for her difficult situation, regardless of the reasons that brought her to this point.

Part of my job as a physician is not merely to diagnose and treat medical problems, but to ascertain the causes underlying illness and attempt to address them. Each patient is unique, with a disease tailor-made to their risk factor: the Vietnam veteran with emphysema from smoking, the diabetic farmer with kidney failure, or the alcoholic with heart failure. It is easy to cultivate a “blame the victim” mentality. Why don’t they eat less and exercise more and stop smoking and drinking and employ some self-control? The myriad of reasons for illness in modern America are more complex than such a reductionist view. Genetics, upbringing, culture, substance abuse, poor coping skills, poverty, war experiences, lack of education, religion, psychiatric illness, physical or sexual abuse, environmental pollution or just plain bad luck may all contribute. I can’t treat a disease in isolation any more than a mechanic can hope to fix the engine merely by changing the tires.

In Florida, I check on the patients each morning and collectively they catalog the complications that accompany obesity: diabetes, hypertension, heart failure, kidney failure, gout, skin and bone infections. Each room a different disease, or more typically, collection of diseases, that ravages the body, all a downstream effect of the weight. After bathing constantly in sugar in the blood, the liver cells become immune to the high levels and the pancreatic cells stop responding the way that they should. The rest of the body’s cells live in a constant state of inflammation, struggling daily to deal with the constant barrage of stress hormones, increasing the rates of heart attack and stroke, and the body becomes more susceptible to infection, the smallest cuts developing into festering, limb-threatening wounds.

By the end of rounds, I realize that Dorothy is not alone. In America, 60 percent of the people are overweight, meaning at least 10 percent over the ideal body-mass index (BMI), and 30 percent are obese, or is at least 20 percent greater than the ideal BMI. The prevalence of morbid obesity, those with greater than 100 percent of the ideal BMI, is 3 percent in men and 6 percent in women. Of my 12 patients, four of them weigh more than 400 pounds, easily meeting the definition of morbid obesity, and another four are obese. Dorothy has her own set of psycho-social issues that enable her obesity, but for the hospital to be occupied by so many obese patients, there must be other factors at play. The epidemic drains the funding from our stressed healthcare system with estimated direct costs for treating obesity-related medical illnesses at over $50 billion per year.

The United States must take a multi-pronged approach to combat the multi-factorial epidemic, but sugary drinks are an easy place to start: Tax sugary beverages to reduce consumption and to raise money for the healthcare system that pays for their effects on society. Given their deleterious effect on America’s health, regulating where and when they can advertise, in particular to children, would change the consciousness of the country. In much the same way tobacco products cannot be advertised on television and public health campaigns have demonized cigarette smoking, a cultural shift towards sugary drinks is in order, given that, according to a study by Centers for Disease Control, 6 percent of our calorie consumption (8 percent in children) comes from these nutritionally empty beverages. How much Coca-Cola would we consume if you never watched an advertisement for it during American Idol and if taxes doubled the price?

The list of societal adaptations to combat obesity must involve all facets of life, many of which would save us money or increase our productivity. For example, the federal government subsidizes high fructose corn syrup that makes us overweight, and then pays for Medicare and Medicaid to treat the problems that it causes. We could increase the availability and lower the price of fresh produce and reduce the consumption of processed foods through regional food economies. More pedestrian-friendly cities, improved nutrition at schools, stand-up desks at work, and insurance discounts for weight loss or enrolment in exercise plans are all options. Powerful political forces stand to lose as we get creative about the obesity epidemic, and we should expect to be in for a long battle for our nation’s health.

“Is the pneumonia going to delay my weight-loss surgery appointment? It’s in three weeks and I’ve done all the preliminary work up and interviews. I don’t want to put this off any longer because my health can’t take it,” another morbidly obese patient laments. She understands that she missed her chance at preventive measures, and the factors that comprised her life up to that point made it difficult to attempt diet and exercise again. “I really think that it’s going to change my life.”

We can continue to over-pay for health care by reducing one patient’s stomach at a time, or we can take a bite out of the factors that contributed to their obesity in the first place in order to save the next generation, and perhaps the federal deficit at the same time.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.