Tag: Obesity

Nueva meta de las escuelas de medicina: médicos que no discriminen a pacientes obesos

Cuando Melissa Boughton se quejó con su gineco-obstetra de un dolor pélvico,  la doctora respondió preguntándole sobre su dieta y sus hábitos de ejercicio.

En ese momento, Boughton pensó que la pregunta parecía irrelevante, considerando el tipo de dolor que sentía. Pero no era inusual viniendo de esta médica. “Cada vez que iba, hablaba sobre dieta y ejercicio”, dijo Boughton, que tiene 34 años y vive en Durham, Carolina del Norte.

En esta ocasión, hace tres años, la médica le dijo a Boughton que perder peso probablemente resolvería su dolor pélvico. Mencionó la dieta y el ejercicio al menos dos veces más durante la cita. Y dijo que ordenaría un ultrasonido para tranquilizarla.

El ultrasonido reveló la fuente de su dolor: un tumor de 7 centímetros lleno de líquido en su ovario izquierdo.

“Odio a esa doctora por la forma en que me trató, como si mi dolor no fuera gran cosa”, dijo Boughton. “Pareció decidir sobre mí basándose en una mirada muy superficial”.

La investigación ha demostrado durante mucho tiempo que es menos probable que los médicos respeten a los pacientes con sobrepeso u obesos, incluso cuando casi las tres cuartas partes de los adultos en los Estados Unidos ahora pertenecen a una de esas categorías.

La obesidad, cuando el índice de masa corporal (IMC) es de 30 o más, es generalizada en el sur y el medio oeste, según los Centros para el Control y la Prevención de Enfermedades (CDC). El estado con la tasa más alta es Mississippi, donde 4 de cada 10 adultos califican como obesos.

La obesidad es una afección común y tratable vinculada a una larga lista de riesgos para la salud, que incluyen diabetes tipo 2, enfermedades cardíacas y algunos tipos de cáncer. A pesar de la prevalencia de la obesidad, conlleva un estigma único.

Los médicos a menudo abordan la práctica de la medicina con un sesgo anti-grasa y no les resulta fácil comunicarse con los pacientes cuyo peso excede lo que se considera el rango normal. Algunos expertos en obesidad culpan a la falta de enfoque sobre el tema en las escuelas de medicina. Otros culpan a la falta de empatía.

Para contrarrestar ambas, la Association of American Medical Colleges planea implementar en junio nuevos estándares de diversidad, equidad e inclusión destinados a enseñar a los médicos, entre otras cosas, sobre el trato respetuoso de las personas diagnosticadas con sobrepeso u obesidad.

Eso no les sucede a muchos pacientes, dijo el doctor Scott Butsch, director de medicina de la obesidad en el Instituto Bariátrico y Metabólico de la Clínica Cleveland. “Es casi como una mala práctica… Los estereotipos y las percepciones erróneas en torno a esta enfermedad simplemente se filtran en la práctica clínica”.

El problema, argumentó Butsch, es que se presta muy poca atención a la obesidad en la facultad. Cuando entrenó y enseñó en la Escuela de Medicina de Harvard durante varios años, dijo Butsch, los estudiantes no recibieron más de nueve horas de educación sobre obesidad, repartidas en tres días en cuatro años.

Melissa Boughton contó que su gineco-obstetra le habló de dieta y ejercicios cuando le dijo que tenía un dolor pélvico. Era un tumor. (Melissa Boughton)

En 2013, la American Medical Association votó a favor de reconocer la obesidad como una enfermedad. Pero, dijo Butsch, los médicos a menudo lo abordan con un enfoque único para todos. “Coma menos, muévase más” no funciona para todos, dijo.

“Hay muchas formas diferentes de obesidad, pero las estamos tratando como si estuviéramos dando la misma quimioterapia a todos los tipos de cáncer”, dijo Butsch.

Todas menos cuatro de las 128 escuelas de medicina informaron que cubrieron contenido relacionado con la obesidad y la medicina bariátrica en el año académico 2020-21, según datos proporcionados a KHN por Association of American Medical Colleges, que no representa a las escuelas osteopáticas.

Aún así, la investigación sugiere que muchos médicos, en todo el mundo, no han sido lo suficientemente capacitados para abordar los problemas de peso. Una encuesta completada por líderes de 40 escuelas de medicina del EE.UU encontró que solo el 10 % sentía que sus estudiantes estaban “muy preparados” para manejar pacientes con obesidad. Expandir la educación en esta área no es una prioridad, escribieron en un artículo de 2020 sobre la encuesta.

Butsch quiere que el Congreso apruebe una resolución que insista en que las escuelas de medicina incorporen capacitación sustantiva sobre nutrición, dieta y obesidad.

El doctor David Cole, presidente de la Universidad Médica de Carolina del Sur, dijo que muchos temas deberían cubrirse de manera más completa en la escuela de medicina. “Hay un tomo enorme, es así de grande”, dijo Cole, levantando la mano alto. “El tema es: cosas que nunca aprendí en la escuela de medicina”.

La Asociación de Colegios Médicos Estadounidenses está tratando de abordar el problema de dos maneras.

En primer lugar, desarrolló un examen de preparación profesional para los aspirantes a estudiantes de la escuela de medicina, llamado PREview, diseñado para evaluar la competencia cultural, las habilidades sociales y para escuchar de los solicitantes, así como su capacidad para analizar las situaciones que pueden encontrar en la escuela de medicina y en entornos clínicos.

“Las llamamos habilidades blandas, pero en realidad son las más difíciles de aprender”, dijo Lisa Howley, psicóloga educativa y directora senior de iniciativas estratégicas de la asociación. Más de una docena de escuelas ahora recomiendan o exigen que los solicitantes presenten sus puntajes del examen PREview junto con los del examen de admisión.

En segundo lugar, en junio, la asociación implementará nuevos estándares de competencia para estudiantes de medicina, residentes y médicos existentes relacionados con la diversidad, la equidad y la inclusión. Esos estándares abordarán el racismo, los prejuicios implícitos y la igualdad de género, y tendrán como objetivo enseñar a los médicos cómo hablar con las personas que tienen sobrepeso.

Después de que se descubrió la fuente del dolor pélvico de Melissa Boughton, la misma médica actuó como si el tumor no fuera “un gran problema”.

Boughton buscó una segunda opinión de un médico que promocionaba su práctica como un consultorio “Saludable para todos los tamaños”. Ese médico la refirió a un oncólogo quirúrgico, quien extirpó el tumor, su ovario izquierdo y parte de una trompa de Falopio. El tumor era grande, pero no era canceroso. Y aunque la cirugía para extirparlo se consideró exitosa, desde entonces Boughton ha tenido problemas para concebir y se está sometiendo a un tratamiento de fertilidad.

“Es una montaña rusa emocional”, dijo. “Me siento muy joven a los 34 años para estar pasando por esto”.

Boughton, quien se describe a sí misma como alguien que “no encaja en la caja del IMC”, dijo que la experiencia le enseñó a elegir a sus médicos de manera diferente. Si el médico pregunta si hace dieta y ejercicio, simplemente “empiezo a buscar otro”.

To Shed Bias, Doctors Get Schooled to Look Beyond Obesity

When Melissa Boughton complained to her OB-GYN about dull pelvic pain, the doctor responded by asking about her diet and exercise habits.

The question seemed irrelevant, considering the type of pain she was having, Boughton thought at the time. But it wasn’t unusual coming from this doctor. “Every time I was in there, she’d talk about diet and exercise,” said Boughton, who is 34 and lives in Durham, North Carolina.

On this occasion, three years ago, the OB-GYN told Boughton that losing weight would likely resolve the pelvic pain. The physician brought up diet and exercise at least twice more during the appointment. The doctor said she’d order an ultrasound to put Boughton’s mind at ease.

The ultrasound revealed the source of her pain: a 7-centimeter tumor filled with fluid on Boughton’s left ovary.

“I hate that doctor for the way she treated me — like my pain was no big deal,” Boughton said. “She seemed to make a decision about me based off of a very cursory look.”

Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories. Obesity, which characterizes patients whose body mass index is 30 or higher, is pervasive in the South and Midwest, according to the Centers for Disease Control and Prevention. The state with the highest rate is Mississippi, where 4 in 10 adults qualify as obese.

Obesity is a common, treatable condition linked to a long list of health risks, including Type 2 diabetes, heart disease, and some cancers. Despite obesity’s prevalence, it carries a unique stigma.

Doctors often approach the practice of medicine with an anti-fat bias and struggle to communicate with patients whose weight exceeds what’s considered the normal range. Some obesity experts blame a lack of focus on the subject in medical schools. Others blame a lack of empathy.

To counter that, the Association of American Medical Colleges plans to roll out in June new diversity, equity, and inclusion standards aimed at teaching doctors, among other things, about respectful treatment of people diagnosed as overweight or obese.

That’s not happening for many patients, said Dr. Scott Butsch, director of obesity medicine at the Cleveland Clinic’s Bariatric and Metabolic Institute. “This is almost like malpractice. You have these physicians or clinicians — whoever they are — relating everything to the patient’s obesity without investigation,” Butsch said. “The stereotypes and misperceptions around this disease just bleed into clinical practice.”

The problem, Butsch argued, is that too little attention is paid to obesity in medical school. When he trained and taught at Harvard Medical School for several years, Butsch said, students received no more than nine hours of obesity education spread over three days in four years.

In 2013, the American Medical Association voted to recognize obesity as a disease. But, Butsch said, doctors often approach it with a one-size-fits-all approach. “Eat less, move more” doesn’t work for everyone, he said.

Parents and medical providers need to take special care when talking to children who have been diagnosed with obesity about their weight, psychologists have warned. The way parents and providers talk to kids about their weight can have lifelong consequences and in some cases trigger unhealthy eating habits. For children who are obese, obesity experts agree, weight loss isn’t always the goal.

“There are many different forms of obesity, but we’re treating them like we’re giving the same chemotherapy to all kinds of cancer,” Butsch said.

All but four of the country’s 128 M.D.-granting medical schools reported covering content related to obesity and bariatric medicine in the 2020-21 academic year, according to curriculum data provided to KHN by the Association of American Medical Colleges, which does not represent osteopathic schools.

Even so, research suggests that many physicians haven’t been sufficiently trained to address weight issues with patients and that obesity education in medical schools across the world is “grossly neglected.” A survey completed by leaders at 40 U.S. medical schools found that only 10% felt their students were “very prepared” to manage patients with obesity.

Melissa Boughton says her OB-GYN brought up diet and exercise at least three times during an appointment and acted as if Boughton’s ovarian tumor diagnosis was “the most normal thing in the world.” She now makes an effort to screen her doctors. (Melissa Boughton)

Meanwhile, “half of the medical schools surveyed reported that expanding obesity education was a low priority or not a priority,” wrote the authors of a 2020 journal article that describes the survey’s results.

Butsch wants Congress to pass a resolution insisting that medical schools incorporate substantive training on nutrition, diet, and obesity. He acknowledged, though, that the medical school curriculum is already packed with subject matter deemed necessary to cover.

Dr. David Cole, president of the Medical University of South Carolina, said plenty of topics should be covered more comprehensively in medical school but aren’t. “There’s this massive tome — it’s about this big,” Cole said, raising his hand about a foot off the top of a conference table in Charleston. “The topic is: Things I never learned in medical school.”

The bigger issue, he said, is that medicine has historically been taught to emphasize memorization and has failed to emphasize culturally competent care. “That was valid 100 years ago, if you were supposed to be the fount of all knowledge,” Cole said. “That’s just not valid anymore.”

The Association of American Medical Colleges is trying to tackle the problem in two ways.

First, it developed a professional readiness exam for aspiring medical school students, called PREview, designed to assess an applicant’s cultural competence, social skills, and listening skills, as well as their ability to think through situations they may encounter in medical school and clinical settings. “We call them softer skills, but they’re really the harder ones to learn,” said Lisa Howley, an educational psychologist and senior director of strategic initiatives at the association. More than a dozen medical schools now recommend or require that applicants submit their PREview test scores with their Medical College Admission Test scores.

Second, the medical college association will roll out new competency standards for existing medical students, residents, and doctors related to diversity, equity, and inclusion in June. Those standards will address racism, implicit bias, and gender equality and will aim to teach doctors how to talk with people who are overweight.

“The bias toward those individuals is way too high,” Howley said. “We have a lot more work to do in this space.”

After the source of Melissa Boughton’s pelvic pain was discovered, the OB-GYN who had recommended diet and exercise to ease her symptoms told Boughton the tumor was no big deal. “She acted like it was the most normal thing in the world,” Boughton said.

Boughton sought a second opinion from a doctor who marketed her practice as a “Healthy at Every Size” office. That doctor referred Boughton to a surgical oncologist, who removed the tumor, her left ovary, and part of a fallopian tube. The tumor was large, but it wasn’t cancerous. And although the surgery to remove it was considered successful, Boughton has since had trouble conceiving and is undergoing fertility treatment as she tries to have a baby.

“It’s an emotional roller coaster,” she said. “I feel very young at 34 to be going through this.”

Boughton — who describes herself as someone who doesn’t “fit into the BMI box” — said the experience taught her to choose her doctors differently.

“You can ask me if I diet and exercise like once,” she said. Any more than that, and she starts shopping for a different doctor.

Bison Pastrami, Anyone? Preschool Assistant Makes Sure Kids Get to Know Indigenous Foods

MINNEAPOLIS — Bison pastrami is not typical school lunch fare, but it’s a crowd favorite at a preschool in Minneapolis.

Fawn Youngbear-Tibbetts — the seemingly always on-the-go coordinator of Indigenous foods at the Wicoie Nandagikendan Early Childhood Urban Immersion Project — is frequently found tweaking recipes in the kitchen or offering homemade goodies like flourless black-bean brownies.

Youngbear-Tibbetts, a longtime Minneapolis resident and member of the White Earth Band of the Minnesota Chippewa Tribe, has made it her mission to bring traditional recipes to the 178 children attending Wicoie, who are taught several hours each day in the Dakota and Ojibwe languages. She said the dishes not only help Native American students and their families connect with their culture, but also bolster their nutrition.

“Part of it is getting their palates [used to] eating traditional foods, so that they want it,” she said. “Our kids are so used to eating all of this processed food — the snacks, the sugar.” She hopes students develop a taste for healthier food they will carry through their lives.

Across the breakfasts, lunches, and snacks Wicoie Nandagikendan serves, Youngbear-Tibbetts incorporates sweet potatoes, fresh fruits, leafy greens, fish, and meat from large game animals like bison, which is extremely low in fat, she said. Recently, she distributed a donation of 300 pounds of bison to students’ families.

Partly because of a lack of access to healthy food, nearly half of Native American children are overweight or obese, Indian Health Service researchers found in a study published in 2017.

A 2018 report from the First Nations Development Institute found that for “Native American children, their school or school-related meals may be the most reliable, consistent and nutritionally-balanced food they receive,” which Youngbear-Tibbetts has found to be true.

Many children at the Minneapolis school come from families with severely limited incomes who may not have cars or be able to get to grocery stores. They often rely on convenience stores for shopping. “A lot of our kids only eat food at school so that’s when it becomes really important to make sure we’re serving the most nutritious” meals, Youngbear-Tibbetts said.

When money is tight, she added, “people tend to purchase the most calories they can with their dollars.”

“That’s potato chips, that’s ramen, that’s highly processed foods, because there’s more calories and it’s cheaper to buy it,” she said.

Youngbear-Tibbetts said many urban American Indian families never learned how to cook Indigenous food. She has taught students how to harvest wild rice and catch fish. She also has shown their families how to smoke and fillet fish.

“We have multiple generations of people and some families that are removed from even knowing how to clean a fish or how to cook deer meat,” she said.

Youngbear-Tibbetts grew up near Leech Lake, between the Minnesota cities of Grand Rapids and Bemidji, where her father taught her to harvest berries and greens, butcher deer, and catch walleye (a freshwater fish common in the northern United States) and whitefish.

By age 10, she said, she could butcher a deer or fillet a fish on her own. By 12, Youngbear-Tibbetts started cooking dinner for her family, partly because “if you cooked, you didn’t have to do the dishes.”

She began cooking regularly in high school after her mother grew sick.

“When she was diagnosed with diabetes, I went to her nutrition class with her,” Youngbear-Tibbetts said. “So that really changed how I ate and how I prepared foods.”

Youngbear-Tibbetts has cooked many of the recipes she serves students for most of her life, including venison, walleye, and meatballs made of turkey, bison, and wild rice. Sometimes she substitutes Indigenous ingredients for foods her students already enjoy. For example, she makes tacos with blue corn tortillas and bison instead of flour tortillas and beef.

She also teaches her students how to identify foods that grow in cities, like crabapples and mulberries, to incorporate into their diets.

Native Americans are nearly three times as likely to develop diabetes than are non-Hispanic white Americans and 50% as likely to develop heart disease, according to federal data.

Dr. Mitchell LaCombe, a family physician at the Indian Health Board of Minneapolis, a community health clinic, said his patients face these issues regularly.

“I can tell people how to eat healthy, but if they can’t afford it or get it or acquire those medicines or those foods, then it doesn’t matter,” LaCombe said.

“The traditional diet seems more like a better diet,” LaCombe said, noting that “incorporating the Western-style diet is when things start to go sour. Especially when you get into the fast foods and the convenient foods that taste good.”

Ariel Gans and Katherine Huggins are Northwestern University graduate students in the Medill School of Journalism’s Washington, D.C., program.