On Sensitivity

I’m not sure if I have mentioned this before, but the career that pays my bills and enables me the time and money to write and publish books is nursing.  I’ve worked in several areas of acute care (i.e., in the hospital) and for the last four I’ve worked in an emergency department.  All the nurses in the facility where I work are required to do quite a few hours of continuing education every year, both to ensure that everybody knows what they are doing, as well as introducing new treatments, procedures, etc.

One of the new things to come along in the last few years has been Bariatric Sensitivity Training.  “Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity” according to Wikipedia, and that’s a pretty good definition.  Thus, bariatric sensitivity training is no less than obesity sensitivity training, which is something that most people in the U.S. could learn to exercise a little better.  Okay, a lot better.

I’ve followed several conversations on Twitter and the various postings of one bright and courageous woman named Mindi regarding the Fat Acceptance Movement.  Until a couple of months ago, I didn’t even know this was a thing.  At first I wasn’t too sure about this new thing, because all you ever hear in the healthcare field is that it’s bad to be fat, you’ll get diabetes, you’ll have high blood pressure, and then you’ll get a heart attack and die.  So, when I started reading about how it’s okay to be fat, it got my attention.

Mindi’s main point is that “All bodies are valid” and it is something she says over and over again.  For the record, she doesn’t only use this in reference to people who are considered obese; she also uses it for the differently abled, and pretty much anyone who isn’t considered “normal” in our narrow-minded and rather judgemental society.  I’ve seen her write that there is little data to link obesity to health issues, but the nurse in me thinks there’s some disconnect to the research she is reading and the stuff the physicians are reading.  This summer I intend to do some research of my own and I’m hoping she’ll help me out by providing me with her info so I can settle it all in my mind.

I want to explore this obesity research thing for two reasons:  one, I’m an RN and I need accurate information; two, I tend to be a rather distrustful sort of individual and I don’t just swallow things without questioning them; three, I have been accepted to the master’s program and intend to pursue a career as a nurse practitioner. When the time comes to help, advise, and guide those individuals who happen to be overweight, I need to know what I am talking about, and I need to have accurate information to back me up.  It’s called “evidence-based practice,” and it’s what we’re supposed to do all the time.

Today I just want to point out that Mindi is saying the same thing as the bariatric sensitivity training I just completed – all bodies are valid.  When I was a kid, my mother said: “If you can’t say anything nice, don’t say anything at all.”  When I went to church, the priest said: “Judge not, lest ye be judged.”  Lately, the people I look to for wisdom and expanding my own spirituality say things like: “You cannot hate someone else without hating yourself, because we all are one” and “The world is like a giant rock tumbler, and the people we come into contact with are there to help rub off our sharp edges and polish us into beautiful gems” and “You get the ‘difficult’ people because that thing that makes you think they’re difficult is something in your personality that needs improvement.”  Stuff like that.  Metaphysics can be grueling at times, but it’s been quite rewarding as far as personal growth is concerned.

Nobody wants to be judged – well, criticized, really – but we all seem unable to keep from doing it to others.  I’m not perfect, I definitely have my moments, but I try.  I do get annoyed from time to time when people make comments like “Well, fatty, lose some weight,” spoken out of earshot of said fat individual – especially when the person making the comment is somebody I know that isn’t happy with their own body and who has trouble losing weight.  Mind you, these people might have an acceptable BMI, but if somebody who is not technically overweight or obese has difficulty losing weight, why do they think it’s so easy for someone who is considered overweight or obese?

Therefore, we have sensitivity training.  Here are a few things I want to share from this online education, on which I took notes.  Other nurses are reading that and thinking I’m insane, so I’d like to point out that I am a kinetic-visual learner, and that I learn by doing.  For me, writing stuff down counts as doing.

The sections of emphasis were: 1, “Obesity As a Public Health Threat”; 2, “Problems of Weight Bias and Discrimination”; and 3, How to Care for the Obese Patient in a Sensitive Manner.”  First off, it seems that referring to obesity as a “threat” is counterproductive to the task at hand.  When communism was regarded as a threat, then communists were likewise considered threatening.  While I may be nitpicking, it seems a different choice of word is in order.

I’m not a fan of BMI.  The Body Mass Index calculation is measured in kilograms per meter squared (medicine is in metrics), obtained by dividing your weight in pounds by your height in inches squared, multiplied by 703.  To use me as an example, I weigh 116 lbs / 60 inches tall = 1.93 x 703 = a BMI of 1359.13, which would mean I’m literally the size of a house and just goes to show you how crappy I am at algebra.  Oh, wait, I forgot to square the inches.  Nevermind, here’s a chart:

BMI

Interestingly enough, this shows that I have a BMI of…. wait, it’s not even on there.  I did see another chart that gave me a BMI of 22, which is technically underweight.  This is an unexpectedly fantastic example of why I think BMI sucks almost as much as the 0 – 10 pain rating scale.

The lesson did go on to say that just because a person has a high BMI doesn’t mean they are fat (think bodybuilders), and that an individual can have “fat stores” with a normal BMI.  BTW, I also hate the world “normal” when used for nursing and medicine, because in nursing school we are taught that there is no normal, but that certain things are WNL or Within Normal Limits.  Other measures used to define obesity were listed as waist circumference (duh), skin fold thickness, and waist-to-hip circumference ratio.  It also lists things like ultrasound, CT, and MRI, but if healthcare providers are using MRI to diagnose obesity, I’d be willing to bet that might be one reason that we’re spending billions on treating the obesity “epidemic.”

The lesson went on to give statistics on the percentage of U.S. adults considered overweight and obese, as well as the health risks associated with being overweight.  Without reading any studies on my own, I can get that obesity is associated with heart disease, high blood pressure, and type 2 diabetes, as well as obstructive sleep apnea and obesity hypoventilation (not breathing deeply/often enough) syndrome, but when they started listing testosterone deficiency, acid reflux, depression, anxiety, and seven different kinds of cancer, my BS meter dinged.  Seven different kinds of cancer?  Are you kidding me?

As for anxiety and depression – is that the chicken, or the egg?  Are we depressed because we are fat? Are we anxious because we can’t find attractive clothes to wear and because people make fun of our fatness?  Or are we eating because we are lonely and sad?  Is food compensating for love?  Are we eating to calm our nerves?  I’ve sure as hell done it.  I’ve been an emotional eater for years and still have menstrual cravings for junk food.  Reading Geneen Roth’s book When Food Is Love was a turnaround point for me.

I seriously doubt that colon cancer is from being fat.  It seems far more logical that it is because of poor diet, i.e., lacking fiber (this also causes diverticulosis).  We are supposed to eat a minimum of 25 grams of fiber a day.  An apple has about 5 grams.  This is where your 5 servings of fruits and veggies comes from:  each serving should have about 5 grams, which gives you 25 grams a day.  35 grams is better.  We shouldn’t be getting our carbohydrates from bread, rice, pasta, etc.  We should be getting it along with our fruit, but that’s a discussion for another day.

The lesson also accuses obesity of causing esophageal cancer.  My understanding is that the primary cause of esophageal cancer is acid reflux.  Supposedly obesity causes acid reflux, so it seems to be a clear path.  But wait – what if the real cause of the acid reflux is stress?  And what if this person copes with stress by eating?  Logic would follow that it was the stress that caused the cancer, not being fat.  I’m not saying that all fat people have eating disorders, just cooking up one scenario.

I checked out cancer.gov and they do mention that women with extra fat on their bodies tend to have higher estrogen levels, so an increased cancer risk is logical there because cancer loves estrogen.  It eats it up and grows big and strong. But still, that doesn’t mean obesity causes cancer.  That higher estrogen level will make it worse, though.  You can read the government’s list of obesity-related diseases here.  It’s endless and doesn’t explain much in depth.

BTW, the lesson also informed me that obesity is a “burden” on the health care system.  Again, there might be a more sensitive way to phrase that, so it doesn’t look like we’re blaming fat people for causing a problem.  They link obesity with a higher number of visits to both PCPs and specialists, as well as more ED visits, hospitalizations, diagnostic testing, and medications.  As far as I can tell, this is because research has associated obesity with all those other health problems.  Yes, if you have diabetes, you’re going to go to the doctor more often.  I blame our typical American diet and the USDA for most of that, but I’ll save that rant for a later date.

The worst part of the bariatric sensitivity lesson is something (somewhat) beyond the writers’ control – the labels for the various BMI categories.  Here’s the list, which is a little different than the chart because it includes an extra category for BMI of ≥ 50:

BMI-classifications

As you see, we have the various categories of “obese.”  The ones in my lesson have Obese, Class I; Severe Obesity, Class II (instead of Severely Obese); Severe Obesity, Class III (Morbidly Obese), and “Superobesity” (Super Obese).  Keeping in mind that this is bariatric sensitivity training, who in their right mind thought that “super obese” would be an acceptable description?  (I didn’t look up what medical or government agency was responsible for naming them thusly, but I will try to find out.  Somebody needs to point this out to them and get it changed.)  Referring to a BMI of ≥ 50 as “super obese” isn’t the most insensitive thing I can imagine, but it certainly isn’t positive.  There are obesity categories of Class I, II, and III, so why is this not Class IV?  We don’t classify heart murmurs as Levine Scale I, II, III, IV, V, and WTF OMG SUPER LOUD MURMUR.  The very fact that an official diagnosis of “super obese” exists is proof positive of deeply entrenched bias where people with obesity are concerned.  Can you imagine seeing that in your medical chart?

I know I’m harping on all the bad parts of this educational lesson, but there was much about it was good.  The fact that I only found a few things to pick on speaks volumes.  Complaining is my favorite pastime; my mother would tell you that I’ve been happily complaining (and arguing) since I learned to talk.  The sections on weight bias and discrimination were well-written and thought-provoking.  I had heard most of it before, but it was a good opportunity to review my own thoughts and biases regarding weight and obesity.  I’ve long been plagued by dislike of my own body (thanks, American media!), and the article was understating it when it said that weight bias and discrimination “may be” a more socially acceptable prejudice.

One thing that really struck a nerve was when it mentioned that people with obesity sometimes hide their embarrassment about size/weight with “difficult” behavior.  In other words, they lash out or behave somewhat inappropriately before they themselves can be hurt.  This makes sense to me.  Is there anywhere on earth that an obese person might feel threatened more than in a healthcare environment, that place where you have to stand on a scale and wait for the hammer of judgement to fall from your caregiver’s hands?

Regrettably, I admit to having developed a perception stereotype that overweight individuals are often dramatic and demanding, due to behavior that I have frequently witnessed.  To clarify, I didn’t see a fat person and think “Here comes the drama.”  It was more like a thought that occurred after the fireworks display.  It was like an epiphany – I have not been seeing dramatic people.  I have been seeing obese people who were causing a distraction from their weight, because they’ve been ill-treated by healthcare providers in the past.  I can’t say I blame them.  I’d much rather have somebody be put off by my loud mouth than the numbers on the scale.  Far better to be rejected or dismissed because of my actions, instead of for my body.  How hurtful to have your very self denigrated by someone to whom you’ve given you trust because of how you look or what a scale reads!

The lesson ended by tasking us as healthcare workers to challenge bias, which basically entails doing the same thing for obese people that we should do for all people who are different from us, whether it be skin color, ethnicity, or ableness of body.  We should not tolerate mockery of anyone for anything.  We would not make fun of a person with a chronic illness like heart disease, diabetes, or COPD.  You don’t hear anybody speaking harshly about the old man paralyzed in bed because he didn’t control his blood pressure and had a stroke.  You do hear uncaring words about the short lady who is as wide as she is tall, who can barely walk and whose feet are constantly swollen.

Obesity is obviously a chronic illness – should we not give those individuals the same respect as the ones who have had heart bypasses or strokes or who rely on oxygen at home?  The only difference is that the illness of the obese is easily recognized to the naked eye (or so we think).  Like racism, if no one ever questions obesity bias, it will never go away.  This is where the Fat Acceptance Movement is a positive force for change.  Whether we are fat or skinny or somewhere in between, we need to honor and uplift and support one another, not tear each other down.

I imagine that sometimes Mindi feels like a voice crying out in the wilderness, but there have been several notable voices like hers throughout history, and they changed the world.  She’s going to change the world, too.  She’s changing it every day, along with many other voices speaking in wisdom and love.  We were all put on this earth to make it a better place.  If I can learn to love and care for other people in spite of my own inner prejudices, then I will be a part of that better-made world.  I’ve made some great strides in the past, and now it’s time to take some more.  Luckily for me, there are awesome leaders to follow, like Well-Rounded Mama, and Ragen Chastain, and of course, Mindi Ferguson.

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