the HAES files: assumptions

by Health At Every Size® Blog

By Michelle May, M.D.

Not long after graduating from medical school, I was sitting in a hospital nurses’ station between two other residents, writing progress notes and orders on our patients. Suddenly a woman ran out of a patient’s room and over to the desk where we were sitting. She came right up to me and said, “Hurry! It’s an emergency!” As I stood up to help, she added, “My father needs a bed pan!” The other residents chuckled as I went in search of the urgently needed item, having no idea where to begin to look. I located a nurse to help her and returned to my work.

I have the highest respect for nurses so I wasn’t offended, but I found it telling that the daughter made an assumption based on a single external attribute: we were all in our twenties, all working on charts, all wearing scrubs with white coats, and all had stethoscopes around our necks, but I was the only woman. I told the other residents that perhaps she didn’t assume that I was a nurse who actually knew something, but perhaps she assumed that as a female, I would be the most friendly and helpful, and therefore, she was right!

While that story has brought many laughs at cocktail parties, it is a good example of an outdated assumption that led to a misdiagnosis and a brief delay in addressing her father’s problem. Any time we make assumptions about a person based on a single attribute, especially an external one, we are likely to make mistakes. You know the old saying: When you assume, you make an …

There is extensive data about the bias, prejudice, and discrimination that occur on the basis of a person’s size and the harm that causes. As destructive as it may be, this form of stigma, when called out, will be judged harshly by rational, fair people. However, it is the hidden assumptions by my generally well-meaning colleagues in the medical and wellness fields that I want to address here.

The erroneous assumption that thin equals healthy and fat equals unhealthy is still deeply entrenched in healthcare despite numerous studies, books, articles, and experts challenging the scientific basis of those assumptions. On the basis of a patient’s size alone (typically using BMI as their defense), smart, rational people justify their assumptions about that person’s health, risk factors, diet, physical activity, emotional state, compliance, and even character.

Even where correlation exists, it does not prove cause and effect—and certainly doesn’t accurately predict an individual’s behaviors or health. It is disrespectful, lazy, and even dangerous to assume one knows anything about a patient’s health, risk factors, or choices without taking a thorough history, performing a skilled physical exam, and ordering necessary labs and diagnostic studies. It is tantamount to guessing.

At best, these assumptions are a shortcut that damages the patient-clinician relationship. At worst, it is discrimination that has potentially serious medical consequences. Here just a few examples of errors made as a result of size assumptions.

  1. A medical assistant compliments a teenager on her weight loss. The teen has been restricting and purging.
  2. A 47 year old woman is told by her doctor that she needs to go on a diet and start exercising to lose some weight. The doctor neglected to ask her patient about her diet and exercise patterns. If she had, she would have known that her patient was vegan and had run five half marathons in the past two years.
  3. A 29 year old male with a BMI of 22 is complimented on his apparent good health. The doctor neglected to ask questions about his diet and exercise patterns. If he had, he would have discovered that his patient eats fast food eight to ten times a week, spends six or more hours a day playing video games and watching TV, and never exercises.
  4. A male with a BMI of 33 and a strong family history of premature cardiovascular disease is diagnosed with hypertension and is told to lose weight. He is not offered antihypertensives for over eight months despite persistently elevated blood pressure.
  5. A 27 year old obese woman comes into the emergency room with severe abdominal pain and delivers an infant into the toilet during the urine collection. She had been diagnosed with polycystic ovarian syndrome but a pregnancy test was not ordered on follow-up office visits despite continued amenorrhea.
  6. A woman being seen for an upper respiratory infection is lectured about her weight.
  7. A 62 year old male with severe knee pain and limited mobility due to osteoarthritis is told that he must lose 50 pounds before he will be considered for knee replacement surgery.
  8. Patients with a BMI over 25 are advised to lose weight—despite lack of evidence for the long term effectiveness of dieting. When unsuccessful at either losing weight or maintaining weight loss, the patients are perceived as non-compliant.

Sadly, there are many other examples of medical care that is adversely affected by size assumptions. (Please feel free to share your stories in the comments section below). While some of these examples are just bad medicine, these mistakes can be avoided if the clinician adopts the Health at Every Size® principles.  It boils down to the clinician asking themselves, “If I eliminated all of my assumptions based on this patient’s size, what would the appropriate questions, exam, diagnostic studies, recommendations, and treatment be?”

7 Comments to “the HAES files: assumptions”

  1. Thank you so much for this post! Working as a clinical dietitian, I see a lot of prejudice against patients with a high BMI. Unfortunately, people assume that this person is automatically unhealthy due to their weight; that his/her medical condition would go away if they just “stopped eating so much”; and that s/he is at fault for being at such a high weight. I’ve found that most people have not even considered the idea of “Health At Every Size” and almost automatically attribute negative characteristics to larger people.

    Along the same lines, if a person falls within the “normal” BMI range, the common assumption is that this patient eats healthy foods and exercises regularly–often not the case.

    We need to stop using weight or BMI as the sole indicator of health and look at what’s going on inside their body as well as in their social/psychological/spiritual sectors.

  2. This has happened to me. I have had a long term ‘female’ issue with bleeding and not once has any doctor and one gynaecologist I was sent to done any tests. I have been prescribed various medications from steroids, contraceptive pill, IUD. This has been happening for over 9 years. Heavy bleeding often lasting months, lots of pain, fatigue, anaemia etc.
    I am too fat be checked properly so they don’t even try. I am scared that I have a horrible cancer of something nasty. Mostly they say it is to do with my age at 47 but I was youger when it started. Also this is something fat women get.

    • Dear Jan,
      I went for years with very little bleeding. Then, wham!

      In my mid-40s, I began having a period that lasted all month, then the next, and the next.

      For a whopping 10 months, my primary doc (who happened to be a a fat-phobic “former” anorexic who considered herself recovered even though she had never received treatment: big mistake! She still had ED thinking) dismissed my non-stop bleeding (!) while spending most of our appointment time each month telling me to lose weight. She said the bleeding was just a “stage of life” issue, implying it was a symptom of pre-menopause.

      Apparently, the symptom manuals don’t put “possible symptom of endometrial cancer” right at the top, where it should be. This is the most common form of gynecological cancer.

      Finally, pals on an internet health board responded to me about the bleeding, telling me to get to an gyn immediately. I demanded a referral from my doc the next day. Three months later, I finally was allowed to see a gyn. When I told her I’d been bleeding massively, non-stop, for 13 months, she went ghost-white, and said, “We need to biopsy you immediately.”

      It turns out *any* bleeding between periods is a symptom of *possible* endometrial cancer.

      It’s actually a symptom of endometrial hyperplasia, or overgrowth of the the endometrial lining. There are 4 diagnosed stages of severity of it. The 3rd stage is considered pre-cancer, the 4th stage is cancer. In stages 1-3, there is a very high rate of it never becoming cancer, with the use of high-dose progesterone. Google around for info.

      I was diagnosed with stage 3, pre-cancer. Another biopsy a few months later revealed cancer. I fought tooth and nail against hysterectomy, because I’d read that hysterectomy is so over-done, and I value each and every organ! as part of our natural bodies, which I believe are more complex than scientists will ever fully understand.

      However, I spent months looking into alternatives to hysterectomy, including acupuncture, Women-to-Women’s site (I called them and they said their hormonal, dietary, and supplements program will not cure endom. cancer), HERS (an anti-hysterectomy organization), and others, and finally even docs with web sites speaking out against hysterectomy told me endometrial cancer is one of the few very good reasons for hysterectomy. That’s because it has such a high likelihood of cure of the cancer, a cancer which would otherwise be fatal w/o hysterectomy.

      So I had the hysterectomy 4 months after the cancer was found on biopsy. Fortunately, it was caught in time, while still Stage 1A, Grade 1. It was less than half way through the uterine wall, (Stage 1A) meaning I didn’t require chemo or radiation, and have a 95-98% chance of “never seeing this cancer again” and full life-expectancy, according to my surgeon, a gynecological oncologist.

      Endometrial hyperplasia is more likely among plus-size women. My surgeon said it is because the increased number of fat cells (which she says produce estrogen) increase our estrogen levels.

      It is especially important for all plus-size women to get in aerobic exercise daily or regularly (Kate O’Hanlan, my surgeon, recommends 4x/week) because it helps the cells secrete estrogen into the blood stream, and then be able to flow out of the body.

      On that surgeon’s web site (Kate O’Hanlan) she recommends weight loss! I tried to explain to her that weight loss attempts just cause weight gain and disordered eating, but she just wouldn’t have any of it. What a shame. Here she is, operating on all these women with weight gain that many of us experienced as a *direct result* of weight loss attempts, which in turn greatly increases the likelihood of endometrial (uterine) cancer!

      She should stop recommending weight loss and advocate HAES, so that her clients don’t keep weight cycling and gaining, risking increased estrogen levels and recurrence of cancer.

      Bottom line: please get to a GYN immediately and get biopsied. Don’t believe you can’t be checked out because of your size (I was told similar from my primary care physician.) A gyn will do it.

  3. As a soon to be qualified Dietitian it bothers me much that we have such a weight focused culture that permeates into what could otherwise be sound medicine and healthcare. That as scientist we fail to apply scientific method in the case of weight. I am however mildly glad that in our classes the BMI is not touted as a tool of assessment in and of itself. There are many assumptions that come into effect when using the BMI that any practitioner or supposed health professional that does not take these into account reveals their ignorance but I would also suggest their incompetence. Great blog Michelle and so thankful there are MD’s who do get this and are willing to speak up.

  4. i am death fat and my dr told me that if i reach over 300lbs i could not get the mri i needed to check my lungs to treat my sarcoidosis. also my mother in law was told she needed to lose weight before she could be treated for cancer..but the cancer got worse and they are now treating her…but not before her through months of we cant treat you b/c it will be too invasive

  5. Elaine My group health coverage expired and was not portable. I have sought individual health insurance and been turned down twice for “unfavorable height to weight ratio”. So now, I am with out health insurance and I cannot apply to the high risk pool until I have been with out insurance for 6 months. When the 6 month wait period is over, the monthly premium will be over $700 per month. Since I am currently unemployed and our family income cannot sustain that amount, it is out of the question. Meanwhile, I am healthy, exercise regularly, take no medications, and find myself without basic preventive care and live in fear of what may happen should I get injured or have an unexpected event that requires health care. I think the insurance companies are discriminating against people with high BMI without taking other factors into consideration.

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