Defining Wellness Disadvantage

Wellness Disadvantage:

A complex set of interrelated factors that combine to confer a lesser likelihood of objective health and wellness for a given patient.

I was having lunch with a fellow healthcare professional when they asked me if I remembered how much a certain patient weighed. It was at an inpatient facility, so weight was a standard metric the appeared at the top of most of the documentation. I replied that I thought it was around 450 pounds. To this the colleague replied, “Is that all? I really thought it would be more.” I had a feeling I knew where the conversation was headed and made a neutral comment about height and laying in bed making it difficult to guess at patient weights. A moment passed and then came, “I just don’t understand how a person lets that happen.”

2006 

When I first started physical therapy school in 2016, I felt very intimidated by my classmates. Most healthcare providers use BMI as a shorthand method to define a person’s size and, often, relative health. A BMI of 25 or greater is considered overweight, but in defiance of U.S. obesity trends, perhaps five or six of the 42 people in my class were clinically overweight.

By contrast, I was class III morbidly obese and the heaviest I had ever been, despite having successfully lost over 100 pounds ten years prior. During that decade of seemingly relentless weigh gain, I moved to a new state, quit smoking, lost my father, switched jobs twice, and went back to school full time to get a professional doctorate.

Both despite and because of changes and progress in other areas, I had put on over a hundred pounds since my personal fitness peak at 26. 

Of course, it wasn't 100 pounds overnight. The first time I decided I needed to do something about my growing waistline in 2008, I was only up by about 20 pounds. Between 2008 and starting PT school in 2016, I tried diets, fasting, running, consulted three different doctors and two psychologists, and went through one prolonged but ultimately unsuccessful bout of attempting to accept myself as I was -- but nothing made a difference as year after year my weight slowly climbed. Expert after expert encouraged me to lose weight as a seeming panacea for all my problems, but after all the time and energy I had already dedicated to simply trying to stop gaining weight, I felt deeply hopeless.

2016

During that first, worst semester of PT school in the August heat of the Midwest, I became soaked in sweat walking to classes from the parking garage. My ankles had started to swell every day and I couldn’t wear most of my shoes. Everything from finding a desk that I could fit inside to completing the functional movement screenings during labs to walking from class to class was hard for me, and the consensus was that is was because I was unnecessarily carrying at least 100 pounds more, on average, than anyone else.

As I watched my classmates going through the same brutally long days of professional school -- all of them young, most of them thin, many of whom ran for miles every day, and one of whom had been at Olympic training camp as a triathlete only months before -- I didn’t resent my classmates for their athleticism. I knew they had earned it with hard work and discipline that I could only goggle at --but it was impossible to ignore that as far as getting through my day-to-day was concerned, I was at a serious disadvantage.

Post-class, pre-workout swelling lines

During winter break at the end of 2016, I decided that despite how impossible it seemed I simply had to do something about my health. Though I felt deeply ambivalent about believing that my weight was the origin rather than a symptom of all my problems, I committed to losing weight mainly because it was the only solution to my health problems on offer. I joined a nearby fitness facility where one of my more athletically-inclined classmates worked out. I downloaded MyFitnessPal and started tracking calories. I made a calendar to track the days I exercised and met my calorie goal. I set a goal to drink a half ounce of water for every pound I weighed and worked up to it until it felt normal. I took unflattering, mean-girl selfies at the gym and made before/after Pic-Collages when I hit milestones. I put pictures of my thinner self on the refrigerator and in the edges of all the mirrors.

I ground out 25 pounds of weight loss like my life depended on it, because by then it felt like it did.

After I started working out, my feet and ankles were no longer content to simply swell every day, and instead they ached constantly, deep in my bones, keeping me awake at night. Despite of my weight loss, my blood pressure had recently climbed to 140/90 at rest and my blood sugar still hovered at it’s elevated, pre-diabetic A1C of 5.6. My face was bright red any time I was moving or the slightest bit nervous, and my skin had started to break out unpredictably. I was getting discouraged, but felt determined to keep trying. 

Fortunately, in the summer of 2017, I got a new primary care provider and was finally diagnosed with two common vitamin deficiencies – B12 and D3 -- that were causing my most painful, debilitating, and frightening symptoms – including two falls I could not explain except to say that I had been walking and then suddenly falling.

These problems might have eventually rendered me unable to walk if my physician hadn’t taken the time to listen to me and try to understand why I felt so poorly at such a young age. 

Now I take a few vitamins every morning and I feel like a normal person again. I haven’t lost all the weight yet, but I’m down 45 pounds overall and still working on it. I'm happy I lost it, but I'm still mad so many people I trusted to know better tried to tell me that it was the cause of all my problems.

Though my weight was a pretty obvious source of unhappiness and stress on my body, losing it never would have made me feel any better because it wasn’t the source of the problem.  

Thanks to all the calorie-counting, I have a pretty solid answer to the question "How did this happen?" when it comes to chronic, avoidable, and grossly neglected health problems; because I once wondered how on earth I let it happen to myself. Though the difficulties I faced in locating an empathetic health care provider were an enormous factor in my long illness, I still spent a very long time blaming myself and my own lack of self-control. Once, in an effort to quantify my own seeming negligence in managing my weight, I once calculated how many calories I would have had to consume over the span of a decade in order to gain a hundred pounds.

100 pounds of weight gain
x
3500 calories
=
350,000 calories

350,000 calories
/
10 years
=
35,000 calories per year

35,000 calories
/
365 days
=
95.9 calories per day

96 extra calories per day is all it would take. 96 calories – less than a single pat of butter – can turn into 100 pounds and morbid obesity. As I watched my colleague shake their head, baffled at how a 450 pound patient comes to be, I had to make a decision about what I would say. How does one communicate this complicated concept in an empathetic way?

How can I help my fellow healthcare practitioners understand and help morbidly obese patients when so often the conversation stops with that shake of the head?

I took a few moments to talk to my colleague about how difficult it can be as an obese patient to get help with healthcare problems when admonishments to lose weight so often replace medical advice long before they reach an inpatient facility. I did not say anything about what I silently suspected was underlying disdain and disgust toward the patient (and thereby, unbeknownst to them, myself). I knew they were a professional and would never overtly show those feelings to a vulnerable patient. But what about the messages those attitudes might communicate to a vulnerable patient nonetheless?

Even when said silently to oneself, to ask “How did this happen?” without seeking any specific answer is an admission that one doesn't really want to know. I have heard variations of that question on the lips of many and more types of healthcare professionals than I care to discuss, and almost all of them are directed toward patient populations whom I view as disadvantaged. From a provider standpoint, patients with morbid obesity, patients who smoke, patients with metabolic disorders like diabetes,  and those who admit to alcohol and drug abuse all appear to be ignoring obvious solutions to their health problems, and healthcare professionals often can’t even guess why because they can’t relate.

I can relate because I’ve been there. I’ve been morbidly obese. I was a smoker for eleven years. I was pre-diabetic. I grew up in a rural area with limited access to healthcare. I know the answer. 

It happens because a 60 billion dollar weight loss industry can buy enough influence to ensure that a whole lot of people with no reason or experience to tell them otherwise believe that maintaining a healthy weight is something that is hard to do and requires them to do odd, difficult, expensive, and often painful things.

Not everyone grows up with the advantage of a mother who is there when they get out of school to give them a ride to soccer practice or a snack or help with their homework. Not everyone lives in a smoke-free home or knows how it feels to breathe clean, clear air every day. Not everyone has easy access to modern healthcare facilities, safe schools, or clean drinking water. Not everyone can just lace up their shoes and go for a run in their own neighborhood. Personal wealth, access to support systems, geography, ability, family history, representation, race, religion, language, nationality, gender, class -- these are the factors that lead to some people having an advantage when it comes to wellness, and some having a disadvantage.

The differences that lead to health inequity and wellness disadvantage aren’t insurmountable. Healthcare providers want to help their patients be healthier, and patients want to feel better and be able to do more with their lives. If patients and practitioners alike recognize the deep complexity of the differences between well and the unwell, we can begin to work together to ensure everyone has an equal chance at health and happiness.