“Why don’t doctors do something about obesity?” This is the puzzled question from a friend that plays on my mind after a recent encounter with a patient that proves unpredictably upsetting.
The patient needs chemotherapy for her newly diagnosed cancer and is understandably terrified. We have spoken at length and now that she is more settled, I tell her I’ll do her paperwork.
“What’s your weight?” I ask, staring at my computer.
Chemotherapy prescribing is based on weight and height unless the patient is morbidly obese, in which case modifications are needed to mitigate toxicity. Accepting the temporary silence, I check the guidelines. I make a mental note that one day, I will need to talk to her about safe and gradual weight loss that will have an impact on not only cancer but also multiple health outcomes.
The silence persists, so I repeat,
“Do you know your weight?”
I turn to her and am startled to see her dissolving in tears.
“Please don’t be angry but in the 30 years of our marriage, my husband has never known my weight, and he has loved me just the way I am. I’m not afraid that he will leave, but I can’t bear to tell him how much I weigh.”
He blinks and nods. And I am mortified. Totally stumped that a mere chemotherapy prescription order, the most automatic thing I do, could unravel the very things my new patient will need to rely on to tackle cancer – love and trust and marriage. Amazed (and knowing I shouldn’t be) that amid all the pacts we make with our spouse and all the secrets we keep, one could be the reading on the bathroom scales. Feeling like I have a split second of grace, I say, “That’s really sweet, and I am sorry to have put you on the spot. But you and I can take a walk to the scales and he can stay here.”
Her grateful grasp of my extended hand says it all. Needless to add, all my good intentions about discussing her weight perish right there. Better an obese patient, I console myself, than an unhappy one.
When she leaves, I find myself musing about the ubiquitous problem of weight. Once a problem of the rich world, the epidemic now sweeps the globe and takes over countries better known for their food shortage. More than two-thirds of Australians, British and Americans have long been overweight or obese but as new data shows Latin America, Indonesia, India and China are catching up. So are Saudi Arabia, Bhutan, Mali, Algeria and Egypt and scores of other nations you wouldn’t guess. Which country has the fastest growing rate of adult obesity in the world? Burkina Faso. (The lowest is Vietnam.) Not only are we getting heavier, we are leading our children into danger even as we know that the best way of maintaining a healthy weight is to prevent excessive gain in the first place.
Obesity is associated with an expanding list of chronic health problems, disability and early mortality so it goes to reason that doctors should work harder at preventing obesity instead of just battling its consequences. But the problem is patients don’t put on weight in the doctor’s office. Unlike, say, the opioid epidemic, where our prescribing habits warrant scrutiny, we are largely powerless over the easy availability of cheap junk foods, the free soft-drink refills, intense advertising to children, increased urbanisation encroaching on open spaces and the daily changing myths about the “best” way to lose weight.
It’s sobering to note that while some governments have intervened to alter the food environment, no country has yet achieved population level success.
The wealthy obese can (partly) mitigate their burden of disease with better drugs for cardiovascular disease but not so their counterparts in the developing world. As with other global epidemics, poorer countries are worse off. The warnings keep piling in but no one is listening. And amid all the noise, the simple message of “eat less, move more”, seems, well, too simple.
But I confess there is another reason why doctors may not want to touch the thorny matter of weight. Our patients are overweight but so are we. It has been shown that doctors judge their obese patients as awkward or unattractive but in fact, our patients are judging us too, which is hardly a surprising revelation about human nature.
Overweight doctors are much less likely to discuss weight loss with patients because they feel hypocritical doing so. Defensive patients tell doctors to heed their own advice before seeking to untangle their problems and indeed, there are doctors who have done just that. Some have been successful and have felt more confident discussing the issue with patients. Some have not been so unsuccessful but have turned the experience into a talking point with their patients.
Yes, the problem of obesity stares me, and my colleagues, in the eye. But what we also get to see up close is that weight is so deeply entwined with food, emotion and identity that it’s impossible to tackle it from a purely medical angle. We will need a multipronged approach that starts with basic health literacy and we don’t have this at present.
Another patient is a retiree who has her hair done and wears her pearls before her annual visit with me.
“And darling, was it a boy or a girl? I was so excited by that tiny bump last year.”
There was a time when such misassumptions irked me but now, I have lost count, so I am happy to use humour.
“The baby actually came out many years ago. But before he reaches high school, you and I must talk about how I lost the bump.”
You can hear a pin drop in the room.
“I guess,” she winces. “If you will still be my doctor.”
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