Commentary

A weighty patient history


 

Mrs. B makes her entrance in a peacock-inspired dress and a hat so flashy it would make Carmen Miranda envious. Decidedly middle-aged with a figure that’s distinctly Rubenesque, my patient makes no bones about her weight: “I’m fat, doctor, and I like my body the way it is.”

We begin with a bit of banter about her latest flamboyant outfit, her husband—a ne’er-do-well to whom she has been married for at least 40 years—and the dwindling value of our retirement plans. Then we go through her current problems: knee pain secondary to osteoarthritis, blood sugar and blood pressure that remain over 200, fatigue, and stress precipitated by her niece, who’s pregnant at 15.

“You know, I think you would really feel better if you lost just a few pounds,” I venture.

“Doctor, I’ve been fat since I was born, and there’s no turning back now,” she retorts.

Mrs. B has made it clear that she’s through with the litany of unsuccessful diets, failed exercise programs, and ineffective weight-loss medications, and she’s not about to have bariatric surgery. If there were a stage of change before precontemplation, Mrs. B would be its exemplar.

I find it hard to disagree.

While I would be the first to admit to the ravages of obesity and our growing national epidemic, I am not convinced that we have effective interventions to offer the majority of our overweight patients. I would venture that many patients would gain more self-acceptance and a greater sense of well-being if we acknowledged that there is little high-quality evidence that diet, exercise, and counseling lead to long-term weight control. Promoting a positive body image and managing other risk factors, I suspect, would be a better approach.

Still, as I add another antihypertensive and increase my patient’s dosage of Lantus, I negotiate yet another exercise plan. We part with encouraging words. Mrs. B promises to take her medications as prescribed and watch her diet during family gatherings; I challenge her to wear a “church hat” on her next visit. Unabashedly flirting now, Mrs. B flashes me a big smile. “You know I’d do anything for you, doc.”

Smiling back, I wave good-bye and turn to my next patient.

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