“It’s getting worse,” my patient lamented. She sat motionless on the exam table, but her sounded like she was trying to catch her breath. Her hips jutted out over the sides of the narrow bed. “My bladder is a mess,” she said. I had seen her in the past for urinary incontinence, and her BMI was not helping her situation: it charted at 57 this morning, whereas at the last visit 6 months ago, it was 50.
I nodded empathetically. She had had a tough year, I understood, with family losses and mental health struggles, but her weight was likely significantly contributing to her incontinence. The human body did not evolve to withhold excess amounts of weight, and the bladder is no exception to this concept.
I would likely not be the first doctor to recommend that this particular patient lose weight. But I have found over recent years that patients can react negatively to weight loss recommendations. When I mention it as a possible treatment option for their leakage, they sometimes wince, as if I have slapped them. They tend to remind me that they know, they’ve heard it before, they’re working on it. It can feel like a net negative interaction: nothing new has been taught to the patient, and no sense of good will or care has been generated.
However, it’s our job as clinicians to counsel our obese patients to lose weight, as we are all keenly aware of the dangers and pervasiveness of the obesity epidemic. The U.S. is one of the heaviest developed nations in the world. According to the CDC, approximately 40% of American adults were obese in the year 2023 (defined as BMI greater than 30). Furthermore, nearly 10% of American adults are currently severely obese (defined as BMI greater than 40), a number that has increased over the last 10 years. The myriad health risks associated with obesity have been thoroughly documented in the literature. Obesity is associated with diabetes mellitus, hypertension, hyperlipidemia, heart disease, and stroke, and various cancers, among various other chronic medical conditions. Obese women may suffer from fertility and pregnancy complications, and obese men may struggle with erectile dysfunction. Plain and simple, obesity is bad for the human body.
Regardless of our knowledge base, though, barriers may exist for those of us who aim to counsel obese patients on the importance of weight loss. The concept of body positivity is popular among Gen Z and on social media, and has taught the public to embrace their bodies, no matter the size or shape. Additionally, because many clinicians rely heavily on Google reviews and patient satisfaction metrics to thrive in their practices, we have to worry about compromising our reputations by appearing overly critical of patients.
Thus, in today’s society, what is the role of the medical community and medical advice when it comes to obesity? When we discuss obesity and weight loss, patients may feel as though they are being “fat shamed,” no matter how gently the topic is broached and discussed. But is it fat shaming, or is it sound medical advice? Can patients tell the difference? Do they even care, when the bottom line is, they hear something negative from another human being and it hurts their self-esteem, even if it’s delivered in the kindest, most benign manner?
I personally think that it is still essential that we remind our patients of the dangers of obesity. There are various ways in which we can do this as a profession. Primarily, we should all encourage healthier living concepts for parents of young children. Similar to adult-based data, childhood obesity rates are on the rise: as of 2020, nearly 20% of children met obesity criteria, and obesity rates have tripled since the 1970s. Certainly, obese children can grow into adults with a normal BMI; however, with the current prevalence of ultra-processed foods and sedentary behaviors, it’s possible that these habits will develop in childhood and continue well into adulthood.
Additionally, we should reiterate the various health benefits of weight loss for our obese patients. We should remind them that many chronic health conditions that overlap with obesity can vastly improve or even resolve with weight loss. As an example, in the case of incontinence, even a 10% weight loss can significantly reduce the amount of daily leakage episodes a person may experience.
Finally, we should simply continue to counsel obese patients on their weight, whether they wish to heed our advice, or not. We freely disclose all other diagnoses; why should we tiptoe around obesity? Presumably, patients come to the doctor for advice from an appropriately trained medical expert. We shouldn’t feel as though we can’t be honest with patients simply because of their body habitus.
Modern medicine has changed immensely over recent years. The internet and its endless sources of misinformation have affected the public’s ability to interpret sound medical advice, and insurance companies have blocked us from ordering tests and medications that we feel are indicated. But we cannot give up the most important tool that we have at our disposal: our voice. It is our duty to continue to employ medical knowledge in order to educate the public, and we should not let yet another aspect of our profession be taken. We must continue to speak up against obesity, and maybe for some patients, it will be viewed as caregiving rather than fat shaming.
Fara Bellows is a general urologist in White Plains, New York. She can be found on TikTok @FaraBellowsMD.
Image by Alphavector / Shutterstock
