You are about to see my patient in some acute setting. Maybe it’s the emergency department. Maybe it’s an ENT consult or ortho. In any case, you just met her. You do not have much of a relationship with her and are just evaluating one part of her health.

And yes, of her many comorbidities, you notice that she has a high BMI. Be her chief concern for back pain, apnea or a recurrent skin rash. It occurs to you that her weight may be contributing to her condition.

You decide you should let her know this and prepare to tell her to take off a few pounds. Maybe you even have a specific number in mind.

Don’t do it.

But wait! Her knee pain is made worse by her weight! So is her back pain! And her apnea!

You are correct. It plays a role. Don’t tell her to lose weight.

But health! She needs to know!

She knows. She’s bracing for the moment you bring it up.

Furthermore, not only is she aware, but she gets reminded every time she interacts with anyone in a medical setting. And sometimes even at a pharmacy, Or when she sees advertising. She gets a nudge at the grocery store as people not-so-secretly check the contents of her cart. People take phone pictures of her when she goes to the gym. Look at the fat lady! Isn’t she funny on the treadmill!?

Before many of these women became obese adults, they were obese children. Or, as one patient told me, “I was the kid who ran home crying.”

I have one patient who gets beaten with the BMI metric so frequently that she has remarked that if she got hit by a bus, the people in the ambulance would suggest she should lose weight.

We stand behind this institutional fat shaming on the premise that it’s our job to promote health. And we are correct. But it’s also our job to be helpful. And to do no harm.

I understand that it’s frustrating. Her back pain may not be caused by her weight, but it’s not doing her any favors. Same with her blood pressure. It’s hard to look at all 300 pounds of her without considering how much better she would feel at 150. And how many problems might be lost along with the inches.

But here is the reality of the evidence:

There is not a continuum of health where the very slender people are at one end without risk factors, and the obese are at the other. ” Fit or Fat” is a mythical binary. I know very unhealthy people who have a BMI of 23. I know very large people who run marathons or who work out five days a week.

Yet when you see my obese patient, you immediately think “inactive,” “lazy,” “disease,” “gluttony” — even though the evidence does not support this linear relationship of weight with morbidity. Obesity is a risk factor. It’s not a gas chamber. It’s really not possible to infer someone’s “health” or “fitness” from their waist circumference alone.

Yet when inclusive advertising uses images of larger models, the companies invariably hear backlash (often from “concerned moms”) that accepting fat is “promoting unhealthy lifestyle choices.”

It’s not a choice. Believe me. There are genetics involved, hard-to-reverse metabolic pathways, a whole lot of forces at play. And I promise you, if it were really a choice, she would choose something else — because weight bias is one of the few prejudices that are still normalized and defended by people who should know better.

People with weight are more likely to get passed over for jobs and to make less money for the jobs they do. They are more likely to be either explicitly or tacitly blamed for their illness. Obese children have scores on the Quality of Life Index similar to children undergoing chemotherapy.

Do you think we health care folks are different? Don’t be so sure. In one study, med students were assigned practice patients in a virtual setting. The “patient’s” chief concern was dyspnea. In the study, patients identified as obese were more likely to get told to lose weight as a first-line treatment versus non-obese patients, who were offered medication.

To frame it another way: Appropriate intervention for an acute problem was withheld in lieu of discussing weight, a chronic issue with a long-term solution.

Obese women are also less likely to seek screening for certain cancers because of fear of embarrassment in a health care setting and consequently have more advanced cancers at the time of presentation.

People choose to keep smoking because they gain weight when they quit. In other words, they fear death by emphysema less than they do than a life with obesity. One study of teenage girls reported that a majority would rather have a limb amputated than be fat.

So yeah — she knows.

Do I speak with my patient about her weight? Of course, I do. Because she wants to lose weight, and I have spent months or years developing a relationship with her, one in which she has learned that I’m not judging her, that I’m not criticizing her and that I honor the efforts she has made.

I have gently corrected her internalized bias when she calls herself “lazy” or “having no willpower” and reminded her of all the areas in which she has excelled as a mother, a professional, and a partner, and of all the ways she actually shows tremendous fortitude and discipline.

I also have evidence-based interventions for weight management and have the time and qualifications to help her make a real plan, not to just tell her “lose some weight” as a throwaway piece of advice — as though she could have done it last night if only someone had told her it was important! In fact, she has already lost 20 pounds this year, which she was feeling proud of until the nurse working her up at your triage area clucked and shook his head as he charted her vitals.

You are seeing her for a specific problem — possibly as a consultant. You’ll see her maybe once, maybe a few times. It is extremely unlikely that, after a lifetime of diets, fasts, therapy, insults and browbeating from her parents, her partner, her doctors, her gym teacher, and strangers on the internet, she is now going to make true, sustainable weight loss as a result of your putting in your two cents today.

So treat her chief concern. Accept her as she is today and help her problem solve. Be the doctor she doesn’t want to avoid, whose office she doesn’t leave in tears. Do you really want to help? Really want to be a hero? Try this out: Be the one person she sees today who sees the person beyond her BMI.

Merideth C. Norris is a family physician.

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