Talking about weight isn’t easy. Case in point, I was scheduled to perform five back-to-back fluoroscopically guided procedures. This was not unusual, but all my scheduled patients happened to be seriously overweight. Excess fat and skin made it difficult to see my needles during the interventional procedures. Therefore, what was ordinarily a routine procedure suddenly became complex and challenging.

I am an interventional pain management physician. For many of my patients, the underlying cause of their medical conditions or a major contributing factor is their obesity. When I encounter these overweight patients, my first instinct is to want to counsel them about nutrition and wellness. I want to warn them that their excess weight could lead to premature death and lower quality of life. I instinctively want to explain to them that the procedures they are asking me to complete are likely to be more challenging and riskier due to their obesity.

Of course, it is not that simple and shouldn’t be. For one, I am not comfortable being blunt with patients about weight problems. I always want to be sensitive to how excess weight makes people feel. In most cases, it is natural to communicate with a patient using accepted medical terms. However, when you are trying to focus on the person and not just the condition, terms like obesity can be offensive and be received with many unintended connotations.

Our society can be cruel at times with this issue. I have been overweight and suffered a lot of pain and anxiety, including bullying. I want to avoid causing my patients any pain. This requires removing some of the directness of orthodox clinical terms with language that will be better received.

Nevertheless, on the other hand, are we missing an opportunity to help by failing to be direct? Do we owe our patients a sense of urgency around this topic? In not addressing this condition head-on, why do we avoid this specific medical issue when delivering care?

Interestingly, there are other behaviors — aggravated conditions, such as smoking and lung disease — where it seems easier to approach patients with much more bluntness. Again, this difference seems to be ingrained in societal perceptions and judgments. The psychological backdrop is particularly relevant in dealing with this topic. Most people do not lose weight to make medical procedures easier for their doctors. The media promotes losing weight principally around the allure of vanity: e.g., slim, beautiful models. In modern society, overall health is a secondary benefit to weight loss. Correctly promoting a healthy self-image has, at times, the unintended consequence that remaining in an unhealthy weight condition is OK.

Messaging that promotes complacency in this area under the guise of self-acceptance may exacerbate our societal crises created by excess weight and unhealthy eating habits. Hopefully, focusing more on comprehensive studies describing the disastrous health consequences of obesity may motivate more people to achieve and maintain appropriate body weight for the right reason. Still, conscious dieters who are already aware that the real purpose of losing weight is to promote health and longevity may become frustrated when they have difficulty shedding those extra pounds. With little to no success, yo-yo dieting becomes a part of their lives as they try various diets. It is incumbent on doctors involved in their care to discern between obese patients trying to address their condition but having a challenging time from those that choose to disregard or misunderstand the consequences of long-term obesity. Both attitudes should be addressed but in fundamentally different ways. Directness may have a larger role to play in the latter.

Most people do not understand that obesity is often a symptom of an underlying condition, physical or psychological. This includes many who work in the health community. At times, an approach to recommend losing weight with a health focus as a primary aim may be placing the cart before the horse. A weight problem’s origin or root cause must be ascertained and dealt with first.

For instance, obese people are less likely to exercise than those already within their target weight. Understanding and addressing each patient’s lack of motivation is essential. Every person is different. As mentioned earlier, the physical fitness level of the metabolic-healthy obese patient versus the physical fitness status of the metabolic-unhealthy obese patient needs to be considered before drawing any conclusions or recommending a course of action. Studies show that you do not need to be thin to reap the health benefits of exercise. Based on my experience with wellness patients, waist circumference matters the most.

As mentioned earlier, a slim waistline protects you against diabetes and heart disease. Being overweight can feel awful, especially in modern society. For some, it can be the worst thing imaginable. It can immobilize the individual, both physically and emotionally. The emotional reactions can be disproportionate and perpetuate the vicious cycle of poor physical activity and weight gain, leading to poor health. Many of these poor health consequence associated with obesity involves higher risks during medical procedures. Given the objective and scientific consequences of obesity, I would argue that there is a need to change our conversations with obese patients. There will always be an expectation to show sensitivity, empathy, and caring. But there is also a need to ensure that conversations are clear, unequivocal, and direct in understanding what is at stake concerning short-term and long-term health, longevity, and overall quality of life. Over-focusing on the potential adverse reaction to the message is not fair to the patient and is a dereliction of duty.

Fostering a caring and strong relationship with each patient and credibility through the consistency of messaging will always help deliver “tough love” medical advice. Each patient is unique and, therefore, should be treated accordingly. This aspect of medical practice represents more art than science and is a skill worth developing.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

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