The patient across from me had been seeing the same primary care doctor for nine years. She weighed in the high 300s. She had high blood pressure, prediabetes, and knees that hurt every morning. I asked her what she’d been told about her weight over those nine years.
“Nothing,” she said. “He never brought it up.”
She wasn’t angry. She was a little embarrassed, as if she’d been keeping a secret that everyone in the room could see. Then she asked me a question that I’ve heard, in one form or another, more times than I can count: “If it was that serious, wouldn’t somebody have said something?”
I’m a bariatric and foregut surgeon. I’ve been doing this work in Miami for over twenty-five years, and this conversation is not unusual. I see it all the time. Patients in the high 300s who have had the same doctor for years. They’ve had their annual physicals. They’ve been treated for sinus infections, back pain, high cholesterol, and swollen ankles. Each of those problems was addressed, often very well. But the one condition driving most of them was never named.
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I want to be careful here, because this isn’t a story about bad doctors. The physicians caring for these patients are, by and large, good clinicians doing exactly what the visit asked of them. The patient came in for a cough, and the cough got treated. It was a yearly physical, so the exam was done, the labs were ordered, and the vaccines were updated. Everyone went on with their day.
That’s the problem. Obesity almost never shows up as the reason for the visit. It sits in the chart as a number, recorded at the start of every appointment, and then it sits there.
The data back this up. In one study of nearly 700,000 adults with obesity across 15 U.S. health systems, fewer than half had obesity documented as a diagnosis, even though their BMI was right there in the record. Among patients with the most severe obesity, almost one in three still had no diagnosis.
I understand why. Bringing up weight is uncomfortable. Visits are short. Many of us were trained at a time when the honest answer to “what can I do about it?” was “eat less and exercise more,” and we knew how well that worked. If you don’t have a good treatment to offer, it’s tempting not to raise the problem at all.
But that’s no longer true. Today we have medications that produce meaningful, sustained weight loss. We have endoscopic procedures. We have metabolic surgery, which can put type 2 diabetes into remission and extend life. The treatments have changed. Our habits haven’t caught up.
And the silence has a cost. By the time many of my patients reach me, they’ve spent a decade or more accumulating the consequences: diabetes that needs three medications, sleep apnea, fatty liver, joints that need replacing, reflux that’s damaged their esophagus. Some of them would have been excellent candidates for treatment years earlier, when it would have been simpler, safer, and more effective. Instead, they find me through a friend, a relative, or an internet search, not through a referral.
What strikes me most is how relieved patients are when someone finally names it. Not because they didn’t know. They knew. They live in their bodies every day. They’re relieved because someone is finally treating it as a medical problem rather than a personal failing nobody wants to mention. One patient told me, “I thought my doctor didn’t bring it up because he’d given up on me.” He hadn’t. He just never got around to it.
So here’s my ask to my colleagues, especially in primary care, who carry an impossible load already. Say the word. Put obesity on the problem list, the same way you would hypertension or diabetes. It takes ten seconds, and the evidence suggests that patients with a documented diagnosis are more likely to get a plan and more likely to lose weight.
Ask one question: “Would you like help with your weight?” Many patients will say yes. Some will say no, and that’s their right. But they should get the chance to answer.
And know where to send them. You don’t have to manage it all yourself. Comprehensive obesity programs offer everything from nutrition counseling and medication to endoscopic procedures and surgery. A referral isn’t a referral for surgery. It’s a referral for a conversation.
My patient in the high 300s did well. She lost more than a hundred pounds, came off her blood pressure medication, and her blood sugar is normal. At one of her follow-up visits, she told me she wished someone had said something ten years earlier. So do I.
The patient in this essay is a composite, with details changed to protect privacy.
Nestor de la Cruz-Muñoz is a bariatric, metabolic, and foregut surgeon with HCA Weight Management and Metabolic Wellness in Miami and medical director of bariatric and metabolic surgery at HCA Florida Mercy Hospital. Over more than 25 years, he has performed about 9,000 bariatric operations, and he runs a regional referral practice for complex reflux, hiatal hernia, and revisional foregut surgery.
He has published more than 50 peer-reviewed papers, directed a bariatric surgery fellowship for ten years, and served as principal investigator on six pivotal U.S. Food and Drug Administration trials of bariatric endoscopic devices. He is a proctor for Intuitive Surgical and GT Metabolic Solutions and a proctor and advisory council member for Levita Magnetics. He shares his work on his website, YouTube, and Instagram.
