Sometimes you need to say it

When I present patients and reach the “body habitus” part of the presentation, I always become a little awkward. I’m acutely aware of body-image issues and I never want to be the cause of a patient’s emotional distress. It has happened a few times that a registrar admonished me, “You need to say it. You need to counsel your patients that they are overweight.”

That’s hard when you believe in “being nice”.

On my rural rotation, I saw a classic example of a case where it should have been said long ago.

A grade-school girl presented to us with clear-cut Cushing’s Disease. She was a preteen of average height, weighing in at 100kg (220lb). She came to hospital not because of her weight, but because she could no longer walk due to proximal muscle weakness.

Thing is, she wasn’t just a little chubby. She wasn’t on that line where some practitioners would argue that if her diet was healthy she was actually okay. It was not a case like that. It was a clear case of being morbidly obese, and nobody had ever said this to her mother (her mother and entire family, by the way, do not have a similar build).

Essentially what we think happened was that her previous doctors were so caught up in being culturally appropriate, because in many African cultures being bigger is better; a sign of wealth and health, that they never mentioned it to the mother. And by purposefully overlooking her weight, they overlooked the other danger signs.

I should probably mention that I’m not judging her previous doctors. It’s not an easy diagnosis to make when your time per patient is limited. But it has been a valuable teaching point for me.

Once the clinicians discussed the matter with mom and daughter, they recognised truth in it. The mom actually cried. She had just never thought something was wrong. We can scratch our heads about that if we really want to, but the point is that by being willing to address a sensitive issue, the clinicians opened the door to investigating the underlying matter and the girl’s myriad other health problems.

Disclaimer: I am aware that there is a lot of debate about BMI and weight in healthcare, and I support the notion that healthcare workers should not unduly contribute to the difficulty many men and women have in terms of body image. I encourage the research being done in this field, but that is not what this post is about. 


  1. TrishaDM says:

    I struggle with that part of the presentation too! I have friends that struggle with weight and it is totally all about how you approach the topic. Often people know weight is an issue, but we don’t consistently learn how to address it in a sensitive but useful way.

    1. Exactly! Like, it’s no use telling someone they are overweight and not offering help in finding a solution, right? And sometimes with limited consultation time doctors don’t seem to have the time to do that, which is a damn shame.

  2. Thank you for this. I am experiencing for the first time in my life obesity issues not due to overeating, but due to a hereditary disease. In fact, my nutritionist says I do not even eat enough; therefore, my metabolism isn’t even working. This weighs heavily on me as I am 100 lbs overweight and seriously it was like one day I am the weight I am suppose to be and the next day I am 80 lbs overweight. For years they could not tell me why and then when I had surgery they found the culprit. So people see you as fat and think that “wow that person is fat” but they don’t think that maybe someone may have underlying problem. I mean no one wants to be obese. It causes a slew of problems and no one wants other people pointing out that they are obese, like they didn’t know this information until “you” pointed it out to them. I am not talking about doctors. I am talk about your average run of the mill people. But I am glad that you addressed this issue.

    1. Thanks for your comment. I wish you the best of luck with your health concerns at the moment. It is never pleasant to be in this situation.

  3. I used to have this problem, to some degree, when I taught elementary school in a low socioeconomic area with things like hygiene and clean clothes. It’s never comfortable.

    1. Oh wow, I can imagine. Especially in that situation where one might be telling someone to give their child clean clothes when they can barely keep their household fed.

  4. Nancy Ackelson says:

    Hi Mariechen,
    You impress me every single time with your ability to be sensitive and thoughtful and compassionate at the same time that you are also able to be straightforward and candid and direct. Huge strengths for your profession from which all of your patients will benefit. Good on you!

    1. Nancy,
      thank you so much. I think I still fail in many aspects but I am aware of the need and so I will keep trying!

  5. anne says:

    Beauitifully put

  6. Nancy says:

    YOU are so welcome! You are awesome and I have no doubt that you will continue to be so!!!!!!

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