Because "FAT" is a Four-Letter Word
For people carrying extra pounds, the word "fat" is often like the elephant in the room that everyone is pretending not to notice. In the case of medicine, this is a very bad thing. The fact is, being overweight (and I won't get mired down in the definition of overweight vs obese vs morbidly obese or whether or not BMI is an appropriate measurement instrument) is a medical condition. It is a significant risk factor for everything from heart disease to pregnancy complications. But no one wants to talk about it. And worse yet, people get offended when their doctor brings it up.
I have been known to spend time on a certain internet message board or two... the majority of the women on these boards are 20-35 years old and married, and are looking to start a family. A surprising number of those (as I mentioned in my last post) have had trouble conceiving. Of course, every healthy young person who wants to have a baby and can't get pregnant in a reasonable amount of time wants to know why. Fair enough.
What I'm seeing, though, are women who are coming back from their doctor's office steaming mad. Why? Because the doctor told them to lose weight, and in some cases, refused to perform invasive investigations until they did. They call their doctors 'insensitive', and 'ignorant' and insist that they know many women heavier than themselves who have gotten pregnant without problems. They demand hysterosalpingographs, exploratory laparoscopy and want to be put on drugs like Clomid. And they're very angry at the suggestion that their weight might be a contributing factor.
Part of the problem is that when someone, even a medical professional, suggests that someone is overweight (I prefer to use the terminology "carrying a few extra pounds"), women don't hear it as medical advice. It doesn't come out the same as 'your cholesterol is high' or 'your thyroid is low'. It comes out wrapped in a lifetime of insecurities and issues. It suddenly comes out in the voice of your mother, telling you at 6 years old that your sundress is 'slimming'. It comes out in the voice of your father, asking you at the age of 15 if you'd put on weight recently. If comes out in the voice of your ex-boyfriend, telling you that you'd have a 'rockin' bikini body' if you just lost a few more pounds. Worst of all, it comes out in the voice that has always shouted in the back of your head that you'd be prettier/happier/more successful if you were skinny. It's hard to separate the 'issue' from the 'issues'. And so the suggestion that losing weight is integral to your health comes out as a social judgement, rather than as medical advice.
Which is too bad. Medical research has shown that patients are more likely to lose weight if their doctor addresses the issue and supports their efforts. And in the situation I mentioned of trying to conceive, a weight loss of as little as 10% of your body weight may be enough to overcome the Unopposed Estrogen Syndrome that is most likely to be the root cause of anovulatory cycles and failure to conceive in women with a BMI over 30. And even if the problem is NOT as straightforward as losing a few pounds, wouldn't you want to try that before resorting to invasive measures that carry risks and side effects?
I wonder-- is the reluctance to accept this advice stemming from the fact that it suggests that it's the womans own fault that she can't conceive? Or is it even deeper than that? Is it because she feels that answer is "too easy" and wants medical intervention to feel that something is actually being done?
In a roundabout way, this leads us to the issue of PCOS (polycystic ovarian syndrome), a complex problem which encompasses benign ovarian cysts, irregular menstrual cycles and insulin resistance. More women are being diagnosed with this today than ever before. It's still unclear if being overweight predisposes you to developing PCOS or if PCOS causes obesity secondary to insulin resistance. But it's the same insulin resistance that is a precursor to adult-onset diabetes, a condition that is known to be caused in part by being overweight. Which came first... Chicken? Egg?
I'll get off my soapbox now. But I'm always hesitant to address the issue of weight with a patient, unless it's directly related to their reason for coming into the office (high cholesterol, knee trouble, diabetes). Maybe I'll get braver as time goes on, because I fear that continuing to ignore the elephant in the room isn't doing my patient any favours.