Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Has your weight changed recently?

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2301 (Published 21 September 2021) Cite this as: BMJ 2021;374:n2301
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on Twitter: @HelenRSalisbury

As doctors, we ask questions about weight many times a day. We may ask because we’re worried about fluid retention in heart failure, or we may be thinking about causes of increased breathlessness or blood pressure. We may be concerned about the possible onset of diabetes, thyroid disease, severe depression, or undiagnosed malignancy. I often find myself explaining to patients that, in this specific circumstance—where we want to rule out serious disease—the fact that they haven’t lost weight is a good thing, although more generally it would be beneficial for their health if they did.

Talking about weight isn’t always easy because the topic is freighted with so much emotion. For some patients, negative thoughts about their body, and questions about what they should and shouldn’t eat, dominate every waking hour. For many others the issue of weight, although not so all consuming, is still a source of shame and fear: shame that they’re not in control of their eating and fear that they’ll be judged and found wanting.

The link between obesity and adverse covid outcomes has been so frightening for a few patients that they’ve found the motivation to lose weight that previously eluded them. However, this doesn’t mean that pointing out such a danger is always helpful to patients: it can end up making them miserable and scared rather than empowering them.

The challenge for doctors is how to avoid adding to the burden felt by people struggling with obesity, or those who are worried about being underweight, without coming across as yet another judgmental voice. We know that referral to a weight loss service helps many people, but we’re also acutely aware that an ill timed reference to body size could wreck a therapeutic relationship.12 We’re also wary of what we may find if we dig too deep while lacking the time or skills to work through issues of adverse childhood experiences, low self-esteem, or current deprivation that may be contributing to the problem.3

As always, knowing your patients can be helpful: if I can remember when we last discussed the topic, I’ll be better able to judge when to leave well alone. Patients who know me may also be more forgiving, and if they already trust me I can be direct with less risk of causing offence. Most importantly, if I know what my patients normally look like I’ll notice any dramatic changes, even when their weight is still within the normal range and they’ve made no complaint.

Sometimes there’s a simple, non-medical explanation for a change in weight: giving up beer or puddings, or taking up jogging, may be enough to explain it. Sadly, withdrawal of state benefits and the resulting food poverty have recently been added to the list of causes in my surgery.

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