Worth the weight

Over the years, I saw Julie – a 45 year old registered nurse – for pap smears, self-limited illnesses, and treated her two school aged kids. Once or twice I’d also seen her husband for various ailments. They are a nice family, functional, and loving to each other. Julie was always courteous, sensible and thoughtful in consults.
 
There was one issue, however, that we couldn’t make headway on. Over the years I’d gently raised it with her, but she would always shut the discussion down. She’d do it kindly, sensibly and thoughtfully, but shut it down nonetheless.  
 
What was this issue? Her weight. She had a BMI of 33.
 
Over the years we’d had open discussions about hormones, body type, and so on. Julie described her diet, which seemed healthy. Her kids and husband both had a normal BMI. She played hockey on the weekends, ate healthy foods, drank a very small amount of alcohol occasionally, didn’t smoke, took no medications, felt her mental health was fine and told me she had a full and healthy life.
 
Around 18 months ago, Julie came in to see me on her own.  Decisive as always, she went straight to the point. ‘I’ve been thinking about my weight and it’s time to get serious,’ she said.
 
She spoke about all the reasons she’d told herself to justify staying overweight, including the idea that it was possible to be overweight and healthy. Then she laughed grimly. ‘I’ve been kidding myself. These are all just excuses. Now I need your help.’
 
She ran through her plan. She would use a weight loss app together with a food and exercise regime. What was my role? Julie had that covered too. ‘I need you to keep me honest. I’d like to come in every two weeks for a weigh-in with you. Could we do that?’
 
I was interested to know why she’d decided to change now, so I asked what had led her start this process.
 
Her eyes filled with tears. Earlier that week, her 12-year-old daughter had come home from school very upset. Julie went to comfort her and asked what had happened. Her daughter said she didn’t want her mum to die. At school, a teacher had covered health issues in class. Julie’s daughter had realised how overweight her mum was. Now here she was, begging her to lose weight.
 
Julie knew it would be tough. She’d been at the same weight for years. But her daughter’s plea had cut through her excuses.
 
‘I need to be the best mum I can,’ she said, wiping her eyes. ‘I need to show her I can do this.’ Then she looked at me. ‘I know you’ve been concerned too. Thank you for asking me about this over the years.’
 
So together we reviewed her plan. To build her app, food and exercise plan, I suggested seeing a dietitian, physio and personal trainer. She followed up with all three, and developed a good food and exercise plan.
 
Julie’s plan worked – but not overnight. Over the next few months, she lost a little weight. Sometimes her weigh-in showed she hadn’t changed over the fortnight. But longer-term, there was a downward trajectory. She stuck at it. The last time I saw Julie, her BMI had dropped to 27. Laughing, she told me her favourite discovery was that her thighs no longer rubbed when she walked. She and her daughter had recently been shopping for a new swim suit. ‘Not a bikini, but not one of those hideous ones with a skirt,’ she said.
 
Julie believes her health has improved as she’s lost weight, and is determined to keep at it.
 
Textbooks would recommend this method as the best way for everyone to lose weight. But many of us find it hard to put these recommendations into practice. Julie’s experience taught me something important about the need to engage with our patients with chronic illnesses over the long term.
 
We GPs are in a wonderful position to do this. Even if patients rebuff our suggestions, with repeated gentle questions, we can show them that we’re here to help. That way, we’ll be there when our patients find their own path to change.
 
*Julie is not her real name.

chronic disease continuity of care GP column Obesity and overweight weight loss