Nurse's musings on weight issues

Several recent Plurk conversations are gelling in my head so I am gonna think aloud here for a bit.
WALL OF TEXT WARNING
Discussions of the fallacy of the "average" discussions of challenges with healthcare and another discussion about the horrors of flying when obese. And I think I sometimes I come off as judgemental or unsympathetic because of the limitations of the medium. So here goes!
First, medicine (in the US) as it is currently practiced is a high volume business that makes its money via tests, imaging, labs, surgery and other interventions. All those things pay the bills, which is why so may practices do those in-house now. Providers are required to see a minimum number of patients a day, carry a large census of patients they are responsible for, and as a result visit times are brief. Medicine is essentially practiced as a game of averages. This test result usually means diagnostic code xxx, which is treated with treatment regimen y. So everyone with a blood pressure over a predetermined norm get drug A, then if that doesn't work drug B. etc. And if 900 of your 1000 patients benefit from your treatments then that is a great success rate. Unless you happen to be one of those 100.
The other side of the coin is patient expectations. We spent a lot of years selling the idea of the miracles of modern medicine. Add popular culture on television and movies to that and you wind up with expectations for healthcare and interventions that are WAY off. The ER team on TV does some chest compressions and the patient is well! Johnny wakes up from his three year coma in perfect health. If the brilliant but curmudgeonly doctor puts his mind to it they can diagnose you by the end of the 30min episode. And cure whatever it is just in the nick of time. Dying is especially elegant in popular media. Great lighting, makeup, fully conscious until you say something profound and slip away. RL is so much messier than that.
Patients often expect that if the doctor would only do ALL the tests, they could find out everything that is wrong with you RIGHT NOW (and sometimes even in the future) and fix it all today. And it doesn't actually work like that. At all.
Human beings and human bodies vary a lot in many parameters, and the idea that there is a "healthy" perfect state is a fallacy. Weights vary quite a bit, as do blood pressure, blood sugar, pain tolerance, and on and on.
Genetics plays a big role - you can have the textbook perfect weight, exercise, eat an ideal balanced diet, go to church every Sunday and still drop dead at 40 of a heart attack. Or get colon cancer at 50, or MS at 35...
Weight is an issue for a number of reasons - heart disease is a combination of genetics and damage from blood pressure, plaque buildup, high blood sugars, etc. Diabetes is the biggest risk of long term obesity, in the insulin resistant form. Genetics play a smaller role in that type. Diabetes leads to blindness, multiple organ failure, amputations, and was a very frequent end stage diagnosis I saw in hospice, usually from kidney failure (dialysis only works for so long).
Most universal issue with weight is one I personally deal with and that is joints. Joints are engineered in humans to work within a certain weight range, with body type and sex playing a role. But your joints WILL wear out eventually at any weight. What excess weight does is speeds up that process. And obviously the more weight you carry the faster it happens.
So back to provider and patient expectations. Providers need a different approach. Currently the attitude is that I am going to educate you on what you need to do in order to improve the health profiles that are outside the norm. Your goals and limitations are not even on the table in most cases.
What needs to happen is a discussion that starts where we are right now. What is it that keeps you from doing what you need and want to do? What does the provider see as a big issue or concern? What is available to help you as a patient meet your goals, if your goals are unreasonable then WHY are they and what would be reasonable goals? And there should ALWAYS be a nurse CM or a social worker available if needed who can direct patients to resources in the community.
As a patient, understand that everything is not fixable. And that anything that stresses your body's ability to maintain balances or does long term damage is going to have consequences no matter WHY that is. Some people CAN'T lose weight, but those people are also going to have to deal with the consequences of that. And the best way to approach that conversation is not to pass judgement. It is to acknowledge that these are the challenges we face and make plans on how we can mitigate the inevitable damage and give some really good quality of life.
Because ultimately sitting down to a nice steak or having an ice cream cone should be a delight, not a prelude to shame.