Guadalupe, age 64, was 5'2" tall and weighed 145 pounds. She fussed over her weight as she drove to the doctor's office. She sighed, knowing that he would tell her to lose weight. "I can do this," she said to herself. "Maybe Weight Watchers -- it worked for me once before."

She had struggled with her weight for decades. But now, it was really interfering with her life. If she got down on the floor with her grandchildren, she had trouble getting up because of the pain in her knees - which she didn't have when she weighed 10-15 pounds less.

She had asthma, and the extra weight made it harder for her to breathe. Both of those problems meant that she wasn't walking or bicycling the way she used to. And that made it harder to keep the weight off.

At her current weight, she would wake up suddenly during the night and feel that she wasn't breathing. That happened a dozen times a night. Her husband said that she snored. Her back hurt when she got up in the morning. She didn't have any of these sleep-related problems when she weighed less.

Her clothes were uncomfortably tight, and she couldn't afford to buy a new wardrobe. She felt bad about the way she looked at work. And hadn't she read something about medical problems that were more likely if a woman's waist is more than 35 inches around?

Yes, she decided, she was really going to try to lose weight.

Her doctor greeted her cheerfully and told her that the bone scan she'd had recently showed that she had osteoporosis. He explained that she had a 30 percent chance of breaking a bone over the next 10 years as a result. He prescribed medicine for her to take, and then asked if she had any other concerns.

"Yes!" she said. "I know I need to lose weight. I'm going to start Weight Watchers tomorrow."

"Not so fast!" he said. "Osteoporosis is your biggest medical problem, and it's better for your bones if you carry a little more weight." He laughed, saying, "You're lucky; it's about the only disease that makes it better to be overweight. Don't you try to lose weight!"

Guadalupe fought back the urge to cry. "Please don't say that. If I don't try to lose weight, then I gain weight."

"It's better to weigh more, given the osteoporosis."

"But --"

"Don't you try to lose weight!"

The visit ended with Guadalupe bewildered and disheartened. Sometime in the next 10 years, she might break a bone -- but what about all the problems that her weight was causing her today? And how could squishy belly fat be a good thing anyway?

She promised herself that she wouldn't let her doctor's words control her life. Yet every time she thought about losing weight, thought about avoiding some calories, she heard her doctor's voice in her head: "Don't you try to lose weight!"

At her next annual check-up, her doctor frowned and said, "You've put on some weight since last year!" He then lectured her about getting her weight under control. She stared at him without saying anything -- how could she respond to that?

What could her doctor have done differently in the first visit? He might have asked her, "Why is it important to you to lose weight?"

Listening carefully to her answers would have helped him to learn about medical problems she had that he hadn't heard about before.

She hadn't told him about those problems before because she was embarrassed. She felt that they were all her fault for weighing so much.

What does it mean that he didn't ask her why she wanted to lose weight? It means that he believed that he knew everything he needed to know to decide what her medical goals should be.

This stance is entirely consistent with the view doctors have traditionally had. An article by Dr. Robert D. Trugg in the New England Journal of Medicine pointed out, "The relationship between patients and doctors. . .has historically been framed in terms of benevolent paternalism."

He goes on to say that this stance has changed, and that now doctors are viewed as experts about medical science, but that patients get to say what matters to them -- which means that they can choose a treatment based on how well it lines up with their wants and needs.

The only problem with his view is that it hasn't made its way down to many doctors' examining rooms -- as Guadalupe found out the hard way.

What could Guadalupe have done differently? If she had planned for the visit in advance, she might have realized that she was now ready to deal with her weight. She could have written down all of her medical complaints that she believed were related to her weight, and suggested a weight loss goal that she thought would fix them.

If she had handed the doctor a piece of paper with these notes on them, she would have increased the odds that the doctor would at least have known what her concerns were. As it was, she never had a chance to tell him.