Why Weight Inclusive Care?
Written by Lauren Elder, Nutrition Student and Brooke Bulloch, RD
Food to Fit Nutrition is a supporter of, and advocate for weight inclusive care (also referred to as critical non weight-centric health care). But what does this mean exactly? In this blog post, we’ll review the history behind Body Mass Index, how the weight-centric approach to care differs from the weight inclusive approach to care, and how all of this has changed our practice as dietitians.
A Little Background
Weight management has been the predominant focus of health improvement and health care regimens across many western countries. This is referred to as the weight-centric approach to health. Whether or not weight is relevant to the presenting concern, patients seeking medical treatment are typically evaluated first on their weight. While basing health on weight status has become so normalized, it’s actually problematic because people in all sized bodies can miss out on appropriate assessment and treatment. For example:
- Higher weight individuals may be denied important and life enhancing surgeries until they lose a certain amount of weight;
- People in straight or smaller bodies may not be considered for certain medical tests because they do not fit the “high risk” profile (ie. high body weight) of a person with a chronic condition.
Despite the Body Mass Index being controversial in its use as a health screening tool, an individual’s weight continues to be categorized into BMI and used to guide medical care and treatments.
The History of BMI
In the 1800s, a Belgian mathematician – Adolf Quetelet – reported that body weight across adults varied with the square of height. It’s worth noting, he derived the formula studying white, French and Scottish participants only. In 1972, the weight (kg)/height (m2) formula, was named the Body Mass Index (BMI). Body Mass Index ranges were then used to classify bodies into “under weight”, “normal weight”, “overweight”, and “obese” categories.
Interestingly in 1998, the BMI cut-offs for “overweight” and “obese” were lowered based on the decision of 9 medical experts. For example, the “overweight” category of BMI changed from 27.3 for women and 27.8 for men, to a BMI of 25 for all adults. Thus, millions of Americans were re-categorized from the “normal weight” BMI to “overweight” or “obese”, instantaneously. The kicker is, research didn’t support this adjustment because an association between BMI and death wasn’t found until a BMI of 40. Furthermore, studies show the lowest mortality rate is found in the "overweight" category with a BMI between 25-30. Turns out the change in BMI classification was for the convenience of epidemiologists (scientists who investigate disease), to provide a uniform codification.
Needless to say BMI is not based on great science, it’s not representative of diverse population groups, it’s a weak measure of population health and was never meant to be used for individual health assessment, and it contributes to bias. Yet, this is the foundation of the weight-centric approach to health care.
Weight-Centric Health Care
Weight-centric health care refers to practices and principles that prioritize weight as the primary determinant of health. The approach assumes that weight and disease are directly related, with disease increasing as weight increases. While studies correlate a high BMI with poor health, the science does not demonstrate cause and effect. Correlation (association) simply suggests a relationship exists, but we don’t know exactly what that relationship is.
While at times a person’s body weight may play a role in their overall health status, this role is greatly over-estimated. And even if a person’s weight status or BMI was negatively contributing to an individual’s health, the question remains: is weight loss sustainable long term? Are weight loss recommendations by health providers actually helping individuals to improve their health long term?
Ways Weight-Centric Health Care May Contribute to Poor Health
The weight-centric approach to care and the push for weight loss may be contributing to worsened health outcomes, especially for people in larger bodies. Here are 2 ways that weight-centric health care contributes to poor health outcomes:
- It promotes dieting and weight cycling. When the emphasis of achieving "health" is based on achieving a “healthy weight”, it implies that we should all strive to shift our body sizes (and in many cases, defy genetics) in order to fit into the “normal weight” BMI category. However, a weight-focused approach to care has been linked to an obsession with food and body, chronic dieting and weight cycling, lowered self-esteem, and increased risk for eating disorders. Because weight loss and weight status is presented as the predominant measure of, and ticket to, improved “health” people may take drastic measures to ensure weight loss (cue the billion dollar dieting industry). Yet, the vast majority of individuals who engage in intentional weight loss regain most of their lost weight within 2-5 years. If weight loss efforts are not sustainable, weight cycling ensues increasing the likelihood of binge eating, osteoporotic fractures, loss of muscle tissue, some forms of cancer (renal cell carcinoma, endometrial cancer and non-Hodgkin’s lymphoma), hypertension, and heart disease. Therefore, no diet can be recommended without considering the potential harms of weight cycling.
- It contributes to weight stigma. Weight stigma are negative weight-related attitudes and beliefs and can take many forms – from weight-based teasing, bullying, harassment, and violence to something as seemingly innocent as recommendations to lose weight or maintain a smaller body. Stigmatization can be intentional or unintentional. While most health care providers never intend harm, weight stigma contributes to poorer health outcomes especially for higher weight individuals. First, individuals may stop seeking the help of health care providers because of medical concerns being dismissed. In other words, higher weight patients are told to lose weight rather than being offered appropriate medical screening, care and treatment options (the same options given to individuals with the same issues in straight or smaller bodies). Second, weight bias perpetuates assumptions about people in higher weight bodies, for example, assumptions about level of physical activity, motivation, or eating habits. In reality, we can’t know a person’s health by looking at them. Finally, people who experience higher levels of weight stigma have more chronic stress, higher blood sugar markers, and raised inflammatory markers. Additionally, weight stigma has been shown to increase the risk of depression, anxiety, and body image dissatisfaction, and has been linked to several poor health behaviours such as disordered eating, comfort eating, sleep disturbance and alcohol use, all of which impact physical health.
Over the years, the dietitians at Food to Fit Nutrition have taken a critical look at weight science and the limitations to a weight-loss-for-health model. Brooke and the Food to Fit Nutrition team have come to learn that this model isn’t serving people well, especially long term. We felt we could do better as providers. We started to make the shift many years ago towards a weight inclusive approach to care.
Weight-Inclusive Approach to Care
The weight-inclusive (non-weight-centric) approach to care was developed to challenge the views in health care that contribute to weight discrimination which also lead to health inequities. The goal of a weight-inclusive approach is to raise awareness of body diversity and the health impacts of weight stigma, to prevent or treat health issues through the lens of behaviour change, and improve day-to-day quality of life. Reducing body weight is not the focus of treatment (although weight changes may or may not occur as an outcome).
There is a large body of evidence supporting a weight-inclusive approach to care, much of which has focused on the Health at Every Size (HAES) principles, including:
- Weight inclusivity
- Health enhancement
- Respectful care
- Eating for well-being
- Life enhancing movement
A review of six randomized controlled trials assessing the HAES-based interventions, found that HAES promoted greater physiological and psychological health outcomes when compared to weight loss programs. One such study compared a HAES-based program that emphasized intuitive eating and size acceptance against a dieting-based, weight-loss program with a sample of 30- to 45-year-old women classified as “overweight” or “obese”. Participants within each program received 6 months of weekly group interventions followed by 6 months of monthly aftercare group support. Findings showed more positive results for the HAES-based program over the 1-year and 2-year follow-ups. Specifically:
- The HAES group decreased total cholesterol, low-density lipoprotein (LDL cholesterol), triglycerides, and systolic blood pressure at the 2-year follow-up and sustained improvements from the 1-year to 2-year follow-ups. On the other hand, the dieting group lost weight and showed initial improvements on many variables at the 1-year follow up, but had regained weight and did not sustain improvement at the 2-year follow-up;
- The HAES group decreased eating restraint, physical hunger rating, disinhibited eating (ie. eat to discomfort in response to negative emotions), drive for thinness, bulimic symptomatology, body dissatisfaction, poor interoceptive awareness, depression, and body image avoidance. They increased self-esteem at both 1-year and 2-year follow-up. Correspondingly, participants in the dieting-based program only reduced disinhibited eating, and reported decreased self-esteem;
- Participant drop out was higher in the diet group (41%) compared to the HAES group (8%). These findings suggest that HAES-based interventions demonstrate better adherence to practices that promote physical health and psychological well-being than dieting-based interventions, and these effects can be sustained over time.
How Weight-Inclusive Care Reduces Weight Stigma
Studies show that if public population and health care professionals are aware of the factors that influence body size and weight (e.g. genetics, social environment, access to health care, and weight discrimination), they gain more empathy for people in larger bodies because they no longer believe weight is solely within an individual’s control. In this way, weight-inclusive practitioners challenge the belief that a particular BMI is a reflection of a person’s health status or moral character. With weight-inclusive care a person isn’t being assessed based on their weight nor are assumptions made based on weight. Thus, weight stigma is minimized allowing opportunity for more respectful and compassionate conversations.
An important way to help reduce stigma is by using more inclusive or neutral language to describe a person’s size. For example, referring to body size as: “larger body” or “higher weight” or “smaller body” and “straight sized”. Some fat activists are reclaiming the word “fat” to be used as a neutral description in a way that other words are used to describe body characteristics such as tall, short, thin, etc. However, “fat” may still have a negative and harmful connotation for many people, so the use of more neutral descriptions are important until the health care provider can ask the individual’s preference. Consider avoiding these terms: “overweight”, “obese”, "normal weight", or “ideal weight” because these terms imply there is a "correct" weight that everyone should attain.
If Not Measuring Weight, What Then?
Science-based practitioners (such as registered dietitians) are required to measure progress and monitor outcomes. So if not measuring weight, how do weight-inclusive practitioners encourage clients to make change? And how are they measuring “success” or progress?
Here are 4 ways that weight-inclusive practitioners may support and monitor clients:
- Compassion-focused behaviour change – self compassion encourages a more positive self-esteem. People with a strong self-esteem are more likely to adopt positive health behaviours.
- Medical nutrition therapy and nutrition-related counseling – using nutrition science and best practice to help ease, work with, or overcome barriers that make it difficult for the individual to nourish in a way that supports their well being. For example, emotional household burden, stress, mental health, shopping or cooking skills, poor food relationship, etc.
- Health promoting behaviours around food and eating – this may include a focus on meal patterns, food intake diversity (adding key foods to the diet), meal/snack balance, realistic planning that fits within a person’s life (e.g. high capacity vs. low capacity days), nurturing a healthy relationship with food, and improving body image.
- Focus on other markers of health/well being – this may include biochemical markers measured in blood work, as well as individual markers such as energy levels, sleep, mood, or gastrointestinal function.
At Food to Fit Nutrition, a weight-inclusive approach to care has helped to minimize the harmful effects of weight discrimination. By removing pressure to lose weight, over exercise, and restrict food, clients are able to focus on specific behaviours that better support their well-being. Even without weight loss, client outcomes may include:
- Improvements in various markers of health (e.g. blood markers, energy levels);
- Improved physical symptoms;
- Improved quality of life;
- Improved self-esteem and self-confidence;
- Better managed chronic condition, or mental illness;
- Improved relationship with food and their body.
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