As registered dietitians and a registered social worker, we support and advocate for weight inclusive care. But what does this mean exactly? In this blog post, we review the history behind Body Mass Index, how the weight centric approach to care differs from the weight inclusive approach to care, and how shifting to weight inclusive care has positively changed our practice.

A Little Background

“Weight management” has been the predominant focus of health improvement 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 life enhancing surgeries unless 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 enough BMI) to possibly qualify as someone who could have 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 and then 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 doesn’t support this adjustment. In fact, an association between BMI and death isn’t connected until a BMI of 40. Furthermore, studies show the lowest death rate is found in the “overweight” category with a BMI between 25-30. Turns out the change in BMI classification was heavily influenced by insurance companies, the dieting industry, and convenience of health scientists.

According to Sabrina Strings’ research – PhD and professor and the University of California – the Body Mass Index is rooted in beauty ideals and eugenics. Over time this was adopted into mainstream medicine as size-based health. But the BMI has never been representative of diverse population groups, and staunchly opposes higher weights due to the connection to black bodies (particularly women of colour). 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 were 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 Contributes to Poor Health

The push for weight loss contributes 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 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, 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. 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 if their medical concerns being dismissed. In other words, patients are told to lose weight rather than being offered appropriate medical screening and treatment options – the same options given to individuals with the same issues in smaller bodies.

Second, weight bias perpetuates assumptions about people in higher weight bodies. 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, 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. We started to make the shift many years ago towards a weight inclusive approach to care.

Weight-Inclusive Approach to Care

The weight-inclusive approach to care was developed to challenge the views in health care that contribute to weight discrimination and 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 occur as an outcome).

There is a large body of evidence which has focused on the Health at Every Size (HAES) principles, including:

• Health care is a human right for people of all sizes
• Well-being, care and healing are deeply personal
• Care is fully provided ONLY when free from anti-fat bias and offered with people of all sizes in mind
• Health is a sociopolitical construct that reflects values of society

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 study compared a HAES-based program that emphasized intuitive eating and size acceptance against a dieting-based, weight-loss program. It included 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 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, LDL cholesterol, triglycerides, and systolic blood pressure at the 2-year follow-up. And participants 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 physical hunger rating, disinhibited eating (ie. eat to discomfort in response to negative emotions), drive for thinness, bulimic symptomatology, body dissatisfaction, and depression. They increased self-esteem at both 1-year and 2-year follow-up. Correspondingly, participants in the dieting-based program  reported a decreased self-esteem.
• Participant drop out was higher in the diet group (41%) compared to the HAES group (8%).

How Weight-Inclusive Care Reduces Weight Stigma

Studies show that if the public population and health care professionals are aware of the factors that influence body size and weight including genetics, social environment, access to health care, and weight discrimination, they gain more empathy for people in larger bodies.  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. This creates opportunity for more respectful and compassionate conversations.

An important way to help reduce stigma is by using more inclusive 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 one can ask the individual’s preference.

Also consider avoiding terms like “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?

Registered health 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 support and monitor clients:

1. 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.
2. Medical nutrition therapy and nutrition-related counseling – the dietitian uses nutrition science and best practice, but also considers the client’s lived experience and worldview to both learn and share knowledge. The dietitian helps to validate, ease or overcome barriers that make it difficult for the individual to nourish in a way that supports their well being. Barriers can include: emotional household burden, stress, poor mental health, neurodiversity, disabilities, shopping or cooking skills, dieting and disordered eating, or a poor food relationship, etc.
3. 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.
4. Focus on other markers of health/well being – this may include blood markers 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 better provide trauma-informed care by minimizing the harmful effects of weight discrimination. By removing pressure to diet, lose weight, or over-exercise clients are able to focus on specific behaviours that support their well-being. For clients who still wish to lose weight (no matter their reason), we hold space for them to explore options, to make changes they feel might help, or to grieve the thin ideal. Overall, client outcomes may include:

• Improvements in various markers of health (e.g. blood markers, energy levels)
• Improved physical symptoms
• Improved quality of life
• Improved body image and self-confidence
• Validation
• Better managed chronic condition, or mental illness
• Improved relationship with food and their body.

Efforts to make people thin, fail over and over, and weight centric health care causes harm. One of the most important ways to improve health is by eliminating oppression. Health improvement is possible without a focus on weight or weight loss, and weight inclusive care is a philosophy that supports respectful and dignified health care. Click here to learn more about our dietitians or book your appointment here.