Food to Fit Nutrition is a supporter of, and advocate for weight inclusive 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.
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:
Despite the Body Mass Index being controversial in its use as a health screening tool, an individual’s weight continues to be categorized, which is then used to guide medical care and treatments.
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 because an association between BMI and death isn’t connected 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 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?
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:
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 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.
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 or may not occur as an outcome).
There is a large body of evidence which has focused on the Health at Every Size (HAES) principles, including:
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. 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 aftercare group support. Findings showed more positive results for the HAES-based program over the 1-year and 2-year follow-ups. Specifically:
These findings suggest that HAES-based interventions demonstrate better adherence to practices that promote physical health and psychological well-being than dieting-based interventions.
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. 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 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.
Consider avoiding these terms: “overweight”, “obese”, “normal weight”, or “ideal weight” because these terms imply there is a “correct” weight that everyone should attain.
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?
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 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 the grieve the thin ideal. Overall, client outcomes may include:
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