Non-weight-centric care, or weight inclusive care, is a response to a pervasive problem in healthcare that is harmful to patients. For years, and without much supporting evidence, providers have operated under the assumption the more you weigh, the less healthy you are. Fortunately, clinical experience and research is waking us up to the reality that this approach to care can be harmful to patients, and that there is a better way.
Weight is just a number
As physicians, we are trained to rely on tangible information, especially numbers. This training is vitally important in so many specialties, but my experience has taught me that when it comes to obesity care and disordered eating, focusing on the number on the scale is the wrong approach. For several years now I’ve been working on trying to learn new ways to better serve my patients.
When I worked in the Weight Wellness Clinic, I encountered so many patients with stories about how physicians discriminated against them due to their size. Too often, they blamed most of their health issues on the patients’ weight without even asking about habits or eating behaviors.
Most physicians don’t know how to talk about weight, nutrition, disordered eating or other topics because they’re not even part of the medical school curriculum. There’s not enough training or awareness about how the way we approach these issues in the clinic has a significant impact on patients’ mental and physical health.
How I approach weight and health in my clinic
My goal is to try to understand how weight-centric and weight-inclusive approaches can serve individual patients without demonizing any particular method. I usually recommend an intuitive eating approach in my practice, but I also understand that not every individual might have the capacity to practice it due to genetic or environmental factors.
I also focus on the patient as the active driver for their health/wellbeing. If the patient isn’t fully on board with our strategies, then we won’t have good outcomes.
Health and wellbeing is not just about weight. There are so many more factors involved, such as:
- How you feel
- How you see yourself
- Your eating habits – are you having regular meals?
- Your sleep – how many hours of sleep do you get? Do you snore?
- Your stress levels
- Your satisfaction with your relationships?
- How your life experiences have shaped you and your relationship with healthcare
The conversation shouldn’t only be centered on the weight number, we should also be mindful of other factors such as body shape, gender, and race. These are important because they impact how you see yourself in a society that tends to celebrate a particular body type (usually white, heteronormative, and thin).
Health at Every Size (HAES) – benefits and limitations
One way to approach non-weight-centric care is called Health at Every Size (HAES), which emphasizes celebrating body diversity, challenging scientific assumptions, and encouraging patients to find joy in movement and eating. While I believe HAES is doing important work to end weight discrimination and a hyper-focus on weight as the most important marker of health, it does have its limitations. For example, it doesn’t leave room to discuss the health benefits of intentional weight loss, which effectively shuts down discussions of how excess fat tissue can increase risk of disease.
HAES research also might not be applicable to patients with more severe obesity. The studies we do have used small sample sizes with mainly caucasian women living in Western cultures with a history of binge eating or chronic dieting. They only looked at people with overweight or class I obesity (BMI 30-34.9). They did not include people with class II (BMI 35-39.9) or class III obesity (BMI equal or greater than 40), who are the largest growing obesity ranges globally and have significant disease and functional limitations.
So there is a lot of wonderful movement happening to encourage health equity and improve the healthcare experience for larger-bodied patients, but we still have a lot to learn. I am committed to staying up-to-date on the research and listening to my patients so I can provide the very best care for patients of all body shapes and sizes.
On a practical level, patients who come to my clinic will notice the following:
- I encourage emotional, physical, nutritional, and social health without emphasizing weight.
- Instead of focusing on changes in weight, I help patients identify health behaviors that they can sustain long-term.
- I help patients notice what is happening in their bodies when health behaviors improve, such as having more energy, fewer gastrointestinal symptoms, enjoying food more, etc.
- Rather than only focusing on BMI, I look at my patient’s weight trajectory over time to identify gains and losses that reflect disordered, emotional, and binge eating.2
Research shows that dieting doesn’t work
Even when people manage to lose weight, they usually gain it back within a couple of years. One meta-analysis of 29 long-term weight loss studies showed that after 5 years, more than 80% of the lost weight was regained.11 Our bodies have sophisticated survival mechanisms to protect fat, which is why most weight loss attempts don’t really work.
On a personal level, this information resonates with me. I don’t like to be told what to do, and if someone tries, I tend to do the opposite. I think that a whole-person approach to wellbeing can’t be top-down. If it’s just me, your doctor, trying to dictate what you should eat and what kind of exercise you should get, we won’t get results. Real changes have to come from within.
My personal experience with weight as a Mexican woman
I have a unique perspective when it comes to talking about weight. Here in the United States, I am part of a minority being a first-generation Mexican woman, but I am also a heterosexual female with thin privilege. After working with white female patients I became more aware of some of the cultural beliefs and differences around weight and beauty.
I now realize that I have had some protection against the thin ideal that was deeply ingrained in most of my white, female patients. In Latino culture, being too thin can be seen as being ill or malnourished since our ancestors came from food scarce environments. Conversely, larger bodies are still a sign of abundance and wealth. Latino and African American communities often celebrate having big breasts, thighs, and glutes.
In the clinic, it was interesting to note that the specific body parts that were the source of dissatisfaction among patients varied across cultures. Everyone across the board wanted to decrease “belly size,” but Latinas and African American women wanted to keep the “breasts and butt”.
This might seem like a superficial observation, but everyone’s unique life experiences and cultural conditioning has a big impact on their body image and self esteem. I’m grateful to have been protected in a way from the white ideal of thinness. Even so, I don’t feel totally comfortable in my body, and I know the same is true for most if not all of my female patients, family, and friends.
For people with disordered eating, weight-centric care can be harmful
There is growing concern about how encouragement of restrictive eating behaviors for weight loss can increase risk of binge eating and bulimia. This happens because restriction can then lead to overindulgence as a response. Dieting has been associated with eating disorder onset and maintenance.
The statistics are pretty staggering. For example, around 30% of patients that seek weight loss have binge eating disorder (BED). This disorder is highly prevalent, underdiagnosed and undertreated. I often encountered these patients in the clinic and had to find appropriate treatment approaches that didn’t focus on weight loss. That being said, studies also show that patient engagement in treatment is lower if we don’t address their weight concerns. I can’t pretend that weight isn’t an issue for my patients, but if the number on the scale becomes our only goal, the patient will suffer.
No silver bullets: Why treatment has to be personalized
Weight-inclusive care is not without its own biases. Most of the research on weight-inclusive approaches has been done on white female populations. In general, the studies don’t fully evaluate how health disparities impact people’s ability to be in touch with satiety and hunger.8,9 Some research shows that people who experience food insecurity are more likely to engage in binge eating behaviors. When thinking about the biological protection of weight as survival, that makes a lot of sense.
That’s why weight-loss medications like GLP-1 (Ozempic, Wagovy) have the potential to be such helpful tools for patients with health disparities and trauma. They work by minimizing the protective metabolic compensation that has allowed us to survive wars and starvation but make it extremely difficult to lose weight.6
Weight loss does improve metabolic health in patients with comorbidities such as diabetes, heart disease, obesity, high blood pressure, etc. Weight loss medications can be a helpful tool in this fight because they give patients with a personal history of scarcity and trauma the ability to regulate meals.
Conclusions
I believe that non-weight-centric care is a much better approach for patients to achieve their health goals in a sustainable, affirming way. While there are nuances to this approach and it doesn’t work for everyone, it’s a huge step in the right direction. As healthcare providers, it’s vitally important for us to learn and understand how life experiences, food availability, and trauma can impact eating behaviors.
If you’re looking for a doctor who will empower you to reach your health goals from a place of self-care, please schedule a 30-minute free intake interview today. Together, we’ll find the root causes of problematic behaviors and begin your ongoing process of evolution and change.
References:
- Social Media Use and Body Dissatisfaction in Adolescents: The Moderating Role of Thin- and Muscular-Ideal Internalisation https://www.mentalhealth.org.uk/explore-mental-health/articles/body-image-report-executive-summary/body-image-childhood
- Shifting the Conversation: Moving Towards a Weight Inclusive Model https://uconnruddcenter.org/wp-content/uploads/sites/2909/2020/11/Shifting-the-Conversation_-Moving-Towards-a-Weight-Inclusive-Model.pdf
- Weight Inclusive Care: Evidence and Best Practices https://www.todaysdietitian.com/pdf/courses/DadaWeightInclusive.pdf
- Prevalence of binge eating disorder in obese adults seeking weight loss treatment
https://pubmed.ncbi.nlm.nih.gov/14655834
- Management of eating disorders for people with higher weight: clinical practice guideline https://www.sciencedirect.com/science/article/abs/pii/S0277953619304526
- Metabolic Adaptations to Weight Loss: A Brief Review https://journals.lww.com/nsca-jscr/fulltext/2022/10000/metabolic_adaptations_to_weight_loss__a_brief.39.asp
- Ethnicity and Metabolic Syndrome https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019432/
- Is intuitive eating a privileged approach? Cross-sectional and longitudinal associations between food insecurity and intuitive eating https://pubmed.ncbi.nlm.nih.gov/36896622/
- https://www.sph.umn.edu/news/food-insecurity-limits-intuitive-eating-in-the-short-and-long-term/
- https://www.nationaleatingdisorders.org/statistics/#general-eating-disorder-statistics
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/#:~:text=In%20a%20meta%2Danalysis%20of,regained%20(Figure%201)4.
