Have you heard of the weight-inclusive approach? Are you interested in making shifts in how you care for yourself and/or how you practice but not sure about how to translate your knowledge into practice with your yourself/patients/clients? This article will explain what the weight-inclusive approach is, why it matters, and some basics for how to implement it.
A brief history of BMI & the weight-normative approach
In 1832 a Belgian astronomer named Adolphe Quetelet came up with the Quetelet's Index to study growth at the population level. Until about 1972, this equation was obscure and unknown to most. In 1972, famed researcher Ancel Keys renamed this equation to the Body Mass Index. In 1998 a panel of medical experts voted to lower cutoffs for overweight from 27.8 to 25. Interestingly, 8 of these 9 experts had ties to the weight loss industry and lowering the cutoff for "overweight" category was not supported by the science. As a result of these new cutoffs, 40 million Americans were considered overweight or obese overnight, funding and fueling the "war on obesity".
In 2013, the American Medical Association labeled obesity as a disease despite their own Council on Science and Public Health recommending they do not make this classification due to the flaws of BMI as a reliable tool to indicate health, especially on the individual level. From there, the standard of care became treating obesity as a disease and the weight-normative approach was codified.
Does it work?
To date, there is no study that shows a safe, effective, long-term or permanent way to lose weight. Up to 98% of weight loss efforts fail within 2-5 years, and most studies about weight loss do not follow people for longer than a year. Up to 2/3 of people who attempt weight loss will end up gaining more weight than they lost. In short, intentional weight loss efforts tend to take people in the exact opposite direction of where they want to go.
This information can be upsetting. How can intentional weight loss efforts not work? Why am I being told to lose weight at the doctor's office, by my family, at church, or on billboards? How can it be that everyone has gotten this wrong?
I know how upsetting this can be. But here's the truth: intentional weight loss efforts make regular, consistent, balanced, satisfying eating more difficult and less likely to happen, especially long-term. Dieting breeds chaos with food, struggles with bingeing, GI distress and overall poorer health outcomes.
Weight and bodies change and will change consistently whether we want them to or not. Weight can either stay the same, decrease or increase. Wanting our bodies to shrink typically doesn't lead to patterns with food or exercise that support health and wellbeing. Putting weight on the back-burner and focusing on health, how you feel, energy levels, etc. is a far more effective way to pursue health. Allowing your body to be the size, shape and weight that it will be when you practice a healthier approach to food and body is far likely to yield healthy patterns than trying to shrink your body.
In short, the weight-centric approach has been associated with food and body preoccupation, weight cycling, reduced self-esteem, binge eating, eating disorders, less ability to make and follow through with health goals, weight stigma, and discrimination. Weight cycling associated with yo-yo dieting increases the risk of cancer, disordered eating, and mortality regardless of starting or ending BMI. A far better approach is to learn how to take care of yourself (food, movement, rest, hydration, stress management, etc.) and allow your body to be the right weight for you as you make those changes.
Weight stigma
When medical providers or family members put pressure on people to diet and/or lose weight, there are many unintended consequences that the research is only now enumerating. Many of these consequences also have their own impact on health even when disaggregated from other factors. Let's dive in to weight stigma and its effect on health and wellbeing.
Tomiyama and colleagues define weight stigma as the social rejection and devaluation that accrue to those who do not comply with prevailing social norms of adequate body weight and shape. Essentially, weight stigma is the impact felt by folks of size by people in their life who see their body as wrong, something to be fixed, or something negative.
Here's what the science says: when people perceive themselves as overweight or obese, they are more likely to try to lose weight. However, there is no association between their perception of their weight and healthier eating habits. Perceiving oneself as overweight is, in fact, associated with lower physical activity levels and higher levels of disordered eating. When someone perceives themselves as overweight, they are more likely to gain weight over time.
When researchers control for disease burden and body weight they have found that experiences of weight stigmatization subject individuals to higher mortality risk. One 2017 study suggest that those with higher self-stigmatization have overall higher cardiometabolic risk. Weight stigma in and of itself is associated with elevated blood pressure, disordered eating, eating disorders, poor body image, low self-esteem, and depression across the lifespan. Even when people lose significant amounts of weight, they on average will report little to no change in internalized weight stigma and body dissatisfaction. Body image dissatisfaction is associated with increased levels of circulating inflammatory biomarkers and may play a role in chronic disease development.
What this all means: believing that your body is wrong or needs fixing impacts your health in a negative way. Being told constantly—both verbally and non-verbally—that you need to lose weight doesn't lead to weight loss long term, but does lead to poorer health outcomes.
What this means if you're a person in a larger body: if past dieting attempts have yielded poorer outcomes for you, if you've felt frustrated with your inability to follow through with weight loss goals, if you are struggling with your body and food, YOU ARE NOT THE PROBLEM. The advice you have been getting, although well intentioned in most cases, is just not informed by the latest science and best practice with food and eating. You don't have to choose between rigid diets and chaotic eating. There's a middle ground that both honors your health and feels sustainable and positive in your life.
What this means if you are a provider: stop telling your patients to lose weight. It's not helpful, doesn't work, and doesn't promote health. There are far better ways to encourage health-promoting behavior.
How to promote health (for healthcare providers)
So what is the weight-inclusive approach? In short, it's an approach to health that takes into account the scientific findings that diets fail us. Weight-inclusive care provides intervention and advice that's free of stigma and based in behavioral interventions that are individualized to each person's unique situation. Weight inclusive care honors diversity in size and doesn't try to change or manipulate bodies, but allows them to change and shift as they naturally do. Weight-inclusive care means the provider has done the work to challenge their biases and recognizes that weight does not equal health.
My number one piece of advice would be to ask yourself how you would help someone with a BMI of 22 who presents with the same issue as the person of size. What would you say to someone with diabetes, heart disease, binge eating disorder, bulimia, GI distress, etc. who has a "normal" BMI? Would you run further tests? Would you encourage more movement (remember, there's such a thing as too much so be sure to ask questions about this and don't assume you know by looking at them)? Would you recommend they eat more fruits and vegetables? Whatever you would say to a straight-sized person is your first go-to as far as answering the question of what do I do instead of recommending weight loss.
It's important to recognize that you cannot look at a person and know how healthy they are. Someone could have a raging eating disorder, throwing up every time they eat, and present with a straight-sized body. Their labs may even look "good". That doesn't mean that they are, in fact, healthy. It means that their body has adapted to their behaviors to keep them alive. The same is true with someone in a larger body. They could be eating well, exercising regularly, and overall taking very good care of themselves. Being in a larger body does not automatically mean that they are doing something wrong or unhealthy. A smaller person can be unhealthy, a larger person can be healthy. There's way more to health than size.
Encourage behaviors, not numbers. Focus on day-to-day practical things that they can do to care for themselves like: eating more fruits and vegetables (don't forget there's such a thing as too much, though!), moving their bodies more regularly, reducing alcohol intake, eating more regular meals, etc. If you aren't sure what the behavioral intervention looks like, feel free to refer to a dietitian who is well-equipped to take the time and energy to provide this type of care. Saying nothing is better than contributing to a person's sense of weight stigma (remember weight stigma harms people's health and gets in the way of people being able to make healthy changes). People are scared to go to the doctor. It makes such a huge difference to have a provider who doesn't participate in body shaming! It's health promoting to practice from a weight-inclusive lens.
Conclusion
This was a brief summary intended to get you started. This is a huge shift and will require much more than just this to make these changes. Stay patient, wrestle with this, talk it through with someone, and know that you are making this world a better place when you are kinder to yourself and when we provide more trauma-informed and weight-inclusive care.
More resources:
Anti-Diet by Christy Harrison, MPH, RD
Intuitive Eating by Evelyn Tribole, CEDRD & Elyse Resch, CEDRD
Just Eat It by Laura Thomas, PhD
Body Respect by Lindo Bacon & Lucy Aphramor
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