What is Weight Inclusive Treatment?

Weight inclusive care is a tenet of social justice in the medical field that is widely misunderstood. When I describe myself as a weight-inclusive dietitian nutritionist, I see people’s expressions change. This treatment paradigm has been misconstrued to be one that “encourages unhealthy behaviors.” Aside from the inherently problematic and scientifically unfounded nature of assuming someone is unhealthy based on their body size (Bacon & Aphramor, 2011), the perception that weight inclusive care encourages unhealthy behaviors couldn’t be further from the truth.

Definitions: Weight Inclusive Care, Weight Normative Care and Weight Stigma

Let’s start with some definitions. Weight inclusive care treats modifiable health-promoting behaviors as an endpoint in improving health outcomes, rather than as a vehicle for weight loss. Conversely, weight normative care focuses on weight and weight loss as the primary indicator of health and well-being (Hunger et al., 2020). Three main assumptions drive weight normative care:

“(1) higher body weight equals poorer health,

(2) long-term weight loss is widely achievable

(3) weight loss results in consistent improvements in physical health.” (Hunger et al., 2020)

Weight Stigma is defined as, “the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape” (Tomiyama et al., 2018). Put simply, weight stigma is the tendency for people to treat fat individuals badly and make knee-jerk assumptions about their lifestyles because of their body size.

Modern healthcare operates under the faulty and widely disproven belief that, “weight stigma (i.e., pervasive social devaluation and denigration of higher weight individuals) promotes weight loss.. and recognizing that one is “overweight” is necessary to spur health-promoting behaviors.” (Hunger et al., 2020) However, an exhaustive review of the literature found that these assumptions are not empirically supported, and that shaming an individual for their weight actually contributes to worse health outcomes among individuals in higher weight bodies. I have a hard time understanding why this surprises anyone. Have you ever been on the receiving end of shame-laden feedback, and found this feedback to be motivating?

I’ll give you some examples of derisive and devaluing feedback, and think to yourself about whether this would inspire you to make a positive change:

The athletic coach we’ve all had: “You’re not fast enough because you’re lazy and you don’t have what it takes.”

High school history teacher, “You’re not getting good grades because you don’t listen in class and you don’t work hard enough.”

Spin instructor: “If you don’t hit this interval you’re a quitter!”

Typically, this type of feedback accomplishes the opposite of what it’s meant to. We internalize the message that we aren’t meant to succeed, and we stop trying. We resent the process and avoid engaging in it. The same is true for weight shame, to a much more extreme degree.

The Problem with Weight-Normative Healthcare

Weight stigma is an independent predictor and maladaptive eating behaviors, including binge eating and use of eating as a coping strategy (Puhl et al., 2020) Furthermore, patients who perceive weight stigma from their medical providers experience twice the risk of high allostatic load over their lifetimes, even when adjusted for BMI, suggesting that weight stigma independently increases allostatic load and worsens health outcomes more than the weight itself does (Guidi et al., 2021). In short, weight stigma actually perpetuates the behavior it is meant to reduce, and worsens the very outcomes that it is meant to improve. Ultimately, many larger bodied individuals avoid seeking healthcare at all after years of exposure to weight stigma because the process of being told their bodies are wrong is too demoralizing (Mensinger et al., 2018).

A 2013 study found that physicians provided less comprehensive and medically sound care to individuals in large bodies than they did for straight-sized individuals. Physicians are found to spend less time, engage in discussion less, provide less preventative interventions, and deliver fewer screenings to patients in larger bodies (Forhan & Salas, 2013). Parents of children in larger bodies report delays in seeking medical care for fear that the doctor will treat their children in a way that harms their mental well-being (Forhan & Salas, 2013).

To date, no studies have been able to operationalize a weight loss solution that has effects lasting beyond 3-5 years for 95% of participants (Rothblum, 2018; Leong et al., 2016; Fothergill et al., 2016). Participants regain all of the weight they have lost, and often times, they return to a weight that is higher than when they started. Weight-focused interventions are continuously found to be less effective than behavior-focused interventions. 

The Solution: Weight Inclusive Healthcare 

In contrast, weight inclusive care prioritizes focusing on health behaviors over body size. For example, an individual in a larger body who went to the doctor and learned they have type 2 diabetes would be instructed to seek out actionable nutrition education and lifestyle changes (preferably from a registered dietitian!) rather than given the blanket statement, “you need to lose weight.”  They would be given the appropriate referrals that could assist them in adopting behaviors that would lend themselves to reducing chronically high blood sugar. If they report that they struggle with binge eating, the referral provided would target reducing the incidence of binge eating behaviors rather than targeting weight loss, since as discussed above, weight-focused interventions are much more likely to fail.

Weight inclusive care combines the numerous clinical indicators that healthcare professionals have at their disposal: biometrics including blood sugar, A1c, glucose tolerance; HDL and LDL cholesterol, triglycerides, and blood pressure (all of which are simple to obtain and part of any robust annual physical); behavioral and psychological information that can be easily be captured in brief assessments and stored in an Electronic Health Records System; and reported ailments; in order to make appropriate recommendations and referrals for treatment. This approach is grounded on patient assessment, rather than on assumption based on weight-related stereotypes. This more comprehensive assessment will facilitate a more precise referral process and give patients the care they actually need, rather than the care that you might assume they need after five seconds of appraising their body size. It fosters a more effective alliance between the patient and the provider, and perhaps most importantly, the patient feels more comprehensively and sufficiently cared for. 

If you are in a larger body, and you have noticed this trend, first of all, I am so, so sorry that the healthcare system has failed you. If you notice your doctor giving you suboptimal care, a helpful place to start is to demand they give you the same care that they would give to a straight-sized person. If you work with a dietitian or therapist who is health-at-every-size aligned, ask them if they have physicians in their referral network who practice from a weight inclusive lens. Ask them for tips on how to advocate for yourself, we can help! If you don’t work with a dietitian or therapist who is health at every size aligned but would like to, you can easily find one in your state at the International Association of Eating Disorders Professionals website. Coming September 2022, the Association for Size Diversity and Health will offer a directory of weight-inclusive providers.

 References

Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9

Forhan, M., & Salas, X. R. (2013). Inequities in healthcare: A review of bias and discrimination in obesity treatment. Canadian Journal of Diabetes, 37(3), 205–209. https://doi.org/10.1016/j.jcjd.2013.03.362

Fothergill, E., Guo, J., Howard, L., Kerns, J. C., Knuth, N. D., Brychta, R., Chen, K. Y., Skarulis, M. C., Walter, M., Walter, P. J., & Hall, K. D. (2016). Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring, Md.), 24(8), 1612–1619. https://doi.org/10.1002/oby.21538

Guidi, J., Lucente, M., Sonino, N., & Fava, G. A. (2021). Allostatic Load and Its Impact on Health: A Systematic Review. Psychotherapy and Psychosomatics, 90(1), 11–27. https://doi.org/10.1159/000510696

Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy. Social Issues and Policy Review, 14(1), 73–107. https://doi.org/10.1111/sipr.12062

Leong, S. L., Gray, A., Haszard, J., & Horwath, C. (2016). Weight-Control Methods, 3-Year Weight Change, and Eating Behaviors: A Prospective Nationwide Study of Middle-Aged New Zealand Women. Journal of the Academy of Nutrition and Dietetics, 116(8), 1276–1284. https://doi.org/10.1016/j.jand.2016.02.021

Mensinger, J. L., Tylka, T. L., & Calamari, M. E. (2018). Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress. Body Image, 25, 139–147. https://doi.org/10.1016/j.bodyim.2018.03.001

Puhl, R. M., Lessard, L. M., Larson, N., Eisenberg, M. E., & Neumark-Stzainer, D. (2020). Weight Stigma as a Predictor of Distress and Maladaptive Eating Behaviors During COVID-19: Longitudinal Findings From the EAT Study. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine, 54(10), 738–746. https://doi.org/10.1093/abm/kaaa077

Rothblum, E. (2018). Slim Chance for Permanent Weight Loss. Archives of Scientific Psychology, 6, 63–69. https://doi.org/10.1037/arc0000043

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16(1), 123. https://doi.org/10.1186/s12916-018-1116-5

Intuitive Eating: What Even is it, and Where Do I Begin?

Intuitive eating has become a household phrase in the last several years, but generally speaking, people tend to misconstrue what intuitive eating actually means, and how to get started. Intuitive eating has gotten a reputation for being an “excuse” for people to eat whatever they want and throw nutrition out the window, and this couldn’t be further from the truth.  Others assume Intuitive eating simply means, “eat when you’re hungry, stop when you’re full,” and while this is certainly a component of the modality, it’s a gross oversimplification.

There is a strong empirical base to support intuitive eating as an adaptive alternative to dieting. A meta-analysis of 97 studies found that intuitive eating was inversely associated with eating pathology indices, body image disturbances, and psychopathology (Linardon et al., 2021). Furthermore, intuitive eating is associated with positive psychological constructs that include self-esteem, improved body image, and improved overall reported well-being (Linardon et al., 2021).

Recently, I was curious about what people in my circle responded when I asked them what intuitive eating means to them. The most common responses I heard were, “eat when you’re hungry,” “eat whatever you want,” and “make good food choices.” And for the most part, each of these phrases has a place in intuitive eating. However, there is much more to it, and I’d like to break it down for you.

The Ten Principles of Intuitive Eating

Intuitive eating is based on a set of ten principles designed to help you make peace with food and allow your food choices to be driven by your internal cues. The principles are intended to work in two key ways, as defined by Evelyn Tribole and Elyse Resche (2012), the two women who brought intuitive eating to life:

1.     “By helping you cultivate attunement to the physical sensations that arise from within your body to get both your biological and psychological needs met

2.     Removing the obstacles and disruptors to attunement, which usually come from the mind in the form of rules, beliefs, and thoughts.”  

 The Ten Principles of Intuitive Eating with brief descriptions are as follows:

• Reject the diet mentality: accept the fact that “one more diet” is probably not going to solve the problems you’re looking to solve. Lean into the idea that dieting has likely worsened your relationship with food.

• Honor your hunger: when you feel hunger, are you allowing yourself to eat? Or are you waiting until the hunger gets intense, to “save calories for later?”  

• Make peace with food: the more you tell yourself a food is off limits, the more you’re going to be driven to overeat when you finally do have it. Making peace with food means we need to stop the binary thought process of categorizing food as “good” or “bad.”

• Challenge the food police: the food police is the place in our brains where we formulate our food rules, the control center that tells us, “no carbs with dinner,” “you need to work out more when you eat bigger meals,” or “you’re not allowed to eat past 7PM.” Challenge these rules—where did we learn them? Are they still serving us?

• Discover the satisfaction factor: what do you need in a meal to feel satisfied? Are you someone who does well with high protein at meals? Perhaps you only feel satisfied when you have multiple textures in a meal, or something cold with something hot.

• Feel your fullness: What signals does your body give you when you’re no longer hungry? Notice what factors make you more vulnerable to getting uncomfortably full: eating too quickly, getting too hungry before a meal, not plating food, etc.

• Cope with your emotions with kindness: Emotional eating isn’t all bad all the time, but we don’t want it to be the only tool we use to cope with negative feelings and emotional discomfort. Having a range of coping skills will pay dividends when we go through rough patches.

• Respect your body: You don’t have to love how your body looks, or even how it feels all the time. If you’ve struggled with an eating disorder or disordered eating, it’s easy to feel betrayed by your body. Maybe loving your body is too much of a jump right now, but what can we do in this current season of life to show our bodies respect and stop fighting our genetic blueprint?

• Movement—feel the difference: We know movement has so many benefits, but many people have a fraught relationship with exercise. Joyful movement is movement we get to do, not movement we have to do. How do you feel before, during, and after movement? Does it energize you? Does it make you feel strong, empowered, or capable? If you can’t think of a form of exercise you find joyful, start with brainstorming a list of exercise that you don’t hate.

• Honor your health with gentle nutrition: The final principle of intuitive eating. Gentle nutrition is a way to honor your health and show your body respect and affection, rather than a way to punish yourself. While diet culture dictates your food choices against your wishes, gentle nutrition can help as one clue to help guide you to what you might choose to eat.

Okay, I Know the Intuitive Eating Principles, Now Give Me Some Action Steps

I think people get stuck with Intuitive Eating because it feels nebulous—a mystified and intangible concept that people can’t quite put their fingers on. I love exploratory work, but I also love action steps.

1.     Keep a food journal—and no, this doesn’t mean MyFitnessPal, Noom, or anything else weird. There are many ways you can do this without it feeling tedious or rigid. One of my favorite ways to do this is by doing a day long summary; at the end of each day, write down how the day went, and what factors seemed to contribute to your overall nutrition self care. For example, I might say, “today, I had more clients than usual, and I let myself go way too long without eating. By 5PM, I was starving, I overate, and I realized it was because I hadn’t eaten in 6 hours.” Now you have a new data point: going long periods of time leads to overeating and feeling uncomfortable. Over time, you’ll build up a data point of internally driven nutrition information to build your own personal nutrition framework.

2.     Keep a running list of food rules that come up when your inner critic gets loud. Ask yourself where that rule came from, and if it’s serving you. Build this list over time, and begin to challenge these rules. A good way to identify a food rule is by looking for statements that start with “should.” Should often implies we broke a rule we made for ourselves, or we internalized from diet culture, and often times those rules are actually arbitrary.

3.     Make a list—a physical list, in writing—of coping skills that you think could occupy your mind when you feel the feelings that typically lead you to turn to food to cope. When emotions run high, we quickly forget the tools in our toolbox, and having them written down can be really helpful. Plug in one of these skills when you feel that initial urge to engage in emotionally-driven eating. Often times, it will give you enough time to come down from the emotion—we like to call this “taking a mindful pause.” My personal favorite coping skills are painting my nails, doodling, hand lettering, and reading.

4.     I’m biased, but of course I’m going to recommend making an appointment with a registered dietitian who has competency in intuitive eating. Most, if not all, dietitians training to treat eating disorders and disordered eating are also trained in intuitive eating. If you’re in Georgia, Maryland, or Tennessee, you can do that with me here, or you can find dietitians in your state at the  EDRDpro website. Intuitive Eating is complex and incredibly nuanced, and a registered dietitian will be able to direct you in the safest and most effective way possible.

Too Long, Didn’t Read, Give me the Intuitive Eating Summary

There is so much more to intuitive eating than eating when you’re hungry, stopping when you’re full, and eating “whatever you want.” With such a strong empirical base, I truly believe intuitive eating is the future of nutrition-related self care. This non-linear process takes a lot of time to learn, and requires a heavy dose of patience and self-compassion. Following the ten principles has the potential to restore your peace with food and relieve you of the baggage that comes with eating. Start small, go slow, and be patient!

References

Linardon, J., Tylka, T. L., & Fuller‐Tyszkiewicz, M. (2021). Intuitive eating and its psychological correlates: A meta‐analysis. International Journal of Eating Disorders, 54(7), 1073–1098. https://doi.org/10.1002/eat.23509

Tribole, E., & Resch, E. (2012). Intuitive eating. St. Martin’s Griffin.

On Body Positivity: Why I Use the Word Fat (and why you can, too)

Pause for a beat. A slight recoil. Shoulders tense up. These are typical reactions when I use the word “fat” in conversation.

I am a health at every size aligned dietitian. I practice from a weight inclusive lens, and I treat individuals across the weight spectrum. Why, then, do I use the word fat in such a cavalier way?

We have negatively charged the word fat for as long as I can remember, as long as my mom, and your moms, and our grandmothers can remember. My first memory of “fat” was at age six, when I got on a scale at a beach house we were renting and worried if the number was high enough to label me as “fat.” It starts early, it runs thick, and it is nearly impossible to avoid.

Picture this: you are out to dinner with friends. You all take a picture, and the group gathers to evaluate the photo. Inevitably, someone interjects, “Delete that! I look fat, we need to take it again.” Another friend jumps to her rescue, “oh my god, you do not look fat!”

Estimates vary, but the data show that somewhere between 69%-91% of women experience body dissatisfaction related to weight, regardless of their position on the weight spectrum (McLaren & Kuh, 2004; Runfola et al., 2013). If the hypothetical situation in question involved a group of six women, then we can deduce conservatively that at least four of these six women face some degree of body dissatisfaction. These four women hear their friend agonizing over the fact that a photo makes her look fat, and they internalize the message that fat is unacceptable. Further, we assure one another that we are not fat; it’s just a bad angle, or an unflattering dress, or bad lighting, or a burrito baby. Inadvertently, this conversation perpetuates the message that should you ever be labeled as fat, your body will need to be fixed urgently. It perpetuates the paternalistic idea that if you are fat, you should be ashamed. This pattern repeats itself, ad infinitum, throughout the lifespan. 

I had a well-meaning professor last semester explain to our class of aspiring mental health counselors why she has banned the word fat from her home, why she interjects every time her niece calls herself fat, and how she swiftly replaces the term with the euphemism, “The F-Word.” While there was no doubt in my mind that her intentions were pure, what her niece was hearing time after time was, fat is something bad, fat is unspeakable, and fat is something to be avoided. Even the modern body positivity movement misses the mark time and time again: “your body is beautiful.” What if it’s not? Aren’t we still worthy?

The truth of the matter is, some people are fat. Many of these people likely will remain fat, despite the lifestyle patterns they adopt (Bacon & Aphramor, 2011). We know the allostatic load imposed by weight stigma and weight discrimination yield worse outcomes than the weight itself (Vadiveloo & Mattei, 2017). We know that the more weight shame an individual feels, the less likely they are to maintain the health-promoting behaviors that we all love to recommend (Mauldin et al., 2022). So, why is it that we feel such a visceral reaction when the word fat is used as a descriptor?

I use the word fat in a non-derogatory way, just like I might describe someone as tall, or muscular, or brunette. I do not employ the word fat as an insult, and when I hear someone call themselves fat, I no longer instinctively reassure them that they aren’t. The more we use this word neutrally, the more fat individuals feel that their bodies are just bodies, without a moral judgment attached. Body positivity is a bit of a misnomer. It implies we must feel positively towards our bodies all the time. Body neutrality, however, removes the element of self-objectification. As defined by NEDA, body neutrality “is a shift in perspective, from body hatred, disgust, and dislike, to body appreciation and respect. It is honouring the body as it is and taking a few steps down the body image continuum towards a more neutral zone.”

Without fail, every time I explain this, someone chimes in with a, “but what about their health?!” I have a lot of thoughts on this comment, but I will summarize them as concisely as I can. First and foremost, I can’t imagine a world where telling a friend that their body is wrong would be the inspiration they needed to adopt health-promoting behaviors. Second of all, you simply cannot independently predict someone’s health status by appraising their body weight (Tomiyama et al., 2016, Bacon & Aphramor, 2011). This myth has been debunked by large scale studies that have found that weight is a highly unreliable independent predictor of health (Tomiyama et al., 2016). Said differently, a fat individual may or may not be unhealthy, just as a straight-sized individual may or may not be unhealthy. Third, and perhaps most importantly, whether or not your friend is healthy isn’t really your business. You’re not their doctor, nor are you their caretaker, and it’s not your responsibility to assure their health status. If you’re wondering how to talk to someone about their body size, I think it’s helpful to follow a general rule of thumb: don’t.

So, what can you do? You can start by omitting pejorative fat talk in your circles. No complimenting weight loss, or noticing someone “looking skinny.” No more fat shaming yourself, or anyone else for that matter. You can replace, “do I look fat in this picture, I don’t want to post it if I do” with neutral statements like, “do you like this picture? I want a second opinion.” Call your friends out when they do the same. My personal favorite interjection when the group gets saturated with fat talk is to inform the group that I find the subject matter boring. Hearing about someone’s body size is simply not interesting to me, and I’ve learned that many others share this sentiment.

Keep in mind that complimenting someone’s weight loss can inadvertently be complimenting their eating disorder, their depressive episode, their high stress period at work, or a number of other factors that we don’t want to positively reinforce. And if it feels comfortable to you, you have the permission to use word fat in a neutral way. It can be helpful to disclaim to others that you use the term neutrally; they might be new to the idea. Reclaiming the word fat can be a powerful step in the direction of body acceptance, and we deserve to live in a world where people are taking these steps.

References

Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9

Mauldin, K., May, M., & Clifford, D. (2022). The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition. https://doi.org/10.1002/ncp.10885

McLaren, L., & Kuh, D. (2004). Body Dissatisfaction in Midlife Women. Journal of Women & Aging, 16(1–2), 35–54. https://doi.org/10.1300/J074v16n01_04

Runfola, C. D., Von Holle, A., Trace, S. E., Brownley, K. A., Hofmeier, S. M., Gagne, D. A., & Bulik, C. M. (2013). Body Dissatisfaction in Women Across the Lifespan: Results of the UNC-SELF and Gender and Body Image (GABI) Studies. European Eating Disorders Review, 21(1), 52–59. https://doi.org/10.1002/erv.2201

Tomiyama, A. J., Hunger, J. M., Nguyen-Cuu, J., & Wells, C. (2016). Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005-2012. International Journal of Obesity (2005), 40(5), 883–886. https://doi.org/10.1038/ijo.2016.17

Vadiveloo, M., & Mattei, J. (2017). Perceived Weight Discrimination and 10-Year Risk of Allostatic Load Among US Adults. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine,51(1), 94–104. https://doi.org/10.1007/s12160-016-9831-7