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