What A Lot of Doctors Get Wrong: Why a Weight Neutral Approach is the Solution to Harmful Dieting
*This is an amalgamation of visits my clients share with me often. I use quotation marks for BMI-related language, because this language is bullsh*t and promotes weight stigma- but is used in research so we are unfortunately stuck with it...
Jane goes to the doctor
A single mom of two goes to the doctor for a sore throat. She’s been struggling at work and fears she might lose her job. Every morning, she has a tension headache. She had to cancel her gym membership because she couldn’t find time to go and wanted to save money anyway. She’s been struggling with constipation, her energy levels are low, and she’s peri-menopausal and having hot flashes and starting to wonder if there is something she should do about it- supplements, hormones? She’s been doing her best to make home-cooked meals for her kids, but some nights she is just so exhausted that she orders pizza (which is fine with them). They love pizza and she honestly needs a break anyway.
She is waiting in the private room now, sitting on the cold, elevated patient bed. She swallows, and it feels like daggers in her throat. She looks around and notices a chart about BMI. She feels a knot in her stomach. The nurse will come any minute to take her blood pressure and weigh her. The blood pressure cuff isn’t scary- hers has always been totally normal. But she knows what’ll happen when they weigh her (it's one of the big reasons she’s avoided the doctor the last several years).
She knows the doctor will tell her she is “obese”, and she knows she'll feel like a complete failure. Her shoulder muscles tighten.
The nurse comes in. She reluctantly steps on the scale and looks up at the ceiling so she doesn’t see the number, but then the nurse says it out loud. Why do they say it out loud, she wonders? She purposely hasn’t weighed herself in years. She doesn’t want to diet anymore. She always ends up binge eating, the weight loss never sticks, and she gains the weight back- and more. The anxiety makes her feel nauseous as she waits for the doctor.
Good morning, the doctor finally enters and shuts the door. What brings you here today, he asks? She smiles at him, motions toward her throat, and tries to take a deep breath to calm herself as she tells him when the sore throat started. She thinks she needs a strep test. She also shared her other symptoms- fatigue, constipation, hot flashes.
The doctor tells her a strep test is a good idea, and he'll order the test. And then she hears that annoying inevitability when you live in a larger body- I am also concerned about your weight, he says. He gives her a pamphlet on BMI, explains how her weight puts her at risk of a myriad of health issues (heart disease, diabetes, cancer), and directs her to follow a “low calorie diet” and try to lose 1 pound a week to “reach a normal BMI”.
He doesn’t say anything about the constipation, energy, or hot flashes.
Her shoulders tense more, her eyes begin to feel the way they feel when you are trying to push down a wave of overwhelm. She has been told to lose weight since she was 10 years old.
She'll leave with a prescription for antibiotics, which was necessary, and a prescription for weight loss- which was not necessary.
Why doctors recommend weight loss: Two things- weight-centric medicine and the love of the BMI chart.
Doctors and other health care providers care about us (their patients). When they recommend weight loss, they think they are protecting us. Doctors who feel this way are working in the weight-centric paradigm of medicine, the belief that higher weight causes worse biomarkers for chronic disease and therefore weight is a good indicator of health. But research doesn’t support that dieting results in significant health improvements, regardless of weight change, and it is not consistently associated with lower mortality rate.
The problem with the weight-centric paradigm, which puts weight and size as a central element of health, is that health is much more complex and attempts to lose weight are often futile- and worse- destructive.
Prescriptions for weight loss don't typically come packaged with a warning label, but they should. Prolonged attempts to lose weight activate physiological and metabolic changes in our bodies that seem to persist, wreaking havoc for a long time after on both our metabolism and our food relationship.
Research shows that damaging adaptations to weight-regulating hormones remain long after we stop dieting which makes it easier to gain the weight back. One study showed a low-calorie weight loss diet for 10 weeks still impacted levels of metabolic hormones one-year post-diet:
Preoccupation with food was higher than before the diet
Appetite and hunger remained elevated a year later after only 10 weeks of dieting
Leptin was lower than normal (hormone that suppresses hunger and increases metabolism)
Peptide YY was abnormally low (hormone that suppresses hunger usually)
Ghrelin was about 20% higher than before the diet (hormone that promotes hunger)
So, a year after dieting, our body remembers this restriction, and there are consequences that cause weight regain and food stress.
Other research suggests with every 2.2 lbs we lose, appetite increases 100 calories a day on average and metabolism decreases by 20-30 calories daily. This is why about 95% of dieters regain the weight with up to seventy-five percent gaining more than when they started.
This weight cycling is associated with greater loss of muscle and lean mass and higher levels of inflammation which can promote damage to blood vessels, increasing cardiovascular risk. There is actually research supporting the idea that deaths associated with higher weights might be more related to weight cycling than actual weight.
...and the BMI chart
Jane noticed it- it is everywhere. The BMI chart is essentially used as a tool to tell us if we should diet. Health care providers make the assumption that we all need to “work” towards a “normal BMI” to improve our health and live longer. But are these assumptions even accurate? Does BMI predict health?
In a way, yes. But not the way Jane’s doctor thinks. A meta-analysis by Flegal et al. found:
the “overweight” category (25-30) lives the longest
the "underweight" (<18.5) category did not do as well as the "grade I obesity" category
the “grade 1 obesity” range of (30-35) was not associated with any increased risk and was similar to the “normal weight” category risk-wise
So being overweight has a protective effect when looking at large scale epidemiological data. Not what most docs are telling us! And the BMI chart was not meant to be used as a tool to assess individuals. Using it to encourage dieting is plain wrong and promotes insidious weight stigma.
Lastly, in the above study, "morbid obesity" was found to have increased associated risk, but encouraging weight loss through the weight-centric approach is not the answer because there's a better way to discuss improving health and quality of life. Let's talk about weight stigma and the weight-neutral approach.
What is weight stigma?
Weight stigma is discrimination and ideologies related to a person’s weight and size. It is related to overt or implicit biases, and it can be very harmful to mental wellness and overall health. A systematic review of the literature found “the greater the weight stigma, the worse the physiological health” and greater weight stigma is tied to worse “eating disturbances, depressive symptoms, anxiety and body image dissatisfaction and the lower the self-esteem”.
Weight stigma negatively impacts health biomarkers (the same ones doctors hope to improve with weight loss!).
For example, weight stigma is associated with increased C-reactive protein, a measure of inflammation, as well as higher blood pressure, increased cortisol (a stress hormone), higher A1c (measure of blood glucose), and more oxidative stress which speeds up aging and can impact brain function.
In adolescents, weight control behaviors which are promoted by weight-centric health care providers, are tied to higher depression and worse self-esteem.
Doctors and care providers are an important source of weight stigma. In a large sample of women living in larger bodies, “69% experienced weight bias by a physician (with over half reporting bias on multiple occasions), 46% from nurses, 37% from dietitians, and 21% from health professionals”.
A better option- the weight neutral approach and assessing fitness
A weight-neutral approach (or a Health at Every Size approach) emphasizes behavior change, and it is focused on long term, sustainable change and increasing mental wellness and overall wellbeing. In one randomized controlled trial of 80 women in larger bodies, the weight neutral group had significant positive changes that continued and were maintained 2 years later. These changes included improved waist-to-hip ratio, lower total cholesterol, increased physical activity, higher fruit and vegetable intake, improved self-esteem, and better quality of life.
If Jane’s doctor was a weight-neutral provider, they would have weighed her backwards and asked if she’d like to know the number with the caveat that weight is not a good health indicator. Then he would have explored her current habits related to her energy level, hot flashes, anxiety, stress, eating, movement, sleep, and constipation instead of just seeing her as a BMI category. He could have reassured her that there are ways to take care of herself without dieting or trying to change her body. He could have given her recommendations for ancillary providers- such as a weight-neutral dietitian (like me) to support in behavioral or a therapy referral to support her stress and coping.
He would also know that cardiovascular respiratory fitness (CRF) is a much better predictor of all-cause mortality than weight or BMI. Barry el al. showed that poor CRF (or being “unfit”) is associated with about a 2 to 2.5 fold higher risk of all-cause mortality regardless of BMI. In the study, the “overweight/obese” fit people had similar risks as “normal weight” fit people, and “overweight/obesity” people with moderate-to-high fitness had lower risk of death than unfit persons in the “normal-weight” category.
Jane’s doctor could have discussed this- that fitness is independent of fatness and better correlated with overall health. If he had provided this support, then he wouldn’t have added to her psychological and emotional stress by being a source of weight stigma.