Weight inclusive care is gaining in popularity, and for good reason. Clinicians who serve people in bodies outside of the “normal” weight range (we all do since 65-70% of people are above the arbitrary “normal” weight on the BMI scale), can keep a few things in mind when providing equitable care and doing no harm. This article will explain what being weight-inclusive entails, why it’s health-promoting, and some ways you can start practicing weight-inclusive care right now.
A word about BMI
The BMI scale was debunked a decade ago, in case you haven’t heard. Turns out It does not help us determine health status. It is sexist and racist and perpetuates weight bias and size-based discrimination. And so all words made up in relation to that scale are also meaningless and harmful, which is why I use “” for words like “obese” and “overweight”, as do my colleagues and friends in the weight-neutral movement. I use the phrase “people in larger bodies” or “higher weight” as neutral terms to describe folks above the “normal” weight category.
What we know about weight and health
I’m not going to dive deep into the research here, but I will make a couple of points that I hope are helpful.
Weight loss and “obesity” research is often incomplete, flawed, and biased
Higher weights are correlated with negative health outcomes, yes. But if we look at the actual research, we see a couple of important points that the media leaves out (why does the media leave this out? I have an idea… they don’t like nuance and because people love to hate fat people). Basically, inappropriate interpretation of the data gives us exhaggerated results.
Most of the time, researchers are not appropriately accounting for confounders and mediators in “obesity” and “weight management” research. That means they are not asking themselves… what, if anything, could be accounting for the worse health outcomes in higher weights other than the weight itself?
As I said, we do see a correlation between higher weight and negative health outcomes. But when we account for age, demographics, diet quality, physical fitness, weight control practices (more on this later), and weight-based discrimination, we see that people in the “obese” category only have a very slight increase in risk . And people in the overweight category, actually live longer!
This just means that we cannot say that one’s weight is the problem, especially when we consider the social experience of living in a larger body. We could talk about nutrition, how active they are, if they’re getting good sleep, getting timely medical care – you see my point.
But let’s just say, for the sake of argument, that someone’s weight IS the reason their health is at risk. Why are we assuming we should be advocating for weight loss?
Weight-loss interventions usually fail and often cause harm
There are ZERO long-term studies showing that weight loss is effective long-term. I will repeat that. There are zero long-term studies that show weight loss works long-term. Most studies that cite successful weight-loss interventions consider 2 years long term, which… it is not.
Most obese persons will not stay in treatment of obesity. Of those who stay in treatment most will not lose weight and of those who do lose weight, most will regain it.—Albert Stunkard (1958)
According to this population-based cohort study, the likelihood of maintaining weight loss at a 9-year follow-up was 1 in 219 for men and 1 in 124 for women. And for those with “morbid obesity”, it decreased to 1 in 1290 for men and 1 in 677 for women. Those are very bad odds, yet we keep suggesting people lose weight.
The most predictable thing one could get out of weight loss – is weight gain. And weight cycling – or losing and gaining the same 20, 30, 50 lbs year after year – IS harmful for health.
Dieting increases anxiety and depression, preoccupation with the way one’s body looks, and eating disorders. And if weight cycling is involved, dieting can slow metabolism, cause loss of lean body mass, weight GAIN, increase cholesterol, and increase insulin resistance.
Weight stigma, on the other hand, has been shown to negatively affect health (and contribute to weight gain).
Broadly speaking, most “obesity” research assumes that adiposity is the cause of negative health consequences. On the other hand, weight stigma research looks at a different angle – what about the social experience of living in a larger body?
Weight bias, weight stigma, and weight-based discrimination is harmful
Weight bias, or weight stigma, is a form of discrimination based on a person’s body size. Research reveals that being treated differently because of body size creates stress in the body, avoidance of timely healthcare due to being treated poorly, and receiving a lower quality of care when they do seek care. Quite maddening (and sad), actually.
Common assumptions about someone based on their body size, including being lazy and unmotivated, do not exclude healthcare providers. The care patients receive is often contemptuous, patronizing, and disrespectful. They are given less time in their appointments, and less access to surgical procedures, and often all of their health issues are blamed on their weight – delaying them from getting the care they need.
You can see why, if weight loss attempts almost always fail, and someone is telling a patient they must lose weight first, their condition could certainly worsen in the time they are “trying to lose weight”.
Anti-fat bias is also a problem in the psychotherapeutic community.
It seems to me (and to the research) that the best way to protect higher-weight people from worse health outcomes is NOT to suggest or assume that they should lose weight.
If this feels complicated for you (and I would understand why it would) – if you have feelings bubbling up like…. but of course they need to lose weight! Being fat is bad…. but.. but… but… I suggest reading this article and considering how dismantling internalized anti-fat bias could go a long way toward everyone’s benefit.
Binge eating disorder (BED)
A major risk factor for developing any eating disorder, including binge eating disorder, is dieting.
An incredibly common, incredibly under-diagnosed disorder, BED is relatively new to the DSM-5 as of 2013. Here is a screening tool to help inform how you could watch out in-session with someone who seems to have a complicated relationship with food and their body.
Be aware that people in all bodies sizes have all types of eating disorders. There are higher-weight people with anorexia nervosa and “thin” people with binge eating disorder and bulimia.
According to one of the leading eating disorder doctors in the country, Dr. Jennifer Gaudiani, the #1 medical complication of binge eating disorder is sub-standard medical and surgical care arising from weight-stigma.
What is Health at Every Size®?
“HAES® is a continuously-evolving framework of care for all people, regardless of body size. It is an ethical alternative to the weight-centered/normative approach to treating clients and patients of all sizes. The Association for Size Diversity and Health trademarked HAES® so that no one individual owns the term. HAES® should not be confused with Healthy at Every Size, and can be interpreted as Health for Every Size.“Kendrin Sommeville, ScD, RD
How to provide weight-inclusive care
Aligning yourself with providing weight-neutral care is quite simple. Many people are seeking out fat-friendly, or HAES-aligned therapists and HAES-aligned doctors these days. This movement is gaining popularity as more research comes out on the physical and mental health benefits, and as more individuals demand equitable treatment.
Weight-neutral care simply means:
- You view health and well-being as multifaceted
- You treat health behaviors and their social determinants as the point for intervention (instead of the number on the scale)
- You agree that people of all sizes, ability levels, and health statuses should be included in healthcare settings
- As a healthcare professional, you must examine and unlearn anti-fat beliefs. These result in poor outcomes, health disparities, and healthcare avoidance by higher-weight people
Adopting a weight-inclusive framework has been shown to be beneficial for patients’ overall well-being. Considering all of this – it is a bad idea to suggest weight loss to anyone.
How to talk to a patient about their weight
First – do not assume anyone has a problem with their weight. Many plus-size people are perfectly healthy, happy, and at peace in their bodies. Ask the nurses in your office to ask people if they want to be weighed instead of assuming they’re okay with it.
If someone has a health condition that is associated with weight, ask them about the things they DO have control of. Ask them about eating habits without making assumptions (including disordered eating). Assess access to healthy food, free time, and a safe place to exercise. Talk about sleep, stress, and mental health.
If you aren’t sure what to say about their diet, here are some ideas:
Do you have access to enough fresh, affordable food? Are you eating regular, balanced meals on a daily basis? Is there anything about your eating habits that you are worried about?
If they seem uncomfortable or give you answers that indicate there is an issue here, you could keep questioning or suggest they see a dietitian. Insurance is, of course, a crapshoot.
Why intuitive eating is health-promoting
It is true that eating a balanced, nutritious diet is good for one’s health. But we actually see that those with rigid control over their diets are more likely to have body image concerns and engage in disordered eating, especially binge eating, than those who use an intuitive approach to eating.
There are over 200 studies now on how the intuitive eating method helps people with health conditions ranging from high blood pressure to diabetes. Intuitive eating is a framework of eating that prioritizes overall well-being over body size. Intuitive eaters listen to their hunger and fullness cues to tell them when to start and stop eating. They find satisfaction without “overeating”, lessen their emotional reliance on food, find joyful and flexible exercise routines, increase self-compassion, and reduce self-judgment with food.
Intuitive eating also helps people improve the quality of their diet and stabilize their weight (ending weight cycling). Intuitive eating is also an extremely helpful framework for eating disorder recovery and body image healing.
How to talk about body image
There is no one right way to help someone with their body image. I know many therapists and other healthcare professionals do a great job of meeting people where they’re at and providing them a safe place to feel frustrated about their body and how it is perceived by society.
My main suggestion is this – make sure that YOU are not upholding the idea that being thin or losing weight is better for them than improving their body image in the body they have now.me
I find it helpful to talk about two things when discussing someone’s deeply difficult feelings about their body. It’s also smart to keep in mind that becoming thin has not been proven to improve anyone’s happiness.
Help them explore the origins of why we, as a society, think that thin is better. Why they, as an individual, think they would be better off thinner. I often ask, “Where did you first get the idea that your body was a problem?”
Where did you first learn this? Did someone tell you that you needed to lose weight? Or that there was something you were doing wrong with food or exercise? Often folks have been told to lose weight by pediatricians or put on diets by their parents. This can be extremely traumatizing and is a major cause for developing eating disorders later in life and is sadly so normalized by our culture.
The harsh reality is yes, our culture is much nicer to thin people. Also white, able-bodied, cis-gender, neurotypical people. It is unfair and it is real. And there is grief needed here, as they are not likely to change that system. They can just adjust the way they relate to it.
If they are deeply afraid of judgment from others, pull that thread to find out what is at the end of it.
Often, folks are afraid of being accused of being lazy, not caring about their health, and maybe being unmotivated, unattractive, or non-compliant. There are so many stereotypes that are made of people in larger bodies – of course, they are worried about this.
What I’ve found to be helpful, in time, is to help educate folks on why the dominant narrative that thin in healthy and losing weight is for the best – is racist, sexist, culturally oppressive rhetoric based on very weak evidence. I spend a significant amount of time on this with most of my clients.
We have all been sold the lie that thin is better, possible, sustainable, and healthier. The Positive Body Image Workbook has proven to be an excellent, thorough guide toward helping oneself, and their clients with body image.
Helpful books and resources for providers
There are so many excellent resources these days to learn more from haes-aligned dietitians, therapists, researchers, and doctors. A favorite podcast would be Christy Harrison’s Food Psych and Aubrey Gordon & Michael Hobbs’ Maintenance Phase. If you’re interested in learning how to talk to kids about fat bodies, Virginia Sole-Smith just published an amazing book, Fat Talk. Then we have How to Raise Intuitive Eaters, about parenting as well. My personal favorite is Reclaiming Body Trust. I recommend this book to nearly all of my clients who have had stigmatizing experiences in their body, losing weight and gaining it back, or whatever other kind of trauma occurs to those living outside of “normal”.
I’d love to be a resource for you. Comment below or email me with questions about any of this.
If you, or anyone you know is seeking a weight-neutral dietitian to help find peace with food, there are many ways to work with me. I see people for individual nutrition therapy for eating disorder care. If they struggle with chronic dieting and body image issues, check out my 6-month high-touch group coaching program called Love Food Again. And I’m always here, on the blog, and over on Instagram helping as much as I can.
Emily Van Eck, MS, RDN specializes in intuitive eating, mindfulness-based eating practices, embodiment with food and movement, and healing from years of weight-bias and disordered eating. She helps womxn find balance, consistency, and peace with their eating habits so they can feel confident to get outta their heads and into their bodies. Emily is a registered dietitian and certified intuitive eating counselor with a master’s degree in nutrition science. Read more about her here.