Why I Practice Weight Neutral Healthcare
A post Weight Stigma Awareness Week reflection.
Weight Stigma Awareness Week ended a little over a week ago, but we’re going to talk about weight stigma today… I gave myself a bit of an extension because why limit these discussions to just one week? Let’s start off with a basic understanding of what I mean when we talk about “weight neutral” healthcare. By other names, it is fat positive, Health at Every Size (r), or weight inclusive. It is for the providers and patients who are looking to improve their wellbeing through healthcare interventions without a focus on weight. At its core it’s a very simple concept: improve health through evidence-based interventions and don’t focus on whether the scale changes. There are a lot of reasons to work in this particular way. We see more retention and follow ups for people who do not feel shamed about their body size. Health can improve even when the scale doesn’t budge when we start increasing healthy eating habits, building a good relationship with exercise, and working on stress-reducing behaviors. We also hear from people in bigger bodies that it is more supportive, helpful, and encouraging. That last one is really the only reason we need to shift the way we practice - because we shouldn’t be causing harm to our patients// we should always been honoring the humanity and needs of our patients to provide good care. If we can provide healthcare in a more supportive, helpful, and encouraging way, isn’t that the goal?
I “grew up” as a dietetic student similarly to most healthcare practitioners. We learned about all the factors that can lead to the development of disease, how to get better at preventing disease/death, and how to treat disease when it still shows up. A hot topic in most of my undergraduate classes was the “ob*sity epidemic”1 I have a few core memories from my education that influenced my questioning of a weight centric2 paradigm.
In my nutrition through the lifecycle course, I remember the professor talking about the low rates of success for weight loss - with the majority of people who pursue weight loss either not losing weight at all or gaining weight back soon after losing the weight. This professor’s solution was that more people should work with dietitians because, clearly, we would be the solution for this weight cycling. We even learned that weight cycling itself is a predictor of poor health outcomes, but, never fear, dietitians were going to eradicate weight cycling by finally having the answers for sustainable weight loss (hint: this isn’t quite the case).
In another course, we learned about dietary recalls, food frequency questionnaires, and collecting data on food intake. We were informed that many people will lie about their recalls to avoid feeling ashamed or getting in trouble for not eating “correctly”. We also were taught to not trust the recalls as many people just don’t know how to measure intake correctly. We know this because obviously people would lose weight if they were eating as little energy as is often reported via a recall. I think about this every time I work with a new client who uses measuring behaviors or who has calorie counted for any length of time - they tend to know as much or more than I do about specific numbers and calories. No, this isn’t every human, but in diet culture, a lot of people have a lot of practice with tracking their food and are not exaggerating their undereating.
In my clinical presentations we would report on cases that we worked with in the hospital and discuss the interventions and support that we would theoretically provide in our future careers as dietitians. As students reported on the complex presentations of clients, one particular professor would usually interrupt and ask, “what is the one thing that this client could do to solve any of the problems you are listing?” The answer? Lose weight. For basically any disease - apparently we just lose weight and it magically goes away (hint: not how it works. It turns out that thin people also get sick).
These aren’t the only examples of weight stigma that I remember from my education, and I’ve experienced some horrendous examples of weight discrimination since. What sticks out to me about these examples are that they were times when I felt both curious and let down by the narrative that humans are untrustworthy narrators of their own experiences and that the surefire way to save the world is with weight loss… but also that people don’t tend to successfully lose weight long term. When I learned about Health at Every Size and Weight Inclusivity, I immediately felt that these treatment styles aligned more with how I view people and what seemed supportive for helping people have a better relationship with food.
The thing is, even in school, we learned that we can see benefits to the human body by improving nutritional status without seeing weight loss. We also learned that focusing too much on weight could backfire and lead to people “giving up” on any positive changes because there weren’t visible signs of their body changing. It’s like we were always on the verge of understanding the benefits of taking the focus off of weight, but always got spooked by our own weight bias and ran back to weight centric views of human health.
So, what does it look like to practice from a weight neutral lens? It means that we don’t utilize weight loss as a marker for success in treatment - particularly weight loss. It could mean that we pursue weight restoration even if your weight is in the “normal” or higher BMI range because your body shows signs of needing that weight gain to function well. Weight neutral healthcare is healthcare - it is every single part of healthcare that is seen to be supportive and beneficial but without the expectation of thinness to receive quality support and interventions. It is not withholding proper interventions until you “lose XX pounds”.
As a dietitian, these conversations introducing an approach that isn’t rooted in weight loss can be tricky. So many of us are taught from a young age to fear fatness and to rate our health and desirability based on our weight to height ratio. If we grew up thin, we were taught to never “let ourselves go” or to “appreciate our bodies now because someday you might gain weight, look like me, and inevitably hate your body”. All of this ignores that many of us will grow and develop similarly to our parents or other genetic relatives. If our family is telling us how much they hate their body and to avoid ever looking like them, we are in quite the pickle when we inevitably start to grow into our parents. If we grew up in a bigger body, there is a good chance you were chastised at doctors’ offices, counseled on weight loss from anyone from a dietitian to some stranger in the grocery store, and started on age-inappropriate diets if you had a family member starting some new trend. Almost none of us grew up with fat positivity in our households. So, when a person walks into (more like logs into) my office to talk about their goals for themselves, something like 75% of the time weight loss is listed in their goals- even in the case of diagnoses like anorexia. To have a dietitian - usually seen as the food police and the keeper of perfect bodies - tell you that we aren’t going to focus on weight as an indicator of success can be pretty surprising.
But here’s the thing. If we add in more fruits and veggies to a diet of a person who is lacking in those food groups, we can see benefits to cholesterol, GI distress, and blood sugar management. If we decrease alcohol consumption in a chronic binge drinker, we might see better stress management and improved stress symptoms. If we throw in some whole grains or beans to a diet lacking in fiber, we can help resolve someone’s constipation. But if we focused on weight loss as the “intervention”, that’s when problems arise. Weight loss isn’t an intervention - it isn’t a behavior that someone can change. We act like losing weight is simple, but the reality is that if losing weight were simple, we would have a population of thin people right now. Eradicating fatness is one of the highest agenda points for public health in our country in this moment - we are putting many, many resources toward making our population thin and we have seen absolutely no progress in this endeavor. What is interesting to me is that we’ve worked harder and harder over the years to add public health initiatives that would theoretically encourage weight loss. We started sending home BMI report cards to families from schools, we started the Let’s Move initiative for young kids, we have increased access and encouragement to bariatric surgery and weight loss drugs for people of all ages (with ever loosening requirements to meet qualifications for the surgery/medicine). When will we pause, look around, and notice that this extreme focus isn’t doing us any favors - humans are not shrinking and health outcomes are not improving. What if we’re causing more harm by pathologizing body size and could actually do more good by encouraging health promoting behaviors rather than weight loss?
I started practicing weight neutrality as a dietitian because it made sense to me. I could see the implications of continuing to harm people in all sizes of bodies and wanted to be a better provider - one who my clients could trust and be honest with. I have continued practicing in this way because I see better outcomes for my clients. They feel better in their bodies, their health markers improve, they develop a healthier relationship with food, their weights actually tend to stabilize - sometimes for the first time in their adult lives, no longer cycling up and down3. My clients are often surprised to notice that they feel better when they don’t have to worry about coming into a session just to talk about what the scale said that week. We are more attuned to our own bodies and internal experiences when we take our external aesthetic out of the picture. We develop more trust in ourselves and our intrinsic wisdom of our bodies. Our brains can be used for more things than calorie counting, weight tracking, and dieting. It’s actually an amazing thing to see the decrease in stress (another often overlooked factor in disease development) when we get to just focus on helping our bodies feel good, feel taken care of, and be well fed.
I thought about getting nice and science-y in this post - I have about 100 scientific articles that I could link and graphs I could point to. The reality is, this is human centered care. Yes, I believe in providing good, evidence-based care and I do believe that this practice style aligns with seeing good health outcomes; but at the end of the day my job is to show up for my clients and help them meet their goals to improve their quality of life. The way healthcare interventions feel is important. The way we stigmatize our patients based on their bodies in a weight centric health care model is harmful - and I don’t really understand how that is even something to be debated. If you are hoping for more science and research on this here are some resources - and also let me know in the comments because maybe I’ll put that on the to-do list for a future post.
Resources:
EDRD Pro Resources - Health at Every Size
Obesity/overweight will be censored throughout this article as they are pathologizing terms for fatness. Fat will be used as a neutral descriptor throughout this article in line with recommendations from fat activists who seek to reclaim the word fat. I use fat similarly to how a person may be described as tall or blonde - without judgement.
Weight centric being the opposite of weight neutral - weight being the core focus of healthcare and seen as a “fix all” solution to any health problem.
This typically feels affirming to my clients who feel afraid that intuitive eating and removing weight loss goals from treatment will result in gaining weight “into perpetuity”. We also see that weight cycling has adverse health effects long term - and this is the most common outcome of dieting. Weight stability is not preferable to gaining weight because of fear of weight gain, but because it is a sign that the body is well nourished and has basic needs met consistently.
This is a great piece. I did grow up in a weight neutral home (in the 60s and 70s no less). Dad was a chef and food was our family thing. Mom, Dad, and I were all fat. My brother not. He wasn't a foodie. Still isn't, poor thing. It was only when I went away to college that I was hit with the barrage of body hatred. Me and my fat girlfriends were nicknamed "The Buffalos." Naturally I did what most any teenaged girl would do. I starved myself, ending up in hospital malnourished. Managing my body has taken great effort, even now at 66 years old. There's no end. So thank you, and thanks to my RD for liberating me from the mirror. It's all so damned hard.