Author
Dr. Katarina Wind (biography, no disclosures)
Acknowledgments: I would like to thank Dr. Lisa Erlanger, Dr. Maya Rosenkrantz, Maria Oswald, Andrew Brown, and Ljuba Pavlovich for their helpful edits and suggestions.
What I did before
Medical school taught me that “obesity” is a cause of morbidity and mortality, and that weight loss is its cure. I recorded patients’ BMIs and counselled them on weight-loss strategies, believing that I was helping them.
What changed my practice
In 2021, I came across the Health at Every Size (HAES) community and the Fat Justice movement. I was dismayed to learn I had been harming patients by focusing on weight, and that there was a large body of evidence challenging the above “facts” (1).
I had never questioned the word “obesity”; I considered it as an objective, neutral label for a disease. In fact, the term is derived from the Latin obesus, meaning “having eaten oneself fat,” inherently blaming fat people for their bodies. Instead, the word fat is being reclaimed by the Fat Justice community as “an objective adjective to describe our bodies, like tall or short” (2).
“Obesity” was only declared a disease in 2013 by the American Medical Association, against the advice of the steering committee they had hired to study the issue. The committee found that “obesity” has “no specific symptoms associated with it,” and that “medicalizing obesity… could lead to more reliance on costly drugs and surgery… [and] some people might be overtreated because their BMI designated them as having a disease, even though they were healthy” (3).
Body Mass Index (BMI), used to define “obesity,” is a measurement created by Belgian mathematician Adolphe Quetelet, to identify the characteristics of the average white man. His work was used to justify the eugenics movement in the 1920s–30s (4). When life insurance companies wanted to charge policyholders based on height and weight, physiologist Ancel Keys (who thought of “obesity” as “disgusting” and “ethically repugnant”) re-introduced the BMI (5,6). BMI is an especially poor measure of health in non-white people, particularly Black women (7). As noted in a recent CMAJ article, we must recognize that “the conflation of obesity with racialized and colonized communities is part of a long tradition of marking marginalized populations as diseased” (8).
Problematic origins aside, I was still convinced that because “obesity” is associated with increased morbidity and mortality, it should be treated. In medicine we pride ourselves on differentiating correlation from causation; yet we have collectively abandoned these principles with regards to the links between “obesity” and poor health. When our studies control for confounding variables such as weight cycling, diet drug use, economic status, and weight stigma, many of these effects disappear (9). Even without controlling for confounders, “most epidemiological studies find that people who are overweight or moderately ‘obese’ live at least as long as normal-weight people, and often longer” (1). Further, up to 75% of “obese” individuals are “metabolically healthy”, based on studies that measured blood pressure, HDL, triglycerides, and plasma glucose (10). Importantly, weight loss, even when intentional, “increases the risk of premature death among ‘obese’ individuals” (1).
If you aren’t yet convinced, and still want to prescribe weight loss, consider that the most common outcome of dieting is weight gain. A review of multiple randomized control trials demonstrated a “[lack of] strong evidence for the efficacy of diets”. Of the few studies that claimed a “success”, the average weight loss was 1.1kg, hardly clinically significant. Across studies, one to two thirds of dieters regained additional weight long-term (11).
Most importantly, there is strong evidence that we harm patients by focusing on weight. We cause fat patients to avoid or delay medical care (12–14); for reasons including a desire to “avoid being fat shamed or being given unsolicited advice to lose weight” (15). When these patients do show up, we provide shorter visits (16), with less healthcare education (17). We feel that heavier patients are “more annoying” to deal with and we have “less patience the heavier the patient [is]” (16). We can even miss life-threatening diagnoses when attributing symptoms, such as shortness of breath, to “obesity” (18). I have yet to hear a physician, when prescribing weight loss, warn their patient of the harms of weight cycling (19,20), or screen for a pre-existing eating disorder, which are more common with higher BMIs (21). We cannot pretend that we will stop discriminating against fat patients while viewing weight as an objective indicator of health.
What I do now
- I no longer counsel patients to lose weight. Instead, I use the evidence-based HAES approach, which shifts the focus to weight-neutral outcomes such as health behaviors. The key lifestyle principles of HAES are “intuitive eating, joyful movement, and body respect”, plus sleep, stress reduction, and social connections. Consideration of barriers, such as food insecurity, is explicit (1). I only discuss weight if the patient brings it up as directly impacting their health; for example, if they cannot perform certain ADLs due to their size.
- I no longer report a patient’s BMI, or use the terms “overweight” or “obese” in medical histories. I will report weight (plus height if indicated) if directly useful, for example, in congestive heart failure, planning for surgeries requiring special equipment, or weight-based medication dosing.
- I screen for eating disorders, regardless of BMI, in patients with fatigue, bloating, or constipation.
- If a patient independently brings up being unhappy at their current weight, I explore the issue further with them. I summarize the points of this article, briefly discuss diet culture, and ask about their relationship with food (eating disorder screening). If they do not screen positive for an eating disorder and are interested in lifestyle changes, I explore the HAES approach with them. If I do not have time, I suggest they book a further appointment to discuss, and I refer them to the resources linked below.
Resources
Highlighted primary articles:
- What’s wrong with the war on obesity? (O’Hara & Taylor, 2018). Accessed Apr 11, 2022.
- Weight science: Evaluating the evidence for a paradigm shift (Bacon & Aphramor, 2011). Accessed Apr 11, 2022.
- The epidemiology of overweight and obesity: Public health crisis or moral panic? (Campos et al. 2005). Accessed Apr 11, 2022.
- Weight loss versus increasing fitness and physical activity for reducing health risks (Gaesser & Angadi 2021). Accessed Apr 11, 2022.
Websites:
- Vancouver Coastal Health Resources:
- Let’s talk about weight. Accessed Apr 11, 2022.
- Focus on Health, not Weight (download PDF from vch.ca). Accessed Apr 11, 2022.
- Obesity Canada:
- Health at Every Size (HAES) – What’s it all about?. Accessed May 15, 2024.
- Campaigning to end medical weight stigma:
- noweigh.org. Accessed Apr 11, 2022.
- HAES Health Sheet Library (how to manage various diseases without recommending intentional weight loss):
- haeshealthsheets.com/the-health-sheet-library. Accessed Apr 11, 2022.
Books:
- Harrison DL. Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness. California, US: North Atlantic Books; 2021. (Request from UBC or find with Worldcat)
- Gordon A. What We Don’t Talk About When We Talk About Fat. Massachusetts, US: Beacon Press; 2020. (Request with CPSBC or find with Worldcat)
Podcasts:
- Unsolicited: Fatties Talk Back (view)
- Hosts: Marquisele Mercedes, Da’Shaun Harrison, Caleb Luna, Bryan Guffey, and Jordan Underwood
- Description: “Join fat activists… as they break down how and why anti-fatness shows up in our lives and relationships”
- My Black Body Podcast (view)
- Hosts: Rawijah Tariq and Jessica Wilson
- Description: “Out stories are medicine … overlooked in spaces that have actively de-centered Black bodies and voices… by supporting this podcast, you can help decolonize narratives about and around Black bodies and facilitate their much-needed healing”
- Maintenance Phase (view)
- Hosts: Michael Hobbes and Aubrey Gordon
- Description: “Debunk the junk science behind health and wellness fads”
References
- Bacon L, Aphramor L. Weight science: Evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9. DOI: 10.1186/1475-2891-10-9. (View)
- Gordon A. What We Don’t Talk About When We Talk About Fat. Boston, Massachusetts: Beacon Press. 2020. (Request with CPSBC or find with Worldcat)
- Pollack A. A. M.A. Recognizes Obesity as a Disease. The New York Times. June 19, 2013. (View)
- Eknoyan G. Adolphe Quetelet (1796-1874) – The average man and indices of obesity. Nephrol Dial Transplant. 2008;23(1):47–51. DOI: 10.1093/ndt/gfm517. (View)
- Friend YF. The Bizarre and Racist History of the BMI. Medium. 2019 [cited 2021 Sep 26]. (View)
- Blackburn H, Jacobs D. Commentary: Origins and evolution of Body Mass Index (BMI): Continuing saga. Int J Epidemiol. 2014;43(3):665–9. DOI: 10.1093/ije/dyu061. (View)
- Sumner AE, Ricks M, Sen S, Frempong BA. How current Guidelines for obesity underestimate risk in certain ethnicities and overestimate risk in others. Curr Cardiovasc Risk Rep. 2007;1(2):97–101. DOI: 10.1007/s12170-007-0016-6. (Request with CPSBC or view with UBC)
- McPhail D, Orsini M. Fat acceptance as social justice. CMAJ. 2021;193(35):E1398–9. DOI: 10.1503/cmaj.210772. (View)
- Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G. The epidemiology of overweight and obesity: Public health crisis or moral panic? Int J Epidemiol. 2006;35(1):55–60. DOI: 10.1093/ije/dyi254. (View)
- Rey-López JP, de Rezende LF, Pastor-Valero M, Tess BH. The prevalence of metabolically healthy obesity: A systematic review and critical evaluation of the definitions used. Obes Rev. 2014;15(10):781–90. DOI:10.1111/obr.12198. (Request with CPSBC or view with UBC)
- Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer. Am Psychol. 2007;62(3):220–33. DOI: 10.1037/0003-066x.62.3.220. (View)
- Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obes. 2006;30(1):147–55. DOI: 10.1038/sj.ijo.0803105 (View with CPSBC or UBC)
- Puhl RM, Peterson JL, Luedicke J. Parental perceptions of weight terminology that providers use with youth. Pediatrics. 2011;128(4):e786-93. (View with CPSBC or UBC)
- Puhl R, Peterson JL, Luedicke J. Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. Int J Obes. 2013;37(4):612–9. DOI: 10.1038/ijo.2012.110. (View with CPSBC or UBC)
- Mensinger JL, Tylka TL, Calamari ME. Mechanisms underlying weight status and healthcare avoidance in women: a study of weight stigma, body-related shame and guilt, and healthcare stress. Body Image. 2018;25:139–47. DOI: 10.1016/j.bodyim.2018.03.001. (View with CPSBC or UBC)
- Hebl MR, Xu J. Weighing the care: physicians’ reactions to the size of a patient. Int J Obes Relat Metab Disord. 2001;25(8):1246–52. DOI: 10.1038/sj.ijo.0801681. (View with CPSBC or UBC)
- Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005;13(9):1615–23. DOI: 10.1038/oby.2005.198. (View)
- Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity “epidemic” and harms health. BMC Med. 2018;16(1):123. DOI: 10.1186/s12916-018-1116-5. (View)
- Montani JP, Viecelli AK, Prévot A, Dulloo AG. Weight cycling during growth and beyond as a risk factor for later cardiovascular diseases: The ‘repeated overshoot’ theory. Int J Obes. 2006;30 Suppl 4:S58–66. DOI: 10.1038/sj.ijo.0803520. (View with CPSBC or UBC)
- Montani JP, Schutz Y, Dulloo AG. Dieting and weight cycling as risk factors for cardiometabolic diseases: Who is really at risk? Obes Rev. 2015;16 Suppl 1:7–18. DOI: 10.1111/obr.12251. (Request with CPSBC or view with UBC)
- Nagata JM, Garber AK, Tabler JL, Murray SB, Bibbins-Domingo K. Prevalence and Correlates of Disordered Eating Behaviors Among Young Adults with Overweight or Obesity. J Gen Intern Med. 2018;33(8):1337–43. DOI: 10.1007/s11606-018-4465-z. (View)
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Comments from the author
How to balance with physicians’ responsibility to discuss the effects of weight on someone’s health?
1. People who live in larger bodies are very aware of their size. They are told by every media outlet to lose weight, and unsolicited comments and advice are given by family members, friends, acquaintances, and often even strangers. Given our society’s obsession with thinness, it is almost unheard of to meet a person in a larger body who has not previously attempted, or is not currently attempting, weight loss for health and/or cosmetic reasons.
2. Multiple large studies have demonstrated that focusing on or discussing weight loss is counter-productive, and paradoxically results in weight gain. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0070048 , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236245/ Regardless of current body size, “perceiving oneself as being ‘overweight’ is counter-intuitively associated with overeating in response to stress… [and] an increased risk of future weight gain”. https://www.nature.com/articles/ijo2015143 The experience of weight stigma is also associated with future weight gain.
3. There are many disease risk factors we do not talk to patients about. For example, we know that childhood ACE’s and low socioeconomic status are associated with many diseases. When was the last time you told a patient with hypertension that their SES is a risk factor, given that “technically” it is modifiable?
4. When you tell a patient that higher weight is associated with a certain disease, do you also inform them of the positive associations with that weight? For example, an American study with a combined sample of 37,000 people found that the “overweight” category had a lower mortality weight than the “normal BMI” category, and that there was no significant difference in mortality between “normal BMI” and “obesity class 1” patients. Often the patients that we are counseling on weight loss fall into these size categories, and are not aware of this positive data. https://jamanetwork.com/journals/jama/fullarticle/200731
5. Here is an example of how we could talk to our patients about weight and disease: “Higher weights seem to be associated as a risk factor for this disease. However, our evidence lacks proof of causation – there are other factors that could be driving this association, including weight stigma at doctor offices. As well, outside of weight-management clinics, which often rely on strict calorie restriction, the evidence is strong that focusing on weight loss is unsuccessful long-term for the vast majority of people, and causes harms such as weight-cycling and eating disorders. However, there are many ways to manage diseases, and risk factors, without focusing on weight – both with medications/interventions, and lifestyle. The Health at Every Size (HAES) approach to lifestyle modification is evidence-based and incorporates intuitive eating, joyful movement, and body respect, as well as other risk factor modifications such as smoking cessation, alcohol moderation, improving sleep, and reducing stress. Weight loss may or may not be an unintended side effect, but is not viewed as a measure of success or failure.”
LEGACY study shows that weight loss of >10% reduced the incidence of paroxysmal AF events… the Diabetes Canada guidelines specifically counsel on weight loss… the Hypertension guidelines, and many others.
It is true that the LEGACY study and many others show benefits with weight loss. However, I question if these studies would come to the same conclusion, if they did not assume, a priori, that weight loss was always good and harmless. Think of any other intervention where you would be comfortable with the study doing the following:
– Not measuring risks or adverse outcomes of prescribing weight loss. For example, there is no mention of screening the participants for pre-existing eating disorders or questioning their relationship with food following the study. I did appreciate that LEGACY was one of the few studies that measured weight-fluctuation (an adverse outcome of dieting), and demonstrated that >=5% weight fluctuation had adverse impacts on cardiac remodeling, insulin resistance, dyslipidemia, and hypertension.
– Not adequately controlling the study. The weight loss intervention was not just calorie-restriction, but an intensive clinic that also managed the following: smoking, alcohol intake, sleep disordered breathing (CPAP compliance was 77% in the RFM group but 33% in the control group), glycemic control, and BP control. If we were truly curious if weight-loss was helpful, we would have both groups attending this clinic, and the only difference would be that one group was prescribed calorie restriction.
– Informing the patients that there is a strong body of evidence demonstrating that when the intervention (weight loss clinic) is removed, a vast majority of patients will regain weight (ie. weight cycling, which the LEGACY study, and others, have demonstrated as harmful).
– Food is central to culture and interpersonal relationships, which we know to be important in health. In the LEGACY study, participants that did not lose more than 3% of their weight were forced to go on a diet of only meal-replacement shakes. This is a drastic measure that goes against our current Canadian food guide recommendations https://food-guide.canada.ca/en/. Is this a culturally safe recommendation? Is it in line with the upcoming anti-racist practice standards (linked below)?
– The LEGACY study and most guidelines have many conflicts of interest with pharmaceutical companies that profit from weight-loss drugs and interventions.
How to address some areas where body habitus is associated with higher risk factors?
I invite you to think of body habitus as more analogous to race or sex (which also carry associations to various diseases, but are not labelled as diseases themselves), than to a co-morbidity such as hypertension or diabetes. The argument for this is as follows:
– Weight, like race and sex/gender, is a visible part of a patient’s identity that follows them everywhere they go. Certain groups (ex: black race, higher body weights), are more stigmatized against than others. For example, did you know that being “overweight” is the primary reason that children are bullied (https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1746-1561.2011.00646.x). In the workplace, people who are “overweight” or “obese” are less likely to be hired or promoted (https://doi.org/10.1016/j.jvb.2008.09.008). Since the declaration of “obesity” as a disease, the prevalence of weight stigma has increased (https://journals.sagepub.com/doi/full/10.1177/0956797618813087). While there are small intervention studies that suggest education on “obesity” as a disease may decrease bias, this has not been shown on a population level. Is it perhaps time to consider that the medicalization of an already stigmatized body type has contributed to harm by legitimizing fat shaming?
– Without ongoing participation in a rigorous weight-loss program that usually requires extreme calorie restriction (ex: meal replacement shakes as above), or a surgical intervention that carries significant risk, weight is not modifiable long-term for the vast majority of people (https://pubmed.ncbi.nlm.nih.gov/17469900/, https://pubmed.ncbi.nlm.nih.gov/26180980/)
– The lines between weight loss for medical reasons and for social/cosmetic reasons are so blurred as to be indistinguishable. The weight-loss industry is a multi-billion dollar industry, and social norms preferring thinness are strong. If we were really focused on health, the media and weight-loss clinics would show before/after laboratory markers, not before/after photos. I find the following thought exercise often helpful: If you were offered an intervention that added 5 good-quality years to your life, but caused 20 lbs of weight gain, would you accept it? If the answer is not an immediate yes, then there is weight bias to unpack.
– The medical community has made positive strides in removing race as a risk factor in certain risk calculation tools. This is an acknowledgement that, although certain factors may be associated with certain diseases, when they are key parts of people’s identities that are stigmatized against, we must be cautious of how we interpret those associations. I am hopeful that the medical community will apply the same thinking to body habitus in the coming years (especially, as noted in my article, BMI/”obesity” has its origins in racism). https://www.nejm.org/doi/full/10.1056/NEJMms2004740
What about other means of measuring this besides BMI, e.g. waist circumference, hip/waist ratio?
I appreciate that waist/hip measurements seem to account better for some cultures, and do not carry the same negative history as the BMI. However, as they perpetuate the same body-habitus focus, these measurements still carry the same problems of weight-based medicine as detailed in my article and above.
Other comments:
I appreciate that there is evidence that short-term weight loss improves disease outcomes, and that this can be extended for a few years for some patients with ongoing involvement in a weight-loss clinic with strict calorie control. The HAES paradigm does not dispute that point, but rather demonstrates that there are alternative ways to promote health that focus on overall well-being and do not have such a high long-term failure rate. It also acknowledges that all people have the right to eat intuitively, listening to their body’s hunger and fullness cues, and to not be judged for this by their physicians. Regardless of whether you agree with all aspects of Health at Every Size, I think it is important to share this information with our medical community. Control of body weight is complex, poorly understood, and stigmatized, and it should be approached with humility and patient-centeredness.
HAES as a growing patient-centered movement that was birthed due to traumatic interactions with the medical system, more frequently for women, Black, and Indigenous peoples. We cannot continue to ignore the harms of weight-centric care, particularly in the light of the upcoming “Indigenous Cultural Safety, Cultural Humility, and Anti-Racism Practice Standard” that all college registrants were informed about via email on January 21st (below). Most of the key 6 concepts in this practice standard are central to the HAES movement, including creating safe health-care environments, and person-led care. https://www.cpsbc.ca/files/pdf/PSG-Indigenous-Cultural-Safety-Cultural-Humility-and-Anti-racism.pdf
While I appreciate the HAES movement, the cancer epidemiology evidence appears to distinguish adult weight gain (body fatness in their words) from other risk factors such as levels of exercise or diet composition. Is there any evidence suggesting that it is not an independent risk factor for the specific cancers listed by the WCRF? https://www.wcrf.org/diet-activity-and-cancer/risk-factors/obesity-weight-gain-and-cancer/
(this question is personal and not an official representation from my organization)
Thanks for this counter to prevailing medical culture and for highlighting the problems of the words we use with patients.
Dr. Wind, I found your article well researched, empathic, and inclusive. Excellent! As a diabetes educator, I frequently meet with clients who have been body-shamed despite their endless, draconian efforts to lose weight. We need more providers such as yourself, and I look forward to reading more publications from you.
Finally, a doctor who gets it. I am a registered dietitian, and this it what I do. Some doctors don’t send me patients now because I don’t support their weight loss consults. I am so happy and relieved!
Cancer is mostly caused by a diet high in free radicals (processed meats, BBQ meats). Those who eat a lot of free radicals are more likely to have cancer and those who eat a lot of bacon, are more likely to have cancer and obesity. The food is the problem. Not the weight. Weight is a symptom, not the cause. Many thin people have cancer. Many overweight people live long happy lives. Obesity does not cause cancer.
Thanks for the great discussion and sharing your information.
ADHD is a very common underlying disorder in people with “obesity” or whatever you name it.
Based on CADDRA statistics, prevalence of ADHD in people with eating disorder is 11.4%. In one study, 1/3 of patients who referred for obesity, had ADHD, of which 65% had binge eating disorder.
SO Please consider screening patients for ADHD with a simple questionnaire: ASRS
Without treating this underlying condition, nothing will help them, really.
Thanks again
I appreciate the information about BMI use in eugenics. Moving forward I’ll report height and weight. Thank you.
Hi Dr. Wind,
Like others, I greatly appreciate the balanced and empathic perspective. I am a psychologist and focus on dealing with ADHD and sleep disorders. Many people in both of these populations struggle with their weight, and too many physicians focus on their weight rather than underlying issues, especially the sleep disorders. I would encourage physicians to do some quick screening for these disorders also, if possible, because addressing them can be life changing.
Again, thank you for the informative article.
Thanks for this approach, I have patients that changed from former doctors just because that physician was blaming any ailment to obesity. I agree that fat shaming is counterproductive and a healthy diet and physical activity are more prone to improve the outcome in better health
Thank you Dr. Wind for pushing us to think about the taken for granted terms that we use and how they may be causing harm. Also, shout out for mentioning Maintenance Phase! It’s a great podcast that deals with all sorts of health topics through a critical lens (and with lots of swears!).
Firstly let me commend Dr. Wind on her inclusive practice and her stance on weight bias and fat shaming. I could not agree more that indeed we as a community need to address health and indeed separate weight from health. The BMI is founded in racist misogynistic practices and we do need something better to indicate determinants of health beyond a scale. I have long championed the use of the word adiposity to refer to fat tissue and the use of adisopathy to refer to metabolic disease associated with adiposity. Words matter.
With that said I encourage Dr. Wind and other trainees and colleagues to learn more about metabolic medicine, obesity medicine and the practice that surrounds it. As a physician who has spent 22 years in the field I along with many of my colleagues champion evidence based medical and surgical treatments that ARE indeed safe and effective. The world of obesity medicine is changing. Newer agents offer as much as 20% body weight loss. Volumes of data now confirm the complex nature of energy regulation, starvation response and the effectiveness of many treatments for weight loss and risk reduction. In short- Dr. Wind- it’s not so simple. If we are truly to advocate for HEALTH AT EVERY SIZE we must acknowledge that there is a place for weight loss as a treatment for metabolic disease and DIETING is not that treatment. I commend you for your thought provoking article to move the needle on weight bias in medicine but I ask that you perhaps spend a day or two with me or one of my colleagues to learn more about obesity and its treatment before you fully change your practice so early in your training. I would argue you may come to an expanded set of conclusions that indeed change your practice further. I include my email here for you to contact me zentner@gmail.com I also welcome anyone reading your article or commenting below to engage in a more nuanced discussion about this issue. Not all size is a disease. Obesity is a disease. How we diagnose it is wrong. Let’s not abandon treatments but instead search for better diagnostic tools. Let’s as a community be inclusive and not divisive about size and the origins of weight and adiposity. Let’s learn from one another and combine evidence with empathy. That is how we change our practices.
High blood sugar, high blood fats, and high blood salt is the cause of chronic illnesses and obesity.
Obesity is the symptom. Dieting is not the answer, weight loss is not either. Changing food habits is. Medications will not change food habits and nutrition, just nutrition markers. Obesity is correlated with illnesses, not the cause of illnesses. If it was, no obese person would live a long time, no thin people would ever get heart attack, hypertension, strokes, cancer and diabetes.
I am grateful for the opportunity to have this discussion and I agree with several points made so eloquently in your article. I do indeed see that many patients struggle and do not lose weight with dieting, and I do not like the word obesity or the use of BMI. I feel that we live in a very weight-promoting world and the huge weight loss industry shamelessly exploits our insecurity about our weight. I also do not agree with the use of harmful drugs and surgery with limited long term benefits.
However, I personally have not worked with any physicians who are interested in fat shaming their patients and indeed we are often too cautious to raise the subject for fear of offending, when many of our patients may even wish to discuss it. I don’t think we should ignore weight as I know many people who are very unhappy about their weight and I do not feel we should shift to just saying that any weight is healthy.
I think we have failed to have proper discussions about what it is to eat well to be healthy rather than to lose weight and we need to put pressure on the food industry to stop selling us cheap rubbish food that is not nutritious. This industry is responsible and is not being held to account. Eating a healthy diet and getting some exercise is not rocket science. There are too many vested interests in keeping us fat and unhappy and it is outside the scope of healthcare alone to fix it.
There is a complicated set of genetic and metabolic factors involved in body weight regulation.
In BC, yet another of our outmoded and non-evidence based approaches is that we in Fee-For-Service Primary Care must suffer, yet can be compensated for, is taking the time to talk to (only) 100 patients a year about lifestyle issues such as smoking, harmful substance use, physical activity, and nutrition. Yet the BC Health Approved Templates in our EMRs for these conversations has check boxes to denote a patient’s BMI and “Obesity” status” and counsel them on “weight loss”. I generally cross this out and type in “encouraging weight loss not indicated”. It is also ridiculous that the Medical Services Plan caps the compensation for conversations about Lifestyle at 100 per practitioner per year. After the first 100, we can have these conversations, but there is no additional financial incentive for us to do so. Just caring, I guess.
Thank you for this excellent article and for contributing to this forum.
Maybe there is a way to diagnose obesity and prescribe weight loss while remaining non-judgmental and understanding the complexity of obesity. Unfortunately it is not possible to be “heatlhy at any size”, obesity is not healthy, and weight loss has been shown to reduce both morbidity and mortality.
Thank you for this informative article. I appreciate you highlighting the significance of how harmful language can be in a clinical setting. I agree that a small change in all health professionals’ behaviour (by implementing non-violent communication) can have a significant impact on establishing improved rapport, compliance and ultimately, a respectful working relationship with patients.
This is a wonderful article and I will be passing it along to many learners and colleagues. Thank you!
Not surprisingly, this topic has generated significant discussion and hopefully respectful debate will help drive learning. What’s clear is there is abundant interest and care amongst clinicians seeking to help their patients.
We are planning future articles on this important issue.
The article has sparked quite an interesting conversation, including what is a “respectful” discussion about weight. However, it seems that most assessments of what constitutes a respectful discussion with patients do not include comments from patients themselves.
I’m a gastroenterologist that deals with patients with NASH (non alcoholic steatohepatitis). This is a condition that can progress to cirrhosis and kill you. This is proven. We’re not guessing. The only known effective treatment is weight loss. Your article makes me feel like you want me to dance around the topic, for fear of emotional harm. It make me feel like the next thing I have to worry about is being labeled as “fat shaming” my patients in this politically correct world.
I go to great lengths to be respectful of my patients and I’m careful in my approach and wording. However, I must be honest with these patients. I have to counsel them that weight loss helps this disease. I spend most of my time, after introducing the idea of weight loss, counselling them to make a reasonable target, as they often get overenthusiastic. I encourage them to do it slowly over a year, avoid crash diets (that can hurt their liver) and avoid anything they cannot maintain over their lifetime. Dieting alone is not the answer, I completely agree. It has to be a multipronged approach. I’m also the first to admit that I am not a weight loss expert. I only record BMI if I need it for a bariatric surgery referral, otherwise I do not see the point.
I do not label people as obese but I would be medically liable if I did not discuss weight loss in this situation.
It’s not about size or image, it’s about being healthy. People can only change if they have good information from which to start (hopefully presented in a non judgmental fashion)
PS. If gaining 20lbs would make me live longer.. .you bet…I’m in.:)
I’m so glad a physician wrote this and I hope respectful discussions can continue with genuine exploration of our own biases towards bodies and weight. I like how Dr. Wind has committed to implementing disordered eating screening. IMO area of disordered eating and eating disorder screening + diagnosis in primary care would be a practical and relevant learning opportunity for primary care physicians and teams. Thank-you!
There is no doubt that the intent of the article to destigmatize adiposity (a preferred term for obesity amongst the bariatric medicine community) is genuine and I commend Dr. Wind for putting forth the issue of weight bias. There is a lot of work to be done in the medical community as a whole to undo the stigmatization that persons with adiposity face in medicine. Dr. Wind is correct that the use of BMI as a measure of adiposity was founded on questionable science and actually was never intended to be used as a measure of one’s health or metabolic status. The term “obesity” does derive from French and Latin with a definition that would offend many people. In this sense, we do need to do better in how we assess persons with adiposity and need to be thoughtful about the language we use in our clinical encounters. However, where this article starts to wade into questionable territory is the recommendation to avoid conversation about weight and addressing weight as a medical issue.
As you know, there is a link between adiposity and metabolic disease. Not all individuals with adiposity will have metabolic complications (or “adisopathy”) or complications related to “fat mass disease” (e.g. joint issues, hypoventilation, lymphatic disease) just in the same sense that there are many individuals with by definition “normal BMI” or “normal weight” who have quite advanced metabolic disease.
We are now in an era where adiposity has been deemed a medical condition by multiple organizations and this has led to advancements in understanding the hormonal, neurobiochemical and psychological influences on weight. As such, in the last 10-15 years there have been great advancements in treatment for adiposity with phamacological agents (for example the recent SURMOUNT trial using tirzepatide), bariatric surgery and treatment of associated eating disordered behaviors through medications or CBT type measures. These treatments are safe and effective. In my personal practice and those of my colleagues, we have been able to offer treatment to individuals who otherwise would have advanced to end stage disease related to adiposity.
If we are truly advocating for our patients and taking into consideration “health at every size,” then we really do need to emphasize the “health” aspect. We need to destigmatize “obesity” but avoiding its discussion with patients and turning away from effective treatments is not the way to do this. As an addendum to the article, I do think it would be important to highlight the advocacy work of Dr. Ali Zentner who founded the COPS (Canadian Obesity Peer Support Program) and outlines how we can address weight bias in our own practices. It may also be worthwhile to have an expert in bariatric medicine comment on the effectiveness of treatment. Obesity Canada also has a framework that can be used in clinical encounters of any type for having a respectful conversation about adiposity. There are now multiple guidelines that outline effective forms of treatment for adiposity where appropriate. “Obesity” is a disease and we need to consider it as such to avoid further harm the to the individuals affected by it.
This is very interesting. I have lately not been harping on my patients’ excess weights. So this gives me more helpful information.
Thank you!
I fully appreciate the content of this article.
I totally disagree that “fat shaming” means we should re-frame the obesity epidemic – any more than cancer/mental illness shaming means we should re-frame their causes.
Not shaming/blaming patients (how about a smoker with lung cancer, a antivaxer with Covid) for the “cause” of their condition should not result in a disengagement in the etiology and cure of their condition(s).
Thus, I reject the essential hypothesis of this paper, but do support the above points.
Sincerely.
This is such an excellent discussion. I have adopted many of the approaches in this article in my own practice over the last few years – including screening for eating disorders in people of all body sizes, screening for ADHD, screening for ACEs, and not weighing patients unless they are babies, specifically need a weight to prescribe a medication or order a test. My patients appreciate this and this approach has spurred many rich discussions in my office. Weight stigma and discrimination in medicine based on BMI is widespread – even in healthcare providers who are well meaning and trying to do their best. As physicians we often hold many levels of privilege that we need to be aware of – consider whether you also hold thin privilege when you are working with patients. Do not equate body size with morality. Consider intersectionality as our patients have many overlapping factors in their lives which lead to how they may appear in front of you. As someone who was taken in by diet culture for too many years, not even knowing what it was, I am so relieved that these conversations are beginning.
Other podcasts which have been valuable to me for understanding these issues are “Let Us Eat Cake” – by the dietitians from the provincial eating disorder clinic ( Hannah Robinson and Ali Eberhardt) https://www.letuseatcakepodcast.com/ and “Food Psych” by Christie Harrison (https://christyharrison.com/foodpsych)
Let’s keep the conversation flowing.
Interesting article. I have seen several patients VERY offended when another doctor or health care professional uses the words obese or obesity to describe them. It seems to me that at some point having a very large weight can indeed shorten people’s lives. I also see in particular orthopaedic surgeons avoiding hip and knee replacements based on weight in recent years. I would like to see an “Obesity Day” CME for family doctors with several presenters talking about different aspects of this.
Thank you for the thought-provoking article and ensuing discussion. I appreciate the challenge to question what we often accept as fact and will reflect on how to respectfully engage patients in addressing the multiple factors impacting their health and weight gain and how to address these factors to improve their health rather than just focusing on weight loss as the goal. Thank you for spurring on this conversation!
First I just want to say how heartened I am by the all responses. I do not expect to undo a lifetime of learning in 1000 words, and the amount of positivity makes me very hopeful and happy for all our patients.
Even those that disagree with the article – I really appreciate your engagement and respectful replies. I am excited to have ongoing conversations as I think we already agree on so much. There is no doubt in my mind that as physicians we all go into this practice wanting to do good, with our patients best interests in mind. I think physicians working at weight loss clinics, especially, go into the field because they see how much patients struggle with weight loss, and want to provide better care.
However, I wonder how much MORE successful we could all be if we adapt the Health at Every Size (HAES) framework. How many more patients would be able to truly focus on increasing nutritious food intake, increasing activity, increasing sleep etc. if they saw the behaviours themselves as a success, rather than a number on the scale. How many more patients would engage with us if they knew we weren’t judging their size and assuming health behaviours. How much more time we would have to manage comorbidities with interventions that actually work long-term?
We make medical recommendations based on risk vs. benefit. We have assumed that weight loss is a risk-free intervention, which this article demonstrates is incorrect. We have also assumed that the benefit of weight loss is very great – however when we look at the long-term data, the true success rate is exceedingly low. If I have a patient in the “obese” range, who also has diabetes that is well controlled with both medication and because they are no longer eating erratically and have stopped weight cycling, who engages in movement and stress reduction that they enjoy – why do I need to ruin all that by prescribing calorie restriction and/or weight loss?
An additional note from Dr. Erlanger, who has years of experience working with the HAES model: There are many “obesity” related diseases that improve with short term weight loss. This is not surprising, as the body makes many adaptations for acute undernourishment that include lower insulin resistance and inflammation. This doesn’t change that the only predictable outcome of weight suppression is weight regain, and that weight regain is correlated more strongly correlated with these same diseases than “obesity” itself. Not having any other treatments does not mean we should use a harmful treatment. If we stop prescribing intentional weight loss due to its well documented long-term harms for the diseases we claim it cures, such as NASH, maybe there will be more research done to find treatments that work in all body sizes! There is evidence that balancing carbs with protein, fibre and fat, increasing movement, improving sleep, relationships, and stress and treating depression and reducing stigma all help disease measures and quality of life measures. This can be done without prescribing weight loss.
Of course, there are barriers. Patients who have spent a lifetime dieting would benefit from being connected with HAES dieticians and counsellors, which we do not have many of (although looks like we have a few above!). As well, we do not presently have any official HAES certifications or courses for physicians. I hope that this article will be the first step towards building this infrastructure.
At the end of the day, this is not about political correctness; it is about kindness, humility, and what the evidence shows actually works for our patients. I encourage people to check out some of the resources and continue learning more.
Dear Dr. Wind,
As an orthopaedic surgeon, I see patients with severe patellofemoral pain on a daily basis.
From a mechanical (physics) perspective, the patella “multiplies” the patient’s body weight by ~5 (joint reaction force).
As you may guess, many of the patients experiencing patellofemoral pain are overweight. I usually draw diagrams and explain the importance of weight-loss and quadriceps strengthening as a means of reducing the joint reaction force and thus alleviating their pain.
I would love some suggestions/ideas on how to address this problem without discussing their weight.
In my practice I have noted that patients with an elevated glucose level that lose weight get better
Sugar control. I have assumed this is beneficial
To their health
Hi Dr Wind. Thank you for this article. It is well written and invites us all to look at the historical teachings about weight through a more critical lens. I can understand where many commenters are coming from when they point out correlations between weight loss and improvements in things like glycemic control or knee pain, and therefore feel it is important to encourage weight loss in patients. I find there is a big piece missing in these types of arguments. We do not know that measuring weights in the office, encouraging weight loss, and counseling about the potential downsides of obesity are actually achieving the goal of healthy and sustained weight loss. These efforts may temporarily help a few patients to lose weight, but I would bet that many more patients would feel more shame, experience more weight cycling, and be less likely to seek care in the future. I believe we would be helping more patients and providing a greater net-benefit to our communities by reducing weight stigma and shame.
One field that weight stigma is alive and well is reproductive endocrinology and fertility clinics. Patients are DENIED access to creating a FAMILY because of their weight/BMI that automatically places them in a higher ASA classification and therefore clinics refuse to perform conscious sedation for egg retrieval and other procedures. It’s modern eugenics. Instead they are sent away and told to lose an unreasonable amount of weight in a short time, leading to metabolic issues, being pressured into bariatric surgery or severe caloric restriction, disordered eating, shame, weight cycling, depression and so on. We are telling these patients that because of their weight they are not ‘good enough’ to have children. Just think about that for a minute, and I hope it’s a sobering thought.
Or, we make them feel like pregnancy in a larger body is extremely high risk and we decide for them whether that risk is worth it. When did deciding a patients risk tolerance fall to the health professional and not the patient? I’m so glad to see people finally paying attention to this urgent issue. And also equally disappointed with the number of people who disagree with this article despite all the evidence available and referenced in this article. Why is that acceptable as a health care provider? Do you just ignore evidence about diabetes? Arthritis? Back pain? Asthma? I fully support HAES principles and dearly hope more providers will acknowledge the harm they are inflicting on the fat community.