Dr. Katarina Wind (biography, no disclosures)
The author 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.
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.
- 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.
- Association for Size Diversity and Health:
- About Health at Every Size® (HAES®). Accessed Apr 11, 2022.
- 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.
- 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)
- 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”
- 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)