What is a ‘weight-inclusive’ doctor?

My wife went to see her primary care doctor a month ago to get help with her migraines. After doing a thorough workup and blood panel, the doctor took my wife down the hall to the office’s “wellness director” and was told she will be put on 1200 calorie a day diet. Huh? How will this help her migraines? Like most physicians, the number on the scale was the determining factor for how to proceed with medical care. Get her BMI down and surely everything else will settle out as well. This is bad medicine, but sadly is the standard of care.

My own primary care doctor knows I’m an eating disorder therapist and specialize in binge eating disorder. But after he checks me over in my yearly physical, says to me “everything looks great,” he leaves me with his standard goodbye statement, “try losing some weight.” Gah!

This is why I was so glad to see the Journal of Obesity come out with an 18 page paper called “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” Full disclosure, a friend and one of my favorite therapists in the field, Dr. Deb Burgard, is a co-author. The purpose of the paper is to evaluate “two methods of working within patient care and public health: the weight-normative approach (emphasis on weight and weight loss when defining health and well-being) and the weight-inclusive approach (emphasis on viewing health and well-being as multifaceted while directing efforts toward improving health access and reducing weight stigma).”

In most Western countries, and the United States especially, patients who are overweight or obese avoid medical care due to overt or covert negative messages about their body by their physicians. As a result, patients wait until a medical crisis occurs and then often face unpleasant and demeaning treatment and attitudes from their providers and continued pressure to lose weight. Weight loss has been proven time and again to be unsuccessful for over 90 percent of people, yet is still the go-to suggestion by most physicians. This leads to the patient disappearing until the next medical crisis. The good docs are starting to ask, “Is there a better way to treat my patients so they don’t just come for emergencies?”

Let’s start with a few basic facts:

• Higher body mass index (BMI) does not cause poor health
• Those who are obese and stable in their weight have no difference in mortality rates compared to those who are stable and non-obese
• Those who yo-yo diet are more likely to have significant medical and mental health outcomes

In the “weight-normative,” or weight-loss approach, we find the following:

1. The data behind the failure of weight loss interventions is clear. Only 1 in 5 can keep even modest weight loss for a year. That number drops precipitously each year out. And these are from the most promising studies with only the most motivated patient samples.
2. There is clear danger in weight cycling, also known as yo-yo dieting. Those who yo-yo diet are found to have higher mortality rates, higher risk for bone fractures and gallstone attacks, loss of muscle tissue, hypertension, chronic inflammation, coronary heart disease, and cancers including renal cell carcinoma, endometrial, and non-Hodgkins lymphoma. Weight cycling leads to permanent metabolic disruption, and subsequent weight loss attempts lead to loss of more lean muscle mass. Emotional disruption occurs as well, including a belief that failed weight loss means the person is less lovable, desirable, and acceptable; this leads to increased depression and anxiety, reduced exercise, and increased binge eating.
3. Eating disorders can develop from attempts to maintain weight loss. The more and longer someone restricts their caloric intake to maintain weight loss, the more likely they are to flip into binge eating behaviors and compensate with bulimic behaviors including vomiting, laxative misuse, excessive exercise, and fasting.
4. Weight stigma (weight-related attitudes and beliefs that manifest as stereotypes, rejection, prejudice, and discrimination towards individuals of higher weights) is heightened by weight cycling behavior. The medical emphasis on “good weight” versus “bad weight” reinforces the internalization of the message that women should be thin, men lean and large muscled, and weight loss is expected. This increases the likelihood of weight-related teasing, bullying, harassment, violence, hostility, ostracism, and forms of overt or covert aggression. Doctors are every bit the culprit here too as stated at the outset of this blog.

The tenets of the “weight-inclusive,” non-diet, Health at Every Size (HAES) approach are as follows:

1. do no harm
2. appreciate that bodies come in all shapes and sizes, and ensure optimal health regardless of weight
3. health is multi-dimensional (physical, emotional, spiritual)
4. encourage self-awareness of how behaviors make you feel; increase the behaviors that increase wellness and happiness and decrease those that make you feel sick, tired, etc.
5. incorporate sustainable, empirically supported treatments efforts and prevention practices into healthcare
6. create healthful, individualized and enjoyable practices into the care program (i.e. fun forms of movement, enjoyable and nutrient-dense foods, adequate sleep and rest, adequate water intake). Engage schools, families and stake-holders to create safe places for physical activity, improve access to nutrient-dense foods, etc.
7. Where possible, work to increase health access, autonomy, and social justice for all individuals along the entire weight spectrum.

And we know a “weight-inclusive,” non-diet approach works.

1. Clinically significant improvement in blood pressure, increased physical activity, self-esteem and reduced disordered eating when compared to weight-normative approach, and with no adverse outcomes.
2. Only 8% of people dropped out of weight-inclusive programs versus 41% of weight-loss programs.
3. Non-diet approach to healthcare has been shown to lead to: increased self-image and self-esteem, hunger and satiety awareness, decreased drive for thinness and bulimic behaviors, and less depression; and still decreased total cholesterol, LDL cholesterol, triglycerides, and blood pressure.

The article, which can be found below, has so much more than I’ve already share. It talks about how to help create better healthcare policy, how doctors can put into practice specific weight-inclusive principles, and directions for future research. If you don’t think your doctor is providing you with the right approach, give them this paper, talk with them about it, let them know that if they disagree with this, you’ll be looking for healthcare that really cares about the whole person and not a number on a scale. That’s how you can affect change for yourself immediately.

My wife and I are standing beside you.

http://www.hindawi.com/journals/jobe/2014/983495/

 

By Andrew Walen, LCSW-C -
 Founder, Executive Director, Psychotherapist at The Body Image Therapy Center. If you would like to get in touch with Andrew please call 443-602-6515 or email [email protected].