For decades weight loss and dieting has been the mainstay of lifestyle intervention. Now clinicians are calling for a healthier approach.

Content Warning: this article discusses weight loss, eating, exercise and ‘obesity.’ 

I sat there in the room, gulping as a clearly distressed woman once again was told about the benefits of weight loss, and the risks of continued weight gain on her future child. 

“You might need the larger cuff,” the consultant said, pointedly. I was one step ahead, trying to avoid bringing too much attention to the change, but evidently failing. 

As I inflated the cuff, the velcro crackled. I gulped again. The cuff was going to come undone before I could take the BP. I felt uncomfortable and guilty. 

The patient went home without a blood pressure measurement. Although asymptomatic, she missed the opportunity to have the early stages of preeclampsia or gestational hypertension detected.  

Before I could digest that this probably wasn’t a new experience for this patient, sitting in the back of the small consultation room, the consultant asks, “how much do you weigh?” 

It catches me off guard, I throw out a number. She throws back that the patient was over 3 times my weight, lecturing me about the risks of obesity in pregnancy. 

I know she’s right. 

But I know the situation is so very wrong. 

I know because weight stigma and bias is rampant in the healthcare sector and contributes inadvertently to the health impacts of obesity itself. More than half of all health professionals exhibit some form of weight bias towards people with obesity and there are countless patient stories, including that of Jen Bray highlighted in a recent ABC article discussing Australians’ motivations to lose weight. 

"Every time I go to the doctor it [my weight] is constantly pathologised without even any medical tools to find out if I actually am unhealthy," Bray told the ABC.

"I keep getting told that the way I am is wrong, but I'm healthy and I exercise … and I'm still wrong."

But, if obesity is such a notable risk factor for disease, surely it should be our focus when it comes to disease prevention. The thing is, there are a variety of risks associated with dieting being our red button response to illness.

Firstly, diets don’t tend to work. For decades, weight loss and dieting has been the mainstay of lifestyle intervention employed. Yet, we’ve consistently seen an increase in average BMI across the Australian population.  

How many times have we said, “first I would recommend lifestyle intervention, particularly weight loss” in the management section of a clinical exam? However, changing eating and exercise habits might not lose the desired amount of weight, or any weight at all due to the complex relationship between food, movement and size. Counterintuitively, one of the strongest predictors of weight gain is weight loss dieting; in those that do lose weight, many regain it. This is disheartening and leads patients who have been tasked with “weight-loss” to be less motivated to maintain these changes - particularly when these changes aren’t pleasant.  

Secondly, this “weight-cycling” or “yo-yoing” between weight loss and weight can actually cause negative health impacts including: a shorter lifespan, increased risk of diabetes, hypertension, hypercholesterolaemia, heart disease and eating disorders, amongst other adverse health effects.

Despite the belief that weight shaming may somehow encourage those subject to it to lose weight, the reverse occurs. The more people are exposed to discrimination and stigma, the more likely they are to gain weight. 

Research by the Obesity Evidence Hub outlines some of the harm caused by weight stigma:

• Health professionals have been shown to act differently with patients with obesity which impacts the quality of care. 
• The physical environment of healthcare settings may contribute to stigma, with inappropriate equipment such as seats, beds or toilets, insensitive signage, to a lack of diagnostic equipment suitable for those with a high BMI. 
• Evidence-based obesity management and support are scarce in Australia.
• Interpersonal and social relationships external to the healthcare system can cause isolation from family, relatives and society. 
• Independent of BMI, fat stigma increases rates of hypertension, inflammation and cortisol levels in the body.

This graphic from the Obesity Evidence Hub describes mediating impact of healthcare providers’ attitudes and behaviours on the association between obesity and health outcomes.  
The Royal Australasian College of Physicians (RACP) has recognised the negative effect of weight stigma, acknowledging in their position statement on obesity, not just the impact of the comorbidities of obesity, but also advocating  for the health sector to provide “leadership in reducing the weight bias which is pervasive in society, including among health professionals.”

“We need to recognise obesity as a systemic and societal problem. It’s not simply a matter of personal choice and responsibility as it is often framed.” - Professor Boyd Swinburn, RACP

So often weight bias is viewed as an individual problem. However, as Professor Boyd Swinburn, who led RACP’s position statement on obesity notes, “we need to recognise obesity as a systemic and societal problem. It’s not simply a matter of personal choice and responsibility as it is often framed.” This argument is consistent with other research which demonstrates that weight status and obesity are not under exclusive personal control.

A key part of the RACP approach also calls for practitioners to optimise health at any weight, whether this is looking at risk factors such as dyslipidaemia, hypertension and comorbidities such as diabetes and sleep apnoea. This is in line with a recent movement calling for a “Health At Every Size (HAES)” approach. 

HAES shifts the focus from weight loss to health promotion. That is, being inclusive of body size, ethnicity, sexual orientation, gender identification and social status while supporting patients to improve other health behaviours. Weight change may or may not be a side effect of changes in eating and movement that are in line with body-initiated cues. 

Contrary to myths that HAES is “anti-health,” or “promotes obesity,” research has shown the opposite. Six randomised controlled trials indicated a HAES approach was associated with statistically and clinically relevant improvements in measures (e.g. blood pressure, blood lipids), health behaviours (e.g. physical activity, eating disorder pathology) and psychosocial outcomes (e.g. mood, self-esteem, body image). More importantly, interventions taking a HAES approach saw substantially higher retention rates when compared to weight-loss. 

HAES and similar approaches to lifestyle change are often not taught at medical schools, where weight is typically medicalised, and high BMI is treated as a medical condition of its own and weight loss the ubiquitous first step to disease management. However, there is a growing number of resources on more inclusive approaches to lifestyle change, the factors (both societal and genetic) that contribute to a diversity in body size and the experiences of those who do face weight stigma in the places which are meant to treat all without judgement. These resources, outlined below, suggest referring patients to HAES dietitians, specialists and other health professionals. They also suggest advocating for a more accessible healthcare system by ensuring the necessary equipment and resources for equitable and adequate care are available, no matter the size of the patient. Such an approach may shift our focus to upstream behaviours, which could also see an improvement to the deficiency of nutrition teaching in medical schools, despite patients turning to their GPs with questions about diet first. 

As research shows, the false equivalence between weight and health has not helped the health of our patients and instead blames them for factors outside of their control. Instead of immediately lecturing the patient about their weight, I wonder if the obstetrician could have taken a non-judgement history about the upstream factors contributing to this? I wonder if the clinic was supplied with the necessary resources to cater for all patients, how the experience would have been different for the woman who sat in the room. 

I wonder if we supported the 60% of Australians who are currently trying to lose weight, to learn more about the role of health behaviours independent of weight and empower them to pursue these in a non-judgemental and inclusive manner. 

What would happen then?

If you would like to do your own research, here are some resources to help you along your journey to more inclusive healthcare: 

• • Health At Every Size Health Sheets: cover a variety of “lifestyle” illnesses and their management, without calling immediately for weight loss
  • HAES Australia has a list of resources and training programs 

Instagram accounts to follow:

• • @drjoshuawolrich: Dr Joshua Wolrich is an NHS doctor and author of Food Isn’t Medicine which explores nutritional science to demystify common diet myths and fight weight stigma. 
  • @haes_studentdoctor: Jess Campbell (she/her) is a Nutritionist and Student Doctor affirming care for ALL bodies. She shares resources to assist in interrogating the weight bias in research and in the treatment of medical conditions
  • Health At Every Size/Intuitive Eaters (Medical Doctors ANZ) is a space for discussion about non-diet, weight neutral approaches using the principles of HAES 

Books (suggested by @haes_studentdoctor) 

• • Health at Every Size - Linda Bacon
  • Body Respect -  Lindo Bacon and Lucy Aphramor
  • The Politics of Size - Ragen Chastain
  • The Body is Not an Apology - Sonya Renee Taylor
  • The Fat Studies Reader - Esther Rothbulum and Sondra Solovay
  • Seeing Patients - Augustus A. White III, M.D.
  • Body of Truth - Harriet Brown