The overall goal of primary care is to improve patient’s health and quality of life
Healthcare providers strive to provide the highest quality care for their patients. Health professionals are responsible for adhering to ethical principles in the care of their patients, such as beneficence (i.e., the obligation to benefit and contribute to optimum health for patients and communities) and nonmaleficience (i.e., the obligation to avoid harming patients and communities).1
The goal of primary care is to improve patient’s health, longevity and quality of life by identifying modifiable behaviors that increase disease risk and help patients change them. US preventive Services Task Force guidelines recommend screening for obesity and offering behavioral interventions. Health policies typically emphasize weight loss as a target for health promotion. Weight loss and weight surveillance feature prominently in public health campaigns and health-related policies from the Surgeon General’s recommendations (U.S. Department of Health and Human Services, 2010) to the National Institutes of Health’s research priorities (Office of disease Prevention,2019). The Equal Employment Opportunity Commission, a government agency designed to protect against employment discrimination, even affirmed that employers can offer reduced insurance premiums to their thinner employees (U.S. Equal Employment Opportunity Commission,2016.) 2
The traditional approach to health care has emphasized the role of body weight as one of the main determinants of health. This weight-normative approach rests on the assumption that weight and disease are linearly related and emphasizes personal responsibility for healthy lifestyle choices. The focus is primarily on weight loss and weight management as the method for preventing and treating health problems.
Today, the number of people considered obese continues to grow. From 1999-2000 through 2017-2018 the prevalence of both obesity and severe obesity increased from 30.5- to 42.5% and severe obesity increased from 4.7% to 9.2% among adults 3
Obesity and severe obesity defined: Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared rounded to one decimal place. Obesity in adults was defined as a BMI of greater than or equal to 30, and severe obesity as a BMI of greater than or equal to 40. 3
Rising weight trends have created an intense focus on weight loss initiatives, but none have generated long-term results for the majority of participants. It is estimated that no more than 20% of participants who complete weight-based lifestyle interventions maintain the weight loss one year later. 1
According to the Center for Disease Control and Prevention, people who have obesity, compared to those who are at a healthy weight, are at an increased risk of serious disease and health conditions, including: All-causes of death (mortality), High blood pressure (hypertension), High LDL cholesterol, low HDL cholesterol, or high levels of triglycerides (Dyslipidemia), Type 2 diabetes, Coronary heart disease, Stroke, Gallbladder disease, Osteoarthritis, Sleep apnea and breathing problems. Many cancers including endometrial, esophageal adenocarcinoma, gastric cardia cancer, Liver cancer, Kidney cancer, Multiple myeloma, Meningioma, Pancreatic cancer, Colorectal cancer, Gallbladder, Breast, thyroid, ovarian.4 Low quality of life, mental-illness such as clinical depression, anxiety, and other mental disorders, as well as body pain and difficulty with physical functioning 3 It has been recently noted that adults with obesity have an increased risk for severe outcomes from Covid-19. 3,6 Individuals who are obese with no metabolic abnormalities are at higher risk of coronary heart disease, cerebrovascular disease, and heart failure than normal weight metabolically healthy persons.7 Current guidelines recommend that “overweight” and “obese” individuals lose weight (weight-normative approach) through engaging in lifestyle modification involving diet, exercise and other behavior change. The weight-normative approach that has been used over the past 20 years has not shown to be effective for helping people lose weight. On top of not being effective, there is great concern that these approaches may cause more harm than good.
The weight-normative approach
The weight-normative approach has heightened obesity awareness and government surveillance which has contributed to fat phobia and weight based stigma that has been shown to cause psychological, behavioral, physical and social harm. Psychological harm includes body dissatisfaction, distraction from other life goals, discomfort and distress, distrust of the body, disembodiment or disassociation from one’s body, and depression. Behavioral harm includes delayed living, delayed health care, dieting, and disordered eating and exercising. Physical harms includes diminished quality of health care, decreased nutrient absorption, decreased satiety, destabilized body weight, increased disease risk factors, and death. Social harms included dehumanization and discrimination, stigma, prejudice, and other forms of oppression. 8 The current weight-normative approach creates and sustains an adipophobicogenic environment which promotes fat phobia and oppression, weight biases, prejudice, stigma, discrimination, bullying, violence, and cultural imperialism. This environment in turn contributes to the reduced physical, mental, social and spiritual health and well-being, and ultimately reduced quality of life for people categorized as obese.8
Not only is the weight-normative approach ineffective at producing and maintaining weight loss, but it may also have unintended consequences including food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination.8
A weight-normative approach emphasis in medical care may overshadow a patient’s health concerns and needs. There is a cultural belief that people have to be dissatisfied with their weight in order to be motivated to improve it, and in fact people are more likely to take care of their bodies when they appreciate and hold positive feelings toward their bodies. 1
Healthcare providers often view obesity as an avoidable risk factor that impedes their ability to treat and prevent disease. Obesity related public health efforts have been identified as potentially harmful because they (a) have been based on limited or poor quality evidence (b) focus on preventing one extreme outcome at the expense of another extreme outcome (c) lack community engagement and (d) ignore the root cause of problems. 1
In Weight-normative practices, body size is pathologized, health practitioners have developed a weight bias toward clients in bigger bodies and this stigma further contributes to poorer health. Weight stigma can occur across a range of life domains, including school settings (higher weight children are often stigmatized by peers, classmates, teachers, and school administration) health care environments (higher weight individuals are stigmatized by healthcare professionals and insurance companies), public health initiatives and workplace settings.9
Despite the high prevalence of obesity, individuals with obesity are frequently targets of prejudice, derogatory comments and other poor treatment in a variety of settings including health care. There is evidence that provider’s communication is less patient-centered with members of a stigmatized group. Health care providers also allocate their time differently, spending less time educating patients with obesity about their health, and fail to refer the patient for diagnosis testing or consider treatment options beyond advising them to lose weight.
Patients with obesity that experience this stigma may feel high levels of stress which can contribute to impaired cognitive function and ability to effectively communicate. Accumulated exposure to high levels of stress hormones has several long term physiological health effects, including heart disease, stroke, depression, anxiety disorder, and diseases that disproportionately affect obese individuals and have been empirically linked to perceived discrimination.
For higher weight individuals, weight stigma has been associated with increased calorie consumption- which also challenges the assumption that pressures to lose weight will motivate people to lose weight. Adults that experienced weight stigma were 2.5 times more likely to become obese.
Other negative effects include avoidance of clinical care. The long-term result of avoiding or postponing care is that people with obesity may present with more advanced, and thus more difficult to treat conditions. 9
With obesity being a stigmatized condition, one side effect of the increased focus on body weight in health may be alienation and humiliation of these patients. A stigmatized trait can lead to experiences of discrimination, low self-esteem, depression, anxiety, and increased stress hormones, heart disease and lower quality of life. People who are overweight are avoiding medical care due to negative messages about their weight and as a result, wait until a medical crisis occurs to seek medical care. 10
Ethical concerns with the weight-normative approach
This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. This is where the growing trans-disciplinary movement called Health at Every Size (HAES) comes in. Health at Every Size (will be referred to as HAES from here forward) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. 11
What is HAES
HAES is a movement that is working towards ending fat-phobia. It is an approach to healthcare that is designed to help people take care of their bodies despite their size, and promotes a social-justice movement that aims to support people of all sizes having access to resources that will support their health. The HAES approach supports acceptance of size and body diversity. This means that all body sizes can see benefits to behavior change. The purpose is to support health behaviors and access to health resources and respectful care for people of all body sizes. 13
For more information regarding Health at Every Size (HAES) see my previous Blog post 12 HAES: Part One. A brief overview of Health at Every Size – Waistline Dietitian
The HAES model of health care supports people across the spectrum (weight as well as socioeconomic) and seeks to end stigmatizing of health problems (healthism), and weight based discrimination, bias, and iatrogenic practices within health care and other health-related industries, as well as other areas of life. The model acknowledges that weight is not a behavior or a personal choice, and that normal human bodies come in a wide range of weights and sizes.
The weight-inclusive approach
A weight-inclusive approach would begin with the premise that all people deserve access to good healthcare and everybody is capable of achieving health and well-being independent of weight, given access to non-stigmatizing health care.
The weight inclusive model seeks to end:
1.The stigmatizing of health problems (healthism).
2.And weight based discrimination, bias, and iatrogenic practices within health care and other health-related industries, as well as other areas of life. The model acknowledges that weight is not a behavior or personal choice and that normal bodies come in a wide range of sizes and seeks alternatives to the overwhelmingly futile and harmful practice of pursuing weight loss. There is no set health-related interventions that prioritize BMI reduction as goal, given that a predominant focus on BMI reduction is linked to weight stigma.
General principles of a weight-inclusive approach
(1) Do no harm. Prescribing weight loss carries the risk of adverse outcomes for adherents and lacks evidence for sustainability over time, potentially setting many patients on a path of weight cycling. The current weight-normative approach bestows negative judgements onto higher weight individuals as unhealthy and that weight can be controlled by will power.
(2)Appreciate that bodies naturally come in a variety of shapes and sizes, and ensure optimal health and well-being is provided to everyone, regardless of their weight. (size acceptance)
(3)Given that health is multidimensional, maintain a holistic focus (i.e., examine a number of behavioral and modifiable health indices rather than a predominant focus on weight/weight loss). There are many behavior changes that can be made to improve health including improving sleep quality, stress reducing activities, physical activity, intuitive eating, and taking medications as prescribed, and participating in regular physical check-ups.
(4)Encourage a process-focus (rather than end-goals) for day-to-day quality of life. For example, people can notice what makes their bodies rested and energetic today and incorporate that into future behavior, but also notice if it changes; they realize that well-being is dynamic rather than fixed. They keep adjusting what they know about their changing bodies.
(5)Critically evaluate the empirical evidence for weight loss treatments and incorporate sustainable, empirically supported practices into prevention and treatment efforts, calling for more research where the evidence is weak or absent.
(6)Create healthful, individualized practices and environments that are sustainable (e.g., regular pleasurable exercise, regular intake of foods high in nutrients, adequate sleep and rest, adequate hydration). Where possible, work with families, schools, and communities to provide safe physical activity resources and ways to improve access to nutrient-dense foods.
(7)Where possible, work to increase health access, autonomy, and social justice for all individuals along the entire weight spectrum. Trust that people move toward greater health when given access to stigma-free health care and opportunities (e.g., gyms with equipment for people of all sizes; trainers who focus on increments in strength, flexibility, V02 Max, and pleasure rather than weight and weight loss).”
Applied to policy this would: Provide environments that give access to all the things that support the well-being of human bodies of all sizes. This may include an end to weight discrimination in schools, insurance, workplaces, and housing. Living wages would be adequate to provide time for self-care, nourishing, affordable, as well as access to food, and recess for all ages, abilities and sizes.
Within health care: Provide health interventions that give benefit to people at any size without discrimination or bias.
This may include medical education on “best practices” for providing healthcare to higher weight people. End BMI based treatment decisions. Base practice on the lived experience of patients: listen and learn. Medical offices would have furniture and equipment that fit higher weight individuals. Obtaining weight would be done in private and would be optional. Healthcare professionals can become educated about links between internalized weight stigma and poor self-care that maintain adverse physical health and negative psychological well-being.
In personal life: Provide yourself with the features of life you find sustainable, within the context of your life, that support well-being. This may include: Reconnecting with your body’s cues to make decisions about what you need to know. Know your worth is not related to your health. Look for ways to improve life and health that do not require a thinner body. 1 ,2
HAES is one of many models which include a weight-inclusive emphasis, and address the broad forces that support health and safe and affordable access to care and helps people find sustainable practices that support individuals and well as community well-being.
The HAES model upholds the ethical principles of beneficence and nonmaleficience by focusing on eradicating weight stigma, honoring human differences (size diversity) and focuses on interventions that promote physical health and psychological well-being.
Studies involving the weight-inclusive approach found participants had decreased body dissatisfaction, decreased bulimic symptomology, reduced dysfunctional eating attitudes, decreased total cholesterol, low density lipoprotein (LDL cholesterol), triglycerides and systolic blood pressure, and improved mood, Increased self-esteem. The key is for both health care professionals and patients to appreciate the extent to which body loathing and shame is associated with a REDUCED engagement in self-care. If patients begin self-care practices that enhance physical health, they will likely feel better psychologically as well; and these psychological gains are linked to future increases in self-care practices that enhance health! People are more likely to take care of their bodies when they appreciate and hold positive feelings toward their bodies.
In order to encourage self-care behaviors, patients need to learn to reconnect with their body and focus on internal body awareness. Internal body awareness is required to be able to know when something is not right with their body as well as attend to their body’s physical and psychological needs. For example, awareness of hunger and satiety cues is needed to determine when and how much to eat In order to prevent under or over feeding. For more information regarding Intuitive eating please see my blog 14 What Is Intuitive Eating? The Good, the Bad and the Key Takeaway for Success! – Waistline Dietitian. Greater internal awareness and appreciating the body are related to higher eating based on physiological hunger and satiety cues and less situational and emotional eating- additional reasons for health care professionals to encourage clients to appreciate their bodies and listen to their bodies internal cues. 1
Healthcare should focus on modifiable health behaviors such as physical activity, diet, smoking, and alcohol consumption and self-care activities (stress reduction, quality sleep). Over the past 2 decades, studies have investigated the impact of weight-inclusive approach on various health and well-being indicators and have found this approach to be more effective in improving various aspects of physiological, psychological, and behavioral care. This includes improved body image, self-esteem, and eating attitudes in children. Improved Intuitive eating, body self-esteem and anti-fat attitudes and dieting behaviors in adults. 8
- The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss (hindawi.com)
- An Evidence‐Based Rationale for Adopting Weight‐Inclusive Health Policy – Hunger – 2020 – Social Issues and Policy Review – Wiley Online Library
- Adult Obesity Causes & Consequences | Overweight & Obesity | CDC
- Obesity and Cancer Fact Sheet – National Cancer Institute
- New CDC data finds adult obesity is increasing | CDC,
- Obesity: A critical risk factor in the COVID‐19 pandemic (wiley.com)
- Metabolically Healthy Obese and Incident Cardiovascular Disease Events Among 3.5 Million Men and Women – ScienceDirect
- What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight-Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift – Lily O’Hara, Jane Taylor, 2018 (sagepub.com)
- Impact of weight bias and stigma on quality of care and outcomes for patients with obesity – Phelan – 2015 – Obesity Reviews – Wiley Online Library
- Strategies to decrease fat stigma in women’s health – Women’s Healthcare (npwomenshealthcare.com)
- Weight Science: Evaluating the Evidence for a Paradigm Shift | Nutrition Journal | Full Text (biomedcentral.com)
- HAES: Part One. A brief overview of Health at Every Size – Waistline Dietitian
- The Health at Every Size® (HAES®) Approach | ASDAH