Why we need a weight inclusive approach to health - an open letter.

Jul 30

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Dear reader,

I am writing to you in the capacity of a Registered Associate Nutritionist (ANutr) specialising in disordered eating to express my concerns with the ways in which we are talking about o**sity and health in our society. The government’s new measures including a ban of advertisements for highly processed foods and calories counts on menus have sparked both support and criticism. I would like to take a moment to zoom out from the proposed strategies and invite you to consider how and why focussing on the “importance of reducing o**sity”, no matter the proposed guidelines is problematic and stigmatising. Not only to individuals in larger bodies, but to ALL members of society and especially those living with past or present eating disorders.

Living in a society which fears higher body weights creates an environment in which eating disorders develop and thrive. A study looking at 5-year-old girls found 34-65% already had ideas about dieting, including the idea of not eating (1). In 2011, 46% of adolescents reported having attempted to lose weight with studies pointing to unhealthy weight control behaviours including diet pills, laxatives and self-induced vomiting (2). Additionally, these dieting attempts predicted both eating disorders or o**sity 5 years later (3). Parental encouragement for their child to diet has also been found to be predictive of risky weight control behaviours and increased weight gain in later life (4,5,6).

I do not believe it is possible to seek to end eating disorders whilst continuing to stigmatise individuals in larger bodies and promote disordered eating under the guise of “health”. How can we help individuals impacted by eating disorders to heal their relationship to food and their bodies when there is quite literally a “war” on bigger bodies? This also leaves individuals stuck in quasi recovery where they may be out of physical danger but are plagued by eating disorder thoughts and behaviours and body dissatisfaction.

There is evidence that a higher BMI is correlated with increased risk of certain chronic health conditions, however, this is a correlation, not causation. Moreover, the majority of evidence has not accounted for the physical and psychological impacts of weight stigma (7,8,9). Research has shown that weight stigma may drive many of the conditions that are typically associated with higher weight bodies including T2DM, elevated inflammation and pro-inflammatory markers, hypertension and cardiovascular disease (7,8,9). Weight stigma is also associated with mental health conditions including low self-esteem, mood and anxiety disorders, body image dissatisfaction and eating disturbances (8,10).

Health at Every Size is a social justice movement promoting fair and equitable healthcare for ALL people (11,12). It is inherently pro-health and anti-shame and it includes fighting the systemic inequalities in access to healthcare that affect many people. For example, The EMBRACE UK Report found that black women are 5 times more likely to die in pregnancy than white women and another study reported that BAME women are more likely to have a poorer experience of health care during pregnancy, delivery and aftercare (13,14). A sample of over 2000 physicians showed strong anti-fat bias that was both explicit and implicit (7). Individuals with higher BMIs report actively avoiding seeking health care due to fear of being stigmatized and when they do seek care their health is often judged solely on their weight (7). There are numerous accounts from women who had their health concerns dismissed and were told to lose weight to later find out they had cancer. In other words, weight stigma is delaying potential diagnosis and treatment of serious conditions.

HAES means we must come face to face with the social determinants of health (15). Focussing on weight as a behaviour allows politicians to overlook zero contract hours, fast food outlets being disproportionately located in deprived areas, the proportion of the population currently dependent on food banks, lack of safe green spaces for movement, damp and poor quality social housing and underfunded schools, leisure centres and NHS services.

Addressing the social determinants of health will play a far great role in reducing non-communicable diseases than focussing on the number on a scale will. HAES promotes nutrition and life-enhancing movement to improve health independently of weight loss so that people can feel comfortable and supported in making changes to their lives. It is also about cultivating respect for ALL bodies and appreciation for size diversity so that no child has to grow up feeling like their body is wrong which is leading to widespread body dissatisfaction, a major risk factor for the development of eating disorders (16).

In addition, research continues to show the ineffectiveness of dieting for weight loss (17). A study investigating the effectiveness of commercial weight-loss programmes showed that the majority fail to produce clinically meaningful results, with clinically meaningful considered to be 5% weight loss (18). A study based on the Biggest Loser programme found that 6 years later, participants had substantial weight regain and still maintained a lower metabolism than before weight loss (19). This suggests the metabolic adaptations that may occur in dieters which may increase rather than decrease body weight over time (20). Most recently, researchers have put forward an evidence-based rationale for adopting weight-inclusive health policy showing how policies that prioritize weigh loss stigmatize individuals in higher body weights and backfire to result in poorer health and ironically weight gain (21). Moreover, self-perception of being “overweight”, even if one is not, further predicts unfavourable health outcomes (21). This also opens up questions about what the government are doing to reduce exposure to unrealistic beauty ideals and how these coupled with new calorie counts on menus and increased fear mongering about higher weights will only increase body dissatisfaction and potential risky dieting behaviours and subsequent eating disorders.

Evidence also shows that individuals in “normal weight” categories can be metabolically unhealthy, whilst individuals in higher BMI categories can be metabolically fit (22). Research has also shown people in higher BMI categories who don’t smoke, drink within the guidelines, eat 5 portions of fruit and veg a day and engage in regular physical activity have been shown to have a similar risk of diseases as those who are of a ‘normal’ weight and also engage in those health-promoting behaviours (23). We need to focus on systemic inequalities and on life-enhancing behaviours that feel good, whilst reducing the stigma and focus on the scale.

Size should not be an indication of health. In no other place in health care is this more true than in eating disorders, where so often we see people being turned away from treatment because their BMI is not low enough to warrant the support. We must do better.

Given the body of evidence, I urge you to reconsider your stance on HAES. I hope you will understand mostly that:

HAES is a social justice movement and pro-health and that being HAES aligned means taking steps towards meaningful change for all bodies.
That using rhetoric like “reducing o**esity is important” contributes to ongoing weight stigma.
That statements like the above and weight stigma are inherently damaging for people with eating disorders. They fertilise the soil for eating disorders to develop and thrive and they make recovery all the more challenging.

It is wrong that we are promoting to certain individuals what we seek to so desperately undo and treat in others experiencing a severe, chronic and life-threatening mental illness. We all care deeply about the health of our loved ones and our NHS and we need to start being more open minded and consider a change of tact. If we truly care about the wellbeing of ALL people, we need to move from a weight centric to a weight inclusive paradigm where all bodies are treated with respect and dignity.

Best wishes,

Isa

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