Why I am a weight-inclusive dietitian

I have strong opinions about being weight-inclusive. But I didn’t start that way. I didn’t even learn about weight neutrality or weight inclusivity until after my university days. I don’t think we even covered weight bias all that much.

I’m proud now to say that I am weight inclusive, and I work to ensure that I am learning and evolving the way I practice to get better all the time.

Where I come from

Trigger warning for ob*sity in this section. I do not mention this word again in this article, so feel free to skip to the next heading (or the one after if BMI is similarly triggering for you).

During my university days, we learned about obesity as a disease. Logically, if it is a disease, then it must be treated or managed. We learned about obesity as being defined by BMI (we’ll come back to that in the next section).

We were supposed to be becoming the experts in nutrition and yet we were taught that Weight Watchers was just as good as what we could do for someone who was trying to lose weight and ‘treat their obesity.’ It just doesn’t make sense.

Then I learned about the Edmonton Obesity Staging Scale – an attempt to move past reliance on BMI. This scale gives people a number from 0-4 to rank how “severe” their obesity is based on what health conditions they have. Yet, at this point, what is the point of using BMI or a stage scale? If a person has health conditions, we can directly address those instead of worrying about their size.

In all my reading, I never found a single lifestyle treatment that had long-term benefits. It made me feel like I was letting future clients down because I wouldn’t be able to help them like I would be able to help people with high blood pressure or diabetes.

This realization is the start of weight neutrality. Before we get to that, let’s talk about BMI.

BMI is BS

One of the many issues with this way of thinking is that we equate body size with health. And there is no clearer example of that than BMI – Body Mass Index.

BMI is calculated by taking your weight (in kilograms) and dividing it by the square of your height (in meters). It gives you a number to quantify the size of a person but tells you nothing else. It tells you nothing about a person’s habits, history, health, or background.

This apparently precise number pretends that knowing your weight at a particular point in time is useful and relevant. It’s not.

If you suddenly start gaining or losing weight, it can be a symptom of something that needs to be looked into. Thyroid function, PCOS (polycystic ovarian syndrome) or other hormonal imbalances, cancer, eating disorders, issues with the digestive tract… It is a long list.

There are other symptoms for each of those concerns, but significant weight change can be a measurable and visible symptom that can cause a health professional to ask questions and uncover an issue. But only if they look past the surface.

Too often, sudden weight loss for someone with a higher BMI is thought of as a good thing, no need to consider why it’s happening. On the flip side, weight gain is blamed solely on a person’s habits.

And we’re not even scratching the surface of genetics, stress, environment, poverty, food insecurity, weight bias, and racial biases.

Not to mention, the original “research” to identify the “normal” was done only on a small population of white men. You can see how that might make for some issues. Ethnic background and gender play a role in how your body develops and how weight is distributed.

Bottom line: BMI is bullshit.

There is no proven lifestyle plan for weight loss

There has never been a protocol of any diet or lifestyle plan that causes the majority of participants to lose weight and keep it off for even 1-2 years.

Frankly, I do not care what “benefits” you are getting over the next 6 months if it is going to cause harm a year from now.

This is the case for all intentional weight loss plans.

Caloric restriction is stressful

Intense exercise and calorie restriction are stressful situations for your body. If you are eating fewer calories than needed to maintain your body, your brain is going to start setting off warning signs. The more extreme the calorie restriction, the harder your body is going to push back.

Your brain and gut will start sending out more hormones that tell you that you are hungry. You’ll think about food more. You’ll be more likely to crave salty, fatty, sweet foods – and the higher the calories the better. Because your system is trying to do what it can to motivate you to survive the famine that is happening.

Your body cannot distinguish between deliberate restriction and famine. And it will do everything possible to survive.

The Complications of Chronic Illness

For those of us with a chronic illness, especially one that affects our joints, we have the added pressure from the health care system and loved ones to “manage our weight”. If our BMI is good, we’re encouraged to make sure we don’t gain weight. If it’s high, we are told to try to lose weight.

We are told that because of our condition, we are likely to gain weight (and that’s bad) so make sure that doesn’t happen.

Or we are told to lose weight to “ease the strain” on our joints. Because it’s easy, don’t you know. 🙄

It begins to feel like a no-win situation, especially if your healthcare providers are the ones pushing that narrative. Either you have to go through the futile and counterproductive attempts to “manage your weight” or you have to ignore (or fight) your healthcare team’s recommendations on weight.

The alternative

The fact is, there is an alternative to this weight-centric narrative – weight-inclusivity. From the perspective of a healthcare provider, we might talk about weight-neutral care.

What is weight neutrality?

Weight neutral care means focusing on measures of health, not weight. Weight-neutral is about not seeking to manipulate your weight but rather letting your body manage your weight without your intervention.

Most health care providers who practice weight-neutrality come to it from the realization that there are no proven methods that lead to sustained weight loss in a majority of cases.

“In light of having no validated methods to help more than a small number of people lose weight and keep it off,” says Marci Evans, RD, CEDRD, CPT, who specializes in body image issues and emotional eating, “we need to use tools that will enhance clients’ health at their current weight without causing more harm — remembering to consider long-term harm as well.” Understanding Weight Neutrality – Food & Nutrition Magazine

Research in this realm tends to use the term “weight-neutral”. It also tends to be the phrase we healthcare providers use when talking amongst ourselves.

What is weight-inclusivity?

I spent quite a while trying to figure out if there is a difference between weight-neutrality and weight-inclusivity. I don’t think there is a huge difference. Both terms acknowledge that weight bias and weight stigma are huge problems. We live in a weight-centric, lose-weight-at-any-cost diet culture – and this causes harm. But it’s also like the Matrix – it’s all around us and most people don’t see it.

Whether there is a true difference or not, there is a difference in the way the two terms feel.

Weight neutral seems to be an easier “sell” to people who are still operating under that weight-centric worldview. They might believe that it is better to lose weight if it can be done “in a healthy way,” but they can acknowledge that there isn’t a protocol for that.

It is easier to put weight loss on the back burner than it is to burn the idea to the ground.

Weight-inclusivity is the acknowledgement that humans naturally come in a wide variety of shapes and sizes. We honour that when we allow our body to be what it is meant to be – without trying to manipulate its size.

We take care of ourselves by eating well. This fuels us and gives our body the nutrients it needs. We savour comfort food. We know that food is more than nutrition. It is part of our culture, our history, our past and our present.

We take care of ourselves through movement. Our bodies crave movement. It keeps us strong, helps us feel good, gives us confidence, and enhances our rest.

We take care of ourselves through rest. We ensure we have enough time in bed so that we have ample time to sleep. But we also rest throughout the day when our body or mind needs the rest.

We take care of ourselves in so many ways. Mentally, physically, and socially.

Weight is a way we could choose to describe our physical body, no different from height, hair colour or eye colour. And weight is not connected to how we take care of ourselves.

What is Health at Every Size (HAES)?

Health and Every Size has 5 principles. https://asdah.org/health-at-every-size-haes-approach/

1. Weight Inclusivity
2. Health Enhancement
3. Respectful Care
4. Eating for Well-Being
5. Life-Enhancing Movement

Humans come in a variety of shapes and sizes. We accept that some people are taller or shorter than average without question. So why is it so strange to think that some people will weigh more or less than the average?

The policies at play in our health system, communities, and government have a role in our health. We should encourage policies and supports that help people access the information, services, and behaviours that improve health and wellbeing.

Weight stigma and weight bias are major health factors. It is easy to see how it affects people with larger bodies. It is also the driving factor of the diet culture that so easily ensnares us.

Eating, movement, and other health-promoting behaviours can be very powerful. But only when we allow our internal cues of hunger, satiety, and pleasure to guide us, rather than external rules (especially those rules intended to manage or control weight).

Put another way, it’s all about respect, critical awareness, and compassionate self-care.

You can improve your health without losing weight.

Let me repeat that and rephrase that.

You do not need to lose weight to feel better.

This has been proven. You can improve your blood sugar, blood pressure, cholesterol, digestion, energy, mood, and more. In other words, weight isn’t part of the solution. (So why do we think it is part of the problem?)

In some cases, you may need medication in addition to the lifestyle stuff, but that is why the medication was invented.

I see so many people trying to avoid medication for their arthritis. They will go to the absolute limit of healthy eating. They will get nearly obsessive about the foods they will not eat because it might trigger a flare. All to avoid taking a medication that was specifically designed to help them.

And it’s not just something that those of us with arthritis struggle with. I’ve seen it in people with diabetes, high cholesterol, high blood pressure, and depression. Somehow medication is seen as this scary thing rather than a tool that we can use to help us. But I digress.

So what about health?

Many people think that being weight-neutral or body-positive or weight-inclusive means that you give up on health. But that is only because our society conflates weight and health. Our culture tells us that people with larger bodies must be lazy and unhealthy. It says that thin is best.

This belief leads to worse health. People do terrible things to their bodies in the name of thinness. People believe terrible things about themselves because of their bodies. People avoid medical providers because of how they have been treated in the past. People are misdiagnosed and mistreated because of how their body looks.

No one is immune to diet culture and weight bias. It takes effort to notice those messages and consciously unlearn those beliefs. But your health is worth it.

Weight is, at best, a symptom.

Your weight at any point in time is meaningless information. Knowing what you weigh today gives me almost no useful information. The only time I’d need to know that is to calculate your protein needs (or for similar calculations), which I rarely do.

Weight gain can be a symptom of something changing in your life. And it could potentially be important information. It can be caused by hormonal or thyroid issues for example.

The same goes for weight loss – particularly unintentional weight loss. While our culture tends to look upon weight loss as a good thing no matter what, the fact is that our bodies are supposed to protect us from weight loss at nearly any cost. Losing weight could potentially be a symptom of something very serious.

My journey is evolving

Even while writing this article, my beliefs were challenged. I have been thinking of myself as weight neutral. Partially, that comes from working in the public health care realm and working with doctors who are nowhere near weight neutral. So I had to find ways to express my understanding of the research in ways they could maybe understand.

As I began to realize the damage of dieting and weight bias, I became more and more uncomfortable with assisting any attempt at intentional weight loss. And yet working in publicly funded health care in a small town. I was the only dietitian most people could see. I felt an ethical obligation to help people who wanted to lose weight because if I didn’t, they would go and seek the services of someone who may end up giving them dangerous advice.

So I helped people. My approach was to try to sell people on the idea that we need to first make sure that you have solid healthy habits, then start experimenting to see how your body responds. This was the line I walked between being honest that there is no plan I can hand them and guarantee weight loss and on the other hand wanting to help them and meet them where they were at.

Now, though I am free from that situation, I still have that paradigm in my head. As I wrote this article, I did some research and had to confront those beliefs that I just shared.

I started writing this article calling myself weight-neutral and ended up feeling called to say that I am weight-inclusive. As I continue on this journey, the words I use will change. The way I am will change. The way I practice will evolve. This is the human part of being a healthcare provider.

Bottom line: Let’s focus on what it means to be well.

Pain-filled and shame-filled exercise leads to avoiding movement.

Feeling judged leads to avoiding those who judge you.

Food restriction causes food obsession.

Food is more than nutrition.

Health is more than physical.

Focus on feeling good. I don’t mean in a hedonistic sense, I mean in the deeper sense. What makes you feel energized, positive, and well?

Tap into your intuition. Move towards habits that energize you and away from habits that drain you.

Start with the “best practices,” and adjust them to find what fits you.

• Sleep well
• Move your body in some way every day
• Eat well
• Take care of your mindset

And if you want support along this journey, I’m available to be your coach. 🙂