Weight inclusivity is a core value of my practice. It means that I strive to provide care that is inclusive to people of all shapes, sizes and weights. While it sounds pretty straight-forward (duh, why wouldn’t I want to be inclusive?!), it can actually be really radical for a diabetes dietitian to practice in this way. Read on for more about how this looks in practice.
What is a weight inclusive approach to health?
The weight inclusive approach is a life-saving alternative (1) to the weight-normative approach (or weight-centric approach). The weight-normative approach considers weight as a key indicator of health and emphasizes weight loss (or pursuit of a particular BMI) as a path to well-being.
In contrast, the weight inclusive approach considers health to be multi-faceted. It focuses on improving access for all persons to compassionate and ethical healthcare, and to eliminate bias and stigma based on body size.
Seeing a healthcare provider who has a weight-inclusive approach means that:
Weight will not be used as a marker of your health status.
Weight loss will not be a prescription.
Weight will not be blamed for other health conditions.
You and the provider will work together to make a plan for your health goals that you can implement in your current body.
Your body will not be seen as a problem, but it will be seen as your teammate that you are working alongside of in pursuit of the life you want, in accordance with your values.
What data opposes the weight normative approach to health?
Weight loss interventions are ineffective long term
Contrary to what I was taught (and many other healthcare professionals), the data show that focusing on weight loss interventions is not effective, and therefore not evidenced-based for long term health. (1) Rates of weight regain and weight cycling are high. Weight cycling (repeatedly gaining and losing significant amounts of weight) is linked to adverse health outcomes. (2)
Risk of developing an eating disorder
Another risk of placing so much emphasis on weight is the chance of developing eating disorders or disordered eating behaviors in order to achieve or maintain weight loss, or as a result of weight loss. Individuals at any body shape or size can experience eating disorders. Dieting (or a pseudonym for dieting like “lifestyle change” or “watching what you eat” or “eat less XYZs”) is a common prescription given by healthcare providers for people in higher weight bodies. But dieting can lead to eating disorders (which have some of the highest mortality rates of any psychological condition) (3).
There are also the negative effects of weight-stigma to consider. In and outside of the healthcare system, people in larger bodies experience stereotypes, rejection, prejudice, and discrimination. The presence of weight stigma is associated with increased health risks, elevated blood pressure, disordered eating, low self-esteem, and mental health issues like depression (1). Taking a weight-normative approach to health perpetuates weight stigma, resulting in negative consequences.
Within the weight normative approach, it is acceptable to treat people in different body sizes differently. Contrarily, the weight inclusive approach means that everyone will get the same access to health interventions and treatments, no matter their weight.
What evidence supports a weight inclusive approach to health?
When compared with weight-focused interventions, HAES (Health At Every Size®) interventions resulted in more successful improvements in physiological measures of health, improved health health practices and improvements in measures of psychological health. And there were no adverse outcomes, along with low dropout rates. (4)
We also know that interventions focusing on improving body acceptance and rejecting the thin ideal result in improved mood, decreased eating disorder symptoms and reduced risk of developing future symptoms. (5)
Does my BMI say anything about my health?
The short answer is- NO! First, The data around BMI cannot prove that BMI causes any specific condition or any adverse health outcome. For a research study to prove causation, they have to be able to control and manipulate the variable, which they cannot do with BMI.
If you do a deep dive on the history of the BMI, you’ll see that it was never intended to be used for this purpose of defining or categorizing health. This episode of the Maintenance Phase podcast does a great job explaining the history.
What do you do if your healthcare providers are not weight inclusive?
Look for a new provider
This may not be possible for everyone, but if you have any flexibility in who you see as your primary care provider or a specialist provider, consider trying someone new. Consider looking for a HAES online group or a fat-positive support group and asking for recommendations. There are some lists online of fat-friendly providers (check out the new ASDAH Health at Every Size® listing!), but some areas will have more options than others.
Vet your provider with questions
Plan an introductory meeting or interview with a provider before you decide to make them your Primary Care Provider (PCP). You can ask them questions like, “Are you comfortable caring for me without weight being a central theme of discussion?” or “Will you be able to leave my weight out of our conversations and provide shame-free care?”
What to say to your provider
Here is a great list of suggested phrases by Ragan Chastain. You can even print out these cards and simply hand one to your provider to let them know how you would like to approach your health.
Look for a weight inclusive supplemental team
Depending on what’s going on with your physical or mental health, you may be looking for a specialist to be on your healthcare team in addition to a PCP. You may be looking for a diabetes specialist, a nutritionist, a licensed professional counselor, a massage therapist, a movement coach, etc.
Look for someone who advertises themselves as “non-diet,” “weight-inclusive,” “anti-diet,” “fat-positive,” or “HAES®-informed.” If they say they help people with weight loss or weight management, that’s a red flag! They are not truly weight inclusive.
If you cannot find a PCP who is fully weight-inclusive, having other people in your corner to support your weight-inclusive approach to health will be affirming and helpful.
Does weight-inclusive diabetes care exist?
Absolutely! It is my life's work. My approach to diabetes care is weight-inclusive, fat positive and whole-person (meaning it incorporates your mental, emotional and social health in addition to your physical health). If you’ve been diagnosed with diabetes or pre-diabetes and been told to lose weight, I want you to know that there is an alternative way to approach managing your blood sugar.
You deserve a healthcare team that supports your desire to make peace with your body. You can advocate for yourself and let them know that you will not tolerate body shaming. Tell them you would like to make a plan for health and quality of life improvements that are not centered on weight loss, and instead focus on changes that are within your control.
Here are my free resources for weight inclusive diabetes care. I hope you find them helpful!
Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C, Calogero RM. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495. doi: 10.1155/2014/983495. Epub 2014 Jul 23. PMID: 25147734; PMCID: PMC4132299.
Rzehak P, Meisinger C, Woelke G, Brasche S, Strube G, Heinrich J. Weight change, weight cycling and mortality in the ERFORT Male Cohort Study. Eur J Epidemiol. 2007;22(10):665-73. doi: 10.1007/s10654-007-9167-5. Epub 2007 Aug 4. PMID: 17676383.
Arcelus, Jon et al. “Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies.” Archives of general psychiatry 68,7 (2011): 724-31. https://doi.org/10.1001/archgenpsychiatry.2011.74
Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011 Jan 24;10:9. doi: 10.1186/1475-2891-10-9. Erratum in: Nutr J. 2011;10:69. PMID: 21261939; PMCID: PMC3041737.
Stice E, Rohde P, Gau J, Shaw H. An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. J Consult Clin Psychol. 2009 Oct;77(5):825-34. doi: 10.1037/a0016132. PMID: 19803563; PMCID: PMC2760014.