Obesity: There Are Three Sides To Every Coin

Last week, the Dietitians of Canada (DC) released a Backgrounder on Obesity and Weight Stigma. In it, the authors, who have backgrounds both in conventional dietetics and in the Health at Every Size/Critical Dietetics field, thoughtfully (and rather comprehensively) review the literature on weight stigma and its possible impact on clinical practice, and take a close look at three narratives regarding the issue of weight and obesity.

The first narrative, referred to as the “weight-centric approach”, which unfortunately still remains dominant, defines obesity based on BMI (a measure of size). According to this narrative, anyone above the BMI cut off of 30, would be considered as having obesity and would be considered a candidate for a weight-loss intervention.  The main criteria for escalation of weight-loss treatments (from behaviour modification to medication to surgery) is based on BMI and often sets a weight-loss goal.

The second narrative, referred to as the “health/complication-centric approach”, which appears to be rapidly emerging amongst clinical obesity experts and professional organisations (including Obesity Canada), takes a non BMI-centric approach that primarily considers actual health status in its definition of obesity and has a primary goal aimed at improving mental, physical, and social health, whereby interventions may or may not involve treatments to promote weight loss (including behaviour modification, psychological interventions, medications, and surgery).

The third narrative, referred to as the “critical non-weight-centric approach”, frames different body weights as a part of normal diversity of body size, does not define obesity as a disease (indeed discourages the use of the term), challenges medicalization of fatness, and promotes the treatment of health issues/concerns regardless of weight (and generally does not consider the use of anti-obesity medication or surgery).

The paper discusses the background, evolution, and pros and cons of each narrative and their potential impact on weight-bias as well as clinical practice.

Clearly, as readers of these pages will be well aware, I have been one of the most vocal critics of using BMI (or any other anthropometric) measure as the primary definition of obesity and would certainly not support a “weight-centric approach” to obesity management.

Rather, my approach would fall firmly within the health-complication-centric approach (indeed the Edmonton Obesity Staging System, which now increasingly being used to guide obesity management, was developed to move the focus from size to health). I have also long-propagated a definition of obesity based on actual health assessments and have championed the notion that any obesity management intervention needs to be assessed on its impact on overall health and not just weight-loss. Fortunately, this notion of obesity is increasingly finding its way into the medical literature and clinical practice guidelines.

But I also see a role for the critical/non-weight centric approach, especially for individual patients, where past experiences dictate that any focus or even mention of body weight or use of the term obesity may exacerbate past traumatic experiences and could potentially promote unhealthy weight preoccupation, highly restrictive unhealthy eating behaviours, excessive exercise behaviours, or overt mental health issues including depression, anxiety, or compulsive behaviours. Thus, clinicians would be well advised to also familiarise themselves with the critical/non-weight centric approach and consider this an option for individual patients, who would likely be harmed or distressed by a more conventional approach.

No matter, which of the latter two approaches one may favour, the good news for all concerned should be that a rapidly growing number of experts in the field as well as professional organisations now recognise that although BMI may still have some value as a population surveillance measure and perhaps as a screening (not diagnostic!) tool in clinical practice, the weight-centric approach based on BMI alone is definitely on its way out (even amongst surgeons, who are now increasingly basing their indications for surgery and assessment of outcomes on the presence of metabolic and other health parameters rather than size).

Thus, if we consider the “weight-centric narrative” as the rim (side) of the coin, it is fair to say that the coin is definitely getting remarkably thinner.

The backgrounder will be available here for the next couple of days, before it disappears behind a firewall (still accessible to people who have access to PEN).

Edmonton, AB