What if Managing Obesity Had Nothing to do with Weight?

What if Managing Obesity Had Nothing to do with Weight?

Photo via the Canadian Obesity Network Image Gallery

A couple weeks ago, I “came out” as a dietitian who no longer helps people lose weight. I’m touched by all the support I’ve received for what I feared was a really “out there” move. In a way, this post is like a “part 2”; it’s all about where I really want my practice to go, given my experience working with people with obesity and with people who have had bariatric surgery.

Redefining Obesity

Many (most?) Health at Every Size practitioners disagree with the idea that obesity is a disease, and stand firmly against bariatric surgery. I think that is partly based on the fact that many still define obesity as having a BMI > 30, an archaic definition that is purely based on weight.

The World Health Organization defines obesity as “the accumulation of excess or abnormal body fat that impairs health“, which I think is absolutely possible—just as too little body fat can have negative consequences, like missed periods (amenorrhea) and bone loss, too much body fat can lead to metabolic disturbances, like insulin resistance, or mechanical issues, like sleep apnea or increased pressure on joints.

In other words, our current definition of “obesity” falsely labels people who don’t actually have a disease. Telling these people to lose weight is akin to telling someone without diabetes to start taking insulin “just in case”. To complicate things further, many people who are trying to lose weight don’t even fall under this incorrect definition of obesity.

For the remainder of this post, I will use the term “obesity” based on the WHO definition, not the BMI definition.

So, Are You Saying Only People with “Real” Obesity Need to Lose Weight?

Most people have little to gain health-wise from trying to lose weight, though I totally acknowledge the persistent pressure on people to lose weight and be thin under the guise of health. So, what about the people who are actually experiencing health problems related to their fatness?

Though it would make more sense to target the “cause”, at this point in time, we actually have no idea how to get rid of this “excess fat” in a way that is safe and consistently effective.

The stats for lifestyle management are abysmal—there are few long-term studies to begin with, and many show that people who try to lose weight actually end up gaining weight in the long run. Even though research shows losing just 5% of body weight can improve health outcomes in people with obesity (though it is unclear whether these improvements are from the weight loss itself or from the change in habits that led to the weight loss), a recent study found that over 50% of participants regain the weight after two years, and after five years, less than 1 in 4 people have kept the weight off.

To make matters worse, this isn’t a case of “it doesn’t hurt to try”, because dieting does hurt. Dieting and attempting to lose weight increases the risk of disordered eating, body dissatisfaction, depression, anxiety and other mental health concerns.

We also can’t prove that “excess fat” is truly the cause of these health conditions. Smaller/thinner people still get diabetes, heart disease, liver disease, cancer, gout—why should their care be different?

First, Do No Harm

Until we can confirm that a person’s health is being impaired by their body fat, and until we have a safe, effective and sustainable way to get rid of this body fat, I would propose that the best care for someone living with obesity is to manage their health conditions as you would someone without obesity. Any suggestion that they should try to “eat less, move more”, count calories or cut back on portion sizes has the potential to harm more than help.

At the same time, this is where work on intuitive eating, mindful eating and body positivity come in. Virtually all people who have obesity have tried to lose weight at some point in their lives, and more than likely have body image or eating issues that we as a society have sadly normalized, or worse, applauded.

Best care for #obesity: Manage health issues as you would for anyone at any size. Click To Tweet

What About Bariatric Surgery?

At this point, bariatric surgery is considered our “most effective” treatment for helping people lose weight. That being said, it’s not 100% effective (currently, most studies measure “success” based on weight, not on how it affects health outcomes) and it carries a HUGE amount of risk.

What fascinates me about bariatric surgery is the recent discovery that the surgery does more than make your stomach smaller and your digestive tract shorter; studies are now showing that the surgery can change the body and health in ways unrelated to weight loss by affecting the bacteria and hormones in our gut.

The problem is, in many places, the surgery is given to anyone who is heavy enough and can afford it. Not only does this mean that a lot of people who are getting the surgery probably don’t “need” it from a health standpoint, they’re also not getting the proper education and support they need to lower the risks associated with the surgery.

I think more research still needs to be done regarding bariatric surgery, but instead of asking, “Will this help people lose weight?” we need to start asking, “Will this help people gain health?” I believe that surgery can, regardless of weight loss, and by digging into how, perhaps we will discover an answer that will be safe and effective for all.


  • Cora on Mar 07, 2017 Reply

    Wow. Great article with concepts that I can’t help agreeing with.
    Mindfulness and body positivity are so important. And although I haven’t yet declared myself as a dietitian who doesn’t help people lose weight (yet), it really resonates with me! Thank-you.

    • Vincci Tsui on Mar 07, 2017 Reply

      Thanks for your comment, Cora! Embracing body positivity and mindfulness is definitely an ongoing journey – I know you will find an approach that fits best for your practice.

  • Hannah on Feb 13, 2017 Reply

    I loved this article! very insightful interesting points, I love how you touched on the ‘eat less and move more’ advice that most people are told obese or not, in regards to living a ‘healthy’ lifestyle and weight loss, when there are so many more factors involved.

    • Vincci Tsui on Feb 13, 2017 Reply

      Thank you for your comment, Hannah! I agree – we need to start moving away from this oversimplified, cookie cutter advice in our health care.

  • Diana Vogel on Feb 09, 2017 Reply

    Love, agree!!! What is your opinion on mental health treatment in regards to this population?

    • Vincci Tsui on Feb 09, 2017 Reply

      Thanks, Diana! Mental health treatment is *so* important. Obesity is highly correlated with many different health concerns, including depression, anxiety and ADHD. Also, I find that people often seek out dietitians first with a goal of losing weight, when often the issue isn’t the food, it is their body image and feelings of self worth. I so wish I was better connected with HAES therapists in my community that I could refer to.

  • Ruth on Feb 08, 2017 Reply

    Bravo. I am an Eating Disorder researcher and advocate, and have had a long term ED myself. I am obese for the first time in my life – at 55 years of age – but I am also healthier mentally than I have ever been, and I am healthy physically – with normal blood results and no disease or markers indicating any health risk. HAES indeed.

    Our society needs so badly to be educated in what constitutes health, and in particular the link between self-imposed starvation and the cumulative risks it brings over time. Many people labeled obese have undiagnosed restrictive eating disorders, and further weight loss attempts will just exacerbate the existing damage.

    Starvation does not produce health; we must learn to see the difference between a body that is kept at an arbitrarily low weight and small size, and one that is thriving and flourishing and nourished, regardless of weight and size.

    Thank you for publishing this important commentary.

    • Vincci Tsui on Feb 08, 2017 Reply

      Thanks for your support, Ruth! I really appreciate it.

  • Kathleen Hernder on Feb 05, 2017 Reply

    Awesome post Vincci!!! I feel like we’ve been on similar journeys in terms of mindset shifts and I’ve been wondering what that would look like if I were still at the Bariatric Clinic. Your take-home of focusing on health instead of weight in bariatric surgery research is such a great one! I hope more emphasis is put there in the future. Thank you for this wonderful article!

    • Vincci Tsui on Feb 05, 2017 Reply

      Thanks, Kathleen! I agree sometimes it feels like such a contradiction to work at a bariatric clinic while adopting a Health at Every Size approach, but I think it is possible.

  • Néma McGlynn on Feb 05, 2017 Reply

    Amazing post Vinci!! I work as a Supermarket RD and have so many customers that come see me for weight loss and most is related to a health condition like diabetes, high blood pressure, etc. Some are referred by their GP, other health professionals or on their own. Almost every one is looking for what they should be cutting out of their diet. It’s sad because our society puts so much emphasis on individual control over what we eat and thinness and if you can’t control that then you lack self control. It’s a horrible message especially as I work in an environment designed to get people to buy more food. My heart breaks when I hear stories like Louise who clearly is not getting the proper care she requires based on prejudgements rather than sound medical inquiry. Your reflection of “will this help people gain health?” vs. “Will this help people loose weight?” is exactly what we all need to be asking ourselves. Thanks for the inspiration!!

    • Vincci Tsui on Feb 05, 2017 Reply

      Thanks for your comment, Néma! I agree that this idea of “self-control” is so pervasive yet so wrong that we have a lot of work ahead of us.

  • LaurJ154 on Feb 05, 2017 Reply

    The hits you are getting may also have to do with the huge heated discussion that happened on artist Les Toil’s Facebook page (he posted your link in support of this article this morning).

    • Vincci Tsui on Feb 05, 2017 Reply

      Thanks for the heads up!

  • Mandy on Feb 04, 2017 Reply

    I agree with everything that you stated. I had Gastric Bypass done 3 years ago. I lost 140Lbs, and although I’m happy that weight is gone, I have many different problems now. It interests me about your study of how Gastric Bypass patients have issues with the different Bactria’s in their gut, because I now have uncontrollable bowel movements, horrible cramps, and extreme nausea every single day. It truely has negatively effected my quality of life. I’m always tired, and my moods are uncontrollable. I wish I had a time machine, or a Gastro Doctor that listened and could help me with my daily routine. Anyways it was nice reading other people’s comments as well.
    Thank you

    • Vincci Tsui on Feb 05, 2017 Reply

      Thank you for your comment, Mandy, and I hope that you are able to connect with a healthcare professional that can help you manage the side effects you are experiencing.

  • BMW on Feb 04, 2017 Reply

    Being a bariatric patient and loosing 96 pounds, the side benefits of the weight loss are the true blessing, in going through the surgery. Gaining health is the biggest! The ability move helps maintain the loss, but even two years after surgery it’s still a mental game to keep the weight off and still allowing yourself to live! Enjoyed your article.

    • Vincci Tsui on Feb 05, 2017 Reply

      Thanks for reading!

  • Louise on Feb 04, 2017 Reply

    I wish my GP was like you. I have serious health problems including a swelling stomach that is rock hard. And constant abdominal pain, swollen breast, armpits very sore and also losing the ability to stand up for more than a few minutes before I collapse and all my GP does is grab my fat and wobble it and say ” are you sure it’s not this causing it”. I’m bedridden now, getting fatter even though I truly don’t eat that much. I see bariatric patients lighter than me eating five times as much. A friend whos boyfriend is obese says her boyfriend eats two McDonald large size meals. I can just about eat one. She says he will go through many bags of crisps and cookies and chocolate and I do not. But she refuses to investigate. So I’m stuck in my house waiting and wanting to die because my life is just existing and not living.

    Thank you wholeheartedly for coming out as you have. We need more doctors like you to challenge the thinking that all fat people are greedy pigs.

    • Vincci Tsui on Feb 04, 2017 Reply

      Thanks for sharing your story, Louise, and I’m sorry to hear about the negative experience that you’ve had with your doctor. Some people have shared with me that they have had luck searching for “health at every size” practitioners in their area. I hope you will be able to find a health professional that will provide the care that you deserve.

  • Lynda Pye on Feb 04, 2017 Reply

    Excellent post.

    • Vincci Tsui on Feb 04, 2017 Reply

      Thank you, Lynda!

  • Erin on Feb 04, 2017 Reply

    Beautiful. These are feelings I’ve started to feel in my practice and nice to know I’m not alone or wrong for feeling this way.

    • Vincci Tsui on Feb 04, 2017 Reply

      Thanks for your feedback, Erin! I agree, I am definitely sensing a shift and it is nice to know that you are not alone.

  • Brenda on Feb 04, 2017 Reply

    I wish there were more like you. Thank you!

    • Vincci Tsui on Feb 04, 2017 Reply

      Thank you for your kind words, Brenda!

  • Elyse Morton, RD on Feb 04, 2017 Reply

    Great job Vincci, a message that more RDs need to vocalize. Keep up the great work!

    • Vincci Tsui on Feb 04, 2017 Reply

      Thanks, Elyse!

  • Kim Young on Feb 04, 2017 Reply

    Great read Vincci! Dr Sharma tweeted a link to this!

    • Vincci Tsui on Feb 04, 2017 Reply

      Thanks for reading, and thanks for the heads up, Kim! I was wondering why I was getting all these hits today. I’m grateful that this message is getting out there.

  • Casey Berglund on Feb 03, 2017 Reply

    Such an intelligent, and thought-provoking post.

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