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.
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.