Last month, I attended the 5th annual Canadian Obesity Network (CON) National Summit. The three days—plus full day of pre-summit workshops—were packed with information and networking, and I went to bed every day exhausted. I took lots of notes that I still need to review and analyze, but here are some of my personal takeaways from the conference.
1. My Work is Needed
As someone who has worked with people who are having/have had bariatric surgery for about 4½ years, I’ve always hesitated to identify as a Health At Every Size® (HAES®) dietitian, because most HAES® practitioners are very much against bariatric surgery, with some dismissing it as “stomach amputation”.
I agree that bariatric surgery is not HAES-friendly or body positive at all. The procedures were created for weight loss and almost all research has focused on weight as an outcome. There is a slow shift toward looking at quality of life outcomes, and at positioning the procedures as treatment for type 2 diabetes (albeit a treatment that is much, much more risky than medication). Still, there’s no doubt that bariatric surgery is not HAES-friendly. Full stop.
So, why am I still so passionate about working with people who have had/are having bariatric surgery?
Some of the facts I learned at the conference are that people pursuing bariatric surgery tend to have experienced more weight discrimination and internalized weight stigma than other people living in larger bodies, that changes in body shape and body size are not associated with improvements in body image, and that after surgery, while quality of life improves over time, mental health actually stays the same or worsens in the long run.
I’m passionate about practicing HAES in the context of bariatric surgery because these are the people who need to know that health and happiness are so much more than weight. They made the difficult decision to have a life-altering surgery because they’ve been told that this will improve their health and happiness, and in some cases, it does to a certain degree. However, most people have the surgery hoping that it’s the silver bullet—despite many clinics emphasizing that it is “just a tool”—and when it turns out that it isn’t, that is when they need support the most, instead of being pushed away for not being “body positive”.
2. Weight Loss is Statistically Improbable
One of the studies cited multiple times at the conference followed over 7,000 patients attending a medical weight loss clinic for over seven years. The study found that in that time, over 70% of patients lost less than 2% of their starting weight despite being followed by a multidisciplinary team that consisted of doctors, dietitians, behavioural therapists and exercise specialists. The actual results might be skewed as the average length of follow-up was less than two years, so by the time the study got to the 7.5 year mark, the number of people left was a lot less than when they started.
The study goes on to say that even patients who didn’t lose weight showed improvement in health outcomes like blood pressure, concluding that “this research together with previous literature suggests that health and obesity may not necessarily track together, and that achieving [weight loss] may not necessarily be required for health benefits.”Promoting 'lifestyle changes' for #weightloss is not evidence-based practice. Click To Tweet
With bariatric surgery, people can lose more weight, but weight regain still happens. One of the presenters stated that the average weight regain after surgery is 8%, with about 40% of people gaining back more than 25% of the weight that they had lost.
3. I’m More Hardcore HAES® Than I Thought
CON has always had messaging that was different from the more commercialized weight loss and diet industry. In their 2010 book Best Weight, CON scientific director Dr. Arya Sharma and Ottawa’s Bariatric Medical Institute medical director, Dr. Yoni Freedhoff, describe “best weight” as “whatever weight [you] achieve while living the healthiest lifestyle [you] can truly enjoy”. More recently, Dr. Sharma has been pushing to redefine obesity away from BMI criteria, and toward using a modified version of the WHO definition, “the presence of abnormal or excess body fat that impairs health.”
It doesn’t seem like everyone’s quite on board; there were many presentations at the conference that still used the BMI definition of obesity, including some presenters that would say that BMI is bullshit, then a few slides later, say obesity rates are increasing based on population studies that looked at BMI.
What was most troubling for me, however, was the attempt to fight weight bias and stigma while promoting the idea that obesity is a disease.
Interestingly, preliminary research that was presented at the conference shows that this tactic works. In one study, participants were asked to read one of three health articles before answering some questions about how they felt about people with obesity. Two of the articles had the exact same information about obesity, except one said obesity was a disease, and the other said that it wasn’t. (The third article was on HIV, for control purposes.) The people who read the article that framed obesity as a disease expressed less negative attitudes toward people with obesity. The thought is that framing obesity as a disease works in a similar way to other diseases where people had previously wrongly attributed personal responsibility, such as addictions or mental health concerns.
While I previously believed obesity is a disease—which, I think, is how we justify prescribing certain behaviours to fat people that would be seen as disordered in thin people—now I’m not so sure. If we were to go with the definition that obesity is “the presence of abnormal or excess body fat that impairs health”, is that a disease state in and of itself? How do we know whether someone has say, high blood pressure because of their excess fat versus another reason? Is there enough evidence that we should treat high blood pressure differently in someone with “excess fat” versus someone without?
Circling back to the idea of framing obesity as a chronic disease in order to fight weight stigma, is this really the best way? The study above looks at external sources of stigma, but what about internalized stigma? Is calling obesity a disease not essentially saying, “It’s OK if you’re fat, but not if you’re also sick?”
I would argue that a better way to fight weight stigma is to normalize size diversity. Just as age, race and sex can impact your health and quality of life, those are characteristics, not diseases; why shouldn’t weight and size be the same? One of the arguments I heard at the conference is people with obesity are suffering/dying because weight stigma is keeping them from accessing proper healthcare. But are they suffering from obesity, or are they suffering from heart disease, chronic pain or mental health concerns?