I recently joined a virtual running training program to work on some personal fitness goals. What’s unique about this program is that it’s designed specifically for women who are overweight or plus size who want to be runners. Turns out, this program was designed just for me.
During one of the training calls, the two coaches in the program discussed that they avoided attending their routine medical exams for fear of weight stigma. I have to admit that I wasn’t shocked. Even as an NP myself, I could relate to the feeling of worry that my weight would be a central topic during a routine medical visit.
Ever since childhood, I have been overweight. And ever since childhood, I have been told (directly and indirectly) that I needed to change. From being teased in elementary school, to being sent from my pediatrician to a nutritionist at age 15, I absorbed the message that I was not worthy in the body that I was in, and that weight loss was the solution.
These messages continued to show up in my young adult and adult life — mainly as self-imposed declarations that I needed to change my body. Occasionally, I would also get the comment or suggestion from a health care professional that my weight was not healthy.
But the thing was, I was healthy, by every other standard of the word. I exercised regularly, ate a nutritious diet, often had a blood pressure of 100/60 and a triglyceride level of 36 mg/dL (that’s not a typo), and no central adiposity.
Over the past few years, as my weight has fluctuated due to a twin pregnancy, twin motherhood, another singleton pregnancy followed by mothering three kids, and a global pandemic. I’ve been feeling some loud cognitive dissonance regarding my health.
Does my extra weight automatically make me unhealthy?
Why can’t I practice what I preach to patients?
Can I be a trusted clinician in an above average-sized body?
I have been taught as a clinician that being overweight and healthy are mutually exclusive. You can’t be both. But I have been tuning in to other messages, mainly those of the Health at Every Size (HAES) philosophy. I was skeptical at first, thinking that HAES was perhaps a philosophy meant to excuse someone for being overweight, but it turns out that a weight-neutral, nutritional, and physical activity approach to health may be a promising chronic disease prevention strategy.
A weight-neutral approach conversation might include language that centers the proposed healthy behavior, as opposed to suggesting weight loss as the objective. For example, in a patient with Type 2 diabetes, the clinician may help the patient establish physical activity or food choice-related goals, rather than weight loss goals. Or, if an overweight patient has functional low back pain, the conversation may revolve around discussing what sort of movements and activities help the patient’s body feel comfortable and strong.
The overall message in weight-neutral conversations is that the individual is worthy of dignity, respect, and care regardless of their size, and that there are other measures of health that will be focused on as part of their treatment plan.
Alternatively, suggesting weight loss as an intervention for symptomatic complaints in overweight individuals is not weight-neutral. For example, if someone comes in with a musculoskeletal complaint, and the clinician suggests weight loss as a primary treatment plan, this could be a stigmatized suggestion that could lead to patient mistrust, which has been suggested to contribute to poorer health outcomes.
While obesity is correlated with numerous chronic health conditions, causality has only been established with two: osteoarthritis and ovarian cancer. The HAES research shows that the focus on weight itself (and thus recommending weight reduction as an intervention for disease prevention) puts the focus on the wrong area, and could actually lead to weight gain.
Additionally, there are findings that a narrow definition of a healthy body size can lead to disordered eating practices, such as severe restriction, purging disorders, and orthorexia. These practices can often remain hidden by the individual, but when their weight loss is praised for weight loss’ sake, these behaviors can be positively reinforced.
HAES is a philosophy that challenges some of the traditional messages we have learned about health, both as patients and clinicians, and while the literature is from the past 20 years, it is promising and serves as a strong call to action for further exploration and empirical research.
As clinicians, we can view the HAES philosophy as an opportunity to challenge the status quo and reexamine whether our well-intentioned approach of weight loss promotion is actually the best one.
We have an opportunity to meet our patients where they are at, and truly assess whether their priorities (as well as our priorities for them) align with an appropriate and sustainable definition of health.
As for me, I’m working on unlearning the dangerous messages that I’ve absorbed from traditional “diet culture,” and honoring my body and my health — from the inside out — with every mile I run.
How do you talk about weight with your patients? Share in the comments.
Amanda Guarniere is a dual-certified adult and women's health NP with a focused clinical background in emergency medicine. She holds a BA in Italian Literature and Violin. She believes strongly in the healing and educational power of storytelling. She is also an entrepreneur and works with other NPs as a career mentor so that they may find personal and professional fulfillment. She is a 2020–2021 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz