Dispelling nutrition myths, ranting, and occasionally, raving


4 Comments

A dietitian’s take on the new Canadian Adult Obesity Clinical Practice Guidelines

Here are my thoughts on the new Canadian Adult Obesity Clinical Practice Guidelines (written as I read each chapter):

Reducing Weight Bias in Obesity Management, Practice and Policy

I was really pleased that they put this chapter first and I really didn’t find anything to object to in it. I was especially pleased to see the recommendation that weight not be a target for behaviour change, both on a population and individual level, and that other indicators be selected for assessing the effectiveness of population health interventions.

Epidemiology of Adult Obesity

This chapter discusses the prevalence of obesity in Canada among different age groups and changes in obesity rates over the past ten years. A definition for obesity is also finally provided:

Obesity is a chronic disease characterized by the presence of excessive and/or dysfunctional adipose tissue that impairs health and wellbeing. Obesity is a complex disease in both its etiology and pathophysiology.12 In epidemiological research, obesity is often determined using the body mass index (BMI), calculated as weight in kilograms divided by height in metres squared (kg/m2).

One thing that bothers me about this framing is the assumption that obesity is a disease in and of itself. I also don’t feel that enough emphasis was placed on the fact that BMI is not intended to be used at an individual level. This despite the fact that nearly every doctor (and many other healthcare professionals) uses it as such. There is disappointingly no mention of the significant limitations to BMI; i.e. that it is not appropriate to use with populations other than white adult men up to about the age of 50.

Essentially, what I get from this chapter is that “obesity” is a major “problem” in Canada but there is no real accurate way to measure it. So, call me crazy, but perhaps if there’s no good way to measure it “obesity” in and of itself is not a true disease or health concern. Perhaps instead, we should be focusing on tangible issues.

The Science of Obesity

A little bit more about BMI at the start of this chapter: “BMI is a fairly reliable anthropometric measurement to stratify obesity-related health risks at the population level.” I think this statement is debatable given the significant limitations of BMI. I truly think that we need to just let go of BMI altogether. Just throw it away. BMI is like the partner who constantly mistreats and gaslights you but because you’ve been together for so long you don’t want to “waste” all that time and energy you invested in the relationship so you stay with them even though that’s only going to prolong your misery. Just dump it already. Just because you don’t have a better option lined-up doesn’t mean you should forge ahead with this complete dumpster fire.

Then there’s this: “The increased availability of processed, affordable and effectively marketed food, abundance of sugar-sweetened beverages, economic growth, behavioural changes and rapid urbanization in low- and middle-income countries are some of the key drivers that promote overconsumption of food.” Sorry, what? Didn’t we just establish that “obesity” is complicated? And yet here we are boiling it down to people eating too much “junk” food. Sigh.

The chapter then goes on to discuss the biology and physiology of “obesity”. Even though previously establishing that BMI is only appropriate at a population level, there is still use of it for individual classification. There is also mention of a percentage of individuals “with obesity” who are metabolically healthy. Another problem, in my mind, of assuming “obesity” is a disease in and of itself. Essentially, you have people who have no health concerns but are labelling them as diseased solely on the basis of the size of their bodies. Didn’t we just talk about the harm of stigma? How is it not stigmatizing to say someone has a disease just because their body is classified as a certain size (based on a flawed measurement)? Why can’t we just focus on known health concerns (such as heart disease) and leave “obesity” out of the discussion entirely.

The chapter concludes by saying that, “Obesity, or excess adiposity, is the result of an imbalance between energy consumption and energy expenditure by an individual.” Boiling the “complex” “disease” of “obesity” (sorry for all the quotation marks!) down to eating more calories than you burn off which is an oversimplification and just further encourages the belief that fat people simply need to get more exercise, which I hope was not the intended message of the authors but nevertheless is what’s implied.

Prevention and Harm Reduction of Obesity (Clinical Prevention)

Don’t be fooled by the title of this chapter. It is not about reducing the harm caused by healthcare professionals when treating “obesity”. It is about preventing “obesity” in patients. I found this statement particularly alarming: “pregnancy and the postnatal period may be particularly important periods for targeted primary weight gain prevention.” People’s bodies go through HUGE changes during pregnancy, and postpartum and it’s NORMAL for bodies to be permanently altered by the process. There is already enough stress and pressure on someone during pregnancy and as a new parent. We absolutely do not need to be adding to the pressure during that time by shaming people for gaining too much weight during a pregnancy or pushing them to lose weight rapidly after giving birth.

I’ve written about it before, but it bears mentioning again that we as a society (and especially as healthcare professionals) do people, especially women, a huge disservice by promoting the message that we should remain one weight throughout adulthood. It is actually normal and perfectly healthy to gain weight as we age, particularly during menopause, and this weight may actually be protective against illness in older adults.

One more thing that I am horrified by in this chapter is the suggestion of encouraging adolescents to self-weigh in an effort to prevent obesity. This is a recipe for creating eating disorders. We should not be pushing this narrative of measuring self-worth on a scale to youth. Rather we should be promoting self-confidence and encouraging them to embrace and respect differences in body shapes and sizes. Promote healthy choices to youth, not bathroom scales.

Enabling Participation in Activities of Daily Living for People Living with Obesity

This chapter is all about how doctors should provide advice to patients classified as having “obesity” on how to perform activities of daily living, cleaning skin folds, and avoiding falls. Which I find a little presumptuous and cringeworthy. I know that I would be offended if a doctor told me, unprompted, how to wash my own body.

The authors even state: “There are significant gaps in knowledge about what it is like to live with obesity in the context of participating in day to day activities including self-care, leisure and life roles.” Here’s a novel idea: how about we allow patients to state their concerns to their doctors and then let doctors provide solicited advice.

Assessment of People Living with Obesity

All the recommendations for healthcare providers in this section (save for one) are graded level D. I don’t know about others, but I am not comfortable moving forward with such low quality evidence.

I appreciate the author’s emphasis on avoiding stigmatizing patients. However, I question whether it is possible to do this when labelling individuals as having a disease on the basis of the size of their bodies. Also, I once again question the recommendation that healthcare providers assess BMI when it was earlier established that this is not an appropriate measure on an individual basis. Do we really want to continue to use a deeply flawed tool just because we don’t have something better? Perhaps we should focus on actual lab work and patient concerns rather than something we know is potentially harmful.

The Role of Mental Health in Obesity Management 

I do think that it’s vitally important to discuss mental health when we’re discussing “obesity”. However, I’m disappointed that this chapter implies that people classified as having “obesity” may have binge eating disorder. It is possible for people with larger bodies to suffer from anorexia and bulimia, and really all types of eating disorders. They are not the sole domain of people with smaller bodies and failure to recognize this increases the risk of harm. I would have also liked to see more connection between this chapter and the chapter on weight stigma. Many of the ill-effects of “obesity” may actually be attributable to weight stigma.

Medical Nutrition Therapy in Obesity Management

I don’t have much to say about this chapter. I might also just be getting tired of reading. I appreciate that the authors state that there is little evidence of calorie restricted diets being beneficial and mentioning that dietitians can provide support for patients.

Physical Activity in Obesity Management

I’m actually surprised that there is supposedly high quality evidence to support exercise for achieving “reductions in abdominal visceral fat” (Grade A!) and losing small amounts of weight and maintaining weight loss (Grade B). The vast majority of research that I’ve seen has shown that exercise is not effective at producing long-term weight loss in most people. Of course, the authors of this chapter also state that physical activity can be helpful in managing a number of health conditions and is beneficial even when not accompanied by weight loss. This is the messaging that I think is best. We should be focussing on being physically active for overall well-being. Otherwise people see it as “work” and a means to an end and it all too often is abandoned.

Weight Management over the Reproductive Years for Adult Women Living with Obesity 

I wasn’t going to bother with the remaining sections (and this is out of order) because they address management of “obesity” and I feel like it’s kind of pointless for me to pass judgement on them when I’ve already established that I don’t believe “obesity” is a disease to be treated. However, as a relatively new mom I couldn’t resist taking a peek at the chapter on reproductive years. And I had a bit of a wtf moment when I read the following: “Primary care providers should offer behaviour change interventions, including both nutrition and physical activity, to adult women with obesity who are considering a pregnancy (Level 3, Grade C),7,8 who are pregnant (Level 2a, Grade B)915 and who are postpartum (Level 1a, Grade A)16 in order to achieve weight targets.” I mean, given that we’ve already determined that these are ineffective means for achieving weight loss why would they be recommended for that purpose? Also, can we please stop obsessing over women’s weight?? Why isn’t there a chapter on managing men’s weight through the reproductive years? Fuck the patriarchy.

Obesity Management and Indigenous Peoples

As a white person, I am uncomfortable commenting on this chapter. I don’t know the backgrounds of the authors but I hope that they are Indigenous. I was pleased to see the recommendation that healthcare providers educate themselves about Indigenous cultures. Also, that they recognize that health inequities exist. However, I’m question why this particular population was singled out and the discussion about Indigenous Peoples being disempowered felt a little condescending. I don’t think that we, as healthcare providers (or humans in general) should be making assumptions about people. Perhaps it would have been better to put a discussion about systemic oppression up-front with weight bias as there are many people who have been harmed by our white patriarchal systems. Perhaps it would be better to listen to patients about their experiences and concerns rather than making assumptions not matter how well-intended.

Final thoughts (aka TL;DR):

I get that the authors have devoted careers to working on treating and preventing obesity so it must be incredibly difficult to let that go. But we need to stop and ask who it’s serving to pathologize obesity, and as well-meaning as it may be if it is not actually causing more harm than good. We need to stop talking about “obesity” altogether and start focussing our time and energy on creating healthy supportive environments and systems. Let’s get a national school food policy, let’s dismantle the patriarchy, let’s implement a universal basic income, let’s eliminate poverty, let’s teach food literacy in schools, let’s create walkable communities, let’s encourage work-life balance.


11 Comments

A smile doesn’t hide your weight bias

 

Inline_1709417_4.3.jpg

I completed an online course on weight bias and stigma for healthcare professionals last week. There was quite a bit that was good but there were a couple of things that rubbed me the wrong way.

If you’re not already aware Obesity Canada states that, “weight bias refers to negative attitudes and views about obesity and about people with obesity. Weight stigma refers to social stereotypes and misconceptions about obesity. These social stereotypes and misconceptions include beliefs that  people with obesity are lazy, awkward, sloppy, non-compliant, unintelligent, unsuccessful and lacking self-discipline or self-control.” 

Weight bias and stigma can cause significant harm to fat people. In fact, they likely cause more damage to people than carrying extra weight itself does.

The course I took was very good about making this clear and provided the facts as well as showing how harmful weight bias can be to patients. However, there was a video with some experts that I felt undermined the message. Here are the quotes that bothered me:

“If weight loss was easy we wouldn’t have the current obesity epidemic that we have.” – Director of Research and Anti-Stigma Initiatives at the Yale Rudd Center

“People think that for someone who’s overweight all they need to lose weight is some self-control and trying harder to eat less and exercise more. If that only worked we wouldn’t have the problem that we have today. The causes of obesity are very complex…” – Director of Research and School Programs at the Yale Rudd Center

The Yale Rudd Center is well-regarded for their work in reducing weight stigma and both of these individuals quoted above are prominent in the field. At first glance what they’ve said seems innocuous. However, the fact that this was a course intended to combat weight stigma, the experts are saying that obesity is an “epidemic” and a “problem” runs counter to the message they’re trying to convey. It just goes to show how deeply ingrained weight bias is when the very experts trying to counter it are inadvertently perpetuating it. When you say that obesity is a problem then you are saying that fat people are a problem. And I don’t see how that’s not stigmatizing.

The other problem I had with the course were the case scenario videos they shared. There would be one video where staff and medical professionals were rude and unprofessional to patients regarding their weight. Then they would show a video that was intended to show a positive interaction. Really the only differences in the “good” videos were that the healthcare professional was all smiles and asked the patient if they could talk about their weight before advising behaviour change under the guise of promoting healthy behaviours rather than telling them directly to lose weight. To me, the message was the same, it was “you need to lose weight” delivered with a smile rather than scorn. There was still no looking at overall health to determine if weight loss was actually warranted, there was still no consideration of other causes of the presenting ailments, and there was still no recognition that simply telling people to eat healthier and move more (especially without first determining what their current lifestyle is like) is not an effective way to get people to lose weight.

Overall, I felt that the message of the importance of not perpetuating weight bias was lost when all the healthcare professionals were still delivering the message to their patients that they should lose weight. And yes, some people can benefit from losing some weight, but this should be determined with appropriate assessment and then weight management options need to be appropriately discussed with the patient. Simply telling someone, on the basis of their BMI, to eat less and move more with a smile is not helpful.

If you do happen to know of a good online weight bias course please let me know as I’m still looking!