Dispelling nutrition myths, ranting, and occasionally, raving


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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.


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Lose the Weight Watchers

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Last year Weight Watchers rebranded as WW because they wanted to pretend that they were about healthy lifestyles and not just weight loss. This week they announced the release of their new weight loss app for kids (as young as eight!) and teens. They’re trying to frame it as “helping kids and teens build healthy habits” but when the central feature of the app is food tracking don’t be fooled; this is Weight Watchers points for kids and creating a “bad food” “good food” dichotomy is likely to do anything but help these kids build life-long healthy habits.

An eight year old tracking every morsel of food they eat with the sole aim of losing weight is pretty much the antithesis of a healthy habit. Rather than help kids develop healthy habits this app is far more likely to instil them with an unhealthy relationship with food and their bodies. And while I personally ascribe to the belief that weight is not indicative of health, I hope that all healthcare providers and parents can see why an app like this could be damaging to children whether or not they view “overweight” and “obesity” as a “problem”. Weight is not a modifiable behaviour and focusing on weight loss as an end goal doesn’t promote the adoption of healthy behaviours. Rather, it promotes restricted eating and quite probably disordered eating habits in order to attain that goal.

Given that very few adults successfully maintain intentional long-term weight loss, I find it baffling that WW claims that their new app is “evidence-based” and will somehow be more successful (if you are measuring success by pounds lost) in children and youth than similar programs have been in adults. It also makes me sad to see the quotes around “stopping arguments about food” so that parents and children get along better. Placing the responsibility for food choices in the hands of an app rather than working on fostering a healthy food environment at home may seem ideal but this doesn’t truly promote healthy behaviours. I know not everyone can afford to work with a registered dietitian (and not all RDs ascribe to the same school of thought when it comes to body weight); however, I recommend Ellyn Satter’s books which can be found at your public library if you want to help your child attain a healthy relationship with food.

It’s also important to keep in mind that WW is a for-profit business. They are not doing this out of the goodness of their hearts. They are doing this because there’s money to be made – one month use of the app is $69 USD. They’re doing this because a “fun” app is an easier sell to parents who are concerned about their children’s weight than working on the division of responsibility, role modelling healthy behaviours and positive relationships with food, and cooking and eating nutritious balanced meals together as a family. They’re doing this because weight bias is so rampant in our society that many people can think of few things worse than being fat and parents are desperate to save their children from that plight. I get that. Parents just want their children to be healthy. Unfortunately, an app that encourages a restrictive diet mentality is likely to achieve the opposite of health promotion.


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What obesity and homosexuality have in common

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A couple of weeks ago I was listening to an episode of Radiolab on which they shared an episode of the short podcast series Unerased titled: Dr Davison and the Gay Cure. They were talking about the former perception of homosexuality as a disorder and the rise of conversion therapy. As I was listening what they were saying really struck a chord with me. I found myself thinking “this is exactly how people are going to think about weight loss counselling one day”.

On the podcast, they were saying, essentially, it doesn’t matter if people come to us wanting to change. What does it actually mean to help them? “The problem that these people are asking us to solve is a problem we created. That we labeled as a problem.” Even if we could effect certain changes, there is the more important question as to whether we should… It makes no difference how successful the treatment is, it is immoral.” And I was like “YES, this exact same thing could be said about weight loss treatment!”

This belief in relation to homosexuality was considered to be fringe and most people weren’t in support of it initially. This parallels the Health at Every Size/body diversity/weight acceptance movement. There is a lot of push-back from people in the medical community and the general public when it’s suggested that weight is not a condition that needs to be treated. Just as with the acceptance of homosexuality as a normal state, there were a few outspoken pioneers leading the movement and with time, it became more accepted by the mainstream. I feel that this is beginning to happen now with weight. More of us RDs who were always taught that “overweight” and “obesity” are unhealthy are coming to realize that people can be healthy at many different sizes.

Of course, there are still hold-outs and there is still conversion therapy happening in some places. Similarly, there will likely continue to be hold-outs who believe that only thin people can be healthy and that BMI is indicative of health. However, I’m hopeful that we’re reaching a turning point and that one day the medical community will agree that weight is not a “problem” and that weight loss treatments are unethical.


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Response to: The Rise of the Anti-Diet Movement: Is it No Longer P.C. to Want to Lose Weight?

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Someone I follow on twitter recently shared this blog post: The Rise of the Anti-Diet Movement: Is it No Longer P.C. to Want to Lose Weight? by another dietitian, Janet Helm. In the post she mused about dietitians promoting themselves as “non-diet” and what this might say about other dietitians. She agreed with many points made by dietitians, quoted in RD/writer Cara Rosenbloom’s recent excellent piece for the Washington Post about non-diet dietitians, but seemed unwilling to go so far as to embrace the philosophy herself. She ended her post with the following questions: “Can’t we all get along? Can’t intuitive eating and body positivity coexist with losing weight?  Why must we line up on two sides?  Why the conflict?” I’m going to do my best to respond to these questions.

First, I too have asked that same question: “Can’t we all get along?” at times. Remember craisingate? Personally, I don’t think that as dietitians we have to agree on everything. It’s okay for us to have different perspectives and approaches. Also, in the case of diet vs non-diet, I don’t see it as an issue of getting along. Maybe I’m blissfully unaware, but I haven’t seen any “non-diet” dietitians attacking other dietitians for promoting weight management. I don’t see dietitians referring to themselves as “non-diet” as lining up on an opposing side or creating conflict. Rather, I see this identification as a way for dietitians to let prospective clients know that they do not promote weight loss as a goal. In a profession which so many believe our sole mission is to help people lose weight I think that it’s necessary for RDs who do not promote weight loss diets to make this clear up-front. I don’t believe the intent is to pass judgement on other dietitians who haven’t embraced the same approach, or to create a professional divide. However, I can see how a dietitian who has built a career around weight management counselling might see this new-ish movement as a personal judgement.

My friend Cheryl Strachan, aka “Sweet Spot RD” wrote an excellent blog post last week (while I was mulling over how best to respond to Janet’s post): Why I can’t help you lose weight. This heartfelt post explained why she would no longer work with clients on weight loss. Providing the current evidence on weight loss and health and the struggle she went through to reach this position. Rather than having me regurgitate all of the evidence here, I recommend you take a few minutes to go read it and then come back.

Done? Okay, great. So you’ll note that Cheryl mentions that when she studied nutrition in 2003 it was accepted without question that weight management was a significant part of being a dietitian. I can tell you that it was the same when I went back to uni to study nutrition in 2006. I’m not sure if things have changed since then. I suspect that they haven’t, at least not completely. It takes time for institutions and society to change. As a dietitian who has worked in weight management in the past I too have struggled to fully embrace health at every size. I understand why a fellow dietitian would ask: Can’t intuitive eating and body positivity coexist with losing weight? It’s an incredibly tough question and the answer is nuanced and it may not be the same for everyone.

I do believe that intuitive eating and body positivity can peacefully coexist with weight loss. However, I think that this can only be the case when weight loss is not the ultimate goal. For me, body positivity is appreciating your body as it currently exists and continuing to appreciate it if you gain weight or lose weight. It’s about treating yourself with respect and compassion and providing your body and mind with the nourishment they need. If you are doing these things with the clandestine goal of losing weight then you are doing yourself a disservice. That being said, it’s okay to want to lose weight. We live in a society that has conditioned us from a very young age to believe that being thin is important. It’s unrealistic to except this engrained belief to vanish overnight. It takes time to relearn to listen to your body and to treat it with respect when you’ve been viewing it as the enemy, a captor, keeping the real you the thin you hidden away. So, no, body positivity and weight loss can’t coexist but yes, body positivity and weight loss can coexist.

I think that as time goes on and nutrition programs update their curriculums, as old-school dietitians are more exposed to evidence regarding the harms of weight bias and weight loss diets, and the hold-outs retire, that things will change. After all, as dietitians we are supposed to provide evidence-based best practice and the evidence against weight loss diets is mounting. Eventually there will be no non-diet dietitians because that will be the approach we all take.


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A smile doesn’t hide your weight bias

 

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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!