WIDLIMS podcast ep #5 – Weight ‘management’ approaches – have we got it wrong?

In this episode, I spoke to my friend and classmate Hanna, who has an interest in public health, non-communicable diseases (i.e. diseases that are not contagious, such as heart disease), eating disorders and obesity. We spoke about...

• weight stigma and the obesity paradox – are we wrong to think obesity is a marker for increased risk of death?
• how overweight is typically managed – through calorie restriction and increased physical activity à la ‘eat less, move more’
• better methods of managing weight that are non-restrictive, sustainable and weight inclusive
• the principles of Intuitive Eating and Health at Every Size
• what we must think of in terms of the bigger picture – our relationship toward food, our food system and health inequalities

Hanna does not have a blog etc, but if you want to get in touch with her, let me know and I can help out with that!

NB this was recorded a while back, ahead of the new government strategy to “tackling” obesity released on 27 July 2020. I will address this more in depth in a future episode for sure!

I also want to say that as a disclaimer, the medical establishment carries a LOT of internalised fat phobia. Despite doing a lot of work personally to unlearn this, I am not quite there yet. Listening back to the episode during editing, there are some fat phobic remarks in it – but I left them as they were rather than edit them out.

Resources and references mentioned in the episode

• The obesity paradox and why diets don’t work
• Weight stigma and its harmful impact
• Fitness vs. fatness
• The NHS 12-week weight loss plan
• EPIC-Norfolk study analysis: 4 health behaviours that matter
• Intuitive Eating principles, Health At Every Size, and the work of Lindo Bacon
  • Association for Size Diversity and Health (ASDAH) which supports HAES (factsheet)
• Best diet for health and weight maintenance (spoiler alert – plant-based!)
• Health inequalities
• Sugar taxes and subsidies

Many of these references are used in context in the article below. I recommend you check it out, and scroll down to the bottom of it afterward for some extra reading.

Obesity, weight stigma and what we need to do on societal and individual levels…

Statistics and impact

Body Mass Index (BMI) is typically used to help decide what is a healthy weight, and is a measure based on an individual’s height and weight. It does not, however, take into account body composition and should not be relied on as the sole marker for health. For example, a body builder or someone else with a lot of muscle mass and low body fat may have a BMI which classes them as obese, despite being what most people may consider fit.

BMI (kg/m²)	Designated as…
<18.5	underweight
18.5-24.9	normal range
25-29.9	overweight
30-39.9	obese
>40	morbidly obese

The majority of people living in the United Kingdom are now not what would be thought of as ‘normal’ weight: over 60% are classed as overweight or obese (1,2). The rate of obesity in children is also on the rise, which used to be a rather uncommon phenomenon.

The health risks of obesity are widely reported on, and public attitudes to obesity are generally negative. Healthcare professionals, too, have a negative view of obesity. However, I wanted to focus this episode and the accompanying article on some less known aspects of obesity and excess weight in general.

It would appear that weight is not necessarily a good predictor for an individual’s risk of mortality, especially not as an isolated factor when other confounding factors are accounted for. The concept of ‘fitness vs. fatness’ stems from research demonstrating how overweight individuals who are physically active and fit, are not more likely to die of any cause, than normal weight fit individuals (3,4). There also is a phenomenon known as the ‘obesity paradox’, where research indicates that overweight and obese individuals with chronic disease may have a survival advantage compared to their normal-weight counterparts (5). Taking the above statements into account, it would follow that using weight as a sole indicator for whether an individual is healthy or not is not justified.

Unfortunately, weight stigma is not uncommon, even among healthcare professionals specialising in looking after obese patients! (6,7). Weight stigma essentially involves discrimination and abuse toward a person, due to their weight. If weight stigma was an effective method for weight management, it would be working as it is highly prevalent: but clearly, obesity statistics imply that it is not working. Indeed, weight stigma (even if somebody thinks shaming someone for their weight can be done ‘with good intentions’) in fact leads to obesity, diabetes, disordered eating and mental health problems, to mention only a few complications (8). We need a change in how people talk to, treat and manage individuals who are overweight.

The mainstay of weight management

Currently, UK government guidelines for physicians managing overweight and obese patients recommend the following (9):

• setting a ‘sustainable’ target weight (although there is no clear guide as to how one may decide on one) and identifying a ‘sustainable’ way to eat which supports long-term weight maintenance, as well as promoting ways to reduce sedentary time and increase physical activity
• self-weighing to aid independent management (this sounds like a recipe for eating disorders, although literature indicates it has no side effects)
• ensure there are ongoing sources of support after any weight loss intervention
• setting goals and planning for ‘relapses’

On the NHS website, one can also find their 12-week weight loss plan, which recommends rather stringent control of diet & exercise, with a focus on calorie counting: men are allowed 1,900 kcal/day, and women only 1,400 kcal/day (10). For those not familiar with calorie contents of foods – that is low. And difficult to achieve, not to mention pretty much impossible to sustain in the long term. We cannot expect people to follow such a plan for 12 weeks, let alone for life! Because, as soon as the restrictive diet is abandoned, weight will creep back up. Study after study has demonstrated that a crash diet will not lead to long-term weight loss.

Furthermore, the body has evolved to be very good at conserving energy. Losing weight will cause appetite to up-regulate (meaning it is really difficult to stick to those restricted calorie allowances) and metabolism to slow down (meaning you will plateau). It is not your fault that diets fail: diets simply do not work (11). Again, there is an ample amount of research on this, and I recommend you check out the references if you are interested in specifics.

Even if dieting did work, at what cost? Counting calories and restricting your dietary intake is dangerous. Tracking and restricting calories has been positively associated with disordered eating, and is also not terribly successful for achieving weight loss (11-14).

Time for a change: weight inclusive approaches

If weight is not a reliable predictor for mortality, and weight loss should not be the aim for healthcare professionals and their patients – what should be instead?

Focus on health behaviours. Research has found the following four factors to be associated with a reduced risk of dying: being a non-smoker, being physically active, having a ‘moderate alcohol’ intake (<14 units/week) and having a plasma vitamin C level >50 mmol/l (a proxy indicator for consuming >5 portions of fruit & vegetables per day) (15). That is it, folks! That right there should be our focus. Eat well, move well and stay away from drugs. A weight inclusive, intuitive eating approach focused on wellbeing is also recommended as opposed to the traditional approach (16,17). See also the ‘Health At Every Size’ and ‘Intuitive Eating’ resources linked above.

In terms of a healthy diet, the best one for maintaining an optimal weight without restriction or deprivation is one which is whole food plant-based. Even if not fully plant-based, that really ought to be the aim – there is ample evidence to support that claim (18-20). The American College of Lifestyle Medicine recommends such a diet, so check them out for more information – as well as the wonderful association called Plant-Based Health Professionals UK which has recipes and factsheets (and is run by a woman – yay!)

In terms of exercise, check out my previous article about strength training and the episode I recorded with Kris from Plant Power Prep. The UK government recommends 150 minutes of moderate intensity physical activity per week, with muscle strengthening exercises on two days per week. When it comes to weight loss, exercise is not that efficient a tool, despite many believing it can help once you hit that weight loss plateau with slowing of metabolism (21). You should definitely still do it though, as physical activity has a multitude of benefits, including improving balance, bone strength, muscular strength, mood and cardiovascular health – which all sounds pretty amazing to me! My personal favourites are weight lifting, dancing, walks in nature and pilates.

Privilege – check yours

Before finishing up, I would like to bring your attention to the issue of privilege. Hanna and I discussed this in the episode, too. Essentially, although obesity is often seen as an individual choice, and there certainly are elements of individual choice factoring into diet and health behaviours, we must not forget that everybody exists in the context of society.

Healthy eating and exercise and the many other factors which impact weight and physical and mental wellbeing are affected by intersections of factors outwith our control. These include, but are not limited to, ethnicity, socio-economic status, geographical location and gender. Health inequalities are real, and they have an impact on a large number of people 22-24).

Have I convinced you yet?

We live in a society which values weight loss and thinness above all else. Diet culture has claimed many victims, and causes many people to suffer today still. As a future physician, I am definitely passionate about health and a good diet and physical activity. I do not, however, believe in deprivation, restriction and working against your body’s natural weight preservation mechanisms. If these are all mind blowing new things to you, I would suggest you read some of the articles linked below and check out the work of Lindo Bacon and give Christy Harrison of Food Psych podcast and Laura Thomas PhD a follow. If you have been shamed by a healthcare professional, here is a handy card you can print out and have with you in order to help you and them realise that is not the way forward.

REFERENCES

1) NHS obesity statistics. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/statistics-on-obesity-physical-activity-and-diet-england-2019/part-3-adult-obesity

2) Government obesity statistics (England) https://commonslibrary.parliament.uk/research-briefings/sn03336/

3) Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a meta-analysis. Prog Cardiovasc Dis. 2014;56(4):382-390. doi:10.1016/j.pcad.2013.09.002 https://www.sciencedirect.com/science/article/pii/S0033062013001552

4) McAuley PA, Artero EG, Sui X, et al. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc. 2012;87(5):443-451. doi:10.1016/j.mayocp.2012.01.013 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538467/

5) Hainer V, Aldhoon-Hainerová I. Obesity paradox does exist. Diabetes Care. 2013;36 Suppl 2(Suppl 2):S276-S281. doi:10.2337/dcS13-2023 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920805/

6) Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033-1039. doi:10.1038/oby.2003.142 https://pubmed.ncbi.nlm.nih.gov/12972672/

7) Puhl R, Brownell K. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring). 2006;14(10):1802-1815. https://journalofethics.ama-assn.org/article/weight-bias-health-care/2010-04

8) Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018;74(5):1030-1042. doi:10.1111/jan.13511 https://pubmed.ncbi.nlm.nih.gov/29171076/

9) Changing Behaviour: Techniques for Tier 2 Adult Weight Management Services https://www.gov.uk/government/publications/adult-weight-management-changing-behaviour-techniques

10) NHS 12-week weight loss plan https://www.nhs.uk/live-well/healthy-weight/start-the-nhs-weight-loss-plan/

11) Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220 http://janetto.bol.ucla.edu/index_files/Mannetal2007AP.pdf

12) Levinson, C. A., Fewell, L., & Brosof, L. C. (2017). My Fitness Pal calorie tracker usage in the eating disorders. Eating behaviors, 27, 14–16. https://doi.org/10.1016/j.eatbeh.2017.08.003 /// https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700836/

13) Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eat Behav. 2017;26:89-92. doi:10.1016/j.eatbeh.2017.02.002 https://www.sciencedirect.com/science/article/pii/S1471015316303646?via%3Dihub

14) Laing BY, Mangione CM, Tseng CH. Encouraging Use of the MyFitnessPal App Does Not Lead to Weight Loss in Primary Care Patients. JCOM. 2015;22(11) [Google Scholar] Simpson CC, Mazzeo SE.

15) Khaw KT, Wareham N, Bingham S, Welch A, Luben R, et al. (2008) Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk Prospective Population study. PLoSMed 5(1): e12. doi:10.1371/journal.pmed.0050012 https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.0050012&type=printable

16) Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. Journal of obesity, 2014, 983495. https://doi.org/10.1155/2014/983495 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132299/

17) Bacon, L., Aphramor, L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J 10, 9 (2011). https://doi.org/10.1186/1475-2891-10-9 https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-10-9

18) Plant-based diets for obesity treatment: Barnard, N., Kahleova, H., & Levin, S. (2019). The Use of Plant-Based Diets for Obesity Treatment. International Journal of Disease Reversal and Prevention, 1(1), 12 pp. Retrieved from https://ijdrp.org/index.php/ijdrp/article/view/11

19) Adventist Health Study: Orlich, M. J., & Fraser, G. E. (2014). Vegetarian diets in the Adventist Health Study 2: a review of initial published findings. The American journal of clinical nutrition, 100 Suppl 1(1), 353S–8S. https://doi.org/10.3945/ajcn.113.071233 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144107/

20) Katz DL, Meller S. Can we say what diet is best for health?. Annu Rev Public Health. 2014;35:83-103. doi:10.1146/annurev-publhealth-032013-182351 https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-032013-182351

21) Johannsen, D. L., Knuth, N. D., Huizenga, R., Rood, J. C., Ravussin, E., & Hall, K. D. (2012). Metabolic slowing with massive weight loss despite preservation of fat-free mass. The Journal of clinical endocrinology and metabolism, 97(7), 2489–2496. https://doi.org/10.1210/jc.2012-1444 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387402/

22) Satia JA. Diet-related disparities: understanding the problem and accelerating solutions. J Am Diet Assoc. 2009;109(4):610-615. doi:10.1016/j.jada.2008.12.019 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729116/

23) NHS Obesity and health inequalities. https://www.longtermplan.nhs.uk/online-version/chapter-2-more-nhs-action-on-prevention-and-health-inequalities/obesity/?fbclid=IwAR3yLywXSZB_nYTrMK8JTK7l56UiPEv4tAHRdK6xPwUpgCJMuo5_6tAHVtU

24) Friel S, Hattersley L, Ford L, O’Rourke K. Addressing inequities in healthy eating. Health Promot Int. 2015;30 Suppl 2:ii77-ii88. doi:10.1093/heapro/dav073 https://pubmed.ncbi.nlm.nih.gov/26420812/

Extra resources… a selection from me and from Hanna

How to respond if you’ve been body shamed by a HCP: http://www.laurathomasphd.co.uk/blog/doctor/

All Our Health: Obesity: https://www.gov.uk/government/publications/adult-obesity-applying-all-our-health/adult-obesity-applying-all-our-health#why-focus-on-adult-obesity-in-your-professional-practice

Let’s talk about weight government infographic: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/675028/LTAW_Final_Infographic_Oct_2017_adults.pdf

Let’s Talk About Weight for healthcare professionals: https://www.gov.uk/government/publications/adult-weight-management-a-guide-to-brief-interventions

Public attitudes to reducing levels of overweight and obesity in Scotland. http://www.healthscotland.scot/media/1705/public-attitudes-to-reducing-obesity-in-scotland.pdf?fbclid=IwAR2v1clfipjYvIPcJkByZkMse9tF-rH5OFhh_0mflrYXGjEtBZ-RUPki8H0

Association between perceived weight discrimination and physical activity: a population-based study among English middle-aged and older adults https://bmjopen.bmj.com/content/7/3/e014592

Obesity Stigma: Important Considerations for Public https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/

Kermit Jones. Obesity is a major risk factor for dying of Covid-19. https://www.theguardian.com/commentisfree/2020/jun/15/obesity-is-a-major-risk-factor-for-dying-of-covid-19-we-need-to-take-it-more-seriously

A societal approach – taxes and subsidies https://academic.oup.com/nutritionreviews/article/72/9/551/1859025 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556391/?fbclid=IwAR3Xqosh1dk4MptEbz6vuekzPlt0W6vsncAkyRsZ5AJZz27TFieGKHBVUyo

Do sugar taxes work? https://www.lshtm.ac.uk/research/research-action/features/uk-sugar-tax-will-it-work#:~:text=The%20UK%20sugar%20tax&text=Officially%20called%20the%20Soft%20Drinks,Revenue%20and%20Customs%20(HMRC). Interesting quotes:

• “Increasing fatness is the result of a normal response, by normal people, to an abnormal situation – the easy availability of cheap, processed food”
• “Supporting and encouraging people to respond more healthily to that abnormal situation is important, but the range of options within which people make their choices is skewed in favour of weight gain rather than weight loss”
• “No approach will work alone, but changing the environments within which those decisions are made is likely to be far more effective than merely exhorting people to make better choices”