Pharmacists are in the front line of the obesity epidemic. But counselling patients on diet behaviour can have troubling consequences. Is it time for a weight-neutral approach? Can patients be ‘healthy at any size’?
Data from around the Western world shows rising levels of people being overweight or obese, with it widely being described as an epidemic. In 1995, the World Health Organization published uniform categories of the Body Mass Index (BMI), the product of two years of work by a specifically established Expert Consultation Group. (See Table 1).
TABLE 1. Categories of BMI
|CATEGORIES OF BMI|
|30-34.9||Class I Obesity|
|30-34.9||Class II Obesity|
|≥40||Class III Obesity|
The categorisation of being overweight or obese is widely accepted as the cause of individuals experiencing a wide array of detrimental health consequences e.g. type 2 diabetes, cardiovascular disease and osteoarthritis.1,2,3,5 Consequently, weight loss achieved through decreasing energy intake and increasing energy expenditure – that is, diet and exercise – is recommended for all individuals presenting who are overweight or obese.1
Despite the widespread recommendation of engaging in diets to lose weight, and the multimillion dollar dieting industry, weight loss achieved through dieting is seldom maintained.1,2,3,4,6 Rather, individuals tend to regain the weight lost and then some, setting the scene for weight cycling commonly referred to as yo-yo dieting.2,6
Meanwhile the engagement in dieting behaviour is linked to a decline in mental health, including the development of eating disorders.2,6,7,8
When the long-term sustainability of weight loss is reviewed, it has repeatedly been shown on average 30–40% of participants are regaining weight within one year; and by 2 to 5 years weight has been regained and more.6,9 Weight cycling has been associated with higher mortality, increased risk of osteoporotic fractures and gallstone attacks, loss of muscle tissue, hypertension, chronic inflammation and an increased occurrence of some forms of cancer (endometrial cancer, renal cell carcinoma and non-Hodgkin’s lymphoma).2,8
For those patients with diabetes, a review of the Action to Control Cardiovascular Risk in Diabetes (ACCORD trial) has highlighted the perils of weight cycling, finding weight fluctuations to be associated with a higher risk of macrovascular and microvascular complications.10 After full adjustment for BMI, this review identified that body weight variability was associated with an increased risk of nonfatal MI or nonfatal stroke or CV death (hazard ratio [HR] 1.25), heart failure (HR 1.59), death (HR 1.74) and microvascular events (HR 1.18) (all P<.0001).10
Weight stigma is prevalent within society as a whole, with women in particular stigmatised across multiple sectors (employment, education, media). In some domains within the United States, discrimination associated with greater BMI is higher than rates of racial discrimination of ethnic minorities.6,9 Weight stigma is equally found to be prevalent in healthcare settings, being observed among physicians, nurses, medical students and dieticians.6,9
Within healthcare bias, negative stereotypes of obese patients are endorsed, with patients being labelled as ‘lazy’, ‘weak willed’ and ‘bad’; furthermore, providers are more likely to report them as being a ‘waste of time’.9 Unsurprisingly, this bias has a direct impact on the quality of care provided to those with obesity.11 Additionally, the focus on weight loss is associated with perpetuation of weight stigma, resulting in individuals delaying the input of health professionals for health concerns.1,2,4,6,8 This is irrespective of whether the health issue is attributable to being overweight or not.2
While the view has been held that stigmatisation of higher weight individuals through inciting societal pressure to lose weight would result in weight loss, evidence is showing differently.11 Weight stigma acting as a trigger for physiological and behavioural changes is associated with weight gain, poorer metabolic outcomes, profound negative impact on mental health and reduced engagement in physical activity.6,11
A new approach
Considering this data, and the first and foremost premise of healthcare professionals being to ‘first do no harm’, the ongoing recommendation of dieting behaviour to obtain weight loss is being challenged by some sectors of the healthcare community.2,4,6,10 Rather than a weight-normative approach, a weight-neutral approach is being proposed, with the Health At Every Size (HAES) initiative being the most widely implemented.2,12
In contrast to some reports, HAES does not promote obesity, instead recognising that extremes of weight (at either end) are associated with detrimental health outcomes.2,4,6,12 However, the initiative does not place weight as central to health,2,4,6,12 but recognises weight itself is an interrelated, complex outcome of many behaviours, not a behaviour of its own.6,13
At the core of HAES is promoting individuals to engage in eating nutritious food when hungry, not eating when full, and partaking in pleasurable (and hence sustained) exercise.2,4,6 In short, it encourages individuals to engage in a fulfilling and meaningful lifestyle.6,9
By shifting the focus away from weight, individuals are encouraged to engage in healthy behaviours regardless of their size, including those in the normal weight category.2,6 Clinical evidence has demonstrated use of this approach resulted in beneficial effects on physiological (e.g. cardiovascular markers), behavioural practices (e.g. increased physical activity and reduced binge eating) and psychological measures (e.g. decreased symptoms of depression and improved self image).2,6,12 Additionally, in contrast to a weight-normative approach, clinical trials have reported no adverse effects from a HAES approach, which has had low dropout rates.2,9,12
It is also noted that the positive effects were achieved despite weight itself remaining relatively unchanged. In stark contrast to weight-loss approaches, longitudinal studies have demonstrated positive outcomes of the HAES approach are maintained at 16-month follow-up.2,4,9,10 HAES works on the premise that health is more than the absence of disease, instead viewing health from the holistic perspective as the presence of wellbeing enabling quality of life.2,6,12
To assist in the process of implementing a HAES, a five-step guide has been developed:
1. Gather evidence to support a weight-neutral approach
2. Understand what the term ‘weight neutral’ means for patients
3. Clarify how you are going to provide weight-neutral education
4. Find support by involving oneself with other HAES health professionals
5. Translate the weight neutral message for clients.13
Given this evidence, and one’s own clinical observations of patients engaging in weight cycling, it was decided to ascertain the potential acceptance of a weight-neutral approach in a community pharmacy setting. To achieve this, pharmacy assistants employed at the pharmacy completed a survey addressing their own perceptions and experiences of body shape/size, weight and health. Further, a sampling of clients was interviewed on this same subject, with their responses also being analysed.
Not surprisingly, both groups demonstrated personal experience with diets, an awareness of the negative impacts of dieting behaviour, examples of weight stigma being present within the healthcare setting, and a willingness to embrace an approach other than current weight-loss diet focus to address the current widespread health concerns.
Despite this openness to embracing a concept other than a weight-normative approach, there was a very low level of awareness of the HAES initiative, and the only individuals who were aware of this approach incorrectly believed it promotes obesity.
Combining emerging clinical evidence with these results, pharmacists in this community pharmacy are now embracing a HAES approach in recommendations made to patients, where historically weight-loss advice through dieting would have been provided.
The adoption of the HAES approach is challenging, as beliefs regarding the benefits of weight loss are ingrained in healthcare. Realising the degree to which weight stigma is unashamedly expressed among staff was extremely confronting, particularly given that we pride ourselves on our level of customer service and professional service focus.
Within the pharmacy setting it is essential that adoption of a HAES approach is not limited to pharmacists, but that pharmacy assistants are also educated to ensure a consistent message is delivered to patients. Training pharmacy assistants to challenge their own beliefs on the significance of weight, and in particular weight loss as a focus, has been ongoing in our practice. The broad range of experience level among pharmacy assistants highlighted the need for training to be tailored to individuals and include ongoing reinforcement of the evidence of shortcomings in a weight-loss-centred approach. The phrase ‘health is our business’ has served as strong reminder of why this change is being embraced.
Implementing a weight-neutral approach to patients has resulted in surprise, with a number expressing their expectation of being told, ‘you just need to lose weight’. Providing encouragement of behaviour changes, focusing on success and recognising obstacles in behaviour change has proven professionally rewarding, with patients engaging in goal setting, as opposed to the defensive body language experienced when previously provided with weight-loss advice.
This was highlighted by a patient who disclosed they have been experiencing episodes of binge eating but had never revealed this to their health professional team due to fear of further ridicule and receiving less assistance for other health concerns.
While the journey of being a HAES healthcare professional has only just begun, so far it has resulted in positive feedback from clients, an apparent increase in rapport and a sense of greater professional accomplishment. As a pharmacist, utilising pharmacology knowledge to recognise when medication may be contributing to weight gain and encouraging prescribers to utilise alternative therapeutic agents is an example of optimising medication management.
As health professionals, we are challenged to continually review clinical practice against the latest evidence. The large body of evidence for the failing of dieting behaviour to positively affect individual’s health in the longer term through sustained weight loss, and the clinically documented negative outcomes of the weight-normative approach, should call into question current practice. The challenge to review practice techniques, one’s own weight stigma and shift to a weight-neutral, healthy behavioural focus is encouraged.
- Haggan M. An ongoing struggle: The obesity dilemma. Australian Journal of Pharmacy, 2018 Nov. 99 (1179): 44–8. At: https://ajp.com.au/features/an-ongoing-struggle-the-obesity-dilemma/
- Tylka TL, Annunziato RA, Burgard D, Daniesldottir S, Shuman E, Davis C et al. The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity [Internet], 2014 [cited 2018 Aug 8]; 2014: 983495 Available from: ncbi.nlm.nih.gov/pmc/articles/PMC4132299/pdf/JOBE2014-983495.pdf DOI:10.1155/2014/983495
- Ramage S, Farmer A, Apps Eccles K and McCargar L. Healthy Strategies for successful weight loss and weight maintenance: a systematic review. Appl. Physiol. Nutr. Metab., 2014 39:1–20. At: https://www.ncbi.nlm.nih.gov/pubmed/24383502
- Nicholson Z. Understanding the ‘health at every size’ paradigm. [Internet]. 2018 May 29 [cited 2018 Aug 8]. Available from: racgp.org.au/newsGP/Clinical/Understanding-the-%E2%80%98health-at-every-size%E2%80%99-paradigm
- Nuttall FQ. Body Mass Index Obesity, BMI and Health: A Critical Review. Nutr Today. 2015;50(3)117–28. At: https://www.ncbi.nlm.nih.gov/pubmed/27340299
- Bacon L. Health at Every Size: The Surprising Truth About Your Weight. Texas: BenBella Inc; 2010. At: https://www.amazon.com/Health-At-Every-Size-Surprising/dp/1935618253
- Butterfly Foundation. Understanding Eating Disorders [Internet] 2018 [Cited 2018 Oct 10] Available from: thebutterflyfoundation.org.au/understand-eating-disorders/causes-of-eating-disorders/
- Gaudiani J. Sick Enough: a Guide to the Medical Complications of Eating Disorders. New York: Routledge;2018. At: https://www.amazon.com/Sick-Enough-Jennifer-L-Gaudiani/dp/0815382456
- Penney TL, Kirk SFL. The Health at Every Size Paradigm and Obesity: Missing Empirical evidence may help push the reframing obesity debate forward. Am J Public Health. 2015;105: e38-e42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386524/. DOI:10.2015/AJPH.2015.302552
- Tucker ME. Weight Fluctuations May Be Deadly in Type 2 Diabetes [Interent]. 2019 Jan 30 [cited 2019 Feb 1]. Available from: medscape.com/viewarticle/908416
- Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR et al. How and why weight stigma drives the obesity’epidemic’ and harms health. BMC Medicine. 2018; 16:123. Available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1116-5
- Ulian MD, Aburad L, da Silva Oliveira MS, Poppe ACM, Sabatini F, Perez I et al. Effects of health at every size interventions on health-related outcomes of people with overweight and obesity: a systematic review. [Internet] Obes. Rev. 2018 Dec; 19 (12)1659–66. At: https://www.ncbi.nlm.nih.gov/pubmed/30261553
- Fletcher M. A professional guide embracing a weight neutral approach for type 2 diabetes care. [Internet] 2018 [Cited 2019 Jan 31] Available from: drive.google.com/file/d/1EbMDm53sSMOnJIf4lkPo8eRY85tTa5q/view?fbclid=IwAR1QKH1Z298LEQWPLpMYdoEeUpRUTab5pNVTd3X5Km9m-xpxVzYzThw2dw
CATHERINE LAIRD MPS is a community pharmacist with 20 years’ experience, including 13 years as a consultant. She has recently undertaken the PSA Graduate Diploma in Advanced Pharmacy Practice.