It's one of the most polarizing questions among clinicians: Is treating obesity while also reducing weight stigma and eating disorder risk mutually exclusive?
In a recent commentary published online ahead of print in the Journal of the Academy of Nutrition and Dietetics, a team of researchers takes aim at what they say is an outdated approach many health care providers still have when it comes to treating patients with overweight or obesity.
In short, health professionals on both sides of the debate should strive to improve access to compassionate, evidence-based and patient-centered care in order to fight weight stigma and end diet culture, the researchers argue, adding that the emphasis should be on health, not weight.
"It is absolutely critical to unlink weight from diet culture," said co-author Katherine N. Balantekin, PhD, RD, an assistant professor in the Department of Exercise and Nutrition Sciences in the University at Buffalo School of Public Health and Health Professions.
"In my opinion, this is the biggest disconnect we are currently seeing in society," added Balantekin, who studies eating behavior in children with obesity and disordered eating. "Working together to eliminate the false dichotomy between eating and weight disorders will help ensure that everyone receives the compassionate care that they deserve. Moreover, we need to continue to work on eliminating other barriers to treatment, including weight bias and stigma."
Weight stigma -; the devaluation of a person based on their weight -; is rampant, the researchers note, citing previous research findings that more than half of health care providers attribute a patient's being overweight or obese to a lack of willpower. This kind of fat-shaming only reinforces negative stereotypes, they say.
The debate extends far beyond health care settings. For example, when Weight Watchers released Kurbo, a weight loss app for children and adolescents in 2019, there was major backlash among eating disorder experts, dietitians and former dieters who criticized the app for placing an emphasis on dieting. For many people, dieting has negatively impacted the relationship they have with food and their body.
With Kurbo, "there was a lot of concern that any focus on weight would cause eating disorders," Balantekin said. "People think of dieting as being the same thing as obesity treatment, when in fact they are extremely different."
The paper notes that a new definition of obesity, backed by Canadian guidelines and the World Health Organization, has emerged. Gone is the emphasis on a body mass index (BMI) of 30 or above. Instead, obesity is now defined as having excess fatty tissue that is associated with negative impacts on quality of life or physical health.
"This new definition takes a health-focused rather than a weight-focused approach, allowing for improved sensitivity to the nuance of the relationship between weight and health status," the researchers write.
It also allows for a shift toward supervised evidence-based obesity treatment, which favors sustainable changes to promote long-term health. This is instead of focusing on dieting or self-directed efforts to lose weight by restricting the amount or types of food consumed. Whereas self-directed diets often promote unhealthy eating practices such as fasting or strict food restriction, supervised evidence-based obesity treatment actually improves health without increasing internalized weight stigma, the researchers write.
The paper's key conclusion is that "treating obesity and reducing weight stigma and eating disorder psychopathology are not mutually exclusive."
There has been concern for a long time that weight loss can trigger or worsen eating disorders, but a large body of research suggests that evidence-based obesity treatment actually improves, not worsens, eating disorder symptoms. This is true for both children and adults."
Katherine N. Balantekin, PhD, RD, Assistant Professor, Department of Exercise and Nutrition Sciences, University at Buffalo School of Public Health and Health Professions
The researchers also call for broad policies such as laws against weight-based discrimination, as well as efforts to further educate health care providers and the general public about the fact that numerous factors beyond self-control affect weight.
Obesity treatments should also screen for and address eating disorders throughout treatment so that individuals can receive specialized care as soon as possible, Balantekin said.
"It is critical to take a patient-centered approach to treatment with a focus on all health needs, which contrasts with the typical provider-centered approach with a focus on weight," Balantekin added. "This means that health care providers need to respect a patient's wishes, including whether or not they want to discuss weight. It also needs to include a conversation where providers clearly lay out reasonable expectations for treatment, including how habits will need to be sustained long-term to see maintenance of weight loss."
Cardel, M.I., et al. (2022) Patient-Centered Care for Obesity: How Health Care Providers Can Treat Obesity While Actively Addressing Weight Stigma and Eating Disorder Risk. Journal of the Academy of Nutrition and Dietetics. doi.org/10.1016/j.jand.2022.01.004.