Weight-Inclusive Care – Endocrinology Advisor

Introduction

Amid the soaring use of glucagon-like peptide-1 (GLP-1) drugs for intentional weight loss, a vastly different movement appears to be gaining traction in health care: Many clinicians are pushing for a move away from the deeply entrenched weight-centric model of care in favor of a weight-inclusive approach.^1-3

This shift has been largely driven by patient feedback, provider advocacy, and a significant body of research demonstrating the ineffectiveness of dieting efforts as well as the numerous harms associated with weight-centric medicine.³

For example, advocates point to the well-recognized flaws with the body mass index (BMI) as a measure of “excess” weight and highlight weight-centric medicine as a key contributor to widespread weight stigma and discrimination, which have been linked to suboptimal care and a range of mental and physical health issues, including disordered eating, sleep impairment, and increased alcohol use.^4-6

In addition, advocates for weight-inclusive medicine emphasize that weight is not a reliable indicator of health and that various strategies have been shown to improve measures of health in the absence of weight loss — including cardiorespiratory fitness, physical activity levels, blood pressure, glycemic control, and other cardiometabolic risk markers, as well as depressive symptoms, disordered eating, and diet quality.^3,7-10

The recently formed Association for Weight and Size-Inclusive Medicine (AWSIM) and other advocacy groups such as Medical Students for Size Inclusivity and the Association for Size Diversity and Health aim to increase awareness about the harms of weight-centric health care and to educate clinicians and others on the benefits of the weight-inclusive model.

To learn more about the growing weight-inclusive care movement, Endocrinology Advisor interviewed endocrinologist Gregory Dodell, MD, assistant clinical professor in the Division of Medicine, Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai in New York, New York, and Lisa Erlanger, MD, clinical professor of family medicine at the University of Washington School of Medicine in Seattle, and founding president of AWSIM.

What Is the Weight-Centric Approach?

Dr Dodell, what are some common misconceptions that may lead endocrinologists in particular to believe that they should practice from a weight-centric approach?

Dr Dodell: Much of our training is geared toward encouraging people to lose weight because of the association between weight and type 2 diabetes (T2D), insulin resistance, and conditions like polycystic ovarian syndrome (PCOS) and thyroid conditions. However, a lot of the research that looks at weight in those correlations or associations doesn’t account for things like weight discrimination and weight stigma, socioeconomic status, and other factors, so there could certainly be a correlation but not necessarily straight-line causation, so I think that’s important to tease out in the research. 

One key question that researchers are exploring is: With things like T2D, is it possible that it’s the insulin resistance that precedes changes in weight, rather than the other way around? Weight is often blamed for insulin resistance and causing T2D, but what if it’s really just this genetic phenomenon, or whatever is going on physiologically, that is causing the weight gain because of the insulin resistance or whatever is occurring on a cellular level?¹¹ 

Why is there a need for a shift away from a weight-centric approach to a weight-inclusive approach in health care?

Dr Dodell: The data is very clear about how harmful weight stigma is, in terms of people avoiding going to the doctor and therefore not getting preventative care.^12,13 Assuming certain health characteristics based on body size, missing diagnoses because of assumptions or blaming things on weight when [weight] may have nothing to do with it, and making recommendations that may not be accurate or reliable based on these assumptions can be harmful to patients.

The evidence shows that weight cycling is worse for people’s metabolic health than staying at the same weight and that fitness — irrespective of any change in weight — improves metabolic health and markers.^14,7 There’s a lot of research to support all of that, and of course, we know that weight is not a behavior. By changing behaviors, weight may change, but it also may not, and that’s okay. 

Dr Erlanger: Patients tell us that our singular focus on weight as a measure of health and target for health interventions isn’t working. Stories abound about — and research confirms — delayed diagnoses and treatment, disrespectful care, health care avoidance, lack of provider skill, and stress that seems to make health worse instead of better. In fact, research confirms that the many effects of anti-fat bias better account for the health disparities affecting larger-bodied patients than fatness itself.^15,16 These effects include downward socioeconomic pressure, chronic stress, health care inequities, and weight cycling, which is the loss-gain cycle of intentional weight loss.¹³

Anti-fat bias functions as a structural determinant of health inequities. The focus on changing the size of patients rather than providing welcoming, equitable, holistic health care actually drives these disparities rather than remediates them.

Weight-inclusive care recognizes the universal right to equitable, compassionate, anti-biased, trauma-informed medical care, regardless of size. We recognize the natural diversity of body size and shape, as well as the harms — disproportionately borne by those with intersecting marginalized identities — resulting from centuries of unsuccessful attempts to reduce this diversity.

We also recognize that weight-centric definitions of health and health care are significant drivers of anti-fatness. At the same time, there are uncountable ways to improve health and support well-being that have nothing to do with weight. When we remove the focus on weight, we open the door for more comprehensive, responsive care for our patients.  

For example, exercise has significant benefits for a multitude of physical and psychological conditions across the weight spectrum. Although the limited effectiveness of exercise for weight loss is well-documented, the prescription of exercise is often given for the purpose of weight suppression, often with concurrent food restriction. When patients don’t have the energy to exercise, when their appetite increases along with activity, or when they don’t lose weight, they are prone to give up.

When we look at physical activity as a weight-inclusive intervention for health and well-being, we can encourage sustainable engagement in movement for its own benefit. When placed in this more realistic context, we also see that there are other ways to improve health when exercise isn’t accessible — for example, improving sleep, social connections, and safety.

Weight-inclusive care doesn’t mean that we promise health to everybody. In fact, health is a dynamic state, and we unfortunately cannot promise health to any person of any size. Weight-inclusive care isn’t just for the largest patients or patients who “can’t or won’t” lose weight. Everyone across the weight spectrum benefits when we reject the medicalization of body size and embrace the full range of health-supporting options.

Providing Weight-Inclusive Care

Dr Erlanger, the word “fat” has long been considered insulting in US culture. Can you tell us about your use of the word in the context of weight-inclusive care?

Dr Erlanger: I use the word “fat” as a neutral descriptor of size, the opposite of the word “thin,” reclaiming the term from the schoolyard and replacing “obesity,” which, by medicalizing and pathologizing fatness, drives the stigma that marginalizes larger-bodied people and contributes to the health disparities they experience.

What led to your personal shift in perspective from a weight-centric model toward a weight-inclusive approach?

Dr Dodell: I give my wife, Alexis Conason, PsyD, the credit because otherwise I wouldn’t really know to practice this way.  She’s a psychologist who embraces body positivity and deals with eating-related issues and disorder eating, and she also came from the bariatric surgery world as a researcher and clinician. As she went into her practice, she started seeing all these patients who were having issues with weight stigma and diet culture, including from doctors they were seeing in treatment, so she wrote a book about it called The Diet-Free Revolution: 10 Steps to Free Yourself from the Diet Cycle with Mindful Eating and Radical Self-Acceptance.¹⁷

After about a decade of her trying to convince me that I should be practicing this way, I read the first 2 chapters, which are very heavy on the research about weight stigma, and it just clicked for me. I realized that the weight-inclusive approach makes sense and that it’s also harmful if you don’t take this approach.

Dr Erlanger: I was brought up — personally and professionally — in the weight-centric model of health. Over the years, and as I learned more about health disparities and trauma-informed care, I recognized how the focus on weight was driving many patients away from health and health care, and that thin people weren’t necessarily happier or healthier. In fact, in college health, I spent a lot of time begging people to eat for their health. This led me to look into the social justice and scientific basis of the weight-inclusive model. It’s not just the right thing to do for patients; it’s the ethical and evidence-based way to practice.

Dr Erlanger, you are the founding president of the recently formed AWSIM. Why was this association formed, and what are some of its main goals and plans?

Dr Erlanger: AWSIM is a professional home for clinicians practicing and learning about weight-inclusive medicine. By providing support, education, and advocacy, we are working to fulfill a vision of equitable, trauma-informed, patient-centered care for people across the weight and size spectrum. We reject the pathologization of body size as a disease or target for treatment. Instead, we recognize anti-fat bias as a structural determinant of health that mediates health disparities for larger-bodied patients and drives an unnecessary — and often unhealthy — focus on body size for people across the size spectrum.

Members tell us they have felt isolated by fighting the status quo, and they are excited about making system-level change. Many clinicians also have personal struggles resulting from anti-fat bias.

AWSIM will provide support for both personal and professional growth. We have a journal club, speaker series, networking events, mentorship programs, opportunities for research and scholarship, and a growing library of resources for practice, education, and advocacy. Regardless of where clinicians are on your personal or professional weight-inclusive journey, we hope they will join us. 

Clinical Recommendations

What would you recommend to clinicians who would like to learn more about weight-inclusive care and take steps to implement this approach in their practices? And what would you say to those who remain skeptical about weight-inclusive care or may be hesitant to move away from the weight-centric model?

Dr Dodell: I think it’s important to recognize that, as endocrinologists, we see people of all shapes and sizes who have the various conditions that we’re seeing, whether it is T2D or type 1 diabetes or PCOS, and the treatment should be the same [for patients regardless of weight], with the same recommendations as far as behaviors go.

Obviously, in this world of GLP-1 drugs, we use those for people with T2D irrespective of their weight, and they are very effective medications. Of course, they’re being used a lot for weight loss, but as an endocrinologist, if you’re treating any of these other conditions, these medications can be used, and they don’t have to be used in a discussion with someone to lose weight, but just as a metabolic medication that can be very effective.

It may help patients in larger bodies who have struggled with disordered eating or weight stigma when you come to it from a lens of, “I’m using this medication to help your diabetes or insulin resistance. Yes, your weight may change, or it may not, but that the goal is to help your metabolic health.” 

Regarding skepticism, I think that’s the art of medicine — we have our own opinions and perspectives, and my approach may not be what certain patients are looking for, but it’s good for patients to have the opportunity to seek out the kind of care they’re looking for.

But my treatment of T2D or PCOS or metabolic liver disease is not going to be any different just because I practice weight-inclusive care. I use the same medication and treat patients the same way. It’s just that the way that I structure and discuss the treatment is intended to avoid stigmatizing the patient or making assumptions about their behaviors, and to certainly not overlook the eating disorders and disordered eating that goes along with a lot of the conditions that we treat. We can derail someone’s recovery from an eating disorder or orthorexia or whatever the case may be, which is probably the worst thing we can do in those 15 minutes or however much time we have with a patient.

Dr Erlanger: It’s understandable to be skeptical. After all, our social and medical training has told us that fatness is bad, unhealthy, and changeable. Many of us have spent our whole personal lives pursuing thinness and our whole professional lives coaching others to do the same. We may have had personal and professional successes doing so and anecdotal evidence that it’s been helpful in some way. 

As a first step, I advise clinicians to consider the experience their larger patients have during their visits. There are changes providers can make that will increase access and improve the experience of fatter patients regardless of how the clinician is approaching weight. Letting their larger patients know that they value their experience and feedback will go a long way.

Additional steps that clinicians can take to implement a weight-inclusive approach include the following:

• Make sure equipment, furniture, and gowns accommodate larger patients. Every room should have extra-large, conical blood pressure cuffs, the largest-size gowns, and high-capacity chairs and exam tables. 
• Make weighing-in optional and provide a way to remove weight from printed materials for patients who request it. Allow patients to defer blood pressure checks until they are comfortable later in the visit.
• Treat the chief complaint. If you offer weight loss as an option, make sure to offer the evaluation and management that a thinner patient would get, and don’t wait to initiate non-weight-based care.
• Do not make assumptions about behaviors or values based on a person’s body. Ask how they are supporting their health now and what questions they have about the next steps.
• If you offer weight loss options, provide full informed consent, including the research limitations, the overwhelming statistical likelihood of weight regain with any method, and the psychological and physical risks of regain. Medical Students for Size Inclusivity created a sample informed consent for GLP-1s for weight.¹⁸ Part of the consent process involves reviewing thorough information about options, including weight-inclusive care.
• Try this question: “Setting weight aside, what do you think would make the biggest difference in your health right now, and how can I support you in that?”