Body weight is a highly contentious issue. Talking about weight has become taboo amongst some healthcare practitioners, especially those who follow a Healthy At Every Size (HAES) and self determination theory style of practice.
For individuals, it’s wrapped in emotion about self-worth and self-esteem. For the public and the media talking about weight, is a way to publicly shame individuals.
I find it disgusting that in our society people are weight shamed. People should never be subject to such discrimination and prejudice. Despite this, I still think taking someone’s weight is useful in the medical context. In the medical field, we do need to talk about weight in a neutral non-judgemental way because it is an important risk factor for health.
There is a space for weight-neutral diet coaching where you don’t need to talk about weight to get to your end result. The end result being, growing to love and respect yourself, improving fitness, dietary patterns, and just being healthy.
HAES style of practice does this fantastically. It has been shown to improve eating patterns in women  suffering from disordered eating and eating disorders.
HAES like other self determination theory styles of nutrition coaching, values the input of the client and takes into consideration their emotional needs and wellbeing. During HAES interventions in particular, ‘weighing in’ doesn’t occur and weight isn’t mentioned. This is because the focus of sessions is to guide individuals on how to eat intuitively to internal signals of hunger and fullness. It focuses on changing behaviour rather than focusing on weight, which is typically emotionally charged.
The problem for me becomes transferring this style of practice to everyone, despite their medical need. There are certain people in which weight management is an important discussion to be had.
When should we talk about weight?
I will start by saying I work in an outpatient obesity unit in a public hospital. The patients referred to us are triaged according to BMI. Our clinics start at a BMI of 35 or more. In one particular clinic we run, our starting BMI is greater than 55 – it’s our super obese clinic. ‘Super obese’ being the medical term used to describe this level of BMI in the same way we use the terms morbid or severe obesity.
In our super obese clinic we use BMI to triage high risk patients. Clinics are set up so there are at least two specialist doctors present and three therapists which consists of a multidisciplinary team. Triaging helps you prepare for the needs of the patients attending.
For people that we see in this context, there is a need to talk about weight because at this level of obesity weight does impact health.
At the moment, there are no nutrition weight management styles of treatment or strategies that have been validated in this particular patient cohort. This is because super obesity is typically an exclusion criteria in studies because of the complex medical conditions that occur due to excess weight. To say any style of practice should be exclusively used in this group is incorrect.
Practice styles, such as HAES, using weight neutral approaches to nutrition coaching is validated in white women with a BMI below 40. It is a successful way to increase wellness and body positivity . This issue is it is not evidence based practice to assume everyone needs the same style of treatment, especially if the treatment used isn’t validated across various groups of people with various needs.
Unfortunately, at higher BMIs, relative risk to health grows exponentially. Disability due to body size is evident, and people are more prone to obesity related disorders like sleep apnoea, hyperventilation syndrome, skin infections, infertility and much more. Patients do not get referred to a specialised outpatient unit because they are well or healthy.
The reality is that discussing weight in relation to health complications is our ethical responsibility. If we do not discuss the implications of excess weight, we are withholding patient knowledge that may or may not help them make informed decisions about their own health care.
Health practitioners need to start regaining control over the word “weight” and “obese”. These terms were not intended to be shaming. They are, after all medical terms, just like diabetes and heart disease.
It’s important to know a patient’s weight for the following reasons:
- Decipher anaesthetic risk before surgery;
- Track treatment progress when excess body weight is impacting health conditions;
- Dose medicines according to body weight;
- Assess equipment suitability for the patient;
- To identify genetic or medical conditions that affect metabolism and ability to lose weight. For example, if weight loss hasn’t occurred during an intervention, then a person can be referred for an RMR. Resting metabolic rate assessment, blood screen for thyroid condition and PCOS or genetic abnormality like Prada Willi Syndrome;
- To measure the degree of fluid retention; and
- To explain blood pressure changes during dialysis.
I’m sure you can also think of many more reasons, why in the medical context, it’s important to know a person’s weight, at all body weights and sizes, not just in those with obesity.
How should you take a person’s weight?
When addressing weight, it must be done with dignity, privacy and respect. Make a point to ask the person if they are ok to weigh themselves today. Don’t make demands. Respect is shown, by showing the other person you have listened to them, you have taken into consideration their needs and wants. You don’t know what people want unless you ask them.
If I see that a person is hesitant about weighing, I reassure them that they don’t have to weigh if they don’t want to and I’m not here to judge them. It’s merely a number to record so we can track change.
I also don’t make a big deal about what the number is. I do not praise or chastise if it’s a higher or lower weight. It’s just a number and we move on. After a person hops off the scales, I just say thank you. If the client wants to know their weight in comparison to the last weight, I tell them; otherwise, I leave it alone.
It’s important to know the weight limit of your scales, so it doesn’t leave you or them in an awkward situation. I feel it’s our responsibility as health practitioners to protect our clients from judgement or embarrassment from simple things that can be easily avoided. Again, it’s about creating an environment that is dignified and respectful.
Can you weigh a person using a client centric approach?
I do believe a practitioner that is trained appropriately and that is empathetic can provide a client centric treatment approach, whilst still being able to weigh a person. You can do this by explaining why you need to take a weight, and how weight is a measure for you, the practitioner, to track change and to see why a treatment is or isn’t working.
Weighing a person in a dignified manner is not synonymous with shaming a person about their weight. The two are mutually exclusive.
It should be outlined to the person that the aim of every session is not to change weight, but to focus on changing behaviour and increasing wellbeing.
What is the best practice style to use?
I’ve been involved in many debates about different styles of behavioural coaching. Amongst dietitians, the HAES style of practice is very popular. In the corporate health and public health arena, motivational interviewing in conjunction with Prochaska’s Transtheoretical Model of Change (TMC), is viewed as the gold standard.
Motivational interviewing (MI) is a practice framework that is used to facilitate internal motivation. The goal is to find the person’s emotional internal drives for change and use this to evoke action to reach change. It is a client centred style of counselling that helps clients explore and combat ambivalence. This style of communication uses open-ended questions, affirmations, rolls with resistance and builds trust between the practitioner and the client.
Motivational interviewing is typically coupled with TMC. TMC recognises that when you try to change behaviour there are certain steps you must pass through in order to change. It factors for relapse, and it’s just a good way for clients to recognise different stages of behaviour change.
Using MI and TMC is a patient centric approach to treatment, however there is no stipulation if you should weigh a person or not, because that issue is irreverent to a patient centric approach.
Whereas, in other specialised treatment units for anorexia and bulimia, Maudsley Family based therapy is thought to be the best outpatient recovery style of treatment for young people. This framework actively involves the patient’s family in treatment.
When you use the Maudsley program, the goal is weight restoration, which means you have to weigh the person at multiple time points throughout the treatment. It recognises that recovery from an eating disorder requires family support and should not rest with the individual. The aim of this treatment is to give parents complete control over what their child eats, when it’s eaten and how much is eaten. The child simultaneously undergoes psychological treatment whilst re-feeding for weight restoration becomes the main focus of parents. Weighing in during this treatment is used to normalise the action of weighing and teasing out the psychological reaction of the person to changes in body weight.
Which one is best?
In short, I recognise that all styles of practice are equally good, and they all have their flaws. They are all effective treatment frameworks to use on certain groups of people, however if you use them in isolation and stay rigid to the framework you are doing clients a disservice.
People are not the same, and people change over time. Whilst the majority of people may respond to your practice style now, it may become an ineffective framework in the future as they grow and want to learn more.
I find some practice styles also ineffective for people who are not insightful. It may be ineffective for people who would rather work with concrete numbers rather that have lengthy conversations about what they do and don’t feel. Others may not have the knowledge to come up with ideas on how to help themselves using the MI approach. Clients may not have supportive families who will implement Maudsley Family Based Therapy either especially if they are young adults.
When should you NOT talk about weight?
As the saying goes, “there is a time and a place for everything”. And I believe this is true for weighing a person. The following scenarios are when I would not weigh a person:
- If a person specifically asks to not be weighed. Part of being a medical practitioner is respecting a patient’s needs and wants.
- If the weighing cannot be done in private or in a dignified manner. For example, walking a patient through a hospital to the basement to weigh on industrial scales because the scales in your office aren’t equipped for that weight. This will have a psychological impact on that person.
- If the person is a child or teen. Children and teenagers do not have the mental processing skills to reason and understand how a weigh in can be disconnected to emotions. Also I believe children and teenagers have the right to be kept as children and enjoy life. They shouldn’t be encouraged to lose weight, but should be encouraged to build new life long behaviours.
- If a person has decided they want to use a HAES approach to managing health.
- If a weigh in is so emotionally charged it interferes with treatment.
- During treatment of anorexia or bulimia, depending on the style of treatment that is being used in your multidisciplinary team.
There are probably many more reasons you can think of, too…
I used to work in a workplace where, under the motivation interviewing and behaviour change model they worked under, forced practitioners to directly talk about weight and BMI. If you didn’t discuss BMI and that outpatient call was pulled for audit, you’d lose “points” in the marking criteria for call quality. This used to be the cause of many arguments between myself and the assessor.
BMI is a tool used by practitioners and epidemiologists to identify relative health risk according to population norms. In an individual consult, it has zero use to the person. For example, it is more relevant to talk about aiming for a reduction in weight of 10% initial body weight. This percentage of weight loss will improve all health markers, reduce sleep apnoea, blood sugars and blood pressure. It’s realistic, relevant and most of all has the focus on their health.
BMI, on the other hand, is an abstract term that people do not fully understand what it means. It is a classification tool to triage people into specialised clinics, and understand relative risk in populations. It is not a tool designed to educate people on how fat they are.
So whilst BMI has its place in research and in triage, it has zero relevance to individuals in consults, so I don’t talk about.
Is the goal of weight loss actually that important?
The sentiment out there is that there’s no point in focusing on weight loss because the research into weight management shows that weight regain is enviable. Whilst I don’t deny this, weight rebound is common. There are still people who are successful at losing weight and keeping it off. For the others who do regain, there is health benefit in losing weight just for that short period of time.
Research has shown that short duration stints of weight loss do result in long-term cardiovascular health benefits . Helping people at the highest health risk achieve weight loss for a short period of time is better than not losing weight at all .
Sometimes helping clients just maintain weight and perform healthy behaviours is good enough, and other times it’s not. Everyone is different.
Different styles of practice suit different individuals with varying health conditions and needs. Many styles of practice can exist and be used simultaneously. They should be viewed as one of the many tools a nutrition professional has in their tool box, to help people with different needs.
We all agree that there is no one-size-fits-all for diets, so when are we going to realise there isn’t a one-size-fits-all practice style for clients?
 M.Charaikda et al. Lifelong patterns of BMI and cardiovascular phenotype in individuals aged 60-64years in the 1946 British birth cohort study: an epidemiological study.
 L.Guangwei et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study.