Iatrogenesis or Good Intentions? Why do Health Care Practitioners Continue to Ignore the Health At Every Size Philosophy?

Travis’ Note: Today’s guest post comes from Registered Dietitian Julie Rochefort, in response to my post last week titled “Time to Watch My Weight“?  More information on Julie can be found at the bottom of this post.  On a personal note, I should add that I don’t believe that weight loss is always a bad goal, but nor do I think it’s the solution for all individuals.  Enjoy the post!

PS. For those interested in the Health at Every Size Movement and the treatment of obesity, we will be hosting a debate in Ottawa in June of this year on the topic “Is Obesity a Disease?”, with two prominent speakers looking at the pros and cons of the medicalization of obesity, among other things.  More details on that event coming soon.

The Problem

As a frequent flyer within the twitterverse (@julie_rochefort; @shift_the_focus), I came across Travis’s tweet which indentified a very pressing and ethical issue facing health care practice today: weight bias.

my bmi is <25. at my physical, the nurse [asked] me to “watch my weight”, lest it should eventually increase to 25

The Issue

Subsequently in his post, Travis questions why his nurse focused on his weight rather than other relevant health behaviours such as, food intake and physical activity.  While I cannot speak from a nursing perspective (albeit, there are many commonalities among health care professions); I argue that the way in which obesity is framed and discussed within healthcare professional education may help to explain the maintenance of the acceptable weight=health mentality.

The Dietitians’ View

During my professional development in dietetics, dietitians were identified as a key player in the national fight against obesity; which in turn defined our role as weight loss “experts”. Accordingly, during my education and training, I was taught and mastered, how to calculate the BMI and, appropriately classify individuals into their respective weight categories. Normal. Overweight. Obese. Obese Class I, II, III.  Once classified, I was expected to ensure those in the normal category maintained their weight and the fat people lost weight. Failure to keep individuals within the supposedly safe BMI range of 18.5-24.9 would question my duties as a professional and put my patient’s health at risk.

While research continues to demonstrate that obese individuals can improve metabolic indicators (e.g. high blood pressure, high cholesterol, insulin resistance and glucose intolerance) independent of weight loss (Bacon and Aphramor, 2011), why is there still such a focus on weight at the clinical level?

Critical Obesity Studies

The weight-centered approach to health was a singular focus of my professional education and training. I wasn’t introduced to an alternative way of interpreting the weight/weight-loss imperative until my second semester of graduate school. Why was this alternative view not incorporated as part of my professional education? Perhaps dietetic educators can help shed some light on that question.

The overstated associations between weight and the risk of disease have given us permission to correct and pose shame onto the fat body defined by a BMI >25.  While Travis was able to overlook the well-intended warnings from the nurse, unfortunately this is likely not the norm.

While clinicians often practice with the best of intentions, a shift away from promoting weight-loss needs to occur if we are to truly commit to our ethical responsibility to ‘do no harm”.

The Next Steps

Incorporating alternative views of fatness is imperative to promoting the health and well being of the population.  I am not sure how this shift will take place. A good way to start this shift is by questioning our traditional approaches to body weight and engaging in dialogue with all members of the health care team, including the patient.

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About the author

Julie Rochefort

Julie Rochefort is a Health at Every Size (HAES) Registered Dietitian and recent graduate from Ryerson University’s Masters in Nutrition Communication program.  Her research interests involve examining weight bias and size discrimination and the impacts on health.

For more information about HAES please feel free to contact her at julierochefort@ShiftTheFocus.ca or visit http://criticaldieteticsblog.org/

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21 Responses to Iatrogenesis or Good Intentions? Why do Health Care Practitioners Continue to Ignore the Health At Every Size Philosophy?

  1. WRG says:

    Thanks for opening the discussion, but good lord, the door is only open a tiny crack. Let’s really get the talk going!

    BTW, I went to Julie’s website and am sad to say that I will be unable to attend the talk on Feb. 2 at Ryerson.

    • Travis says:

      FYI, I’m hoping to have an “Intro to HAES” post at some point in the near future. I personally know only the basics about the approach, and I think it would be good for me personally and for our readers to learn more about it (no guarantees that I will embrace all aspects of it, but I’d certainly like to learn more).

  2. This was very refreshing to read, thank you for posting it and thanks to Julie R. for writing it!

    I’ve been reading a few articles here and there on your blog since about the time it started, and only yesterday did I finally notice that you guys are Canadian! Obviously my rant on your previous blog entry was blaming the for-profit, corporate nature of my own U.S. health care system for the impersonal service I typically receive. I guess I have to back up a few steps. It seems from reading your blog and comments that such problems are not unknown in your nationalized system either. Whether it’s the quest for profits, or the government mandate to serve more citizens with tight funds, either way our modern system seems driven to treat medical patients/subscribers with statistical approximations and boilerplate advice. I hope Canadians will have success in demanding more personal medical care via their government, since it’s so very difficult to do so when dealing with a corporation.

    • Travis says:

      Glad you enjoyed Julie’s post!

      And no worries RE not knowing we’re from Canada (although Peter is actually based in New Zealand at the moment). Our blog network is hosted in the US, and that’s where most of our traffic comes from (along with a good dose from Europe as well). So a comment related to any healthcare system or the particularities of any country are just fine with me!

  3. Todd I. Stark says:

    Keep in mind that there are different classes of circumstances that involve obesity as a risk factor, and that the likelihood of being able to control obesity in individual cases is very difficult to predict. I was suffering from severe sleep apnea, reflux, and a number of symptoms related to very high blood glucose. I had a choice of losing weight, going on a of different meds and treatments, or dying. I lost 70 lbs mostly of adipose and every one of those symptoms went away. If I had accepted my weight I have very little doubt that I’d be a whole lot worse off today. If I had only the doctor’s suggestions as to what to do, I’d not have succeeded. The doc was very pessimistic that I’d be able to do it, and communicated that message. I think “acceptance and realism” will work for some classes of situation, but they are clearly not a good one size fits all message. I think many people need to be given the tools to help themselves as much as possible first, not statistical pessimism and well meaning acceptance messages. It’s entirely possible that we can change the negative statistics to some degree if we have the right tools.

    • Brian K says:

      Many athletes and body builders have a calculated BMI much greater than 25. I think the point of this post was that strict BMI is only applicable to people who live a particular lifestyle. Travis obviously does not practice a lifestyle in which a BMI of 25 would be considered alarming. Healthcare professionals need to be educated about this and learn to treat their patients dietary needs on a case by case basis. In a lot of cases, BMI is not a “one fits all” solution.

      • Travis says:

        Good point Brian.

        Although I’d like to point out that the “muscle weighs more than fat” argument doesn’t apply to a tremendous portion of the population, aside from young athletes and bodybuilders. That doesn’t negate the other issues with a BMI-centric approach, I just find that while this is a legitimate weakness of BMI, the fact that it ignores body fat distribution is a much bigger concern to me personally, and an issue which I think probably influences more people (e.g. they may still have a high body fat percentage, but it may be distributed in a way that is unlikely to carry much health risk).

  4. Todd I. Stark says:

    Several different issues here are easy to confuse, and people are going to prioritize them differently. One is how to accurately asses the risk of obesity on health. We don’t neccessarily agree on how much adipose tissue you need to be considered and the same level isn’t equally a risk for different people, and different people weigh the risk differently. Same as any other risk assessment.

    BMI is not optimal. Is there a better criterion? Not everyone who is obese is unhealthy. Do we have a reliable way of determining who is? What exactly should doctors be taking into account in their recommendations? What is the real cost of wrongly telling athletes they should lose weight , compared to failing to address the real risks of obesity? Seems like we have more questions than answers to the really critical questions and telling people to lose weight would, if they actually could do it, help more often than it hurts under current conditions.

  5. WRG says:

    A few thoughts:

    We do have ways of assessing health that do not depend on the BMI. I recommend people read the work of Dr. Steven Blair to learn more on being fat and fit.

    The issue of the BMI and athletes is really of little importance. Overweight is a societal issue. We are trying to improve population health and not striving to make everyone into a high-level athlete.

    The argument that Health at Every Size is a cop-out and that people are going to die or become severely ill if they give up their quest to lose weight is again the kind of argument that can only be used on an anecdotal basis. In fact, most people (especially women, I would argue, since their bodies naturally have a higher percentage of body fat than men) make themselves increasingly fatter the more they diet. What we want is to stop people from dieting up the scale and thus help to avoid situations where weight may end up playing a significant role in one’s health status. By concentrating on dieting at all costs, we are doing a disservice to the vast majority of overweight people. Again, I urge you to read the work of Dr. Blair.

    HAES also gets a bad rap because people seem not to hear the first word in the expression: health. The assumption is that HAES actually advocates unhealthy behaviours. This is totally erroneous, unless one believes that the only true indicator of “good health” is the BMI. Healthy behaviours include such things as eating healthy foods in reasonable portions and participating in physical activity to the best of one’s abilities. These behaviours do help to improve one’s health. They do not necessarily lead to any or any significant weight loss. If we start measuring health indicators other than weight, we will start to see that many people who actually practice HAES *do* often become healthier–they may still remain fat, though.

    The more I explore the issues of health and weight, the more it becomes evident to me that weight is an impossibly complex thing. Though most laypeople continue to cling to the notion that “calories in – calories out” actually works for everyone in exactly the same way, this is far from the case. Although virtually every mainstream health professional, journalist and filmmaker seems to come back to this terrible oversimplification, the facts don’t lie: 95% of people who lose weight just don’t keep it off. I cannot believe that all these people–many of whom have made weight loss practically a full-time job–are essentially lacking in willpower and lazy slobs. Do you really believe that naturally slim people are all walking around counting every calorie and morsel of food they put in their mouths? Or that the naturally slim are truly more virtuous than the overweight?

    There’s a fascinating documentary that was made in Britain entitled “Why Are Thin People Not Fat?”. Although it too feels the need to bow to the dieting gods, it documents the difficulties that a group of slim young people had trying to gain weight. My favourite part was when the researchers determined that the Asian man’s metabolism was getting increasingly fast to stop him from gaining weight, despite his over the top diet.

    Bodies come in many shapes and sizes. Most of those who diet end up much larger than their bodies were actually meant to be. Given this situation, we have to at least start exploring new paradigms for health. Tell me, where has dieting got us as a society?

  6. Julie Rochefort, RD says:

    WRG: You have captured the main facet of HAES (health) along with the main argument or resistance that come along with this movement. When I first introduce colleagues and students to HAES many of the first reactions is “What the…” followed by a puzzled look.

    What is often neglected is the fact that weight doesn’t really tell us anything significant regarding someone’s health. Its a symptom at best. But what makes this “symptom” unique is that in order to improve the underlying health factors that are potentially causing this increase weight (diabetes, inactivity, nutrition intake ) is that improvements in this factors may not result in weight loss. So when you don’t lose weight but improve your activity level, nutrition intake and hey, self-esteem are you healthy? or still part of the problem?

    Health care /health promotion/ researcher needs to back up and take a real look at what’s underlying the rising rates of of heart disease, diabetes…etc. The epidemic is not purely fatness.

    Thanks for all your critical input and comments.


  7. I have a suspicion, and maybe someone else can tell me from your much deeper expertise than mine whether this is true, that as people adopt increasingly healthy habits in general, they tend to regulate their weight better, een if they don’t focus specifically on dieting or weight loss.

    I suspect this because most people I know who go from being sedentary and eating completely ad libitum from convenience foods to making some reasonable attempt at better nutritional choices and being more active usually (though not always) seem to move toward both better health and less body fat without really trying specifically to lose weight. So it seems to me that specifically trying to lose weight for some reason tends to be a much more difficult strategy. Perhaps because it is so much more narrowly focused and the outcome expectations are more extreme. So perhaps without intending to, we engage various forms of psychological and physiological reactance, whereas nudges might be more effective.

    Perhaps if that’s true, it goes hand in hand with the philosophy of being healthy at any size, but if it is true it may also mean that health at any size is a more reasonable way to start to achieve less extreme size than so many of us have become. Or am I off base here?

    • Travis says:

      I’m guessing that the others may want to jump in here, but I just wanted to point out that adopting healthy behaviours may bring about weight loss for many people, but it is unlikely to get someone to a “healthy” body weight in many cases (unless they are starting with a BMI just slightly above 25 to start with). In the post that led to this one, a number of commenters complained that they had lost considerable amounts of weight through lifestyle changes, but were still counseled by their clinicians to reduce their weight further to get their BMI below 25. And the frustration of not getting to that “ideal” weight may then lead people to give up on their lifestyle changes.

      So I guess my only point is that focusing too much on a somewhat arbitrary ideal weight may ironically prevent people from adopting or maintaining a healthy lifestyle that may help them get to a healthier weight (or a healthier body composition through the reduction of abdominal fat and/or increase in muscle, neither of which are reflected well by the number on the bathroom scale).

  8. Todd I. Stark says:

    So i’m hearing that it may well be that the focus on weight is in itself counterproductive even though we mostly all agree that as a group we have been getting larger and that at some point this largeness increases the risk for chronic illness for at least some significant percentage of us. The weight is just the wrong target, and not just that we use bad measures of weight? Am I understanding the argument?

  9. Douglas Satcher, M.D. says:

    The idea of “Healthy at Every Weight” is a wonderful idea, but far from true medical reality. While it is true that being at or near a BMI of 25 is not a total indicator of your health, it is an indicator of risk of future problems.

    The BMI is not the best test of determining all future risks of complications, but for population studies it is currently the best method available to determine future risk. The BMI cannot accurately determine which person has more intra-abdominal fat compared to another. This is one of the main limitations of the BMI.

    First, I will provide you will the medical evident that there is no such thing as HAEW. There is or should be “Being as Healthy as possible at every weight”. There are true and meaning benefits of weight loss with a little as 10-15 lbs and moderate exercise. The “Diabetes Prevention Trial” in 2001 showed that there was a 50% reduction over 3 year in progression of patients being pre-diabetic to becoming Diabetic by 10-15 lbs weight loss and 30 minutes of brisk walking 5 days per week. When patient lose 30-50 lbs or more, they are able to stop or significantly reduce medications for diabetes, hypertension, and gastroesophageal reflux.

    Further medical evidence of against the idea of “HEAW” is 30 year study in the Journal “Circulation” of the American Heart Association in January 19, 2010 (http://circ.ahajournals.org/cgi/content/full/121/2/230). The summary is as follows:
    Conclusions—Middle-aged men with MetS had increased risk for cardiovascular events and total death regardless of BMI status during more than 30 years of follow-up. In contrast to previous reports, overweight and obese individuals without MetS also had an increased risk. The present data refute the notion that overweight and obesity without MetS are benign
    conditions. (Circulation. 2010;121:230-236.)

    MetS= Metabolic Syndrome = is described briefly as elevated insulin levels, elevated blood pressure, and elevated triglycerides.

    If the medical information isn’t good enough to prove that overweight and obesity is associated with complications, I refer you the the ultimate authorities, Actuaries. The society of Actuaries published the economic costs of Obesity in the following article. However, the best way to see the associations with obesity is by scanning the 80 page article available for download at their site. I have attached the current link: (http://www.soa.org/files/pdf/research-2011-obesity-relation-mortality.pdf).

    Obesity is a very difficulty disease to control. However, it is important to keep the facts separate from the reality. It would be wonderful if having the few extra pounds did not translate into a lifetime of chronic medical problems. The reality is that we have to eat better consistently and avoid eating out as much as possible. A person’s risk of various diseases and obesity is directly related to eating how many times a person eats out a week.

    In closing, the facts are the facts. I have been researching this issue for about 5 years to get the information which is clear and unequivocal. There has been much written to the contrary, but the long term studies have only recently been able to show the problems which are clearly associated with obesity. Obesity is thought to be an inflammatory disease which affects almost every organ system in the body. It is not an benign illness as many would lead you to believe. For men, a BMI >30 increases the risk of Diabetes 10.4 times; for women, it increases Diabetes risk 48.9 times. (Page 16 of the Study from the Actuary Site).

    So, I would continue to encourage you to work the best to obtain the “Being as Healthy as possible at every weight”. Every step toward this goal will reduce your future risks of disease.


    Dr. Douglas …..

    • Travis Saunders, MSc, CEP says:

      Thanks for the thoughtful comment Dr Douglas.

      I appreciate what you’re getting at, but is the “as healthy as possible at every weight” message meaningfully different than the Health At Every Size message, if we assume that the vast majority of obese individuals will remain obese (or at least overweight), even if they adopt an extremely healthy lifestyle?

      The relationship between height and mortality serves as an interesting comparison. Short people have a higher risk of dying from heart disease, even after adjusting for SES (http://jech.bmj.com/content/54/2/97.full & http://aje.oxfordjournals.org/content/168/5/497.short & http://jech.bmj.com/content/65/Suppl_2/A26.1.short). We could spend a lot of time talking about how, like it or not, being short is a risk factor that people should worry about. But we wouldn’t do that, since there is no good way to increase an adult’s height. It’s similar to how my risk for various diseases is higher than my wife’s simply because I’m a man… but I don’t lose sleep over it because there’s not much I can do about that.

      So I don’t dispute that weight is independently associated with health. I just wonder whether it’s worth focusing so heavily on weight when we know we’re not very good at influencing it. If we had a simple and effective way to reduce weight then I’d be all for it, but unfortunately we don’t.


  10. Douglas Satcher, M.D. says:


    I briefly reviewed the links in your response. Those patients are not good examples to quote or compare since they mention that those patients’ shortness is a function of malnutrition and other indicators of illness which affect their ultimate growth and height. Therefore, shortness in those patients are an indicator of disease related to childhood illness and malnutrition.

    A line from the first article is as follows:

    “Long term secular trends in height have been associated with changing mortality rates in Britain and elsewhere.54 In Britain for people born during the second quarter of the 19th century height decreased with year of birth, then increased for people born after the mid-century.54 This pattern is strikingly similar to mortality trends. All cause mortality showed no improvement (and in some places even increased) over the second quarter of the century, and then from around 1850 mortality reductions were seen in a cohort specific manner, first for children, then for young adults and then for older adults.55 56 Both the height and mortality data suggest that childhood circumstances started to improve around the middle of the 19th century and that people who were young children during this period took with them, as their cohort aged, a reduced mortality risk”

    The same is true for many patients with a very low BMI. It is often an indicator of chronic disease and these patients are usually are excluded from long term studies.

    Dr. Douglas

    • Travis Saunders, MSc, CEP says:

      But you could make similar arguments for obesity – there is much evidence to suggest that adult obesity and metabolic disease is due to environmental factors experienced during childhood, or even in utero.

      I guess my main point is whether we should focus on weight (even if it is associated with health risk) if it is unlikely that a person will be able to sustain significant weight loss , even if they have the best medical care available. I question whether it’s worth focusing so much on an endpoint that we’re not very good at influencing, when we could focus instead on other endpoints (e.g. metabolic health, etc) that may be more easily influenced.

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  12. Douglas Satcher, M.D. says:


    I just read a very good up to date article on the New York Times website . Another article which confirms the information I previously quoted.
    The link is: http://well.blogs.nytimes.com/2012/03/07/getting-fat-but-staying-fit/

    With regards,

    Dr. Douglas