Shifting the focus to health, not weight: First, do no harm

As members of the Nutrition Committee, we often get ask­ed by colleagues, “What are the best weight-loss diets?” This is a difficult question to a complex problem. The diet industry is huge and, as evidenced by the obesity epidemic, largely unsuccessful. The constant battle with the scale has been shown to cause weight-cycling and preoccupation with weight, low self-esteem, eating disorders, and nutritional def­icits resulting in illnesses such as anemia and osteoporosis.

While there are obvious medical benefits of weight loss such as reductions in rates of diabetes, sleep apnea, osteoarthritis, and gastroesophageal reflux, just because someone is overweight does not necessarily mean they are also unhealthy. Thus, as physicians we need to focus more on encouraging healthy eating and lifestyles rather than the scale.

There is significant concern that emphasizing weight loss as an indicator of health can negatively impact physical and mental well-being. A “do no harm” approach is critical to avoiding unintended consequences associated with weight-driven approaches, including decreased body satisfaction, repeated cycles of weight loss and weight gain, reduced self-esteem, increased incidence of eating disorders, and the perpetuation of weight-based stigma/discrimination.[1]

Reflect on the language used with patients and adopt weight-neutral terminology. Literature overwhelmingly cautions against using terms such as “overweight,” “obese,” or “fat.” Promoting body size acceptance and goals to improve health behaviors such as physiological measures (i.e., blood pressure, blood glucose, or cholesterol levels) and mental health status are more effective than a goal of weight loss. 

Weight stigma has negative consequences. Youth who have a positive body image and greater self-esteem are more likely to eat healthfully and engage in physical acti­vity.[2,3]

Physicians can attempt to help pa­tients struggling with weight issues to develop healthier eating and exercise habits without focusing on weight. It is important for physicians to examine their own personal attitudes, beliefs, and assumptions regarding weight and assure that they do not inadvertently promote weight stigma. We need to recognize the natural diversity of body weight and avoid promoting the stereotype that it is necessary to be thin in order to be healthy.

Key points for physicians dealing with overweight patients

•    Be brief, as conversations as short as 5 minutes can have an impact on patient behavior.[4]
•    Use weight-neutral language (advise their weight is “not in a healthy weight range” or for children their weight “has increased faster than their height”) and avoid making judgments or assumptions based solely on a patient’s weight.
•    Help patients accept their body for what it is, at a higher-than-average weight as long as they are healthy.
•    Focus the discussion on healthy eating and physical activity behaviors. 
•    Assess patient’s readiness for change and identify SMART (specific, measurable, achievable, realistic, and timely) goals.
•    Encourage families to eat together as much as possible, and to avoid discussing weight particularly during meal time. 
•    Screen for disordered eating (see the SCOFF Questionnaire box).[5] Disordered eating attitudes and behaviors are sufficiently common in Canadian adolescent females to warrant routine screening.[6]
—Kathleen Cadenhead, MD, Chair
—Margo Sweeny, MD
—Barb Leslie, RD
—Helen Yeung RD
—Margaret Yandel, RD
Nutrition and Health Committee

The SCOFF Questionnaire
Sick—Do you make yourself Sick because you feel uncomfortably full?
Control—Do you worry that you have lost Control over how much you eat?
One—Have your recently lost more than One stone (14 lb.) in a 3-month period?
Fat—Do you believe yourself to be Fat when others say that you are too thin?
Food—Would you say that Food dominates your life? 
Each “yes” equals 1 point; a score of 2 indicates a likely diagnosis of anorexia nervosa or bulimia.7

Additional resources
http://keltyeatingdisorders.ca
www.bigbrothersbigsisters.ca/en/Home/Programs/GoGirls.aspx 
www.familyservices.bc.ca/professionals-a-educators/jessies-legacy
www.healthlinkbc.ca
www.mindcheck.ca

Acknowledgment
With special thanks to Kimberley Korf-Uzan, BSc, MPH, BC Mental Health and Addiction Services.

This article is the opinion of the Council on Health Promotion and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Bacon L, Aphramor L. Weight science: Evaluating the evidence for a paradigm shift. Nutrition J 2011;10:5.
2.    Neumark-Sztainer D. Preventing obesity and eating disorders in adolescents: What can health care providers do? J Adolesc Health 2009;44:206-213.
3.    Danielsdottir S, Burgard D, Oliver-Pyatt W. AED guidelines for childhood obesity prevention programs. Academy for Eating Disorders News­letter 2009;17. 
4.    National Institute of Health. Talking with patients about weight loss: Tips for primary care professionals. Weight-Control Information Network, US Department of Health and Human Services; 2005.
5.    Currin L, Schmidt U. A critical analysis of the utility of an early intervention ap­proach in the eating disorders. J Mental Health 2005;14:611-624. 
6.    Public Health Agency of Canada. A report on mental illnesses in Canada, 2002. Accessed 14 February 2012. http://www.phac-aspc.gc.ca/publicat/miic-mmac/pdf/chap_6_e.pdf.
7.    Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. BMJ 1999;319:1467-1468.