DOI: 10.1002/ncp.

10885

INVITED REVIEW

The consequences of a weight‐centric approach to

healthcare: A case for a paradigm shift in how clinicians
address body weight

Kasuen Mauldin PhD, RD1,2 | Michelle May MD3,4 | Dawn Clifford PhD, RD5
1
Department of Nutrition, Food Science, and Packaging, San José State University, San José, California, USA
2
Department of Clinical Nutrition, Stanford Health Care, Stanford, California, USA
3
Am I Hungry? Mindful Eating Programs and Training, USA
4
Department of Psychology, Arizona State University, Tempe, Arizona, USA
5
Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona, USA

Correspondence
Kasuen Mauldin, PhD, RD, Department of Abstract
Nutrition, Food Science, and Packaging, Current healthcare is weight‐centric, equating weight and health. This
San José State University, One
Washington Square, San José, CA 95192‐
approach to healthcare has negative consequences on patient well‐being.
0058, USA. The aim of this article is to make a case for a paradigm shift in how clinicians
Email: [email protected] view and address body weight. In this review, we (1) address common flawed
assumptions in the weight‐centric approach to healthcare, (2) review the
weight science literature and provide evidence for the negative consequences
of promoting dieting and weight loss, and (3) provide practice recommenda-
tions for weight‐inclusive care.

KEYWORDS
dieting, obesity, overweight, weight stigma, weight‐centric, weight‐inclusive

I N T R O D U C TI O N to shift to a weight‐inclusive approach. Although other

review articles have also addressed the differences
Currently, the widely prevailing paradigm in clinical between a weight‐centric approach and a weight‐
practice (and society at large) assumes body size can be inclusive approach,24–26 the target audience for this
used to predict an individual's health, body size is review is physicians, and, therefore, we provide practical
responsible for various diseases, and body size is subject strategies for aligning with weight‐inclusive care in
to permanent manipulation through diet and exercise. medical settings.
This weight‐centric approach (see Table 1 for terminol-
ogy and their definitions1–23) emphasizes weight and
weight loss for health. This approach has been shown to THE C URR E NT W E IGHT ‐ CENTRIC
be ineffective for the vast majority of patients in the long PARADIGM
run, and it has adverse consequences.24,25 This article
will explore the physiological and psychological conse- There are two main reasons why the current weight‐
quences of a weight‐centric approach to health and how centric paradigm has been perpetuated:

© 2022 American Society for Parenteral and Enteral Nutrition.

Nutr. Clin. Pract. 2022;1–16. wileyonlinelibrary.com/journal/ncp | 1

2 | MAULDIN ET AL.

TABLE 1 Terminology and definitions in weight literature

Term Definition
Weight‐centric terminology
Weight‐centric Defined as having the six following tenants: “(a) the belief that weight is under individual control, (b)
the belief that weight gain is caused by an imbalance in caloric intake and energy usage, (c) the
belief that health status can be predicted by weight, (d) the belief that excess body weight causes
disease and early death, (e) the belief that methods for successful long‐term weight loss involve
the modification of eating and exercise patterns, and (f) the belief that losing weight will result in
better health.”1
Often used as a synonym for weight‐normative.
Weight‐normative An approach that “rests on the assumption that weight and disease are related in a linear fashion,
with disease and weight increasing in tandem. Under the weight‐normative approach, personal
responsibility for ‘healthy lifestyle choices’ and the maintenance of ‘healthy weights’ are
emphasized. On the basis of these beliefs, the weight‐normative approach focuses on weight loss
and weight management to prevent and treat a myriad of health problems.”2
Often used as a synonym for weight‐centric.
Diet culture “Often used by those within the broad anti‐diet movement to critique the pervasiveness of dieting
norms and practices in online blogs.”3
Dieting “A regimen of eating and drinking sparingly so as to reduce one's weight.”4
Weight control/weight “The process of adopting long‐term lifestyle modification to maintain a healthy body weight on the
management basis of a person's age, sex and height.”5
Weight‐inclusive terminology
Weight‐inclusive An approach that “rests on the assumption that everybody is capable of achieving health and well‐
being independent of weight, given access to non‐stigmatizing health care. This approach
challenges the belief that a particular BMI reflects a particular set of health practices, health
status, or moral character…weight is not a focal point for medical treatment or intervention.
Weight is not viewed as a behavior….”2
Weight‐neutral An approach that focuses on “improving patients' relationships with food, removing moral
judgments around food, building awareness of hunger and fullness cues, emphasizing emotional
and physical wellness over the pursuit of a lower weight or size, and advocating for removal of the
stigma experienced by persons with larger bodies.”6
Sometimes used as a synonym for weight‐inclusive, but weight‐neutral implies more passive rather
than active inclusion.
Health At Every Size® A paradigm that supports “size‐acceptance, to end weight discrimination, and to lessen the cultural
obsession with weight loss and thinness” and promotes “balanced eating, life‐enhancing physical
activity, and respect for the diversity of body shapes and sizes.”7
Nondiet Emphasizes “eating in response to physiological cues, i.e. using hunger and satiety as regulators of
food intake as opposed to dietary restraint, and enhancing body acceptance, regardless of whether
an individual is successful at weight control.”8
Antidiet A phrase that refers to individuals who are antidiet culture or share a belief that diet culture is
harmful.9
Intuitive eating “an adaptive form of eating characterized by a strong connection with internal physiological hunger
and satiety cues.” Those who eat intuitively are “not preoccupied with food or dieting and do not
label certain foods as ‘good’ or ‘bad’. Although taste is important, they often choose foods for the
purpose of enhancing their body's functioning. They are aware of and trust their body's internal
hunger and satiety cues and use these cues to determine when and how much to eat.”10,11
Mindful eating An approach to eating that supports becoming aware of “thoughts, feelings, and physical sensations
related to eating, reconnecting us with our innate inner wisdom about hunger and satiety.” It is
conceptualized as “being aware of the present moment when one is eating, paying close attention
to the effect of the food on the senses, and noting the physical and emotional sensations in
response to eating.”12
NUTRITION IN CLINICAL PRACTICE | 3

TABLE 1 (Continued)

Term Definition
Satter Eating Competence “An inclusive, evidence‐based, and practice‐based conceptualization of the interrelated spectrum of
Model (ecSatter) eating attitudes and behaviors that transcends current conceptualizations of food management.”
Competent eaters are “positive, comfortable, and flexible with eating and are matter‐of‐fact and
reliable about getting enough to eat of enjoyable and nourishing food.” There are 4 basic
components of the model: (1) eating attitudes, (2) food acceptance, (3) internal regulation, and (4)
contextual skills.13
Additional terms
Weight stigma “The social rejection and devaluation that accrues to those who do not comply with prevailing social
norms of adequate body weight and shape.”14
Internalized weight stigma “When a person is aware that he or she has a stigmatized identity and applies negative societal
stereotypes to oneself.”15
Weight bias “Negative weight‐related attitudes, beliefs, assumptions and judgments toward individuals who are
overweight and obese.”16
Implicit weight bias “Implicit biases involve associations outside conscious awareness, such as unconscious assumptions
about patients with higher weight that may lead to different healthcare treatment.”17
In contrast, explicit biases are conscious.
Internalized weight bias “Applying negative weight‐based stereotypes to oneself and engaging in self‐blame for one's weight
status.”18
Healthism Discrimination on the basis of health status, including both health‐related traits as well as health‐
related conduct.19
Thin privilege “Thin privilege represents all the social, financial and practical benefits a person gets because they
are thin or in a relatively smaller body.”20
Examples:
• “It is easy to find clothing in my size that is my style.”
• “When I order food at a restaurant, no one questions my order based on my body size.”
• “People don't notice my size when I sit next to them in an airline seat.”
Weight cycling (also known “Intentional weight loss followed by unintentional weight gain.”21
as yo‐yo dieting)
Social determinants of “Social determinants of health (SDOH) are the conditions in the environments where people are
health born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and
quality‐of‐life outcomes and risks.”22
Intersectionality “Intersectionality promotes an understanding of human beings as shaped by the interaction of
different social locations (e.g., ‘race’/ethnicity, Indigeneity, gender, class, sexuality, geography,
age, disability/ability, migration status, religion). These interactions occur within a context of
connected systems and structures of power (e.g., laws, policies, state governments and other
political and economic unions, religious institutions, media). Through such processes,
interdependent forms of privilege and oppression shaped by colonialism, imperialism, racism,
homophobia, ableism and patriarchy are created.”23

1. Paradigms are difficult to break through. Paradigms are difficult to break through
2. Bias exists in the evidence informing practice.
The weight‐centric paradigm is so well established that it
Before we discuss the weight‐centric paradigm, it is often restated in studies without providing supporting
should be noted that in Table 1, we have included references. For example, statements such as, “Over-
common terms in weight literature and their generally weight and obesity have negative health effects”27 can be
accepted definitions. found in the articles referenced in this review.
4 | MAULDIN ET AL.

Established paradigms are difficult to break through, perpetuated by media portrayals of constructed con-
creating delays in adoption of newer, proven paradigms. cepts of health and beauty. Because of the entrenched
This phenomenon is called the Semmelweis Reflex, the paradigm that higher body weight causes various
tendency to reject new evidence or new knowledge diseases and is reversible, research and selection for
because it contradicts established norms, beliefs, or publication favors studies focused on lowering body
paradigms.28 The Semmelweis Reflex is named for a weight. This bias affects how people in larger bodies are
Hungarian pediatrician who, in the mid‐1800s, had viewed in clinical practice and the general public.
difficulty convincing his colleagues to wash their hands Further, it fuels society's obsession with body image and
between patients to prevent purpureal sepsis because weight.32
doctors “took offence from the notion that they The weight‐centric paradigm can lead to confirma-
themselves were the conduits of this fatal infection.”28 tion bias in weight research. In 2010, Aphramor reviewed
One major reason shifting away from the weight‐centric all weight loss articles published between January 2004
paradigm is challenging is because of the assumptions and December 2008 in The Journal of Human Nutrition
underlying the terms commonly used in healthcare to refer and Dietetics.33 The review evaluated the validity of the
to body size. For example, medical literature commonly claims made in the selected articles.33 For example, in
uses the words “ideal weight,” “normal weight,” “healthy one research study that was reviewed, the authors made
weight,” “overweight,” “obese,” and “morbidly obese.” the claim that the most successful weight loss strategy
These terms are potentially problematic for a number of included a commercial weight loss program such as
reasons.29,30 “Ideal weight,” “normal weight,” and “over- Weight Watchers or Jenny Craig, in combination with
weight” imply that there is a “correct” weight everyone decreased food quantity, cutting down on fats/sugars,
should be, ignoring natural human diversity. “Healthy and exercise, but their determination of weight loss
weight” presumes that people are automatically healthy or success was based on a weight loss over 2 years of only
unhealthy at a certain weight. “Obesity” and “morbid 0.03 kg compared with a group with no intervention.34 In
obesity” are medical terms that pathologize body size. another study examined, authors claimed their study
Further, the origins of the word “obese” is from the Latin interventions were ultimately successful in achieving
obesus, “having eaten until fat,” which incorrectly repre- weight loss in those who complied, but this conclusion
sents the cause of fatness.31 Shifting away from the weight‐ does not accurately reflect that 64% of participants had
centric paradigm would require interrogating the assump- withdrawn by week 8, that some participants gained
tions underlying common terminology. weight, and that weight rebound was common.35
The weight‐centric paradigm is based on numerous Aphramor concluded that “weight management research
flawed assumptions addressed in this article: appears to occupy a hallowed place where deviations
from regular scientific conduct are readily tolerated, for
• High body weight causes poor health and mortality. example, continued support of research programes that
• Advising patients to lose weight is an effective do not adequately report adverse effect, or rely on
intervention. acceptance of common assumptions that are
• Weight is under an individual's control. inadequately supported by data, which in turn may point
• When weight loss and health improvements are not to a lack of stringency in research ethics decisions
sustained, it is the fault of the patient. regarding weight management.”33
• Health improvements seen after a weight loss inter- Weight‐centric literature subscribes to the narrative
vention are due to the weight loss, not the behavioral that weight loss is achievable and needed for health, but
modifications and the intervention itself. when one looks at the data, the majority of the study
• Advising patients to lose weight is a harmless populations do not achieve long‐term body weights
intervention. defined as normal based on body mass index (BMI).36
For example, Montesi et al published a comprehensive
This review explores the evidence and suggests a review of various recent weight loss studies and their
paradigm shift in the way clinicians think about weight. outcomes.37 Although the narrative of the review and the
studies cited indicate long‐term weight loss maintenance,
the data results show the following:
Bias exists in the evidence informing practice
1. The definitions of successful long‐term weight loss are
The weight‐centric paradigm is driven by weight bias arbitrary and inconsistent. Weight loss data are
and assumptions about weight and health in research reported as percentage of weight loss from initial
and clinical practice, along with societal pressures body weight or as specific amounts (eg 2.5 kg) lost,
NUTRITION IN CLINICAL PRACTICE | 5

and the duration of weight loss maintenance is not not surprising that clinicians are trained to treat many
well defined (6 months, 1 year, 5 years, etc). ailments by prescribing weight loss. It is imperative that
2. Weight loss is modest and likely below what most clinicians critique the scientific evidence backing weight
patients (and clinicians) expect. loss recommendations.
3. The majority of studies are not truly long‐term, often
not beyond months or 1 year.
4. The majority of the study participants did not sustain ADDRESSING ASSUMPTIONS
weight loss even within the time frames studied. AB OUT WE I G HT AN D HE A LT H

Selection bias in weight‐centric literature should also To address common flawed assumptions in the weight‐
be considered, as those who opt to participate in weight centric approach to healthcare, we present the evidence
loss studies may exhibit more restraint38 and lower to answer the following questions.
disinhibition39 in their eating behaviors than the general
population, skewing study populations and results. In • Does higher body weight cause morbidity and
addition, study participants who achieve weight loss are mortality?
more likely to stay in a study, whereas those who do not • Is advising patients to lose weight an effective
are more likely to be lost to follow‐up.40 intervention?
For example, the National Weight Control Registry • Why is sustained weight loss difficult?
database has been used in research publications that • Are there adverse health and ethical implications of
argue long‐term weight loss maintenance is possible. promoting weight loss?
However, the eligibility criteria for participants to be in
this database is having maintained at least a 30‐pound In this review, we critically examine the weight
weight loss for 1 year or longer.41,42 By selectively science literature and provide evidence for the negative
recruiting participants who have had long‐term weight consequences of promoting dieting and weight loss.
loss to be included in a study and then concluding that
long‐term weight loss is possible highlights the issues
with design bias in the research.43 Despite these research Does higher body weight cause morbidity
limitations, clinicians use results from such studies to and mortality?
guide their weight‐centric recommendations. To be fair,
researchers who established the National Weight Control Body weight is used to calculate BMI, commonly used to
Registry have stated that “Because this is not a random assess an individual's disease risk. The BMI formula
sample of those who attempt weight loss, the results have (ratio of weight in kilograms divided by height in meters
limited generalizability to the entire population of squared), originally called the Quetelet Index, was
overweight and obese individuals. The value of this developed by mathematician Lambert Adolphe Jacques
project lies in identifying potential strategies that may Quetelet in 1832 to measure and characterize the average
help others be more successful in keeping weight off.”44 man, not to assess obesity or health risks.46 In 1972,
Given the record‐keeping required to be part of the Ancel Keys renamed it the “Body Mass Index” and used
National Weight Control Registry database, perhaps it is it as a proxy for body fat percentage. Keys explicitly
not surprising that those who are successful at weight judged BMI as appropriate for population studies and
loss report rigid monitoring, strict caloric restriction, and inappropriate for individual evaluation.47 Though ini-
intense exercise routines. In other settings, these behav- tially used by epidemiologists, the popularity of BMI
iors can be used to screen and diagnose an individual spread to doctors who wanted a quick way to estimate
with an eating disorder.42,45 body fat in individual patients. Although a BMI corre-
Research outcomes focused on weight and weight lates with the percentage of fatness in a population, it is
loss are often used as surrogate markers for improved often a poor predictor of an individual's body fat
health. As a result, many nonweight‐related factors percentage.48 For example, one study showed the average
(which are more difficult to measure and collect) that body fat percentage with a BMI of 35 was 32% in a certain
impact health are ignored.32 In addition, because of the population, but the range of percentage of body fat was
entrenched weight‐centric paradigm, there is publication highly varied between 18% and 47%.49 BMI has also
bias, in which studies that fit the paradigm are been criticized because it disproportionately stigmatizes
preferentially accepted for publication. people of color.50
Biased scientific literature provides the evidence and BMI categories do not reliably predict risk of disease
basis for clinical guidelines and practice; therefore, it is compared with cardiometabolic data. In 2016, Tomiyama
6 | MAULDIN ET AL.

and colleagues explored National Health and Nutrition overweight category (0.94) and “Grade 1 obesity”
Examination Survey data from 2005 to 2012. They (0.97).57 The risk of death increases with a BMI of >35
compared 40,000 NHANES participants' cardiometa- (1.34).57 In other words, the risk of death is lowest in the
bolic measures (blood pressure, triglycerides, choles- overweight and grade 1 obesity BMI categories. This
terol, glucose, insulin resistance, and C‐reactive pro- meta‐analysis did consider adjustments for confounding
tein) to their BMI category. They found that 24% of factors, but it was limited by the data collected in the
people in the “underweight” category and 30% in the studies included in the analysis.
“normal” category were metabolically unhealthy and Recommendations to eat less and increase physical
nearly half of overweight individuals and 29% of obese activity ignores the deeply rooted social determinants of
individuals were metabolically healthy. They con- health that often influences the opportunity and ability to
cluded that 75 million US adults’ health is being engage in health‐supporting behaviors.58 Public health
misclassified based on BMI when compared with their recommendations and patient care treatment plans must
cardiometabolic data.51 consider factors such as income, access to healthcare,
Even though BMI does not accurately represent education, early childhood development, stress, food
individual body composition, BMI is commonly reported insecurity, and housing. For patients who wish to focus
in weight research. The evidence on which we base clinical on adopting new health‐supporting behaviors, they must
practice is limited by the data reported. Often, epidemiol- have their basic needs met, along with resources such as
ogists find associations between higher body weight (or safe neighborhoods to engage in physical activity, low‐
BMI) and certain health conditions, such as osteoarthritis, stress working environments, and live in areas in which a
sleep apnea, hypertension, and coronary heart disease. variety of foods are available, such as fruits, vegetables,
However, the available research does not confirm that and lean sources of protein.
excess body weight causes these conditions; causation can
only be shown through controlled experiments. Studies that Key points:
report associations between BMI and morbidity or mortality
often fail to control for important mediators and modera- • BMI was developed to describe populations, not
tors, such as social determinants of health, weight stigma, individuals.
weight cycling, insulin resistance, mental health, and • BMI does not accurately infer body composition or
health‐supporting habits.24,52 It seems probable that body disease risk.
weight is, for the most part, a proxy for many unmeasured • Many of the assumptions about body weight and
variables.53 For example, aerobic fitness has been shown to morbidity and mortality are based on correlation,
be a better predictor of health risk,54 yet it is not often rather than causation.
measured, likely because BMI is easier to collect. • Although weight is associated with morbidity and
Matheson and colleagues55 examined the association mortality, there are confounding variables that may
between health‐supporting habits and mortality in a sample explain the relationship between weight and health but
of 11,761 men and women from the National Health and are often not accounted for in epidemiologic studies.
Nutrition Examination Survey III. They calculated the
hazard ratio for all‐cause mortality (adjusted for age, sex,
race, education, and marital status) by BMI and number of Is advising patients to lose weight an
health‐supporting habits: consumption of ≥5 fruits or effective intervention?
vegetables per day, regular exercise >12 times per month,
moderate alcohol consumption, and not smoking. Hazard There are two metrics by which we could evaluate the
ratios for mortality decreased with increased health‐ effectiveness of weight loss as an intervention: (1) How
supporting habits. There were no differences in hazard sustainable is the weight loss? (2) Does weight loss lead
ratios between BMI categories for those who reported all to improvements in morbidity and mortality?
four positive habits.55 One generally accepted, yet arbitrary, definition of
Furthermore, in a systematic review and meta‐ successful long‐term weight loss is losing at least 10% of
analysis exploring the link between BMI and all‐cause initial body weight and keeping it off for at least 1 year.59
mortality, researchers analyzed hazard ratios of all‐cause This definition of success should be challenged, but
mortality relative to normal weight based on BMI (which regardless, it is clear from research literature and recent
was assigned a hazard ratio of 1.00). They found that comprehensive reviews of primary articles that the
people who are underweight are at higher risk of death majority of individuals find long‐term weight loss
(1.25–2.97) than people who are in the normal weight difficult to achieve.36,37,60–68 For example, in a review
category.56 The lowest risk of death was found in the of 31 long‐term studies on dieting, the majority of
NUTRITION IN CLINICAL PRACTICE | 7

individuals were unable to maintain weight loss over the modification. In most weight loss research, it is not
long‐term and one‐third to two‐thirds of dieters regained possible to attribute health improvements to changes in
more weight than they lost.69 A review of behavioral weight as opposed to changes in behavior.24 Studies on
weight loss interventions in primary care showed small weight loss interventions that report short‐term improve-
reductions in body weight (−1.36 kg at 12 months and ments in health frequently do not differentiate the effects
−1.23 kg at 24 months), which are unlikely to be of the intervention, such as changes in exercise,
clinically significant.27 nutrition, clinical or group support, from changes in
In a review of 278,982 primary care electronic health weight. From a public health perspective, we must
records from family practices in the United Kingdom, the consider whether we could attain the desired improve-
annual probability of achieving normal body weight was 1 ments in health through behavioral changes without
in 210 for men and 1 in 124 for women with obesity.70 The focusing on weight loss as the desired outcome.
probability declined with increasing BMI category. In For example, the stated goals of the Diabetes Preven-
patients with morbid obesity, the annual probability of tion Program (DPP) lifestyle intervention were a mini-
achieving normal weight was 1 in 1290 for men and 1 in 677 mum of 7% weight loss and a minimum of 150 min of
for women. The annual probability of experiencing a 5% physical activity. However, the original article states, “the
weight reduction was 1 in 12 for men and 1 in 10 for women DPP was not designed to test the relative contributions of
with obesity. For patients with morbid obesity, the annual dietary change, increased physical activity and weight loss
probability of achieving 5% reduction in body weight was to the reduction in the risk of diabetes.”74 A 10‐year
one in eight for men and one in seven for women. Among follow‐up of the DPP showed that although the lifestyle
participants who lost 5% body weight, >50% had regained group initially lost a mean of 7 kg by 1 year, they gradually
within 2 years and 78% by 5 years.70 The evidence shows regained, weighing about 2 kg less than they did at
that long‐term weight loss is difficult to achieve. randomization. The drug‐treatment (metformin) group
In 2013, Tomiyama and her research team explored lost a mean of 2.5 kg during the DPP and maintained most
whether losing weight actually leads to improved health.71 of that weight loss. The placebo group's mean weight loss
Across all 21 randomized controlled weight loss trials with was >1 kg from DPP entry.75 A 15‐year follow‐up study
at least 2 years of follow‐up, there were minimal showed similar results.76 Despite the fact that weight loss
improvements in health outcomes (such as total choles- is minimal, suggesting that other factors (such as physical
terol, triglycerides, systolic and diastolic blood pressure, activity) may account for the decrease in progression to
and fasting blood glucose), and none of the changes were diabetes, patients are often referred to the DPP and similar
correlated with weight change.71 The Look AHEAD trial programs for weight loss for the prevention of diabetes.77
investigated whether an intensive lifestyle intervention for There should be a shift in attention away from prescribing
weight loss would decrease cardiovascular morbidity and weight loss as a primary goal of treatment and towards
mortality among such patients with type 2 diabetes.72 The actionable behavior modifications that can improve actual
intensive lifestyle intervention consisted of prescribing health markers such as blood glucose levels.
1200−1800 kcal/day, meal replacement products, at least
175 min/week of moderate activity, and weekly group and Key points:
individual counseling sessions during the first 6 months,
with decreasing frequency over the course of the trial. At 9 • Long‐term weight loss is difficult to achieve for most
years, the study was stopped because of futility; the individuals.
intensive lifestyle intervention focusing on weight loss did • Pursuing weight loss does not reduce morbidity or
not reduce the rate of cardiovascular events in overweight mortality.
or obese adults with type 2 diabetes.72 In fact, some studies • Health improvements seen with a short‐term weight
suggest that weight loss is linked to increased mortality loss intervention may be attributed to the behavioral
risk. For example, a longitudinal cohort study showed that modifications and the intervention itself rather than
after adjusting for age, race, smoking, health status, and weight loss.
preexisting illness, weight loss of 15% or more from • Weight is not a behavior and, therefore, is not subject
maximum body weight is associated with increased risk of to behavioral modification.
death from all causes (regardless of maximum BMI).73
These findings bring into question whether there is
adequate research to support the pursuit of weight loss Why is sustained weight loss difficult?
as an effective and sustainable intervention.
It is also essential to recognize that weight is not a Although a myriad of factors impact body weight, an
behavior and, therefore, is not subject to behavioral individual's body weight is determined mostly by
8 | MAULDIN ET AL.

genetics.78–81 In other words, an individual has a reduced sensitivity to satiety signals.88 They have alterations
predisposed body shape and size predominantly dictated in their neurohedonic systems that make food more
by their genes. Because of the reliance on BMI to assess rewarding.108–111 Thus, attempts to lose weight via caloric
weight, and often health status by healthcare and public restriction promotes compensatory eating, making weight
health professionals, many patients in larger bodies are loss efforts difficult.
prescribed weight loss. Dieting via caloric restriction or deprivation may result
The underlying flawed assumptions are that all in short‐term weight loss, but the long‐term outcome is
people who are deemed overweight or obese need to, more often weight regain.86,107 Persistent alterations in the
and can, lose weight. Often individuals who are gut microbiome associated with dieting have also been
genetically predisposed to higher weights start attempt- implicated in the promotion of accelerated postdieting
ing to lose weight in their youth and experience many weight regain.112 Patients who attempt to lose weight often
cycles of weight loss and regain in their lifetime.82 experience multiple rounds of weight cycling. Periods of
Attempts to lose weight and keep it off are rarely weight stability in between bouts of weight cycling allow
successful, as evidenced by the dieting industry being a signals to normalize.88 For example, when considering
multibillion dollar enterprise that continues to grow.83 adipose cells, weight loss leads to a decrease in cell size,
Patients who attempt to lose weight through dieting whereas weight gain or regain leads to initially an increase
and other lifestyle changes may experience initial weight in cell numbers and then an increase in cell size.101 In
loss. And although the initial rate of weight loss may be essence, weight cycling results in total body fat mass
fast, it inevitably plateaus.37,62,72,84 Even when a patient higher than what it was prior to weight loss, since weight
is still restricting calories and/or increasing physical loss and regain increases both adipocyte number and
activity, additional weight loss, if any, is slow, and weight size.101 Thus, the physiological consequences of weight loss
regain is common.37,62,67,68,72,85,86 Over time, this cycle of and caloric restriction are long‐lasting,113 making further
weight loss and regain becomes not only psychologically attempts at weight loss even more difficult.
disheartening but also physiologically damaging. The probability of a person genetically predisposed to
Physiological adaptations that accompany weight loss be in a large body attaining normal weight per BMI
make sustained weight loss difficult. These adaptations are standards is low.70 It could be argued that remaining at
mediated by changes in metabolism and energy storage one's predisposed body size and not attempting weight
and changes in the regulation of appetite, hunger, and loss remains healthier and safer than losing weight and
satiety.87–96 These are compensatory mechanisms that regaining (weight cycling). A more accurate study of the
prevent our bodies from wasting away, and over time, link between weight and health would require examining
especially with weight cycling, a new homeostasis emerges. a population that has never dieted or experienced weight
Previously published reviews have detailed the meta- cycling.
bolic adaptations resulting from caloric restriction and
weight loss, including a decrease in basal or resting Key points:
metabolic rate.88,97–99 The decrease in energy expenditure
associated with weight loss can in part be explained by a • Body weight, shape, and size are predominantly
decrease in body mass, specifically lean mass, which is a determined by genetics.
main determinant of basal energy expenditure.88,100 The • Long‐term weight loss is not sustainable in most
loss of fat mass also reduces energy expenditure, as adipose individuals because of the physiological adaptations
tissue not only produces hormones that regulate metabo- with dieting and weight loss that often lead to weight
lism but also acts as a target site for homeostatic regulation. regain and weight cycling.
In fact, recent research has highlighted the plasticity and
key roles adipose tissue plays in regulating energy
metabolism, food intake, insulin sensitivity, and whole‐ Are there adverse health and ethical
body physiology.101 Changes in hormones that regulate implications of promoting weight loss?
nutrient metabolism and fuel oxidation promote energy
storage, making sustained weight loss difficult.93,101,102 Promoting weight loss has contributed to individuals in
These adaptations explain why dieters eventually experi- larger bodies experiencing weight bias and discrimina-
ence a plateau in the rate of weight loss. Their bodies are tion.114 Many researchers and practitioners have docu-
utilizing the calories they consume more efficiently. mented links between promoting weight loss and
With caloric restriction and weight loss, one's hormonal worsening societal weight stigma.14,115
milieu also promotes heightened and prolonged About half of US adults have been a target of weight‐
hunger.95,97,103–107 Dieters have elevated appetites and based teasing, unfair treatment, or discrimination.116
NUTRITION IN CLINICAL PRACTICE | 9

physician may decide not to screen or test someone in a

thin body for diseases often associated with higher
weight (such as type 2 diabetes or heart disease).
Similarly, a physician may order laboratory values for
patients with higher weight simply because of their
weight, even if presenting symptoms, family history, or
other risk factors do not warrant doing so.
When clinicians promote weight loss, they not only
contribute to societal weight stigma, they may unin-
tentionally set their patients up for lifelong weight
cycling patterns.14 With most patients regaining lost
weight within the first year, permanent weight loss is
elusive,40,126 often resulting in feelings of frustration and
failure for patients. Weight cycling, which occurs across
the weight spectrum, takes a toll on mental health.21 and
is linked to metabolic and cardiovascular disease risk
factors.127 Alberga and colleagues128 investigated strate-
gies to reduce weight bias among healthcare providers
FIGURE 1 Framework for weight‐inclusive patient care
and found 17 interventions aimed at various healthcare
practices
disciplines. Interventions utilized various bias‐reduction
strategies, including trainings and assigned readings, but
their impact on long‐term reduction of weight bias is
Individuals across the weight spectrum report experien- unknown.128
cing weight bias.117 Weight bias is a result of social Dieting has also been linked to eating disorders and
inequities, meaning that those at a lower weight are disordered eating.82,129,130 In 2013, Liechty and Lee
treated differently from those at a higher weight.114 explored the connection between dieting, body image
Weight stigma, which is defined as “the social rejection distortion, and extreme weight loss behaviors and
and devaluation that accrues to those who do not comply eating disorders in 14,322 adolescents.131 They found
with prevailing social norms of adequate body weight and that early dieting, depression, and body image distor-
shape,” results in physiological stress, emotional distress tion predicted dieting or extreme weight loss behav-
(depression, low self‐esteem, and body dissatisfaction) and iors.131 In addition, early depression and dieting were
is linked to increased calorie consumption, lower physical associated with binge eating in young adulthood, and
activity, and disordered eating.14,118–120 early body image distortion was associated with an
Weight bias is prevalent in the healthcare and fitness eating disorder diagnosis. Weight stigma sets up a
industries.121,122 In a sample of Canadian physicians, vicious cycle, with documented links to dieting
16.5% believed that patients with higher weight tend to patterns, disordered eating behaviors, and increased
have “bad behaviors” and 27.8% felt that patients with stress and cortisol levels, ultimately worsening physi-
obesity are often noncompliant with treatment recom- cal and emotional health.132
mendations.123 Up to 69% of women with higher weight Despite the multiple metabolic mechanisms in place
reported experiencing bias from health providers.124 As a to counter attempts at negative energy balance and the
result of weight stigma, patients may avoid clinical care; well‐documented incidence of weight regain, those
be less likely to seek recommended screening for some pursuing weight loss often experience self‐blame.133 This
types of cancer (breast, cervical, colorectal); may present is often referred to as internalized weight bias, which is
with more advanced, difficult to treat conditions; and defined as an individuals' belief that they deserve the
may withdraw from full participation in the visit, stigma and discrimination they experience as a result of
affecting their ability to recall advice or instruc- having a larger body.134 Higher weight individuals and
tions.121,125 Furthermore, patients experiencing weight those with eating disorders typically report high levels of
bias often avoid seeking medical treatment.123 These internalized weight bias, which some have linked to the
factors may partially explain associations between weight public health messaging surrounding the “obesity
and certain diseases. epidemic.”135
Another way weight bias can negatively influence Nonetheless, the desire to lose weight is common in a
care is in the way that practitioners make assumptions culture that idealizes thinness and demonizes fatness.
about health status based on body size. For example, a Despite the yo‐yo dieting and weight cycling many
10 | MAULDIN ET AL.

TABLE 2 Weight‐inclusive patient care practices

Patient care practice Action items
Clinician
Address weight bias • Learn about the complex genetic, environmental, biological, psychological, and social
contributors to weight.
• Examine your explicit beliefs and stereotypes about weight.
• Examine your implicit associations; take the online Implicit Association Test – Weight at www.
implicit.harvard.edu
• Consider thin privilege. For example, a thin patient does not worry about their doctor telling
them to lose weight while a higher weight patient often fears this conversation.
• Check and change your assumptions. Common flawed assumptions include:
◦ Higher weight patients are unhealthy; lower weight patients are healthy.
◦ Higher weight patients are not practicing healthy behaviors; lower weight patients are
practicing healthy behaviors.
◦ Higher weight patients' symptoms are due to their weight.
◦ Higher weight patients' symptoms would improve with weight loss.
◦ Higher weight patients want to lose weight.
◦ Only higher or lower weight patients have eating disorders.
Don't “diagnose” your • Don't dismiss symptoms based on weight bias.
patient based on their • Focus on treating the condition rather than the weight.
body size • Provide your patient with the same diagnosis and treatment you would provide to a thinner
patient with a similar concern. Ask yourself, “Do thin people get this health problem? What do
I recommend/prescribe for them?” Start there.
Screen all patients • Utilize appropriate screening for cardiometabolic health (e.g., blood pressure, fasting blood
glucose, cholesterol, or triglycerides).
• Ask all patients about lifestyle behaviors. Don't skip asking your lower weight patients about
their exercise and dietary habits or assume your higher weight patients have poor habits.
Optimize well‐being for • Optimize psychological and physical health and well‐being of people of all shapes and sizes.
people of all sizes • Be cautious about healthism: patients have the right to pursue health, but not the obligation.
• Use patient‐centered communication such as motivational interviewing.
• Remember, weight is not a behavior, and therefore is not subject to behavioral modification.
• Encourage feasible, sustainable behaviors by focusing on the benefits of balanced eating,
physical activity, and self‐care for improved health and well‐being
• Ask about small changes your patients are interested in making (e.g., eating, activity, stress
management, sleep, etc.).
• Introduce mindful and intuitive eating as an alternative to restrictive dieting.
• Encourage enjoyable leisure and physical activity.
Practice environment
Provide a safe, shame‐free • Implement a zero‐tolerance practice policy for comments or humor that stereotypes or
environment degrades anyone based on a physical identity or attribute.
• Work to eliminate microaggressions—intentional or unintentional verbal, behavioral, or
environmental indignities that communicate hostility or negativity toward people who hold
less power in society. Examples of weight‐related microaggression are not having gowns that
cover a patient's body or suggesting a diet to a patient who came in for an unrelated concern.
• Provide waiting room chairs that are comfortable and safe; including some that are armless.
• Make sure exam tables are stable.
• Make appropriate‐sized medical equipment readily accessible, such as scales, blood pressure
cuffs, gowns, speculums, and needles for vaccinations.
• Demonstrate that your practice values diversity, such as a Mission Statement, non‐stereotypical
images in magazines, advertisements, pamphlets, and artwork.
Reduce focus on weight • Weigh patients less frequently. If possible, limit weigh‐ins to well visit checkups and weight‐
related complaints.
• Weigh privately if possible.
NUTRITION IN CLINICAL PRACTICE | 11

TABLE 2 (Continued)

Patient care practice Action items

• Allow patients to decline to be weighed and/or decline to be informed of their weight. Patients
are autonomous and have the right to consent to or decline any medical intervention without
difficulty.
• Train your staff not to comment on the patient's weight (even in a complimentary manner).
• Ask permission before discussing weight with the patient. (Be aware that for people with a
history of an eating disorder, being weighed and/or discussing weight can be triggering.)
• Be cautious of discussing a minor's weight in their presence.
• Be aware of stigmatizing language (i.e. “morbid obesity”). When a descriptor is necessary, use
terms like “higher weight.”
Systemic issues
Social justice • Where possible, work to increase health access, autonomy, and social justice for all individuals
along the entire weight spectrum.
• Recognize the impact of social determinants of health, including the structural and political
issues that affect health and well‐being.
• Be aware of intersectionality; patients with multiple stigmatized identities may experience
mutually reinforcing sources of oppression that can negatively impact their health.
• Show compassion for how difficult it is to live in a culturally stigmatized body. Support your
larger patients in handling the unique challenges of their bodies.
• Remember, weight loss doesn't stop weight bias. Bias is a social justice issue. People deserve to
live free of bias and prejudice no matter what they weigh.

patients have experienced, they may present to their HO W T O M AK E T HE SHIFT F R OM

clinician for weight loss advice. Participating in weight WEIGHT ‐ CENTRIC T O WEIGHT ‐
control activities may be an expression of internalized IN CLU SIVE CAR E
weight stigma, shame, and the desire to escape the bias
and oppression that they face in their daily lives. In There is promising evidence that supports shifting from a
addition, patients may ask about weight management in weight‐centric to a weight‐inclusive approach when
an attempt to preempt the “weight loss talk” they are supporting patients in improved health and well‐being.
anticipating from their clinician. Given the In two different systematic reviews of nondiet interven-
ineffectiveness and potential adverse effects, discussing tions, both sets of authors reported nondiet participants
weight loss strategies because a patient asks for them is experienced improvements in psychological health in all
analogous to prescribing an antibiotic for an obvious viral studies that tracked such outcomes, along with no
infection simply because the patient requests it. The worsening physical health.136,137 The weight‐inclusive,
conversation should be shifted to address relevant health nondiet interventions that were evaluated in these
inequities, along with health‐supporting behavior systematic reviews varied in terms of their length and
changes that are of interest to the patient, while taking approaches, though topics covered typically included
the focus off of weight. eating in response to hunger and fullness cues, finding
enjoyable forms of movement, and body size acceptance.
Key points: Those receiving the nondiet interventions were com-
pared with those who received either no group interven-
• Promoting weight loss worsens societal weight stigma, tion or a traditional weight management program. In
often leads to weight cycling, and increases the risk for some studies, participants experienced improved biomar-
disordered eating and eating disorders, all of which kers in the absence of weight loss.136,137 Furthermore, the
can negatively impact health and well‐being. attrition rate was much lower in the groups receiving the
• Dieting and weight cycling also lead to negative nondiet interventions.136,137 Since none of the nondiet
psychological consequences. intervention studies resulted in worsened health out-
• Instead of focusing on weight and weight loss, comes and all of them improved markers of psychologi-
healthcare and public health recommendations should cal health, practitioners should consider the known
address environmental and social determinants of advantages of weight‐inclusive approaches for patient
health. well‐being. Promotion of interventions that “emphasize a
12 | MAULDIN ET AL.

nonrestrictive pattern of eating, body acceptance, and 2. Tylka TL, Annunziato RA, Burgard D, et al. The weight‐
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