• Sonia Rodriguez

Assumptions about body size and health

Assumptions about body size and health are interfering with our ability to provide effective and compassionate care.

I've been a dietitian for almost 12 years now, and one thing that I can say for certain is that we have a definite problem with weight bias in the medical field. Most medical providers I have worked with, myself included have made assumptions about a person's body size and their health status.

Here's why that's detrimental and possibly even dangerous: by assuming someone is healthy or unhealthy simply based on body size alone opens the provider up to missing a whole host of potential conditions or the possibility of inciting conditions that weren't even an issue in the first place.

Most of what we know about body size and health is related to correlation, not causation. This means we can notice a relationship between someones body size and certain health markers but we cannot say for sure that body size causes any particular disease.

How do we even decide what a "healthy" size should be? As a dietitian in school we were taught to use BMI charts as an indicator of health and optimal weight status. Lets get a little info on the BMI and you can decide for yourself how good of an indicator this actually is.

The now widely used BMI chart was originally developed in the 1830's by an astronomer, who was using body size of the European population as a statistical tool for various tests of laws of probability applied at the population level. This had nothing to do with health associations. This tool was adapted by the life insurance industry as a way of determining risk of death. (Unfortunately most of this data was gathered from rich white men). And in fact more recent data that is more representative of our population show that carrying a little more weight as we age is actually protective against death.

To top all of this off, in 1998 the NIH, which was in charge of setting BMI categories decided to change the thresholds for what was considered "overweight" and "obese". This resulted in millions of Americans being shifted into "overweight" and "obese" categories literally overnight.

So how is this assumption affecting our ability to provide care? Probably the easiest answer would be denying access to treatments because of the size of ones body. This is a particularly sticky problem for dietitians as we have been deemed "weight loss experts". I can't tell you the number of times patients were referred to me for "weight loss first" before being offered medications to control blood sugar or cholesterol. I was complicit in what I would now describe as withholding care, and this is interfering with our ability to provide effective and compassionate care to patients.

We know statistics on long term sustainable weight loss are dismal (most people regain weight within 1-5 years, and two thirds of those people gain more than their starting weight). So why are we still considering weight loss as the first line of treatment? If a medication had that kind of failure rate, you'd probably opt not to take it.

But this kind of treatment doesn't just affect people in larger bodies. People in the "normal" BMI range are being done a disservice as well. In the past I've assumed that someone in a "normal" body size is probably participating in health promoting behaviors and has low risk for disease as well as mental health conditions. The longer I've worked with a multitude of patients the more I hear stories of disease conditions going undiagnosed because someone "doesn't fit the profile for diabetes" or restricted dieting and eating practices congratulated for what is actually an underlying eating disorder and distress related to food and body behaviors.

Body size is not an indication of health status. As nutrition professionals it is our responsibility to educate and call in our providers. It's time for us to educate and voice what we know about weight science and eating behaviors. The reality of the situation is that anyone in any body size can benefit from evidence based medical nutrition therapy that mostly has nothing to do with changing the size and shape of our bodies, but rather impacts those markers we know are correlated with better health outcomes. Our patients deserve to have access to this type of care, it should never be withheld on the basis of a "weight loss first intervention."