I’m a weight-inclusive healthcare provider, but that wasn’t always the case. In fact, when I decided to go back to grad school to study nutrition science and become a dietitian, my goal was to help people lose weight.
At that time, I was deeply, deeply subscribed to diet culture and the idea that weight = health. I was riding the wave of “success” of my latest and most intensive weight loss project (excessive exercise + micro-managing every bite that went into my mouth). I felt virtuous and morally superior, yet there was a little voice in my head asking me if what I was doing was truly healthy in the broader sense.
As I worked through the two years of science class prerequisites I needed before I could apply to grad school, I was more or less maintaining my weight loss (if I gained a few pounds I doubled down until it came off again), but it was harder and harder to maintain even though I was doing everything “right.” I was killing it in biochemistry and anatomy, working full time, and still managing to keep up my rigid fitness and nutrition plan. When I started grad school and had to spend part of each day on campus, I batch cooked, made spreadsheets, woke well before dawn to lift weights, and did everything I could to continue to maintain the weight loss I was so freaking proud of.
Shifting to a weight-inclusive mindset
In spite of all that, the weight started to come back. I set intentions to more than double down (triple down?) the next time I had a school break, but I was tired. Tired of making weight loss another full time job.
I was also starting to question the belief that it was possible to maintain weight loss for the long term by simply working “hard enough.” I was startled by the realization that the very behaviors we treat in people with eating disorders are behaviors we applaud or even prescribe in people who weigh “too much.”
As I read more and more “obesity” and health research, I started to see the holes in the researchers’ assumptions and methods, including how they almost never factored in things like fitness levels, yo-yo dieting or the effects of weight stigma.
I also learned more about the effects of weight stigma (or any form of oppression) on physical and mental health. I learned that being physically active and having other basic “healthy habits” like eating vegetables, not smoking, and not drinking excessively more or less erased the gap in health that some studies found between people in “normal” BMI bodies and those with BMIs in the “overweight” or “obese” ranges. Again, most studies don’t factor in those things, which is why weight science is so disturbingly flawed.
I was still mentally navigating all of this when I finished my internship, graduated, and passed the grueling exam to become a registered dietitian nutritionist. I continued to mentally navigate all of this through my first few years as a dietitian. Eventually, the idea of weight inclusive care grabbed my attention, and the more I learned, the clearer it was that this was the only way to provide care.
So, what is weight-inclusive care?
Weight-inclusive and weight-neutral approaches to care
Interest in weight-inclusive care has been increasing among healthcare providers as well as people seeking healthcare. So what does “weight-inclusive” care mean, and how does it differ from “regular” care?
Weight-inclusive care is an approach that assumes that patients of all weights are capable of achieving health and wellbeing if they have access to non‐stigmatizing health care. This approach also challenges the belief that a particular BMI reflects a particular set of health behaviors, health status, or moral character. Weight is not a focal point for medical treatment or intervention, nor is it viewed as a behavior.
Similar to weight-inclusive care is “weight-neutral” care, which has been defined as an approach that focuses on improving patients’ relationships with food, emphasizing emotional and physical wellness over the pursuit of a lower weight or size, and advocating against weight stigma.
I used to use the term “weight-neutral” to describe how I practice, but I now prefer “weight-inclusive,” while the two terms are synonymous in many ways, weight‐neutral implies passive rather than active inclusion. Sometimes, word matter.
Also, weight-neutral care can sometimes fall into the trap of “healthism” via the idea that it’s OK to be fat as long as you meet (or are striving for) a certain standard of health. Weight-inclusive care includes the understanding that “health” is an amorphous concept. Health is going to vary from person to person, and each person’s level of health may ebb and flow across their lifespan. It also recognizes that someone may not choose to (or have the ability) to pursue heath.
The standards for healthcare in this and most other countries is not weight-inclusive, or even weight-neutral. They’re “weight-centric,” also referred to as “weight-normative” because it represents the standard paradigm in medicine, public health, and in society.
Weight-centric/weight-normative approaches to care
The weight-centric/normative paradigm emphasizes the idea that “excess” weight causes chronic disease and other poor health outcomes. It also emphasizes weight loss as a treatment for many health conditions and concerns even when evidence-based treatments such as medication, surgery or physical therapy are available.
It’s not uncommon for patients with a body mass index (BMI) in the “overweight” or “obese” range to receive weight loss recommendations when seeing a doctor for a sore throat or a skin condition.
The weight-centric paradigm has been defined as having these six tenants: The belief that…
- weight is under individual control
- weight gain is caused by too many “calories in” and too few “calories out”
- you can predict someone’s health status based on their weight
- excess body weight causes disease and early death
- changing eating and exercise patterns can produce long‐term weight loss
- losing weight will result in better health.
The weight-centric/weight-normative approach assumes that weight and disease are related in a linear fashion, and the fatter you are the more diseased you are or will become. It also emphasizes personal responsibility for “healthy lifestyle choices” and the importance of maintaining a “healthy weight.” These beliefs drive the weight‐normative approach’s focus on weight loss and weight management to prevent and treat a myriad of health problems.”
While the weight-inclusive and weight-centric approaches differ greatly in the emphasis each one places on weight, healthcare professionals using either approach might have some things in common. For example, they may recommend similar self-care practices. Again, the big differences lay in how much importance each approach places on body weight in the context of health and medical treatment, in their perceptions of how much we can change body weight, and how healthcare providers respond to patients based on their weight.
Weight-inclusive care for all
Weight-inclusive care is good for patients of all body weights, for many reasons. With weight-centric care, fat patients may receive a prescription for weight loss instead of evidence-based care, as I mentioned, while thin patients may not receive certain preventive screening exams because of the belief that because they are thin, they can’t possibly have issues with blood sugar or cholesterol. (I use both “fat” and “thin” as neutral descriptors.)
With weight-centric care, providers often assume that fat patients eat an unhealthy diet and don’t exercise, and may treat them with disbelief if they speaks up and says, “Well, actually…” They may assume that thin patients eat healthfully and exercise regularly, even if they don’t. This means demeaning some patients and missing the opportunity for health-supporting lifestyle recommendations in others.
With weight-centric care, fat patients with anorexia (called “atypical” anorexia even though it’s not really atypical in terms of frequency) are often dismissed (or told they must have binge eating disorder). “Normal” weight patients who display (or express concern about) disordered eating behaviors are often dismissed because their bodies “look just fine.”
However, with weight-inclusive care, providers don’t assume anything about their patients because of their weight (except perhaps that their fat patients have likely experienced weight stigma, including from previous healthcare providers).
The weight-centric approach is not improving health for the majority of individuals across the BMI spectrum. It’s clear that an approach to health that focuses on weight and weight loss is not the most effective paradigm in terms of health outcomes or patient-centered care?
What does weight-inclusive care LOOK like?
If you were to go to a weight-inclusive healthcare provider, one of the first things you might notice is physical accessibility. When you walk into the office, its set-up communicates to all patients that their healthcare needs will be met without shame or discrimination.
The waiting room has furniture that fits higher-weight individuals. So does the exam room, which also includes a blood pressure cuff that fits larger arms. If you need a larger-sized gown, the nurse or medical assistant can grab one that’s already supplied in the room (rather than getting flustered and going to hunt one down…or worse, telling you that they only have one size.)
You won’t be automatically asked to weigh in. There’ll be “hop on the scale” if you’re there for a sore throat or a skin rash. If they do want to weigh you, they ask for permission and explain why they want this information (do they just want to update their records, or is it needed to monitor a specific health condition or to make sure a medication is dosed correctly?).
If you say, “No, thank you” to being weighed, no one will get irritated with you, give you the side eye, or treat you as being “non-compliant.” The providers and support staff will have received continuing education or other training about weight bias, including implicit (subconscious) bias. They’ll also know that weigh-ins can be triggering or even traumatic for some people.
If you say “OK,” you’ll be weighed in a private area (none of this being weighed out in the open in a busy hallway nonsense), and you’ll have the option of “blind” or “closed” weighing — closing your eyes or standing backwards and not being told your weight.
What does weight-inclusive care FEEL like?
Your doctor and the other providers and staff won’t assume anything about your health based on your weight or body size. They’ll go by things like your health history (including what’s already in your chart and answers to questions they ask you), any concerning signs or symptoms you’ve been experiencing, what you tell them about your health behaviors, and any tests they order.
If you’re in a larger body, your provider won’t give you a weight “lecture.” If there is a reason to discuss weight, they ask the patient’s permission first, and if that permission is given, they explain why they brought it up. They don’t assume a patient wants to lose weight, or that they have or haven’t ever tried to lose weight before.
If there is ever a reason that a your weight of concern and weight loss could have some benefit (this is not usually the case, but it can happen), weight loss would be discussed in the context of other treatment options. You would be fully informed about the potential risks of weight loss by any means (including weight regain, medication side effects, etc.). If you have a history of eating disorder behaviors, your doctor wouldn’t put weight loss on the table. (Sadly, there are MANY cases of people in larger bodies struggling with or recovering from an eating disorder only to have a weight-normative provider blithely recommend weight loss.)
Weight-inclusive providers challenge weight-based stereotypes and can be a safe harbor if you’ve experienced weight stigma from other providers. You’ll know they’re focused on your psychological and physical health, and not your weight. You’ll probably be more likely to keep up with preventive and follow-up care because you know that if you have a health problem, the focus will be on treating the actual condition.
Why being weight-inclusive is more than “being nice”
There’s been a disturbing trend in the weight-centric/weight-normative healthcare spaces of co-opting the fight against weight stigma/bias/discrimination. A fight that was started by fat activists and allies who demand the right for non-stigmatizing care.
Weight-centric providers who believe they are against weight stigma may have the best of intentions, and this may be because they don’t really understand weight stigma. Anti-weight stigma efforts in the context of weight-normative healthcare often looks like treating fat patients kindly while they continue to suggest weight loss as the cure for most ills.
This is still stigmatizing, because it is still centered on the belief that a patient’s weight and body size are problematic, and that their size is causing their health problems. Even though in most cases, there are ways to directly treat the problem without the patient resorting to dieting, taking weight loss drugs that can have serious side effects, or having surgery on their digestive tract.
Again, I think many weight-centric providers do have good intentions, and have simply bought into the “anti-weight stigma” propaganda from “obesity” advocacy groups that take money from pharmaceutical companies that produce weight loss medications, and from companies that promote bariatric surgery.
Don’t get me wrong, being treated nice is better than not being treated nice. But when your provider still views your weight and body size as a problem that needs to be fixed, that’s still weight stigma.
Select citations from this article:
Dugmore JA, Winten CG, Niven HE, Bauer J. Effects of weight-neutral approaches compared with traditional weight-loss approaches on behavioral, physical, and psychological health outcomes: a systematic review and meta-analysis. Nutr Rev. 2020 Jan 1;78(1):39-55.
Mauldin K, May M, Clifford D. The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Nutr Clin Pract. 2022 Dec;37(6):1291-1306.
O’Hara L, Gregg J. Don’t diet: adverse effects of the weight centered health paradigm. In: De Meester F, Zibadi S, Watson RR, eds. Modern Dietary Fat Intakes in Disease Promotion. Humana Press; 2010:431‐441.
Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C, Calogero RM. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.
Carrie Dennett, MPH, RDN, is a Pacific Northwest-based registered dietitian nutritionist, journalist, intuitive eating counselor, author, and speaker. Her superpowers include busting nutrition myths and empowering women and men to feel better in their bodies and make food choices that support pleasure, nutrition and health. This post is for informational purposes only and does not constitute individualized nutrition or medical advice.
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