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Weight Bias in Healthcare

Important Concepts

Weight Bias

Weight bias is defined as, "... negative attitudes, beliefs, judgments, stereotypes, and discriminatory acts aimed at individuals simply because of their weight. It can be overt or subtle and occur in any setting, including employment, healthcare, education, mass media and relationships with family and friends."

- from the Obesity Action Network (OAN)'s Weight Bias page

 

HAES

The Health At Every Size (HAES) framework  has been embraced by some dietitians, eating disorder providers, and other clinicians as a means to combat the traditional weight-centric culture that prioritizes dieting and weight loss as means to become healthy. HAES nstead prioritizes listening to your body, eating what feels right for you and physical movement.

  • HAES Principles (see more at the ASDAH website)
    • Weight Inclusivity
      • Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
    • Health Enhancement
      • Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional and other needs.
    • Eating for Well-being
      • Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.
    • Respectful Care
      • Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
    • Life-Enhancing Movement
      • Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.
  • Brief timeline
    • HAES began in the 1960s in reaction to society's changing beauty standards, which had shifted to idealize thin bodies.
    • Advocates posited that thinness was in fact NOT the right thing for every person and that losing huge amounts of weight could actually be detrimental to individuals' health.
      • In 1967, Lew Louderback wrote an article called "More People Should Be Fat!" that appeared in a major US magazine, The Saturday Evening Post, which expanded on this idea.
      • In response to this article, Bill Fabrey reached out to Louderback and, together, they researched Fabrey's book Fat Power, and in the creation of the National Association to Aid Fat Americans (NAAFA) (later known as the National Association to Advance Fat Acceptance) in 1969, a nonprofit human rights organization.
  • History of HAES
  • Gard L (2006, September 13). Fat! Fit? Fabulous! Meet the East Bay activists and researchers at the center of the new civil-rights movement known as Health at Every Size. Retrieved from:https://web.archive.org/web/20080619131109/http://www.eastbayexpress.com/news/fat__fit__fabulous_/Content?oid=291413.

Articles

  • Ulian MD, Aburad L, da Silva Oliveira MS, Poppe ACM, Sabatini F, Perez I, Gualano B, Benatti FB, Pinto AJ, Roble OJ, Vessoni A, de Morais Sato P, Unsain RF, Baeza Scagliusi F. Effects of health at every size® interventions on health-related outcomes of people with overweight and obesity: a systematic review. Obes Rev. 2018 Dec;19(12):1659-1666. doi: 10.1111/obr.12749. Epub 2018 Sep 27. PMID: 30261553.
     
  • Dimitrov Ulian M, Pinto AJ, de Morais Sato P, B Benatti F, Lopes de Campos-Ferraz P, Coelho D, Roble OJ, Sabatini F, Perez I, Aburad L, Vessoni A, Fernandez Unsain R, Macedo Rogero M, Toporcov TN, de Sá-Pinto AL, Gualano B, B Scagliusi F. Effects of a new intervention based on the Health at Every Size approach for the management of obesity: The "Health and Wellness in Obesity" study. PLoS One. 2018 Jul 6;13(7):e0198401. doi: 10.1371/journal.pone.0198401. PMID: 29979699; PMCID: PMC6034785.

Size Acceptance Movement

What is the Size Acceptance Movement?

 

 

History of the Size Acceptance Movement

Body Mass Index (BMI)

"Body Mass Index (BMI) is a calculated measure of body weight in kilograms divided by height in meters squared (Keys et al., 1972).

BMI = weight (kg) / height (m)2

A screening measure

The AAP and the Bright Futures Guidelines [PDF-245KB] recommend annual BMI screening for children and teens as part of routine pediatric care. BMI is a screening measure used to identify whether a BMI falls into the underweight, healthy weight, overweight, obesity, or severe obesity category. Because children are growing, their BMI values need to be expressed relative to other children of the same sex and age. These are called BMI-for-age percentiles.

An indirect measure of adiposity

BMI is highly correlated with direct measures of adiposity (body fatness), such as dual energy x-ray absorptiometry (or DEXA). However, BMI is not a direct measure of adiposity, and BMI does not distinguish between fat and fat-free body mass. Compared to direct measures of adiposity, BMI is simpler, less expensive, less invasive, and collected in routine pediatric health care."

- What Is Body Mass Index (BMI)?

CDC
 

Origins of the BMI

  • "We reflect upon Ancel Keys’ classic article, reprinted here, which dealt with a leitmotif of his long career: body mass, its composition, measurement, function and meaning for health, disease and survival.1 This preoccupation was reflected in some 50 of Keys’ 500-odd publications. Along this historical vein, our colleague, Warren Winkelstein, in a note just before his death, reminded us that the mid-19th century Belgian polymath, Adolphe Quetelet, under the premise that ‘the transverse growth of man is less than the vertical’, derived the function most used today to characterize relative body weight, that is, the ratio of weight (kg) over height (m) squared.2
    It was in the 1972 article, reproduced here partly because of its voluminous citations, that Ancel Keys gave Quetelet’s calculation its modern name, body mass index (BMI), along with evidence to support its current wide usage."

- Henry Blackburn, David Jacobs, Commentary: Origins and evolution of body mass index (BMI): continuing saga, International Journal of Epidemiology, Volume 43, Issue 3, June 2014, Pages 665–669, https://doi.org/10.1093/ije/dyu061

 

History of the BMI

  • "The 1972 Ancel Keys' Study and Its Major Limitations

    BMI was originally established in the 19th century by a statistician and rebranded in the 21st century by a physiologist for capitalist and research benefits [,]. Neither of these individuals were medical professionals.

    Keys did not intend on implementing BMI for medical use; he was a physiologist intrigued by the human body and its statistical analysis. He described it as a simple, obtainable measurement that translated with ease to the research setting. In his study, he acknowledges the superiority of body density in assessing body fat mass but states that it is not feasible for routine or survey use due to its time-consuming nature. "


- Pray R, Riskin S. The History and Faults of the Body Mass Index and Where to Look Next: A Literature Review. Cureus. 2023 Nov 3;15(11):e48230. doi: 10.7759/cureus.48230. PMID: 38050494; PMCID: PMC10693914.

Criticisms

  • Why BMI is flawed - and how to redefine obesity.

    • "An imperfect measure" There’s no doubt that significant amounts of fat can harm organs, raise the risk of cardiometabolic conditions and wreak havoc on mental, physical and functional health.The problem comes with using BMI as a proxy for the amount of body fat. Two adults with similar BMIs could carry different amounts of fat. At a given BMI, older adults tend to have more fat and less muscle than younger adults do. Relationships between BMI, fat mass and health also differ between sexes: women, for instance, tend to have more body fat than do men at the same BMI. Even so, “the distribution seems to be actually way healthier in women”, says Francisco Lopez-Jimenez, a cardiologist and obesity researcher at Mayo Clinic in Rochester, Minnesota. Their fat tends to lie in the buttocks, hips and thighs, whereas men usually accumulate belly fat, which is linked to poorer health outcomes. Adult BMI charts don’t reflect this variability. And the cut-offs between BMI categories — which are the same in most countries that use the index to diagnose obesity — are “something between science-based and arbitrary”, says Lopez-Jimenez."


-Prillaman M. (2023). Why BMI is flawed - and how to redefine obesity. Nature, 622(7982), 232–233. https://doi.org/10.1038/d41586-023-03143-x
 

  • Visaria A, Setoguchi S (2023) Body mass index and all-cause mortality in a 21st century U.S. population: A National Health Interview Survey analysis. PLoS ONE 18(7): e0287218. https://doi.org/10.1371/journal.pone.0287218
    "The risk of all-cause mortality was elevated by 21–108% among participants with BMI ≥30. BMI may not necessarily increase mortality independently of other risk factors in adults, especially older adults, with overweight BMI. Further studies incorporating weight history, body composition, and morbidity outcomes are needed to fully characterize BMI-mortality associations."

  • AMA: Use of BMI alone is an imperfect clinical measure. 

    • "Body mass index (BMI) is easy to measure and inexpensive. It also has standardized cutoff points for overweight and obesity and is strongly correlated with body fat levels as measured by the most accurate methods. But BMI is an imperfect measure because it does not directly assess body fat.On top of this, the current BMI classification system is misleading about the effects of body fat mass on mortality rates, according to an AMA Council on Science and Public Health report presented at the 2023 AMA Annual Meeting in Chicago.“Body mass index (BMI) is easy to measure and inexpensive. It also has standardized cutoff points for overweight and obesity and is strongly correlated with body fat levels as measured by the most accurate methods. But BMI is an imperfect measure because it does not directly assess body fat. Numerous comorbidities, lifestyle issues, gender, ethnicities, medically significant familial-determined mortality effectors, duration of time one spends in certain BMI categories and the expected accumulation of fat with aging are likely to significantly affect interpretation of BMI data, particularly in regard to morbidity and mortality rates,” says the council’s report. “Further, the use of BMI is problematic when used to diagnose and treat individuals with eating disorders because it does not capture the full range of abnormal eating disorders.”