Weight Inclusive Practice: Shifting the Focus from Weight to Social Justice

Publication: Canadian Journal of Dietetic Practice and Research
18 November 2019

Abstract

Obesity is framed by mainstream media and health care professionals as an “epidemic” contributing to the ill health of the population. This paper reviews literature related to dominant discourses about weight in dietetics, drawing on literature from other health care disciplines, and how these discourses influence patient care. Emerging, competing discourses are also reviewed. Literature highlighted that dietitians and dietetic students are often biased and hold stigmatizing beliefs toward “overweight” and “obese” patients. No research has been conducted in Canada addressing this question, leaving this as an opportunity for future research. Weight stigma and interventions focused on weight have multiple negative implications for individuals, especially those living in larger bodies, including reluctance to seek health care, poor body image, subsequent weight gain, and increased disordered eating. There are alternative discourses emerging, which shift the focus away from weight and toward social justice. The ways in which dietetic students are trained to “manage” weight, and how dominant discourses influence this training, is an important area of future exploration. Dietetic professionals are encouraged to reflect on their weight biases and educate themselves on weight inclusive approaches to health, such as Health at Every Size and Well Now.

Résumé

L’obésité est représentée par les médias grand public et les professionnels de la santé comme une « épidémie » qui contribue au mauvais état de santé de la population. Cet article examine d’une part la littérature du domaine de la diététique portant sur les discours dominants concernant le poids, en tirant parti de la littérature d’autres disciplines des soins de santé, et d’autre part la manière dont ces discours influencent les soins aux patients. Les discours concurrents émergents sont également examinés. La littérature a permis de relever que les diététistes et les étudiants en diététique ont souvent des préjugés et des croyances stigmatisantes à l’égard des patients obèses ou ayant un excès de poids. Aucune recherche n’a été menée au Canada sur cette question, ce qui laisse la place à de futures recherches. La stigmatisation liée au poids et les interventions qui mettent l’accent sur le poids ont de nombreux effets négatifs sur les personnes, en particulier sur celles ayant un poids élevé, par exemple une réticence à se faire soigner, une mauvaise image corporelle, un gain de poids subséquent et une hausse des troubles de l’alimentation. Or, de nouveaux discours émergents mettent l’accent sur la justice sociale plutôt que sur le poids. La manière dont les étudiants en diététique sont formés pour « gérer » le poids et la façon dont les discours dominants influencent cette formation sont des domaines qu’il sera important d’explorer. Les professionnels en diététique sont encouragés à réfléchir à leurs préjugés par rapport au poids et à s’éduquer sur les approches de la santé inclusives, comme Health at Every Size et Well Now.

Get full access to this article

View all available purchase options and get full access to this article.

Financial support: None.
Conflict of interest: The authors declare that they have no competing interests.

References

1
Bacon L. Health at Every Size: the surprising truth about your weight. Dallas, TX: BenBella Books; 2010.
2
Bacon L, Aphramor L. Body respect: what conventional health books get wrong, leave out, and just plain fail to understand about weight. Dallas, TX: BenBella Books; 2014.
3
Bacon L and Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10(1):9.
4
Blackburn-Evans A. The obesity epidemic: why are Canadians getting fatter? EDGE: How Research Works; 2004.
5
Mitchell N, Catenacci V, Wyatt HR, and Hill JO. Obesity: overview of an epidemic. Psychiatr Clin North Am. 2011;34(4):717–32.
6
World Health Organization. Controlling the global obesity epidemic [Internet]; n.d. [cited 2018 Apr 13]. Available from: http://www.who.int/nutrition/topics/obesity/en/.
7
Lake A and Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Promot Health. 2006 Nov;126(6):262–7.
8
Aphramor L. Validity of claims made in weight management research: a narrative review of dietetic articles. Nutr J. 2010;9(1):30.
9
Alberga AS, Pickering BJ, Alix Hayden K, Ball GDC, Edwards A, Jelinski S, et al. Weight bias reduction in health professionals: a systematic review. Clin Obes. 2016 Jun;6(3):175–88.
10
Gingras J and Brady J. Relational consequences of dietitians’ feeding bodily difference. Radical Psychology: A Journal of Psychology, Politics & Radicali. 2010;8(1):1–18.
11
Monaghan LF, Colls R, and Evans B. Obesity discourse and fat politics: research, critique and interventions. Crit Public Health. 2013 Sept;23(3):249–62.
12
McPhail D, Brady J, and Gingras J. Exposed social flesh: toward an embodied fat pedagogy. Fat Studies. 2016;6(1):17–37.
13
Pawlikowski P, Rico N, and Van Sell SL. Positivism: a concept analysis. Int J Nurs Clin Pract. 2018;5:284.
14
Ramos Salas X, Forhan M, Caulfield T, Sharma AM, and Raine K. A critical analysis of obesity prevention policies and strategies. Can J Public Health. 2017;108(5–6):e598–608.
15
Ramos Salas X, Forhan M, Caulfield T, Sharma AM, and Raine K. Authors’ response to invited commentary by Brady and Beausoleil. Can J Public Health. 2017;108(5–6):e646–7.
16
Cooper C. Fat and proud: the politics of size. London, UK: Women’s Press; 1998.
17
Whittemore R and Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005 Dec;52(5):546–53.
18
Aphramor L. Is a weight-centred health framework salutogenic? Some thoughts on unhinging certain dietary ideologies. Soc Theory Health. 2005 Nov;3(4):315–40.
19
Rich E and Evans J. ‘Fat ethics’—the obesity discourse and body politics. Soc Theory Health. 2005;3:341–58.
20
Nutter S, Russell-Mayhew S, Alberga AS, Arthur N, Kassan A, Lund DE, et al. Positioning of weight bias: moving towards social justice. J Obes. 2016;2016:3753650.
21
Brady J, Gingras J, and Aphramor L. Theorizing health at every size as a relational–cultural endeavour. Crit Public Health. 2013 Sept;23(3):345–55.
22
Medvedyuk S, Ahmednur A, and Raphael D. Ideology, obesity and the social determinants of health: a critical analysis of the obesity and health relationship. Crit Public Health. 2018;28(5):573–85.
23
Calogero RM, Tylka TL, Mensinger JL. Scientific weightism: a view of mainstream weight stigma research through a feminist lens. In: Roberts TA, Curtin N, Duncan LE, Cortina LM, editors. Feminist perspectives on building a better psychological science of gender. Cham, Switzerland: Springer; 2016. p. 9–28.
24
Barlösius E and Philipps A. Felt stigma and obesity: introducing the generalized other. Soc Sci Med. 2015 Apr;130:9–15.
25
Puhl RM and Heuer CA. The stigma of obesity: a review and update. Obesity. 2009 May;17(5):941–64.
26
Schwartz MB, Vartanian LR, Nosek BA, and Brownell KD. The influence of one’s own body weight on implicit and explicit anti-fat bias. Obesity. 2006 Mar;14(3):440–7.
27
McArthur LH and Ross JK. Attitudes of registered dietitians towards personal overweight and overweight clients. J Am Diet Assoc. 1997;97(1):63–6.
28
Berryman DE, Dubale GM, Manchester DS, and Mittelstaedt R. Dietetics students possess negative attitudes toward obesity similar to nondietetics students. J Am Diet Assoc. 2006;106(10):1678–82.
29
Puhl R, Wharton C, and Heuer C. Weight bias among dietetics students: implications for treatment practices. J Am Diet Assoc. 2009;109(3):438–44.
30
Stone O and Werner P. Israeli dietitians’ professional stigma attached to obese patients. Qual Health Res. 2012 Jun;22(6):768–76.
31
Harvey EL, Summerbell CD, Kirk SFL, and Hill AJ. Dietitians’ views of overweight and obese people and reported management practices. J Hum Nutr Diet. 2002 Oct;15(5):331–47.
32
Diversi TM, Hughes R, and Burke KJ. The prevalence and practice impact of weight bias amongst Australian dietitians. Obes Sci Pract. 2016 Dec;2(4):456–65.
33
Edelstein S, Silva N, and Mancini L. Obesity bias among dietitians by using the fat people-thin people implicit association test. Top Clin Nutr. 2009 Jan;24(1):67–72.
34
Swift JA, Hanlon S, El-Redy L, Puhl RM, and Glazebrook C. Weight bias among UK trainee dietitians, doctors, nurses and nutritionists. J Hum Nutr Diet. 2013 Aug;26(4):395–402.
35
Oberrieder H, Walker R, Monroe D, and Adeyanju M. Attitude of dietetic students and registered dietitians toward obesity. J Am Diet Assoc. 1995;95(8):914–6.
36
Fikkan J and Rothblum E. Is fat a feminist issue? Exploring the gendered nature of weight bias. Sex Roles. 2012 May;66(9):575–92.
37
Setchell J, Watson BM, Gard M, and Jones L. Physical therapists’ ways of talking about overweight and obesity: clinical implications. Phys Ther. 2016 Jun;96(6):865–75.
38
Schwartz M, Chambliss HO, Brownell KD, Blair SN, and Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033–9.
39
Kwan S. Framing the fat body: contested meanings between government, activists, and industry. Sociol Inq. 2009 Feb;79(1):25–50.
40
Dwyer JJM, Starr A, Mills C, and Haines J. Undergraduate, female, nutrition students’ perceptions of curricular influence on attitudes toward individuals with obesity. Can J Diet Pract Res. 2016 Dec;77(4):177–82.
41
Cotugna N and Mallick A. Following a calorie-restricted diet may help in reducing healthcare students’ fat-phobia. J Community Health. 2010 Jun;35(3):321–4.
42
Atkins J and Gingras J. Coming and going: dietetic students’ experiences of their education. Can J Diet Pract Res. 2009;70(4):181–6.
43
Oliveira TC, Czeresnia D, and Portes Vargas E. ‘I ought to reeducate myself’: normative discourses and eating practices related to weight loss in women of the popular strata. Demetra: Food, Nutrition & Health. 2017;12(3):523–38.
44
Swift JA, Choi E, Puhl RM, and Glazebrook C. Talking about obesity with clients: preferred terms and communication styles of UK pre-registration dieticians, doctors, and nurses. Patient Educ Couns. 2013;91(2):186–91.
45
Gray CM, Hunt K, Lorimer K, Anderson AS, Benzeval M, and Wyke S. Words matter: a qualitative investigation of which weight status terms are acceptable and motivate weight loss when used by health professionals. BMC Public Health. 2011;11(1):513.
46
Jung Franziska UCE, Luck-Sikorski C, Wiemers N, and Riedel-Heller SG. Dietitians and nutritionists: stigma in the context of obesity. A systematic review. PLoS ONE. 2015 Oct;10(10):e0140276.
47
Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, and Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015 Apr;16(4):319–26.
48
Alegria Drury CA and Louis M. Exploring the association between body weight, stigma of obesity, and health care avoidance. J Am Acad Nurse Prac. 2002 Dec;14(12):554–61.
49
Amy NK, Aalborg A, Lyons P, and Keranen L. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obesity. 2006 Jan;30(1):147–55.
50
Lewis S, Thomas SL, Blood RW, Castle DJ, Hyde J, and Komesaroff PA. How do obese individuals perceive and respond to the different types of obesity stigma that they encounter in their daily lives? A qualitative study. Soc Sci Med. 2011;73(9):1349–56.
51
Thomas S, Karunaratne A, Lewis S, Castle D, Knoesen N, Honigman R, et al. ‘Just bloody fat!’: a qualitative study of body image, self-esteem and coping in obese adults. Int J Ment Health Promot. 2010 Feb;12(1):39–49.
52
Friedman KE, Reichmann SK, Costanzo PR, Zelli A, Ashmore JA, and Musante GJ. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obes Res. 2005 May;13(5):907–16.
53
Thibodeau PH, Perko VL, and Flusberg SJ. The relationship between narrative classification of obesity and support for public policy interventions. Soc Sci Med. 2015 Sept;141:27–35.
54
Anderson C, Peterson CB, Fletcher L, Mitchell JE, Thuras P, and Crow SJ. Weight loss and gender: an examination of physician attitudes. Obes Res. 2001 Apr;9(4):257–63.
55
Mann T, Tomiyama AJ, Westling E, Lew A-M, Samuels B, and Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220–33.
56
Mackie G, Samocha-Bonet D, and Tam CS. Does weight cycling promote obesity and metabolic risk factors? Obes Res Clin Pract. 2017;11:131–9.
57
Mehta T, Smith DL, Muhammad J, and Casazza K. Impact of weight cycling on risk of morbidity and mortality. Obes Rev. 2015;15:870–81.
58
Field AE, Manson JE, Taylor CB, Willett WC, and Colditz GA. Association of weight change, weight control practices, and weight cycling among women in the Nurses’ Health Study II. Int J Obesity. 2004 Sept;28(9):1134–42.
59
Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, et al. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity. 2016;24:1612–9.
60
Association for Size Diversity and Health. HAES® Principles [Internet]; n.d. [cited 2018 Apr 13]. Available from: https://www.sizediversityandhealth.org/content.asp?id=152.
61
Bacon L, Stern JS, Van Loan MD, and Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105(6):929–36.
62
Rapoport L, Clark M, and Wardle J. Evaluation of a modified cognitive-behavioural programme for weight management. Int J Obesity. 2000 Dec;24(12):1726–37.
63
Provencher V, Begin C, Tremblay A, Mongeau L, Corneau L, Dodin S, et al. Health-at-Every-Size and eating behaviors: 1-year follow-up results of a size acceptance intervention. J Am Diet Assoc. 2009;109:1854–61.
64
Bacon L, Keim NL, Van Loan MD, Derricote M, Gale B, Kazaks A, et al. Evaluating a ‘non-diet’ wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. Int J Obesity. 2002;26:854–65.
65
Gagnon-Girouard M, Bégin C, Provencher V, Tremblay A, Mongeau L, Boivin S, et al. Psychological impact of a “Health-at-Every-Size” intervention on weight-preoccupied overweight/obese women. J Obes. 2010;2010:928097.
66
Mensinger JL, Calogero RM, Stranges S, and Tylka TL. A weight-neutral versus weight-loss approach for health promotion in women with high BMI: a randomized-controlled trial. Appetite. 2016 Oct;105:364–74.
67
Clifford D, Ozier A, Bundros J, Moore J, Kreiser A, and Neyman Morris M. Impact of non-diet approaches on attitudes, behaviors, and health outcomes: a systematic review. J Nutr Educ Behav. 2015;47(2):143–55.
68
Ulian MD, Aburad L, da Silva Oliveira MS, Poppe ACM, Sabatini F, Perez I, et al. Effects of Health at Every Size® interventions on health-related outcomes of people with overweight and obesity: a systematic review. Obes Rev. 2018;19(12):1659–66.
69
Humphrey L, Clifford D, and Neyman Morris M. Health at Every Size college course reduces dieting behaviors and improves intuitive eating, body esteem, and anti-fat attitudes. J Nutr Educ Behav. 2015;47(4):354–60.e1.
70
Brown LB. Teaching the “Health At Every Size” paradigm benefits future fitness and health professionals. J Nutr Educ Behav. 2009 Mar;41(2):144–5.
71
Rosalez A, Ozier A, Kubal A, and Parker J. Teaching the Health At Every Size! curriculum to dietetics students: do anti-fat attitudes change? J Nutr Educ Behav. 2015;47(4 Suppl.):S11.
72
Association for Size Diversity and Health. Trademark guidelines [Internet]; n.d. [cited 2019 Jun 16]. Available from: https://sizediversityandhealth.org/content.asp?id=159.
73
Gingras J and Cooper C. Down the rabbit hole: a critique of the ® in HAES®. J Crit Diet. 2012;1(3):2–5.
74
Aphramor L and Khasteganan N. Re-orientating dietetic interventions for adults with eating and weight concerns: a qualitative study of the Well Now course—Part 1. J Crit Diet. 2016;3(2):56–66.
75
Aphramor L. Well Now glossary [Internet]; 2016 [cited 2018 Jun 15]. Available from: http://lucyaphramor.com/dietitian/glossary/.
76
Aphramor L. Think paper: Well Now theory and HAES theory; 2016 [cited 2019 Jun 16]. Available from: https://lucyaphramor.com/dietitian/wp-content/uploads/2016/12/think_paper_well_now_theory_and_haes_theory._website._dec _2016.pdf.
77
Harrison C. Food Psych #135: body respect, weight-inclusive care, and Health at Every Size with Lucy Aphramor; 2017 [cited 2019 Jun 16]. Available from: https://christyharrison.com/foodpsych/5/body-respect-weight-inclusive-care-and-health-at-every-size-with-lucy-aphramor.
78
Khasteganan N and Aphramor L. Re-orientating dietetic interventions for adults with eating and weight concerns: a qualitative study of the Well Now course—Part II. J Crit Diet. 2016;3(2):67–76.
79
Academy of Nutrition and Dietetics. Debate: a conversation on weight management and Health at Every Size. Philadelphia, PA: Academy of Nutrition and Dietetics; 2018 [cited 2019 Feb 1]. Available from: https://eatrightfnce.org/sessions/669455/.

Supplementary Material

File (cjdpr-2019-034suppla.docx)

Information & Authors

Information

Published In

cover image Canadian Journal of Dietetic Practice and Research
Canadian Journal of Dietetic Practice and Research
Volume 81Number 3September 2020
Pages: 127 - 131

History

Version of record online: 18 November 2019

Authors

Affiliations

Meredith Bessey MScAHN(c)
Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS
Daphne Lordly DEd
Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, NS

Metrics & Citations

Metrics

Other Metrics

Citations

Cite As

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

There are no citations for this item

View Options

Get Access

Login options

Check if you access through your login credentials or your institution to get full access on this article.

Subscribe

Click on the button below to subscribe to Canadian Journal of Dietetic Practice and Research

Purchase options

Purchase this article to get full access to it.

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

View options

PDF

View PDF

Full Text

View Full Text

Media

Media

Other

Tables

Share Options

Share

Share the article link

Share on social media