Thread by @RFentonMD

How to counsel about health w/o talking about weight (@Margaret1473)

First, just bc obesity is associated with a condition doesnt mean its the cause. Correlation doesn’t mean causation! There’s no evidence showing wt loss (isolated from nutrition & exercise) improves health.

2. dieting/weight loss is not sustainable for 9/10 people. Most regain the weight...and risk feeling like failures.

3. Every body has a set point range it likes to maintain. The body works hard to keep it, like increasing hunger on a diet. Yoyo dieting increases the set point😳

4. Weight is not an indicator of health. Ex: There are athletes of all sizes, including higher weights. There’s a also a thing called the obesity paradox that shows people who are overweight or “stage 1 obesity” (BMI 30-35) actually live longer than those that are normal weight.

5. BMI is crap!! Yeah, I said it. It was created from insurance tables that were used to decide policies based on moral (not medical) body ideals. These ideals came from stereotypes that fatness was a sign of laziness and no self-control, assumptions rooted in racism (yikes!).

BMI charts for children are even less scientific🤦🏾‍♀️.

6. Weight stigma, like other forms of oppressions can lead to anxiety, depression, eating disorders, distrust, healthcare avoidance, and even further weight gain. By trying to help, we can actually cause harm.

So what now?

When I take any behavioral history, I start off by declaring a no-judgment zone. I might even tell them about the time I lied about exercise on my doctor’s form 🤣 to show we all fear being judged. I explain that I’m asking these questions to get the truth and see how I can help.

If talking about physical health, I say, “I don’t care about your weight or what number it is. I care more about the nutrition you’re giving your body and how you find ways to be physically active. Those are better indicators of health than a number. Sometimes weight changes...

Sometimes it doesn’t. If it doesn’t change, you didn’t anything wrong. You’re just at your body’s set point.” I intentionally avoid words like diet and exercise because they can bring strict ideas of what people should be doing. Instead, I encouraged regular meals with balance.

Physical activity can look like different things for different bodies. I recommend some type of movement that brings them joy, ideally gets their heart pumping, and that they can sustain. If they hate running, they don’t have to run. Some kids help parents with chores for fitness

I take an activity and 24 hr food recall and ask the child, with parents’ assistance to decide one or two goals they want to work on i.e. eat breakfast or try youtube workout videos. Then, we discuss barriers because spoiler alert PEOPLE GENERALLY KNOW HOW TO CARE FOR THEMSELVES.

Doctors spend so much time learning and “educating” patients who know what to do, but may not have the time, resources, or privilege to do it. Education is most likely NOT the problem.

Then, I ask patients, would you like to talk about your weight. If no, I just move on.

If yes, I give them a little BMI context and explain that I care more about trends and our goal is to find a routine that allows the body to maintain its set point. I never give an answer to, “how much should they lose?” Or “what weight should they be?” Also, trends matter!

One of my mentors said, every change tells a story. So ask about what’s going on with a sudden drop or increase. It could be stress, food insecurity, trauma, etc. The best way to address is connecting them to appropriate resources or mental health support, if indicated.

Finally, screening labs are still recommended. I introduce them as nutrition-sensitive conditions, not obesity-related. I explain that wt is related but not causing them. The risk can be higher if there’s a family history. If abnormalities, then nutrition and activity can help.

Phew! This thread was a lot longer than I planned. For more reading, check out Fearing the Black Body, Body Respect, and The Body is Not An Apology.

I really need fo write this somewhere more formal than twitter, but y’all got the first pass 🤣

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