New guidelines redefine 'obesity' to curb fat shaming

Is focusing solely on body mass index the best way for doctor to frame obesity?

Photo by Jeff J Mitchell/Getty Images
  • New guidelines published in the Canadian Medical Association Journal argue that obesity should be defined as a condition that involves high body mass index along with a corresponding physical or mental health condition.
  • The guidelines note that classifying obesity by body mass index alone may lead to fat shaming or non-optimal treatments.
  • The guidelines offer five steps for reframing the way doctors treat obesity.

Doctors determine obesity by dividing a patient's weight by their height, producing a measure called body mass index, or BMI. Patients with a BMI of 30 or higher are considered obese.

But is this the best way to frame obesity?

In new guidelines published in the Canadian Medical Association Journal, a group of doctors argue that, while knowing a patient's body mass index is useful, healthcare professionals should take a more holistic approach to treating obesity — one that doesn't overfocus on weight-loss through exercise and diet.

The authors say this new model could improve treatments and reduce weight stigma. After all, the old model typically frames obesity as a "self-inflicted condition" caused by a lack of personal responsibility, which may affect "the type of interventions and approaches that are implemented by governments or covered by health benefit plans."

"For the longest time, we blamed our patients, we blamed people living with obesity for the lack of willpower in terms of overeating, in terms of not being physically active," co-author Dr. David C.W. Lau of the University of Calgary's Julia MacFarlane Diabetes Research Centre, said in a podcast. "We now know this is a totally misperceived perception."

The new guidelines define obesity as "a prevalent, complex, progressive, and relapsing chronic disease, characterized by abnormal or excessive body fat (adiposity) that impairs health." Under this definition, someone would only be considered obese if they have a high body-mass index and a corresponding physical or mental health condition.

The guidelines aren't arguing that weight isn't relevant to health. After all, there's no shortage of research showing that having a high body mass and excess body fat boosts your risks of developing many conditions, such as heart disease, diabetes, stroke, depression, respiratory problems and even certain cancers.

But one key complication is that obesity is caused by many factors. For example, the guidelines note that the condition is influenced by genetics, epigenetics, neurohormonal mechanisms, associated chronic diseases and obesogenic medications, sociocultural practices and beliefs, social determinants of health, built environment, individual life experiences like adverse childhood experiences, and a host of psychological factors.

As such, a straightforward "eat-less, move more" strategy might not work equally for everyone. The guidelines note that "obesity management should be about improved health and well-being, and not just weight loss."

A new 5-step system for treating obesity

To help primary care practitioners better treat obesity, the doctors outlined five steps:

  1. Recognition of obesity as a chronic disease by health care providers, who should ask the patient permission to offer advice and help treat this disease in an unbiased manner.
  2. Assessment of an individual living with obesity, using appropriate measurements, and identifying the root causes, complications and barriers to obesity treatment.
  3. Discussion of the core treatment options (medical nutrition therapy and physical activity) and adjunctive therapies that may be required, including psychological, pharmacologic and surgical interventions.
  4. Agreement with the person living with obesity regarding goals of therapy, focusing mainly on the value that the person derives from health-based interventions.
  5. Engagement by health care providers with the person with obesity in continued follow-up and reassessments, and encouragement of advocacy to improve care for this chronic disease.

Insider noted that some health professionals and body-positive advocates don't think the guidelines go far enough in reframing obesity treatment. The update still points "to individual bodies as the problem, not culture," registered dietitian Rebecca Scritchfield, told Insider.

But it's also possible to see how some health professionals may worry this new model could discourage patients from taking the initiative to tackle weight-loss on their own, through exercise and dieting.

In a 2020 opinion piece published in Frontiers in Nutrition, Dr. Elliot M. Berry argued that misplaced "medical and political correctness" may lead to the abrogation of the physician's responsibility to properly care for patients.

"For example, some doctors are now even reluctant to raise the issue of obesity lest they be accused of fat shaming by not accepting their patients' proportions (despite the quote at the head of this opinion piece), and thereby receive poor approval ratings in an atmosphere where popularity is equated with good healthcare."

Berry offers a list of nine steps that he thinks could help the healthcare industry better treat obesity, without shaming patients or falling prey to political correctness.

Berry concludes his piece:

"Parental and individual responsibility, choice and self-management clearly have a place near the center of the stage in the obesity tragedy. Otherwise, it is like going to see the play Hamlet and the Prince fails to make an appearance."

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