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Content Note: Today’s post includes disturbing behavior from a powerful organization that risks the physical and mental health of higher weight people.
The Academy of Nutrition and Dietetics (AND) has released what they are calling “Evidence-Based Nutrition Practice Guidelines” for higher weight people. There is a public comment period until March 25th, 2022. I’ll be commenting based on this post, and I will include the link to add your own comment at the bottom of this piece.
The request for comment explains “Clinical practice guidelines are recommendations for clinicians about the care of patients with specific conditions.” (In this case they are considering simply existing in a fat* body to be a “condition.”)
They go on to claim that these guidelines are “based upon the best available research evidence and practice experience.”
Unfortunately, I don’t believe that is remotely true. In fact I think the research is very clear that if these guidelines are adopted as is, they will do incredible harm. Below are some of the many reasons why.
Before I go into a specific response I want to make clear that the weight stigma that seems to be driving these recommendations is based in, and inextricably linked to, racism and anti-Blackness and so does disproportionate harm to people of color and Black people (Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.)
Below is the basis of my response to them (In the interest of keeping this newsletter from being unwieldy, I’ve included links to get more information.) Below that I have some broader questions that I think we need to be asking.
Body size as pathology
First, they are adopting the concept that simply existing in a higher weight body (regardless of actual health status) is a “pathology” to be solved by weight loss, including using “person-first” language which has been championed by those who sell dangerous and expensive weight loss methodologies, making me wonder if they are in some way aligned with those interests.
Here are the reasons why pathologizing a body size (or height/weight ratio in the case of BMI) is not an ethical, evidence-based perspective
They recommend that all higher weight people be given traditional weight loss interventions in order to “improve BMI, percent weight loss, waist circumference, blood pressure and quality of life. “
Note that 3 of their 5 goals focus on body size and not health. One way to entrench yourself in the weight loss paradigm is to make body size manipulation (rather than actual health) the goal of the intervention. They’ve triple-downed on this here.
I don’t believe that weight loss is shown to be an ethical, evidence-based intervention to lower blood pressure, but we’ll get to that in a moment.
Suggesting body size manipulations as a way to improve quality of life suggests that people who experience weight stigma should change themselves to suit their oppressors. As a queer person who came out in the mid-90’s this has echoes to me of the ways that so-called “conversion therapy” was suggested to solve homophobia for queer people by “making us straight.” Since weight-loss fails the vast majority of the time (which we’ll talk about momentarily,) this pins their higher-weight clients’ hopes of a better life on an intervention that almost never works (and an industry that blames its victims for the intervention’s failures.)
Weight loss as an ethical, evidence-based intervention
They recommend the same caloric restriction methods that studies since the 50’s have shown are not effective, with the vast majority of people regaining any weight lost in the short term and up to two-thirds regaining more than they lost
Here is a timeline of research since the 1950s that shows the failure rates of the methods being suggested by these guidelines.
Moreover, the failure of these interventions is not benign, and the resulting weight cycling has been shows to create negative impacts on the higher weight patients upon whom they are foisted.
Here is research around the dangers of the weight cycling (which is the most common outcome of these interventions)
Very small amounts of weight loss create “health benefits”
Their guidelines utilize the claim (created not through clinical trials, but through attrition due to the abject failure of weight loss interventions) that 3-5% weight loss can result in cardiometabolic health improvements. (So, in the case of a 200 pound person, we are talking about only 6-10 pounds.)
Here is the evidence against that claim
Guidelines Specifically Against Weight-Neutral Care
The last of the proposed guidelines states:
“For adults with overw*ight or ob*sity, it is suggested that RDNs or international equivalents not use a Health at Every Size® or Non-Diet approach to improve BMI and other cardiometabolic outcomes or quality of life”
The first thing to notice is that by creating outcome goals based on size/BMI rather than actual health, they are trying to discredit weight-neutral interventions on the basis that they don’t create weight change. This is a common trick of the weight loss industry and the research they fund. If you make weight-loss a target outcome, then you discredit weight-neutral interventions from the start. If you make health improvements the desired outcome, then weight-neutral interventions are shown to provide greater benefits with less harm. It’s helpful to recognize this trick that is used to continue to advance the weight-loss paradigm by putting the focus on size instead of actual health. Also, by only naming HAES and anti-diet they have ignored the more general category of weight-neutral interventions.
In terms of cardiometabolic outcomes, there is plenty of research around the improvement of cardiometabolic outcomes through HAES and non-diet approaches:
Gaesser and Angadi, a massive review of existing research found that:
The mortality risk associated with ob*sity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA)
most cardiometabolic risk markers associated with ob*sity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs
increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss
Wei et. al. and Matheson et. al. both found health improvements through weight-neutral interventions. Matheson in particular found that “When stratified into normal weight, overw*ight, and ob*se groups, all groups benefited from the adoption of healthy habits, with the greatest benefit seen within the ob*se group.)
Bacon and Aphramor made this case convincingly (and with thorough citations for further reading)
Finally we have “quality of life.” Besides the fact that, again, by suggesting weight loss to improve quality of life the Academy of Nutrition and Dietetics aligns itself with size-based oppression while absolutely ignoring any negative quality of life impacts of the weight regain that is the most common outcome of what they recommend, there is evidence of HAES/anti-diet interventions improving quality of life.
As Tylka et. al. explain:
Data from randomized controlled trials have upheld the efficacy of programs with a weight-inclusive emphasis, such as HAES. Specifically, participants following the HAES model achieved statistically and clinically significant improvements in physiological measures (e.g., blood pressure), behavioral practices (e.g., increased physical activity, decreased binge eating), and psychological measures (e.g., increased self-esteem, decreased depressive symptoms) and did not demonstrate any adverse outcomes, despite the fact that weight remained relatively unchanged. Other research has supported the weight-inclusive approach, such that living in a body-accepting environment (i.e., one without weight stigma) is associated with higher body appreciation and lower habitual appearance monitoring, independent of BMI. The weight-inclusive approach, then, upholds the ethical principles of beneficience and nonmaleficience and can be used as a springboard for generating additional clinical and public health interventions.
For additional reading, you can find a research bank here divided into research that supports the weight-neutral paradigm (that AND is disparaging) and research that explains the issues with the weight-loss paradigm (that AND is promoting.)
Given the fact that AND is so blatantly not just ignoring research around the failure rate and potential harm of their proposed “interventions,” but in fact actually attacking the evidence-based weight-neutral paradigm, I think we need to be asking some serious overall questions about these guidelines and the AND.
1. Are the people creating these guidelines ignorant of the research, or are they unable to understand it? Or do they know about it and understand it, but are going against it on purpose. If the former, why are they in charge of writing proposed guidelines? If the latter, why?
2. Is this profit driven? Are the people driving these recommendations financially invested in the weight-loss paradigm? Are their funders? Is this about their pharmaceutical ties? Are some critical mass of their members so invested in selling weight loss that they are pressuring the organization to create guidelines that go against the science?
3. Are these decisions political? The AND does significant lobbying and has put out numerous papers supporting the weight loss paradigm. Are they ignoring the evidence and doubling down in order to avoid having to say that they’ve been wrong?
4. Is their goal to avoid competition with those dietitians who are working from an evidence-based, weight-neutral perspective by threatening the work and careers of dietitians who won’t swear fealty to the weight loss paradigm?
I don’t have the answers to these questions, but I’d like to. I believe that many of the professionals who are harming fat patients aren’t doing it on purpose. But intentional or not, fat patients/clients are the ones who pay the price, with a higher price being paid by those at the highest weights and those with multiple marginalized identities.
The research is out there and has been for years, so at some point we have to decide that ignorance (or disbelief) of the research isn’t an excuse for harming fat patients and clients.
You can add your comment about these guidelines here (you can read the guidelines themselves here with a trigger warning for weight stigma and glorification of disordered eating behaviors. They also provide guidance based on a gender binary, ignoring the existence and trans and non-binary people.)
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Also just did a little digging. At the bottom of the guidelines it says: These guideline recommendations were developed based on the evidence from the Adult Weight Management Systematic Review. To view the review, visit www.andeal.org/awm. So I went to the review.
There are several disclosures about conflicts of interest by the review team, as well as these key findings:
1. In adults with overw*ight or ob*sity, weight management interventions provided by a dietitian result in significantly decreased BMI and waist circumference, and increased percent weight loss and a likelihood of achieving a 5% weight loss.
2. In adults with overw*ight or ob*sity and T2DM, weight management interventions may reduce fasting blood glucose levels.
3. In adults with overw*ight or ob*sity, limited evidence suggested Health at Every Size/Non-Diet interventions provided by a dietitian did not affect cardiometabolic outcomes.
Notice how the first key finding has nothing to do with health markers other than weight. The second finding says "may reduce" not "will reduce". The third finding is pulling on "limited evidence".
Thank you for going into the details here! I was wanting to spread the word about these harmful guidelines but didn't have the capacity to break it down. Now I can share your newsletter and ask people to comment on the guidance!