A HAES® Aligned Dietitian Reviews New Clinical Practice Guidelines for Obesity


*Trigger warning: The term obesity will be used in this article as defined by the document being reviewed. The views presented in the summary of the guidelines are not necessarily those of The Balanced Dietitian.*

You may have seen news stories in the last week about the new clinical guidelines for obesity in Canada that just came out! This article will explore what these new guidelines are and present where these guidelines fit in with the weight neutral approach that we promote at The Balanced Dietitian. Read to learn more!



The new clinical guidelines for the treatment of obesity in Canada (1) were long overdue as the last version of this document came out in 2007 (2). There has been a large amount of new research done in the last dozen years regarding chronic diseases, nutrition and weight management so it was definitely time for an update! These guidelines were published on the 4th of August by the Journal of the Canadian Medical Association (CMAJ). They developed by Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons. Most of the authors of these guidelines are medical doctors and researchers but the authors also include a few dietitians, two occupational therapists and a psychiatrist (1). These new guidelines step away from BMI as the only way to define obesity in a person, raise the issues of weight bias and stigma and starts to shift the goals of obesity management away from weight loss alone towards improving health in general (1). These guidelines are a step in the right direction however they do still contain elements that do not align with HAES® and some contradictory information which is what we will be exploring today.

This article will go through the 5 steps in the patient arc which are meant to guide health care providers on caring with people living with obesity and our opinion on them.

Step 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.” (1)

This first step of caring for people living with obesity recommends that practitioners treat obesity as a chronic disease, caused by an excess in body fat accumulation which impairs health and increases the risk of diseases and mortality (1). They state that obesity as a chronic disease presents differently in all people and that treatment should be long term and tailored to the person (1).

There is an association between chronic diseases and obesity, on a population level, people with obesity are more likely to live with chronic diseases such as type 2 diabetes, certain cancers and heart disease for example (3). Many international organisations do call obesity a chronic disease including the WHO (4), however, this is only the case when the excess weight is linked to adverse health effects (1) and not simply based on the weight of a person or what they look like. The positive sides of treating obesity as a chronic disease is that it could shift the blame away from the person as being responsible for their excess weight. Stating that obesity is a chronic disease recognises that a person is not obese because of their own individual lifestyle choices but that there are many factors such as environmental or genetic factors contribute to excess weight in an individual.

On the other hand, identifying obesity as a chronic disease could stigmatize the people affected by it even more. It could lead to a higher weight stigma as people living with obesity will be further “other-ed” by society as the body they live in can be labelled as “sick” because of the way it looks. The general public does not distinguish between excess weight and what is considered to be obesity and may think that all people living with larger bodies are affected by obesity as a disease and further stigmatize these people.

There is an initiative to change the name of the chronic disease now called obesity (the health problems related to excess adipose (fat) tissue) and instead call it Adiposity-Based Chronic Disease (ABCD) (5). As obesity is a term used by the general public to describe people living with excess weight, renaming the health condition related to excess adipose tissue could help neutralize the stigma related to obesity automatically being associated with negative health effects.

With regards the second part of this recommendation, obtaining patient permission to talk about their weight should be promoted in the medical field. Reducing weight bias is required in the medical system and this can start with open communication and trust between a practitioner and their patients. (Listen to this podcast on weight biais)

This recommendation for open communication should also be applied to anything that is discussed with a patient. I would like my doctor to ask my permission to talk about my sexual health, digestive issues, hair loss, skin conditions as well, wouldn’t you? When it comes to discussing obesity as a disease with a patient, the conversation will unfortunately likely very weight centric. Instead of focusing on their body as a problem because of excess adiposity, why not put the conversation about weight to the side and ask permission to talk about nutrition, exercise, how the person feels about their body and body image?


Asking patient for permission prior to talking about their weight is a great to keep in mind but I feel as though it's a guided permission. It still tells the person that weight is the issue in this situation and that it should be talked about. Furthermore, most people may not feel comfortable saying no to their health care providers and will still feel obligated to engage in this conversation. I believe the question should be: What would you like to talk about today? What concerns you?


Step 2: “Assessment of an individual living with obesity, using appropriate measurements, and identifying the root causes, complications and barriers to obesity treatment.” (1)

This step of the treatment guidelines for obesity brings the focus away from BMI as a sole marker of health, however the guidelines do include weight, height and waist circumference as measurements to include in routine physical examinations for all adults (1). The other element of this step is to recognize the “root cause” of obesity, this is a good element to recognize, as we know, individuals rarely are to blame for their weight which can be genetic, due to certain medications, socioeconomic factors, social determinants of health, life experiences and psychological factors (1).

BMI can be used on a population level for statistical reasons and these guidelines do make it clear that BMI is not a good tool to use for individuals (1). Yes, taking anthropometric measures (height, weight, waist circumference) of a patient can be useful in certain situations (for population health statistics, medication dosing, etc.) but practitioners should be made aware that for certain people, having knowledge of their weight and BMI can have negative effects on their mental health. It should be recommended that practitioners offer blinded weights (if weight is necessary) and weigh the patient less often as per the patient’s preference. As of myself, I do not weigh any of my clients as weight itself is not an indication of health.



Identifying root causes for obesity is positive step as it takes the blame away from the person and identifies that they are not individually responsible for their weight. On the other hand, identifying a root cause for obesity is a difficult task and may not be possible to address in a productive way. Yes, this root cause should be taken into consideration when determining a treatment plan for a person, but this may place the responsibility on the person to change that root cause which may not be possible. Furthermore, in my opinion, identifying the root cause also reinforces that the weight itself is an issue that needs to be changed.


Identifying barriers to any treatments can be beneficial but practitioners must be careful not to present these barriers or root causes as something that is the individual’s responsibility to fix or to change themselves when this simply may not be possible (ie: economic status, culture, genetics, etc.).


Step 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.” (1)

The main points presented here are that adults living with obesity should receive individualized care that takes into consideration their needs. The first step of treatment of obesity presented is nutrition and exercise, they state that it is important for all to have a balanced diet and to engage in physical activity (1). Where this step no longer aligns with HAES® or weight neutral care is that it promotes weight loss as a goal, they promote a 3-5% weight loss which has been shown to improve health (6). However, in the study that they chose as evidence for this, only half of the participants were able to maintain the 5% weight loss over 8 years (6). So their evidence for weight loss as a goal is based on a 50% long term success rate... This is, in my opinion, totally inadequate.

The guidelines also state that the weight loss varies between people and is not necessarily related to the individual’s efforts (1) which is a large part of weight neutral care, beneficial actions may not have significant effects on weight but they can still have beneficial health effects (7). They also refer to a “best weight” for somebody’s body which may not be the “ideal” weight as per the BMI scale (1). This is another step towards rejecting the BMI and tends towards the set-point theory that is a large element in HAES® and presented by Lindo Bacon, PhD in his book Health at Every Size (8). The set-point theory states that your body has a weight range of about 20 lbs (9kg) that it wants to stay at, where an individual can eat intuitively and listen to their body to attain (8). The guidelines also include recommendations about psychological and behavioural interventions as behaviour changes are required to improve health (1). This is aligned with HAES as the base of health is to make health promoting changes people’s lifestyles, regardless of size (9).

There are also very brief guidelines with regards to pharmacotherapy and bariatric surgery, we will not spend too much time on this as I am not a medical doctor but there are a few elements to point out in these sections. The guidelines for both pharmacotherapy and bariatric surgery both still rely on BMI which was recommended not to be used on an individual level in other section of the document (1). This to me in contradictory. They make a point to say that using the BMI is not an accurate tool, yet they pick and choose when to use it. Those wanting to treat obesity with pharmacotherapy and/or bariatric surgery should have very thorough conversations with their health care providers that outline all the risks and benefits of such interventions that can have negative or positive effects, both physically and mentally (10,11). There exist more specific guidelines with regards to pharmacotherapy (12) and bariatric surgery (13–15).

It is important to note that someone’s nutrition, physical activity, sleeping habits and stress levels can all be improved, this may not directly impact body weight but can still have significantly positive effect on overall health and well being without weight loss (7). The guidelines also specify that only addressing one aspect of lifestyle is not enough to provide proper management of obesity (1). This aligns with HAES, a person and their lifestyle should be treated as a whole to meet someone’s needs (7).


Step 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.” (1)

This section of the guidelines focusses on the relationship between the health care team and the patient, they encourage open communication between the health care provider and the patient to determine patient centered goals and sustainable behaviour changes (1). As we saw in the podcast about weight stigma , and as I mentioned earlier there is a large presence of weight stigma in the medical system. Encouraging trust and reciprocity in the treatment of people living in larger bodies is a step in the right direction when it comes to promoting health as well as reducing weight stigma.


The best part in my opinion of this recommendation is that they strive to redefine “success as healthy behaviour change regardless of body size or weight” (1). This is a wonderful step in the right direction towards weight neutral care and HAES®, however this message seems to get lost within the rest of the document as weight loss was recommended as a goal in the previous section.


Step 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.” (1)

The main message of this step is to continue to advocate for effective care for people living with obesity which would allow practitioners to deliver the best evidence based care to their patients living in larger bodies (1). They continue to mention the barriers regarding access to obesity management programs, health care providers with expertise in obesity and the long wait times for referrals and surgery and the high cost of treatment (1). They then present that Canadians should be able to turn to regulated health professionals such as dietitians and doctors instead of being “left to navigate a complex landscape of weight-loss products and services, many of which lack a scientific rationale and openly promote unrealistic and unsustainable weight-loss goals.” (1). I have a lot of opinions on this! I would argue that some of the recommendations they have are unrealistic and unsustainable (i.e. promoting weight loss based on evidence with a 50% success rate...).


This guideline focuses largely on intensive interventions for obesity, pharmacotherapy and bariatric surgery. As these guidelines were written largely by doctors and by bariatric surgeons, it is normal that the focus be on these treatment options. (Also maybe a conflict of interest having bariatric surgeons recommending bariatric surgery...)


However, more focus in this section should be put on the access to nutrition care as a first way to help those who want to improve their health. This advocacy for more treatment for those who need it should open the door to the use of HAES® and weight neutral care to inform practice and the use of intuitive eating in obesity management as these are evidence-based approaches that are being explored more and more and with positive results (16,17).


Conclusion:

To conclude, these guidelines have taken many steps in the direction towards in the right direction however there are still many ways that they can improve.

Here are things I like about it:

  • It puts BMI aside (unless you qualify for pharmacotherapy or bariatric surgery)

  • It placed emphasis on weight stigma in the health care system and talks about removing our bias

  • It talk about getting permission/consent around weight

  • It brings up the point that you can engage in healthy behaviours without any weight loss and still see position health outcomes.

  • It states that registered dietitian are the nutrition experts and should be part of the clients health care team

  • It redefines success as healthy behaviour change regardless of body size or weight (well in some places!)

  • They encourages follow ups and advocacy for health care

Here are things I don't like

  • It is still very weight bias

  • It is contradictory (Ex: don't use BMI -use BMI, you can be healthy without weight loss but lose weight, don't follow unrealistic and unsustainable advice unless it

  • It places a lot of emphasis on weight loss

  • Defining obesity as a chronic illness increases bias.

  • Focusing on weight as the issue when we have evidence that health behaviours are a better predictor of health outcomes.

  • The fact that they mention Weight Watchers, Jenny Craig and optifast in the medical nutrition therapy section.. (Again contradicting information.. using a "nondiet approach" yet referring to diets)



They base their recommendations on science and as more and more weight neutral approaches are being researched, the guidelines will only evolve. These new guidelines put aside BMI as a sole way to measure health, they encourage practitioners to recognize the multifactorial etiology of excess weight and try to reduce weight bias. The guidelines have come a long way since 2007 and hopefully in the next version, there will be even less focus on weight loss and more focus on health behaviours


Marie-Pier Pitre-D'Iorio, RD, B.Sc.Psychology

Thank you to Céleste Bouchaud, RD for this great article!



References:

1. Wharton S, Lau DCW, Vallis M, Sharma AM, Biertho L, Campbell-Scherer D, et al. Obesity in adults: a clinical practice guideline. Can Med Assoc J. 2020 Aug 4;192(31):E875–91.

2. Lau DCW, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ Can Med Assoc J. 2007 Apr 10;176(8):S1–13.

3. Hruby A, Hu FB. The Epidemiology of Obesity: A Big Picture. PharmacoEconomics. 2015 Jul;33(7):673–89.

4. Allison DB, Downey M, Atkinson RL, Billington CJ, Bray GA, Eckel RH, et al. Obesity as a Disease: A White Paper on Evidence and Arguments Commissioned by the Council of The Obesity Society. Obesity. 2008;16(6):1161–77.

5. Mechanick JI, Hurley DL, Garvey WT. ADIPOSITY-BASED CHRONIC DISEASE AS A NEW DIAGNOSTIC TERM: THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2017 Mar;23(3):372–8.

6. Eight-Year Weight Losses with an Intensive Lifestyle Intervention: The Look AHEAD Study. Obes Silver Spring Md. 2014 Jan;22(1):5–13.

7. Bacon L, Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J. 2011 Jan 24;10(1):9.

8. Bacon L. Health At Every Size: The Surprising Truth About Your Weight [Internet]. BenBella Books; 2010 [cited 2020 Aug 9]. 400 p. Available from: https://lindobacon.com/health-at-every-size-book/

9. ASDAH: Health At Every Size® Approach [Internet]. [cited 2020 Apr 20]. Available from: https://www.sizediversityandhealth.org/content.asp?id=19

10. Madura JA, DiBaise JK. Quick fix or long-term cure? Pros and cons of bariatric surgery. F1000 Med Rep [Internet]. 2012 Oct 2 [cited 2020 Apr 6];4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470459/

11. Padwal RS, Majumdar SR. Drug treatments for obesity: orlistat, sibutramine, and rimonabant. The Lancet. 2007 Jan 6;369(9555):71–7.

12. Pedersen SD, Manjoo P, Wharton S. Pharmacotherapy in Obesity Management. :12.

13. Biertho L, Hong D, Gagner M. Bariatric Surgery: Surgical Options and Outcomes. :13.

14. Glazer S, Biertho L. Bariatric Surgery: Selection & Preoperative Workup. :10.

15. Shiau J, Biertho L. Bariatric Surgery: Postoperative Management. :15.

16. Penney TL, Kirk SFL. The Health at Every Size Paradigm and Obesity: Missing Empirical Evidence May Help Push the Reframing Obesity Debate Forward. Am J Public Health. 2015 May;105(5):e38–42.

17. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005 Jun;105(6):929–36.

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