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Although the stakes couldn’t be higher and the promotion of healthy behavior is paramount, the emphasis on BMI and weight is likely to yield little benefit. The Association for Size Diversity and Health (ASDAH) developed Health at Every Size (HAES) to take the focus off of weight change and place it more squarely on health, thus supporting people of all sizes to take care of themselves and improve health outcomes.
This article breaks with traditional biopsychosocial approaches and, instead, celebrates the growing movement of fat acceptance. Here, the word “fat” is used in lieu of obesity or “larger size” because I am supporting the efforts to strip it of the loaded social connotations. The suggestions here not only reflect the risks for rheumatology patients but also the very real iatrogenic effects associated with traditional weight loss interventions.
In rheumatology, body fat is a cause and consequence of disease processes. Physical inactivity and involuntary reductions of muscle mass, combined with increased body fat, defines rheumatoid cachexia, which characterizes somewhere between 10% and 67% of rheumatoid arthritis (RA) patients. In fact, rheumatoid cachexia is reported to foil traditional body mass index (BMI) measurement and researchers have actually suggested lower BMI cutoffs (specifically, that they be reduced by 2 kg/m2 or to 23 kg/m2 for overweight and 28 kg/m2 for obesity). Using these and the traditional BMI cutoffs, 18%-31% of rheumatoid arthritis (RA) patients meet the criteria for “obesity” and more than 60% of those patients exhibited “overweight.”
Fatness is associated with the overproduction of pro-inflammatory molecules, which is particularly dangerous for patients with immune-mediated and chronic inflammatory diseases. Fatness has also been linked with a range of other chronic diseases, including type 2 diabetes, hypertension, cancers, gallbladder disease, coronary artery disease, and stroke. Patients with RA, in particular, have an increased risk for coronary heart disease events. Although the stakes couldn’t be higher and the promotion of healthy behavior is paramount, the emphasis on BMI and weight is likely to yield little benefit.
The roster of traditional intervention efforts for fatness have focused on pharmacological, surgical, or behavioral strategies, but the long-term sustainability of those efforts is disappointing. Research suggests that patients advised to lose weight regain 30% to 40% of their lost weight within 1 year and all of the lost weight within 2 to 5 years. A significant percentage of patients advised to lose weight actually show weight gain after their gradual return to baseline weight. In fact, the largest and longest-randomized dietary intervention clinical trial of more than 20,000 women, the Women's Health Initiative, reported the same. In the intervention arm of this initiative, participants maintained a low-fat and low-calorie diet and were advised to significantly increase their physical activity (representative of the best-case scenario of weight loss interventions). After almost eight years on this restrictive diet, there was no measurable change in weight and the average waist circumference actually increased. More recent research suggests that two-thirds of dieters regain more weight than was lost on their diets and experienced other negative health effects due to dieting. For example, restrictive diets are related to reduced bone mass and increased cortisol production—both of which are related to increased risk for the very diseases that diets endeavor to prevent.
So, what is a rheumatologist to do about fatness? First, do a quick self-check on your own bias. Research suggests that physicians spend less time with fat patients and often fail to refer them for diagnostic tests. Survey data suggest that physicians exhibit less patience with fatter patients and perceive them to be “…a greater waste of their time the heavier that they were” and “…more annoying.” Awareness of the potential for bias in medical decision-making goes a long way towards reducing its impact. Additionally, rheumatologists need to understand how complicated the relationship is between fat and social stigma, culture, socioeconomic status, psychological well-being, and health. So, rather than risking poor patient rapport, non-compliance, or treatment failure, consider a more humane and more empirically-supported model of health promotion, Health at Every Size (HAES).
The Association for Size Diversity and Health (ASDAH) developed HAES to take the focus off of weight change and place it more squarely on health, thus supporting people of all sizes to take care of themselves and improve health outcomes (see below). The HAES movement encourages body acceptance, supports intuitive eating, and supports active embodiment: physical activity for movement and health rather than to shape the body. In controlled studies, HAES approaches have been demonstrated to improve health habits, self-esteem, psychological well-being, and metabolic health. Specifically, HAES interventions are related to clinically relevant improvements in physiological measures (eg, blood pressure, blood lipids), health behaviors (eg, physical activity, eating disorder pathology), and psychosocial outcomes (eg, mood, self-esteem, body image). No studies report adverse changes in measured variables.
This model also promotes self-advocacy and social justice. With that in mind, consider directing your patients to the work of HAES revolutionaries like Ragen Chastain and be prepared to see some real change.
The Health at Every Size® Principles are:
Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
Health Enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.
Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
Eating for Well-being: Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.
Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.