Editor’s note: This conversation has been lightly edited for length and clarity.
Losing weight is the mainstay of the non-pharmacological treatment for patients with various diseases such as diabetes, hypertension, hyperlipidemia and fatty liver. However, Katarina Wind, a family physician in British Columbia who has published multiple pieces on weight-inclusive care, is championing a novel and arguably controversial clinical approach. Rather than encouraging her patients to lose weight to improve their health outcomes, she focuses on healthy behaviours without setting a goal of weight loss or gain. The following is a conversation with Wind.
Q: What prompted you to change your mind on the concept of weight loss in medicine and started you down the path of analyzing the research a little deeper.
A: It was actually a personal journey that took me there first in terms of the healing from my own eating disorder that I hadn’t really recognized as such. I wasn’t in a classically underweight body even when I was engaging in a lot of eating-disorder behaviours and had eating-disorder symptoms. But our classical teaching of eating disorders is that most people can’t have an eating disorder if their BMI (Body Mass Index) isn’t under 19 or 18.5. So, I really didn’t recognize that in myself for a long time.
A lot of the learning we had in medical school reinforced some of those behaviours I was practicing despite experiencing negative side effects. As I was starting to recover, I came across some literature about weight-inclusive care and intuitive eating, the idea of following your body’s inner hunger and fullness cues, with some caveats. And I started recovering after I discovered intuitive eating. As I was going through that process, I began to realize that the same behaviours we were prescribing to patients were my exact same behaviours when I had an eating disorder. I became aware of the Health at Every Size movement and became really curious about it. And every time I learned something, I was like, “Oh, that makes more sense.” But it totally goes against what we’ve learned in medical school and society. And I connected with a wonderful physician in the United States who had been practicing weight-inclusive care for a number of years and served as a mentor for me. And then I started sharing my learning through articles and doing workshops as well. That’s how my journey began. And I’m still learning every day.
Q: What are some of the unhealthy behaviours that you feel the traditional weight-loss approach promotes?
A: Calorie counting is the main one. When you look at some of the articles promoting weight loss, the calorie restrictions can be quite extreme. For example, they recommend restricting intake to 1,200 calories a day. In fact, there’s old studies that used that marker as a calorie count of starvation. Additionally, we have people calorie counting but not accounting for how much they are burning. We demonize certain foods that we consider high in calories (like) fats and sugars even when those foods might be what we’re craving and may be part of our different cultures.
(Some) recommend restricting to 1,200 calories a day. But older studies have used that same count as a marker for starvation.
Demonizing foods can also lead to binge-eating disorders. Traditionally, we think binge eating is like an addiction that needs to stop. However, sometimes binge eating is your body indicating that you need more calories and a wider variety of foods. It’s almost like your body is saving you from anorexia. Some of the strategies of dietary changes within weight-inclusive care are more additive. Are you eating at least three meals a day plus snacks? If you have diabetes, you can pair a sugary snack with fat or protein to decrease the glucose spike. Are you getting enough fruits and vegetables? Those sorts of additive behaviours can improve health without demonizing certain foods.
Q: Is calorie counting itself an unhealthy behaviour? Or is it perhaps that our calorie restriction is set too high? If your patient requires a higher calorie intake because they’re active, then perhaps having a more liberal calorie target would be a better approach? Or do you oppose the entire concept of calorie counting in general?
A: I would say that I oppose the whole idea because everybody is unique. In medicine, all our studies are completed on a population basis but every person is individual and where they fall on that line in study averages is very different. Very few physicians are of this mindset. Those with this mindset are dieticians (while) people like physicians say lose weight. However, we do not really go into depth of how that should be happening.
Q: Much of our current obesity epidemic is a trend of our society toward more unhealthy foods and sedentary lifestyles. Should physicians rely on obesity classifications (like BMI) as a clue to look deeper into the eating habits or exercise of those patients?
A: I would challenge the assumption that anyone who eats unhealthily and doesn’t exercise is going to be “obese.” There are lots of people who have unhealthy eating habits and don’t exercise that still have a “normal” BMI. Conversely, there are many who are in traditionally obese bodies who eat a well-rounded diet and exercise regularly.
Rather than looking at weight as a proxy for who you should further examine, I would argue that we should be looking at things like diabetes or hypertension. We know that there is correlation with very high body sizes and some of these metabolic outcomes. But the important thing is twofold: What do you do about that correlation and what other things are going on that’s making that correlation true besides simply the body size?
For example, one thing that we know is correlated with both higher weights and poor health outcomes is weight cycling. The very act of losing and gaining weight repetitively is correlated with both of those things. If there’s someone in a larger body who already eats a well-rounded diet, exercises regularly, has their stress and sleep managed and doesn’t have any comorbidities, honestly, I’m not going to do anything about their weight. Conversely, if I have someone who’s in a normal weight body who is developing diabetes, is eating one large meal a day and then trying not to eat for the rest of the day, I might still address that even though they don’t need to lose weight. And then again, if I have someone in a larger body and they don’t have what I would consider healthy eating or exercise behaviours, we can work on those. The weight might change, it might decrease or it might not. But that’s not my goal.
Q: You mentioned how we have some studies that correlate higher body size with certain metabolic issues like diabetes. How should we interpret those studies that conclude obesity is linked with high blood pressure, diabetes and various other comorbidities?
A: Let’s talk specifically about mortality. There’s a lot of studies on how mortality correlates to body size. And one of the most famous studies, The Obesity Paradox, showed that the lowest mortality group of any group is in the overweight range. And you probably didn’t hear about this study in med school because, number one, it doesn’t go with the teaching; number two, there is no money in it.
We have to recognize how much money pharma and the diet industry is making.
We have to recognize how much money pharma and the diet industry is making. As much as we like to think our medical curriculum is completely unbiased, there is a lot of money in this industry and money is where the research is, right? So, research showing the benefits of not focusing on weight isn’t done because it’s not funded. If you take two people in the obese body range and one has a history of frequently dieting and weight cycling and the other doesn’t, the one who has a history of weight cycling is in a significantly higher mortality range. Having healthy habits (lack of cigarette smoking, lack of excessive alcohol intake, at least a few servings of fruits and vegetables a day, a moderate amount of exercise) automatically brings the mortality of higher BMI participants back down to baseline. We know those are behaviours that are sustainable.
Q: The weight cycling itself, by definition, would be considered a failed diet because the weight initially intentionally decreased and then increased again. What about if somebody had dieted successfully? Do you think that would have had a positive impact on their health?
A: In medicine, we usually prescribe things based on their potential for success and need to treat. Different studies have had really different levels on this, but usually the success rate of diets is less than five per cent in the long term. The diets that are successful show like two pounds (of weight loss). So usually, in medicine, we don’t prescribe things that are only successful in less than five per cent of the population when we know that there’s a likelihood that it could harm the other 95 per cent.
I would think about the actual behaviours of people who have lost weight. Are they stressing out about food all the time and have a lot of behaviours that actually look like an eating disorder? What do their metabolic markers look like? If someone has changed behaviours, is in a smaller body, has good mental health and is not being overly restrictive, I’m fine with that. I’m not against weight loss. But I would just say that I would focus on behaviours rather than on the outcome because the outcome generally seems to be kind of out of our control.
Q: We would probably find a lot of common ground between this approach and the more traditional approach. It’s difficult to imagine that the existence of adipocyte (fatty) tissue correlates directly with health outcomes. I would argue it is more likely that having more fat cells or having fewer fat cells correlates as a proxy for healthy behaviour. Would you agree that if those classified as obese with a fatty liver lose weight, they can stall the progression of the fatty liver. Another example would be that losing weight reduces blood pressure or that losing weight brings down A1C.
A: In the short term, decreasing calories and losing weight improves your blood sugar and your diabetes because your body is in starvation mode. So, I think (those results) might be both the decrease in adipocytes as well as the behaviours. The problem is (the traditional approach) doesn’t work. It just doesn’t work. We just have such a hard time wrapping our heads around that. We don’t prescribe Ativan for anxiety even though it really works in the short term because it doesn’t work in the long term. So yeah, we’ve got lots of data that losing weight in the short term helps with diabetes and hypertension but it doesn’t work in the long term.
Q: What if we were able to change our approach toward counselling about weight loss and healthy behaviours? I know in practice that might be more difficult to implement. However, if we were able to develop these approaches to encourage sustainable weight loss, would that be beneficial in the long term?
A: That’s where dieticians come back in, right. So, if you have someone with diabetes and you send them to see a weight-inclusive dietician, they’re going to have them eat regularly throughout the day and pair sugars with fats and proteins to blunt glycemic responses. They are going to promote walking after meals to improve the glycemic response.
In essence, they will promote healthy behaviours but these may or may not lead to weight loss or weight gain.