Weight-Inclusive Approaches to Nutrition and Dietetics: A Needed Paradigm Shift

This Perspective article encourages the ﬁeld of nutrition and dietetics to move away from a weight-centric paradigm that emphasizes weight loss and weight management as primary health outcomes. This approach can perpetuate weight stigma, which is associated with poorer health behaviors, poorer mental health, disordered eating, and even increased mortality risk. We propose an alternative approach — adopting a weight-inclusive paradigm — that focuses on providing care across the weight spectrum by centering health behaviors rather than weight. This approach allows individuals of all sizes to have equitable access to high-quality nutrition and dietetics care


INTRODUCTION
In the US, as well as much of the globe, health is often viewed through a weight-centered lens. 1,2It should come as no surprise, then, that the preprofessional dietetics curriculum is also routinely taught from a perspective that centers weight, avoidance of excess weight gain, and weight loss as primary targets for health promotion and disease prevention. 3,4Prominent components of a weight-centered perspective include considering higher weight to be a (strong) causal factor in poorer health, viewing weight loss as widely achievable and sustainable, and thus advocating for weight loss as a reliable strategy to improve health. 1,2,5,6owever, the assumptions that under-lie this perspective largely do not hold up to empirical scrutiny. 5,6At the same time, a weight-centric perspective belies the complex nature of body weight regulation (involving biological, psychological, environmental, and social factors) and can perpetuate the already widespread and detrimental stigma faced by heavier individuals in health care and allied health settings. 7,8Rather than emphasizing weight in dietetics education (and practice), here we argue for adopting an evidence-based paradigm that will allow our field to more fruitfully support health across the weight spectrum.The authors outline such a paradigm, focused specifically on its implications for adult nutrition and dietetics education.

ASSUMPTIONS UNDERLYING A WEIGHT-CENTRIC APPROACH
Weight-centric approaches often hold body mass index (BMI) as an essential health indicator, regardless of other reliable markers of both physical health. 1,2,6Of course, there is a body of research linking higher BMI with chronic diseases such as cardiovascular disease, type 2 diabetes (T2DM), and cancer, 9 although there are challenges related to causality and the strength of this relationship. 5Using BMI as a proxy for health is often fraught, however, as numerous studies have shown it to be an inaccurate indicator of metabolic health.For example, in a nationally representative sample of US adults, Tomiyama et al 10 found that almost 50% of individuals in the "overweight" BMI category, about 29% of individuals in the "obese" category, and about 16% of individuals in the "obesity grades 2 and 3" categories were metabolically healthy, whereas 30% of individuals in the "normal" BMI category were metabolically unhealthy.This significant heterogeneity underscores why focusing on weight-related proxies for health (eg, BMI) is misguided and may actually undermine care for individuals across the weight spectrum.In addition, BMI does not reflect body shape or composition, particularly in populations such as people of color and women, 11 further highlighting its limitations as a proxy for health.
Further complicating what we know about weight and healthrelated outcomes, higher BMI is not uniformly associated with higher mortality. 5−15 Indeed, in their meta-analysis of 97 studies with >2.88 million people, Flegal et al 15 found that individuals in the "grade 1 obesity" category had comparable mortality rates as those in the "normal" BMI category; elevated mortality risk was only observed for individuals with a BMI ≥35 (ie, those in "grades 2 and 3").This pattern suggests a nonlinear association between BMI and mortality risk, in which risk is elevated primarily at the lower and higher ends of the BMI distribution.Moreover, Matheson et al 16 found that positive health behaviors are more strongly related to mortality rates than BMI.Clearly, BMI and weight are imprecise indicators of health, and a system built on these variables can be explicitly harmful by stigmatizing patients with higher weight, subsequently leading to poorer health outcomes for these individuals. 5 weight-centered perspective on health promotion often holds that weight loss is under individual control and is, therefore, widely achievable.Not only is the likelihood of moving from a higher BMI category to a lower one exceedingly rare, but even a 5% reduction of weight is unlikely for most in the long term. 17ven when advocates of a weightcentered approach concede that significant weight loss is challenging to attain, there is still the assumption that when weight is lost, it will reliably improve health.This is difficult to reconcile with the extant literature.For example, a review of 21 randomized controlled trials by Tomiyama et al 18 found that the amount of weight lost on diets was not significantly related to improvements in cardiometabolic outcomes such as blood pressure, blood glucose, and cholesterol.A meta-analysis of 14 randomized exercise interventions among prehypertensive and hypertensive individuals shows a similar pattern.Although intervention participants did see improvements in blood pressure, these improvements were not reliably associated with the amount of weight lost. 19This exemplifies a core aspect of our perspective: improvements in health can result from improved health behaviors independent of weight loss.Moreover, a focus on weight (loss) can lead individuals to cycle or fluctuate in their weight over time, which is associated with poorer health.Indeed, weight cycling increases cardiometabolic risk factors such as insulin resistance and hypertension, 20−22 incident cardiovascular events, 23 and is associated with increased mortality risk. 24

WEIGHT STIGMA IN HEALTH CARE AND ALLIED FIELDS
Weight-centric approaches in health care can perpetuate weight stigma, or the devaluation and mistreatment of individuals with higher weight. 25xperiencing stigma as a result of both implicit and explicit anti-fat biases is associated with myriad negative health consequences, including psychological and physiological stress, and can itself lead to numerous adverse health outcomes. 25,26−32 Attempts to avoid or escape weight stigma can likewise result in disordered eating behaviors and cognitions, including body dissatisfaction, drive for thinness, and bulimic symptoms. 26,33,34Weight stigma is also associated with sleep disturbance and alcohol use, 34 as well as suicidal ideation, 35 all of which contribute to long-term chronic health conditions.Furthermore, weight stigma itself has been shown to increase mortality risk. 36Although there is compelling longitudinal evidence linking weight stigma to poorer outcomes over time, 36−38 this area of work faces challenges with causality akin to those faced by observational studies in the weight science literature more broadly.However, a recent metaanalysis of experimental studies identified a clear causal relationship between discrimination and immediate mental health outcomes, including stress. 39When experienced more chronically and over a longer period, it is plausible that this stress may contribute to the poorer health outcomes noted above.
The occurrence of weight stigma in the health care setting is common and particularly harmful to patient health and well-being.Assumptions that higher BMI patients will be noncompliant with care recommendations, are lazy and lack willpower, and are less worthy of a provider's time and respect than lower BMI patients have been documented. 40ther interactions that can color the provider-patient relationship include clinicians attributing any health concern to weight, telling patients to stop eating so much or engaging in patronizing conversations about a patient's weight. 8Even if offered by practitioners as well-intentioned efforts to improve health and wellbeing, a health care provider hastily identifying body weight as the cause of patient symptoms without conducting a thorough assessment can lead to misdiagnoses and undermine patient trust in the provider. 40−45 Many registered dietitians and nutrition professionals similarly hold anti-fat attitudes and weight-related biases. 46,47Cori et al 48 found that dietitians classified higher BMI individuals as greedy, unattractive, and lazy.This bias is likely stronger for patients at the higher end of the weight spectrum.A study that examined how dietitians view individuals of varying higher weights revealed that dietitians had significant and more frequent negative attitudes toward higher BMI targets, rating them as less likely to be successful workers, less likely to find someone to marry, less healthy, less likely to lead normal lives, and more likely to be ashamed of their weight. 49onsidering the pervasiveness of weight stigma in the health care setting, it is perhaps not surprising that anti-fat attitudes also exist among individuals undergoing dietetics education and training (up to 88% of students in 1 study). 50In a study of undergraduate dietetics students, participants were required to read 4 mock health profiles of patients; these profiles varied only by patient weight status and sex. 51Results showed that the students with stronger anti-fat attitudes rated the higher BMI patients' diet quality as being poorer than that of the lower BMI patients.In addition, these students rated higher BMI male and female patients as less likely to comply with treatment recommendations despite the profiles being identical on those factors.As the weight-centered paradigm is deeply entrenched in the dietetics field, this can certainly influence clinicians' thoughts about themselves, as well.In a study examining dietetics students with higher weight who experienced weight stigma in their educational journey, participants identified physical space constraints, judgments about food, and body-size-focused assignments requiring students to disclose their weight as factors that insinuated the types of people (ie, thin and healthy) who belong in dietetics setting and those who do not.Furthermore, discussions about "obesity" throughout the curriculum also alienated dietetics students with higher body weight. 52Given the impact of weight stigma on patient access to highquality care, there is a pressing need to require weight-inclusive curricula in dietetics education.

ADOPTING A WEIGHT-INCLUSIVE PARADIGM
A weight-inclusive perspective in health care focuses on objective health markers and behaviors, taking the focus off of weight.It creates an environment that allows individuals of any weight to access health and wellness without stigmatization. 53A weight-inclusive perspective includes the assertions that body weight diversity is natural and acceptable, healthfulness can exist regardless of body weight, and social determinants of health impact wellness above and beyond these biometrics.
There is evidence that a focus on health behaviors rather than weight is advantageous for health promotion.A randomized trial of a health intervention for higher BMI chronic dieters that emphasizes a Health at Every Size (HAES) paradigm rather than weight loss or dieting showed long-term success for a host of health outcomes. 54,55In this study, the HAES group was encouraged to rely on intuition regarding food rather than to restrain food intake and to practice size acceptance rather than trying to lose weight.The dieting control group was encouraged to restrict caloric intake to facilitate weight loss.Individuals in the HAES group showed a significant decrease in total cholesterol from baseline to 2 years later, whereas the diet group did not show any change in total cholesterol.In addition, the HAES group showed 2-year sustained improvements in low-density lipoprotein (LDL) cholesterol, systolic blood pressure, and depression, whereas the diet group did not.Finally, cognitive restraint and self-esteem improved in the HAES group 2 years later but actually worsened in the diet group.One randomized controlled trial also found that participants involved in a weight-neutral condition experienced a greater decrease in LDL cholesterol than those in a weight loss condition after an intervention for health promotion. 56Another weight-inclusive paradigm, intuitive eating, has also been associated with a lower LDL/highdensity lipoprotein ratio and triglycerides, 57 and there is some evidence that intuitive or mindful eating interventions have an equivalent (if not better) impact as weight-centric approaches on physiological measures such as glucose levels, total cholesterol, blood pressure, and inflammatory markers in certain populations. 58This evidence highlights that weight loss is not an essential target in health interventions, although more research is needed, a point we return to in the discussion.
As research on weight-inclusive interventions continues, researchers should focus on clearly conveying the clinical significance of their findings rather than merely emphasizing statistical significance.Although existing research in this domain makes drawing clinical conclusions challenging, 2 studies offer valuable insights.Specifically, the interventions conducted by Mensinger et al 56 and Bacon et al 54 led to an average reduction in LDL of 0.28 mmol/L and 0.48 mmol/L, respectively.By comparison, a year of statin therapy-the leading cholesterol-lowering treatment-is associated with an average LDL reduction of 1.1 mmol/L. 59onetheless, given the problematic nature of providing weight-centric care 60 and the emerging evidence that weight-inclusive care can support overall patient health and wellbeing, change is needed within dietetics education to align with the latest evidence.

MOVING TOWARD A WEIGHT-INCLUSIVE PERSPECTIVE IN DIETETICS
Nutrition and dietetics professionals -including clinicians, researchers, and educators-are responding to the mounting evidence of the negative consequences of weight-centric care, 4,60 which include weight management strategies that perpetuate weight stigma and increase eating disorder risk. 61Bailey et al 62 reported that 34% of dietitians who responded to a survey of a random sample of 5,000 dietitians reported being in alignment with the HAES paradigm.In their study, anti-fat attitudes related to weight control blame and physical unattractiveness were significantly lower in dietitians who aligned with this paradigm.For Canadian dietitians, almost half report using solely nonweightfocused care, and only 14% are using only weight-focused approaches. 4n the basis of the Academy of Nutrition and Dietetics 2016 position statement, Interventions for the Treatment for Overweight and Obesity 63 and the 2022 Evidence-Based Practice Guideline for Adult Overweight and Obesity Management, 64 a weight-centric approach continues to be recommended while acknowledging the need to minimize weight bias.According to Tylka et al, 6 a weight-centric approach includes "principles and practices of health care and health improvement that prioritize weight as a main determinant of health."In line with this definition, the 2022 Evidence-Based Practice Guidelines are weight-centric with statements such as excess adiposity, typically assessed withBMI (calculated as kg/m 2 ), 64 is causally linked to the development of many adverse health outcomes, including but not limited to the risk of mortality, cardiovascular disease, prediabetes, and T2DM.Furthermore, the executive summary of recommendations for registered dietitians includes statements such as, "Prescribed calorie levels should be tailored on the basis of estimated or measured needs and should be adjusted to improve weight outcomes, as appropriate for and desired by each client." Others have pointed out that even advocating for weight loss perpetuates weight bias and stigma within the health care setting. 35,60,65A professional paradigm shift is warranted in which the focus is on the enhancement of health and well-being instead of weight change.Such recommendations could center on the individual needs of the patient or client with treatment plans and public health initiatives that support disease prevention and management.
Dietitians have several weightinclusive treatment options that center on health and well-being instead of weight.One such option is the Eating Competence Model, which emphasizes eating pleasure, internal regulation of eating, dietary variety through heightened food acceptance skills, and regular meal frequency. 66nother weight-inclusive paradigm that has been researched over the last decade is intuitive eating. 67,68In a sample of > 18,000 dietitians, the majority were knowledgeable about the approach, and most had a positive attitude toward it. 69Of the respondents, 73% reported that they support or strongly support the use of intuitive eating to maintain a healthy lifestyle.In addition, dietitians with more education and more experience in nutrition or weight management counseling were more likely to use nonrestrictive intuitive eating paradigms in their practice.
Paradigm shifts within a profession often require substantial educational and competency adjustments that are informed by organizational policy.As the largest organizing body of nutrition and dietetics professionals, the Academy of Nutrition and Dietetics included principles of Diversity, Equity, and Inclusion (DEI) in their mission and goals. 70,71hough weight stigma is a social justice and health equity issue, 65,72 standards of practice continue to emphasize a weight-centric perspective in dietetics practice. 73Adding an emphasis on weight-inclusive education and practice as part of organizational DEI goals is essential for creating a more equitable and inclusive dietetics education and profession.This emphasis will allow for the formation of policies that help students, educators, and practitioners achieve competence and performance goals aligned with the DEI mission.
Lichtfuss et al 4 reported that although 45% of Canadian dietitians were practicing from a nonweightfocused perspective, 81% of their survey respondents indicated they did not receive any formal training in this area.They concluded that "education and training programs must better prepare dietitians to implement practice approaches beyond [weight-centric approaches]."Students must be prepared as future health care professionals to enter informed discussions with their patients and provide individualized and compassionate care that fosters trust.Therefore, a revamp of textbooks and curricula used to teach introductory nutrition courses as well as senior-level metabolism, medical nutrition therapy, and applied community-oriented courses is needed to address evidence-based weight-inclusive care.Dietetics educators are encouraged to include the following concepts, among others, in their curriculum: differences between association and causation when examining weight and health; complex metabolic pathways that favor body weight homeostasis and the harmful effects of weight cycling on mental and physical health; potential negative mental health side effects of weight-centric approaches such as restriction, deprivation, calorie monitoring, and regular weighing; physiological, psychological and behavioral effects of weight stigma; weight-inclusive dietary interventions such as intuitive eating and mindful eating.−76

DISCUSSION
Weight-centric care-particularly in nutrition and dietetics-can be harmful, leading to mistrust of health care providers, delay of essential medical care, and the pursuit of goals such as weight loss that do not reliably improve health.Promoting the idea that body weight is largely under an individual's control perpetuates weight stigma in our profession.As such, we see a clear need for a paradigm shift in the field, one that fully embraces the idea of supporting health across the weight spectrum.
To realize this shift, we need to evaluate critically and ultimately reimagine our approach to dietetics education.We hope that this article opens up a larger conversation designed to ensure that the field of nutrition and dietetics lives its mission of empowering persons to thrive through food and nutrition, 73 a mission that can be achieved by adopting a weight-inclusive foundation of care.Although we have focused here on important indicators of cardiometabolic health and mortality, the broader relationship between weight and health is similarly complex and not as straightforward as often assumed. 5This underscores the need to focus on actual indicators of health and important health behaviors rather than less precise proxies such as weight.
There are some noted limitations of the existing literature on weight-inclusive or weight-neutral approaches in health care.First, many studies are conducted with a narrow participant pool of heavier White women, which may limit the generalizability of those results to the broader population.However, this is also a feature of the research underlying the weight-centric approach.79 Attending to the representativeness of samples must be of paramount concern in future research examining the impact of weight-inclusive approaches to care.
Furthermore, although the benefits of a weight-inclusive approach for disordered eating, body image, and mental health are well-documented, there is a need for additional research examining physiological outcomes (eg, inflammatory biomarkers such as C-reactive protein).However, these psychological outcomes are of relevance and importance to many in the nutrition and dietetics field.As such, we are advocating for greater consideration of weight-inclusive approaches to education and care while recognizing that additional research is needed to both broaden and deepen our understanding in this domain.Finally, it should be noted that the research on weight stigma and health reviewed here cannot speak directly to causality (see Emmer et al 39 for a metaanalysis of causal research on discrimination more broadly).In some cases, this is unavoidable, such as research examining the long-term health and mortality implications of weight stigma, 36−38 and mirror study designs often leveraged in the literature examining the long-term impact of weight itself.However, the weight stigma literature would benefit from methodological approaches that strengthen the ability to make causal claims and consider advanced analytic techniques (eg, directed acyclic graphs 80 ) for causal inference when relying on observational data.
In  81 ), which is in contrast to a weight-inclusive approach. 5,6As outlined above, the assumptions underlying these guidelines could be more deeply scrutinized, particularly in the context of disciplinary standards of professional practice.Although we focused on adult nutrition and dietetics in this Perspective article, there is a clear need to consider how the paradigm described may (or may not) translate to younger populations.
The field of dietetics has a unique opportunity to lead the effort to reduce weight stigma and weightcentric care by implementing changes at the preprofessional education level.Individuals and professional organizations tasked with creating and revising dietetics education learning outcomes and curricula may consider implementing a weight-inclusive approach as 1 strategy to support this type of care becoming standard practice moving forward.As noted in the 2022 standards, "RDNs are well equipped to provide care and are at the forefront of advocating for weight-inclusive built environments, policies, and personcentered communications to minimize harm and maximize benefit." 73e could not agree more, and now is the time to do so by fully embracing a paradigm shift toward weight-inclusive nutrition and dietetics education.

IMPLICATIONS FOR RESEARCH AND PRACTICE
Adopting a weight-inclusive approach can ensure that everyone has access to high-quality nutrition and dietetics care, regardless of their weight.This approach, in part by reducing weight stigma, can remove a significant barrier to care for patients with higher weight.With this paradigm shift comes the opportunity to systematically engage in research that furthers our understanding of how a weight-inclusive perspective can best be integrated into both training and practice to support the well-being of all patients.There may be situations in which practitioners and care providers have a medically necessary need for weight-related information, including dosing for certain types of medication, weight restoration in the context of eating disorder treatment, and monitoring fluid gains in the case of chronic diseases.In cases in which clinical best practices necessitate the use of weight, approaches such as blind weighing can still be adopted to minimize the psychological salience of weight while maintaining clinical rigor.As research and practice in this area grows, it is important to maintain an updated understanding of weight-related science, including the dynamic environmental, psychosocial, and biological factors underlying weight and its potential impact on health.From a clinical intervention perspective, inflammation should be considered a pressing target given its clear role in the pathophysiology of chronic disease 82 as well as the emerging evidence implicating weight stigma in inflammatory processes.As more allied professionals adopt this approach, research and practice can continue to work synergistically to identify the most effective strategies to instill and implement an approach to care that is weight-inclusive.A shift to a weight-inclusive paradigm within nutrition and dietetics would make the field a leader in providing stigma-free care.