'The Scream' Edvard Munch (1893)

There is an expectation in Australia that when we receive health care it stems from science-based medicine and evidence-based practice. To this end many health professionals use guidelines generated by the National Health and Medical Research Council (NHMRC) to inform their practice. The NHMRC describes itself as “Australia’s leading expert body promoting the development and maintenance of public and individual health standards”.

One of the NHMRC’s numerous publications is The Clinical Guidelines for the Management of Overweight and Obesity in adults, adolescents and children in Australia (NHMRC, 2013). The 2013 publication provides general practitioners (GPs), practice nurses, Indigenous health workers and allied health-professionals with guidelines for best practice for the 63% of Australian with a BMI classed as overweight or obese (Australian Institute of Health and Welfare, 2016).

In short, the guidelines recommend that primary health providers Ask those who live in larger bodies about their weight and Advise weight loss. This will not be news for many Australians who have received unsolicited weight loss advice from their primary healthcare provider, even when their weight bore no relevance to their presenting health condition. 

So, where is the insanity in these recommendations? Surely the guidelines should encourage health professionals to reduce a factor linked to increased health risk? The problem lies in the mind-boggling contradiction that exists between the recommendations and the evidence. That is while the guidelines recommend weight loss they also include the following evidence statement:

“Weight regain is common after weight loss that is achieved with lifestyle interventions. Weight loss is maximal at six to 12 months. Regardless of the degree of initial weight loss, most weight is regained within a two-year period and by five years the majority of people are at their pre-intervention body weight” Grade A Evidence (NHMRC, 2013)

At this point if you are baffled as to how the clinical guidelines can both recommend weight loss and concede that long-term weight loss is unachievable, you are not alone. What makes the recommendations even more mystifying is that the pursuit of weight loss is not without risks. The potential harms of weight loss include disordered eating (Fairburn & Harrison, 2003), anxiety and depression (French & Jeffery, 1994), and weight gain above pre-intervention weight (Fildes et al., 2015).

This may be a little confusing given the public health messages that weight loss is required to improve metabolic health if you have a BMI that is classed as overweight or obese. It is important to note that in the research studies demonstrating improved metabolic health the weight loss is moderate (2-5kg), and achieved through lifestyle interventions such as improved nutrition and increased physical activity. However, the studies attribute the positive outcomes to weight loss alone while the contribution of improved health behaviours are ignored.

Ultimately, the recommendation for weight loss which will inevitably fail only serves to devalue the health-behaviours engaged to achieve it. Beneficial lifestyle interventions are also often overlooked for people in smaller bodies who are assumed to be metabolically healthy. The irony is that health-behaviours have the potential to significantly reduce the health risks associated with a higher BMI. Those who maintain a number of common health behaviours have been shown to have a similar low level of risk of all-cause mortality regardless of BMI (Matheson, King, & Everett, 2012). I make this point not to imply any moral obligation to pursue health but to highlight how weight-centric healthcare absolutely fails people in larger bodies.

So, what are some sane recommendations for weight management? Firstly, provide all healthcare consumers with a more sophisticated assessment of their individual health risk than BMI. Next, abandon intentional weight loss to the ‘Wellness Gurus’, who are the true experts in cherry-picking the research and ignoring the evidence. Finally, both healthcare consumers and providers should replace the pursuit of weight loss with the pursuit of client-centred sustainable health-behaviours.

 

Mandy-Lee Noble, APD

 

References:

Australian Institute of Health and Welfare. (2016). Australia’s health 2016, Chapter 4 Determinants of health - Australian Institute of Health and Welfare. Retrieved from https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true

Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. The Lancet, 361(9355), 407–416. https://doi.org/10.1016/S0140-6736(03)12378-1

Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A. T., & Gulliford, M. C. (2015). Probability of an obese person attaining normal body weight: Cohort study using electronic health records. American Journal of Public Health, 105(9), e54–e59. https://doi.org/10.2105/AJPH.2015.302773

French, S. A., & Jeffery, R. W. (1994). Consequences of dieting to lose weight: Effects on physical and mental health. Health Psychology, 13(3), 195–212. https://doi.org/10.1037/0278-6133.13.3.195

Matheson, E. M., King, D. E., & Everett, C. J. (2012). Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. The Journal of the American Board of Family Medicine, 25(1), 9–15. https://doi.org/10.3122/jabfm.2012.01.110164

NHMRC. (2013). Summary guide for the management of overweight and obesity in primary care. National Health and Medical Research Council, 1–26. https://doi.org/ISBN 1864965932

 

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