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From the perspective of efficacy as well as ethics, body weight is a poor target for public health intervention.
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There is sufficient evidence to recommend a paradigm shift from conventional weight management to Health at Every Size. More research that considers the unintended consequences of a weight focus can help to clarify the associated costs and will better allow practitioners to challenge the current paradigm. Continued research that includes larger sample sizes and more diverse populations and examines how best to deliver a Health at Every Size intervention, customized to specific populations, is called for.
Our proposed guidelines are modified, with permission, from guidelines developed by the Academy for Eating Disorders for working with children [ 7 ]. They should focus on health, not weight, and should be referred to as "health promotion" and not marketed as "obesity prevention. Weight is not a behavior and therefore not an appropriate target for behavior modification. These guidelines outline ways in which health practitioners can shift their practice towards a HAES approach and, in so doing, uphold the tenets of their profession in providing inclusive, effective, and ethical care consistent with the evidence base.
We accept this argument; we have used "overweight" and "obese" throughout this paper when necessary to report research where these categories were used. We recognize, however, that "normal" does not reflect a normative or optimal value; that "overweight" falsely implies a weight over which one is unhealthy; and that the etymology of the word "obese" mistakenly implies that a large appetite is the cause. Both also speak and write on the topic of Health at Every Size and sometimes receive financial remuneration for this work. LB initiated the collaboration.
Both authors contributed to conceptualizing and drafting the review. LB was lead researcher and undertook the systematic review and designed and completed the tables. Both authors approved the final manuscript. Deb Burgard conceptualized the obesity cost analysis. National Center for Biotechnology Information , U. Journal List Nutr J v. Nutr J. Published online Jan Linda Bacon 1 and Lucy Aphramor 2, 3. Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Linda Bacon: gro. Received Oct 1; Accepted Jan This article has been corrected. See Nutr J. This article has been cited by other articles in PMC. Abstract Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. Introduction Concern regarding "overweight" and "obesity" is reflected in a diverse range of policy measures aimed at helping individuals reduce their body mass index BMI 1.
Investigation Group type a n Population Number of treatment sessions Follow-up number of weeks post treatment Attrition Improvements Decre-ments Physio-logic Health behaviors Psycho-social Provencher, et al. Open in a separate window. Assumptions underlying the conventional weight-focused paradigm Dieting and other weight loss behaviors are popular in the general population and widely encouraged in public health policy and health care practice as a solution for the "problem" of obesity.
Assumption: Adiposity poses significant mortality risk Evidence: Except at statistical extremes, body mass index BMI - or amount of body fat - only weakly predicts longevity [ 32 ]. Assumption: Adiposity poses significant morbidity risk Evidence: While it is well established that obesity is associated with increased risk for many diseases, causation is less well-established. Assumption: Weight loss will prolong life Evidence: Most prospective observational studies suggest that weight loss increases the risk of premature death among obese individuals, even when the weight loss is intentional and the studies are well controlled with regard to known confounding factors, including hazardous behavior and underlying diseases [ 91 - 96 ].
Assumption: Anyone who is determined can lose weight and keep it off through appropriate diet and exercise Evidence: Long-term follow-up studies document that the majority of individuals regain virtually all of the weight that was lost during treatment, regardless of whether they maintain their diet or exercise program [ 5 , 27 ].
Assumption: The pursuit of weight loss is a practical and positive goal Evidence: As discussed earlier, weight cycling is the most common result of engaging in conventional dieting practices and is known to increase morbidity and mortality risk. Assumption: The only way for overweight and obese people to improve health is to lose weight Evidence: That weight loss will improve health over the long-term for obese people is, in fact, an untested hypothesis. Health at every size: shifting the paradigm from weight to health This section explains the rationale supporting some of the significant ways in which the HAES paradigm differs from the conventional weight-focused paradigm.
The following topics are addressed: 1 HAES encourages body acceptance as opposed to weight loss or weight maintenance; 2 HAES supports reliance on internal regulatory processes, such as hunger and satiety, as opposed to encouraging cognitively-imposed dietary restriction; and 3 HAES supports active embodiment as opposed to encouraging structured exercise. Encouraging Body Acceptance Conventional thought suggests that body discontent helps motivate beneficial lifestyle change [ , ]. Supporting Intuitive Eating Conventional recommendations view conscious efforts to monitor and restrict food choices as a necessary aspect of eating for health or weight control [ ].
Supporting Active Embodiment HAES encourages people to build activity into their day-to-day routines and focuses on helping people find enjoyable ways of being active. Clinical Ethics There are serious ethical concerns regarding the continued use of a weight-centered paradigm in current practice in relation to beneficence and nonmaleficence. Public Health Ethics The new public health ethics advocates scrutiny of the values and structure of medical care, recognizing that the remedy to poor health and health inequalities does not lie solely in individual choices.
Conclusion From the perspective of efficacy as well as ethics, body weight is a poor target for public health intervention. Appendix 1 Critics challenge the value of using BMI terminology, suggesting that BMI is a poor determinant of health and the categories medicalize and pathologize having a certain body. Authors' contributions LB initiated the collaboration. Acknowledgements Deb Burgard conceptualized the obesity cost analysis.
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