Primum non nocere. First, do no harm.
This is the first tenet of the naturopathic oath we all take on graduation day from college, and the most critical.
As naturopaths we strive not to add to the burden of problems of our patients. To refrain from further damaging their physical, mental or emotional wellbeing. To not intervene in such a way that will in any way harm.
Doing nothing is better than doing something that will cause harm.
In many ways, we are very good at abiding by this foundational tenet.
And yet... there is something insidious going on within the naturopathic profession that has not been called out. And despite our best intentions, it is doing serious harm to our patients, our profession, and ourselves.
That thing is a weight focussed approach to health. Whether directly or indirectly, promoting weight loss does irrefutable harm.
Even if it's weight loss "for health". Or weight loss "for fertility". Or weight loss just for the sake of weight loss, because "who doesn't want to be a bit leaner?"
To illustrate my point I'll set the scene. The other week I received two emails: one from a very well known nutraceuticals company promoting its weight loss seminar to naturopaths and other natural health professionals. The other was the exact same email, forwarded on to me from a major natural medicine education institution to its students.
This is not okay.
As I'll illustrate shortly, a focus on weight loss does unequivocal harm. This is in direct opposition to the first and most crucial naturopathic tenet.
It's 2019, and I propose that it's time that practitioners in the field of naturopathic medicine universally adopted a non-diet, weight neutral, Health at Every Size approach. For the sake of our clients, our best practice, and for the future longevity and validity of our profession, we must steer the ship away from the weight-centric doctrine it is starting to (and arguably, has) become and back towards true preventative and holistic medicine.
The kind of medicine that naturopathy sprang from. The kind of medicine that does no harm. The kind of medicine that treats the whole person, not a number on the scales.
Natural medicine was never meant to be used as a weight loss fad.
Naturopathy has the power to bring about incredible healing. I've experienced this first hand. I've seen it in my clients and those of my colleagues.
The naturopathic medicine community (and the yoga community, one of the other domains I hang out in) are exciting potential doorways to better health that are continually shaped by new discoveries and innovation.
The use of evidence-based herbal medicine, nutrition, and lifestyle modifications, all articulating along a backbone of nature as healer, form a potent combination which - when applied with care and pointed wisdom - can work wonders that allopathic medicine simply cannot. This is especially so in the areas of disease prevention, hormonal balance and chronic disease management, where modern medicine often fails to bring about lasting results coupled with quality of life.
And yet, like any healing system in the 21st century where diet culture also exists, both the naturopathy and the yoga communities can be incredibly weight centric.
Meal replacement shakes, ketogenic bars and weight loss supplements make up a significant sector of the practitioner only range of some of the biggest supplement companies that service and educate both naturopaths and naturopathic students. This sends a clear message to current and future practitioners:
"Weight loss is a normal - and very profitable - part of naturopathic practice."
Weight loss seminars and workshops delivered by these companies encourage health practitioners to perpetuate the lucrative weight centric approach that has woven itself into modern naturopathic medicine.
But naturopathy was never intended to focus on weight loss. As more than one of my naturopathic lecturers have proclaimed, we ought to treat the person, not a disease. And certainly not a number on the scales.
Weight loss doesn't work - even if it's 'natural'
Whenever our recommendations have a weight loss focus, they are bound to fail. And they will probably do harm.
Of course it's not just naturopaths; many GPs, dietitians and other allied health professionals still prescribe weight loss despite level 1 evidence that such interventions do not work in the long term:
"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)
Given this, how can we continue prescribing weight loss to our patients? The ethical, sane, evidence-based answer is, we cannot.
It's time we upped our game. Or at the very least, it's time that we considered the strong evidence against weight loss dieting.
This evidence is now so strong that both the Royal Australian College of Physicians and the American Academy of Paediatrics recommend that we stop telling our patients to lose weight and start focussing on improving their health behaviours instead:
"Treatment services should primarily focus on helping people with obesity to achieve optimal health at any weight. This will involve health professionals taking active steps to reduce weight bias and acknowledge (...) that sustained weight loss is uncommon and failed weight loss attempts have negative psychological and physiological effects."
- RACP Position Statement on Obesity, May 2018
What about the benefits of weight loss?
We assume that these recommendations are based on benefits found in research. For many health practitioners, these recommendations justify our continued weight centricity in clinical practice.
But when we look at the evidence that weight loss directly improves health (and that these recommendations are supposed to be based upon), what we find is underwhelming.
The so-called benefits according to the research:
- Small amount of weight loss which lasts no more than 12 months, and
- Possible small changes in secondary health markers which also do not last.
People tend to lose 5% of their body weight during the "intervention" phase – usually early on (approximately the first 12 weeks, which is about as long as most weight loss studies last). After this initial phase, weight starts to creep back on. There is a clear trend that body weight is mostly restored by 12 months. For a significant proportion of dieters, all of the weight that was initially lost is regained, plus some.
It should be clear by now that long-term (2-5+ years) intentional weight loss is unachievable for the majority of people.
Despite the evidence clearly pointing to this fact, the clinical guidelines continue to recommend weight loss to people in larger bodies. Which is baffling to say the least. (The rationale for the disparity between research and guidelines is a whole other kettle of fish I will not go into here).
Furthermore, weight loss attempts do not necessarily promote health. More often than not, they actually deteriorate health.
A weight loss focus does harm
In other words, a weight loss focus directly opposes the naturopathic principle of "first, do no harm".
I hear plenty of practitioners declaring that they don’t promote weight loss diets. And it may be true that they no longer be do weigh-ins or count calories. But often, covert dieting thoughts and beliefs like these are still reinforced by many natural health practitioners.
A weight loss focus - even if disguised using the terms "lifestyle diets", "weight loss for wellness", or other such rhetoric - can and all too often does lead to:
- food and body preoccupation
- weight discrimination
- weight gain above pre-intervention weight (Fildes et al., 2015)
- anxiety and depression (French & Jeffery, 1994)
- development of disordered eating (Fairburn & Harrison, 2003) or an eating disorder (Stice & Ryzin, 2018), the deadliest type of mental health diagnosis
- development of body dysmorphia, and/or exercise abuse
- loss of lean tissue (from muscles and organs)
- long term metabolic disturbance (Fothergill et al, 2016)
- repeated cycles of weight loss and regain or 'weight cycling', the insulin resistance and overactive sympathetic activity caused by which is at least as likely to increase risk for diabetes, hypertension and cardiovascular disease than simply maintaining a higher weight (Dulloo et al, 2002).
Weight loss dieting has all these harmful effects AND for 95% of people it doesn't even work in the long term (2-5 years and beyond). The small percentage of people who do manage to maintain weight loss in the long term often go through cycles of weight loss and gain before stabilising at a lower weight, damaging their health in the process.
These statistical unicorns may also have to practice damaging disordered eating behaviours or even develop a diagnosable eating disorder, in order to maintain the lower body weight.
Whenever we make fat the problem and weight loss the solution, these are side effects - however unintended they may be.
Behaviour change - not weight loss - improves health
It's important to understand that for those who embark on weight loss and experience health improvements, the positive effects of weight loss are mostly explained by the adoption of healthier lifestyle behaviours rather than the weight loss itself.
- A 2013 review of a number of long‐term randomised controlled diet studies shows that the health benefits of dieting have been found to be very small, and much more likely to be related to the aforementioned improved health behaviours than the actual amount of weight lost (Mann et al, 2013).
- A number of studies indicate that improved health markers come from behaviour changes (e.g. improving diet variety and quality, increasing exercise, social support, and stress management) independent of weight loss (Ernsberger, Paul & RJ Koletsky, 1999; Gaesser, 1999; Miller, 1999; Dengel, 1995).
- Lifestyle behaviours like dietary quality, physical activity, smoking and alcohol intake far are stronger determinants of death and disease than BMI classification (Matheson, King & Everett, 2012; Queensland Health, 2016).
To prescribe health recommendations based on someone's weight is simply not best practice.
Many health and fitness professionals are cottoning on to the realisation that it's not weight loss, but lifestyle behavioural changes that make people healthier. That health improves regardless of whether body weight changes or stays the same.
As a result many of these practitioners are now offering weight neutral care, including General Practitioners, Accredited Practising Dietitians, Clinical Psychologists, Psychotherapists, Counsellors, Exercise Physiologists, Occupational Therapists, Nurses and Personal Trainers. The numbers of practitioners making their practices weight neutral is growing.
Naturopaths, it is time to get onboard.
"But I don't promote diets; I encourage lifestyle change"
We are kidding ourselves.
Let's get one thing clear: promoting lifestyle changes with the goal of weight loss IS promoting weight loss. And as discussed, a focus on weight loss and the maladaptive behaviours that go along with it (dietary restriction, over exercise, tendency to use weight loss fads) are incredibly harmful.
Please understand that there's nothing wrong with changing lifestyle habits. I'm a non-diet dietitian and holistic nutritionist currently completing my naturopathic training. I’m also a yoga teacher. I am 100% in favour of lifestyle changes to support health - my livelihood is almost entirely built on helping people to do this.
The problem comes when these recommendations - be they related to nutrition, exercise, or even meditation (yep, seen this) - are coupled with a focus on weight.
So is weight loss bad?
Weight neutral approaches simply do not promote weight loss as a health strategy. They focus on addressing behaviours, and weight is not a behaviour.
Weight loss in and of itself is not the problem. The FOCUS on weight loss is the problem.
The war on obesity has taken its toll. Extensive “collateral damage” has resulted: Food and body preoccupation, self-hatred, eating disorders, discrimination, poor health… Few of us are at peace with our bodies, whether because we’re fat or because we fear becoming fat."
- Linda Bacon, author of Health at Every Size
When people feel empowered and supported in caring for themselves, they are more likely to engage in and sustain health promoting behaviours which directly improve health markers. Yet current public obesity interventions collectively crowned "the war on obesity" may be having the opposite effect through perpetuation of weight stigma.
Weight stigma is a form of social prejudice toward people of higher body weight. Stigma of any kind instills deep personal shame, which generates stress, impairing the functioning of the immune system and damaging health (Puhl & Heuer, 2010).
Weight stigma also delays appropriate medical care as higher weight people are less likely to seek out timely medical advice due to the fear of being shamed by health providers.
Weight stigma is likely to drive weight gain and damage physical and psychological health.
The first tenet of the naturopathic creed is "do no harm." Yet a weight centric approach does untold physical and psychological harm through stigma, and through unhealthy dieting behaviours. Therefore a focus on weight loss is antithetical to the philosophy of naturopathic medicine.
Shifting to weight neutral approaches
"There is an evidence-based, compassionate alternative to the war on obesity. It’s called Health at Every Size. It involves switching your focus from weight to health and supporting your patients in doing the same. Everyone can benefit from good health behaviours."
- Linda Bacon, author of Health at Every Size
This is where Health at Every Size® (or HAES* for short), Intuitive Eating (Van Dyke & Drinkwater, 2014), and the Non-Diet Approach all come in.
These weight neutral approaches have been tested in a number of randomised controlled trials (RCTs). So far, two systematic reviews (Tylka, 2014; Clifford, 2015) of these RCTs have confirmed that even without weight change, lifestyle interventions lead to positive outcomes on biochemical measures, psychometric factors and health behaviours.
Health at Every Size® in particular ties in beautifully with naturopathic principles as it takes a bigger picture, truly holistic approach, encompassing not just physical health but also mental, emotional and social health. I remember one of my first lectures at naturopthic college, having the WHO definition of health hammered into my brain:
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
- World Health Organisation
Rather than focussing on weight, HAES empowers the individual to care for themselves in a number of ways, through:
- addressing health behaviours
- acknowledging and dismantling weight stigma
- being inclusive of human diversity in terms of body size, ability, sexual orientation, gender identification, ethnicity, and socioeconomic status.
In short, Health at Every Size brings greater awareness, choice, and peace to both patients and practitioners.
With their holistic, patient-centred, and whole-system approach, weight neutral approaches like HAES, the non-diet approach and intuitive eating fit the naturopathic philosophy perfectly.
And considering the health fund rebate changes coming into affect in Australia in April 2019, it seems even more pertinent that naturopaths work towards an ethical, evidence based way of practising to maintain the integrity and validity of the field, to continue to help more people and to abide by the original naturopathic tenet of do no harm.
With hope that you will course correct with me,
This is the first in a series of articles on non-diet naturopathic medicine. Stay tuned for part 2, where I will address the second tenet: address the root cause.
Here is a small compilation of resources that naturopaths and naturopath students can use when beginning their exploration of weight neutral approaches:
Willer F, The Non-Diet Approach Guidebook for Dietitians, Lulu Press, Brisbane (2013)
And some links to pieces I've written on these approaches:
The Non-Diet Approach
Health at Every Size
* ‘Health at Every Size’ and ‘HAES’ are Registered Trademarks of the Association for Size Diversity and Health and used with permission.