To weigh or not to weigh. Which is more likely to protect against gaining excess weight?
Women tend to put on extra pounds during midlife, increasing the risks for obesity and related conditions like hypertension, diabetes, heart disease, stroke and some cancers.
That’s the reasoning for new recommendations from a federally supported group of OB-GYNs, family physicians and other health professionals. They’re urging doctors to counsel female patients ages 40 to 60 who are normal weight or overweight about ways to prevent obesity.
Not everyone likes to be weighed. Some patients and health professionals worry that too much emphasis on a woman’s weight may lead to harmful effects, including anxiety, stress, weight stigma, avoidance of doctor visits and even the development of eating disorders.
Some patients may go to extreme lengths to lose weight or prevent weight gain, said psychologist Christine Peat, director of the National Center of Excellence for Eating Disorders at the University of North Carolina at Chapel Hill.
“Sometimes they’ll end up resorting to behaviors that are actually eating disorder behaviors or things that can be really risky,” Peat said. These include restricting calories to dangerously low levels, making themselves throw up, and abusing laxatives or diet pills.
The recommendations, published in August in the Annals of Internal Medicine, were developed by the Women’s Preventive Services Initiative, a national coalition of health professionals and patient representatives. The group, which advises the federal government, said midlife women gain an average of about 1.5 pounds a year due to factors such as aging, becoming more sedentary and the hormonal changes of menopause.
Primary care doctors are advised to talk to women between 40 to 60 who have a normal or overweight body mass index, or BMI, about maintaining their weight or limiting it to prevent obesity. BMI takes into account one’s weight and height.
A normal BMI number is 18.5 to 24.9, an overweight BMI is 25 to 29.9, and an obese BMI is 30 and up.
Dr. Kimberly Gregory, a co-author of the recommendations, said BMIs can be calculated for middle-aged women when they are weighed as part of their well-woman care.
While she has never had a patient decline to be weighed, she said patients always have the right to refuse.
“I think I would take that as an opportunity to understand why,” she said. “Does she have concerns about her weight or eating habits? [I would] emphasize the importance of a healthy diet and exercise.”
The goal is to try to stave off serious illness, not to upset women about their weight, said Gregory, a professor of obstetrics and gynecology and vice chair of Women’s Healthcare Quality and Performance Improvement at Cedars-Sinai Medical Center in Los Angeles.
More than 70% of American women ages 40 to 60 are overweight or obese, she said, and the group wants to make sure women are aware of the risks.
“I understand that sometimes we’re uncomfortable or embarrassed [being weighed], but we can’t change or improve things that we don’t measure,” said Gregory.
Not just a number on a scale
A former-nurse-turned-writer, Monica Romano, 55, of Bellingham, Washington, knows that sometimes weight checks are necessary.
But as someone who considers herself overweight and is recovering from binge eating disorder, she refuses to be weighed at every doctor visit because the practice can lead to anxiety and shame.
“It just has felt for a long time intimidating and reminiscent of the diet culture and the old-school Weight Watchers meetings where you’d get weighed in front of everyone,” Romano said. “And then you would either be celebrated for weight loss or met with the look of indifference or no eye contact if the number didn’t change or went up. Weight doesn’t define me. It’s only one measure of health.”
The recommendations state that counseling may include individualized discussions of healthy eating and physical activity at well-woman visits and that “more intensive interventions can be used, when available, and may include referrals.”
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In making the recommendations, the group reviewed clinical trials of almost 52,000 middle-aged women that compared various behavioral interventions versus no intervention for preventing weight gain and obesity. Four of five trials that looked at counseling showed “favorable weight changes,” with weight loss ranging from 1.9 pounds to 5.5 pounds. The studies varied in their interventions, intensity and follow-up, so the group could not determine the optimal counseling methods or number of sessions required.
The group noted one study that looked at the psychological effects of counseling did not find that patients were more depressed or stressed.
But Samantha Slaven-Bick, 51, a Los Angeles publicist, said she would not appreciate such counseling. She is well aware that she’s gained some weight over the last decade. At 5 feet, 2 inches tall and 107 pounds, she’s not overweight but still weighs more than she did in her 20s and 30s.
She believes a patient’s weight can be medically important information for a physician to have, but she doesn’t want to know the number when she’s weighed at the doctor’s office. In fact, she turns her back to the scale and is not interested in discussing her weight or obesity prevention.
It’s important that we’re not just looking at the number on the scale or a BMI number to tell us who’s healthy and who’s not.
Christine Peat, University of North Carolina at Chapel Hill
“I’m not overweight, but I would still be triggered by that conversation and it would still make me feel bad,” said Slaven-Bick, who follows a healthy diet, strength trains, runs 9 to 12 miles a week and bikes another 40 to 50. “I’m carrying around 10 pounds more than I used to, and that may not sound like a lot, but on my frame it’s definitely extra padding that I would have to completely starve myself to get rid of.”
Rather than focusing on an individual number, UNC’s Peat recommends that doctors emphasize behaviors that are modifiable and good for everyone, such as eating a variety of healthful foods, getting moving and sleeping enough.
“I think it’s important that we’re not just looking at the number on the scale or a BMI number to tell us who’s healthy and who’s not,” she said.
Is BMI accurate?
BMI is a common tool for measuring obesity, but it’s not perfect. It doesn’t, for instance, differentiate between body fat and muscle, which is why bodybuilders can have obese BMIs even though their levels of body fat are low.
BMI numbers also do not necessarily correlate to good or bad health since BMI doesn’t take into account factors that can influence health such as diet, exercise and genetics. That’s why someone with an overweight BMI but a healthy lifestyle can have no medical problems while someone with a normal BMI may have high cholesterol or other issues.
Dr. Mary Rosser, an obstetrician-gynecologist and director of Integrated Women’s Health at Columbia University in New York, supports the new recommendations and said it’s important to discuss a healthy lifestyle with patients of all ages.
But she wouldn’t insist on weighing a patient who didn’t want to get on the scales.
“I have never been punitive about it with a woman who doesn’t want to be weighed, because I know there must be something that is behind that,” she said. “And that is not my goal, to make somebody feel bad.”
Instead, she said, conversations about healthy lifestyle can discuss weight in ways that patients may find less objectionable.
“You can talk about clothes fitting and how they do or don’t fit, and how people feel about themselves, and where they feel the best weight is for them,” she said.
‘Don’t weigh me’ cards
Some doctors have started offering patients the option of using cards that state: “Please don’t weigh me unless it’s (really) medically necessary.”
The group that makes the cards, More-Love.org, maintains that most health conditions can be addressed without knowing a patient’s weight and that talking about weight like it’s a problem perpetuates weight stigma and may prompt some people to avoid doctor visits.
Many people struggle with weight loss.
Melissa Prestipino, 47, a physical therapist in Sparta, New Jersey, learned firsthand that counseling to eat better and exercise more doesn’t always make the pounds melt away.
She “was stuck” at 150 pounds for years. At 5 feet, 2 inches, that put her BMI in the overweight category. Doctors told her to eat better and exercise, but she already was leading an active, healthy lifestyle. She later found out that she has a condition called insulin resistance that was the culprit.
“I’ve led my own personal journey with that number being so discouraging and my not getting the right health care until a doctor really listened to me and realized my body wasn’t doing what it was supposed to do,” Prestipino said. “But the rest of the practitioners kept saying, you know, eat better, eat right, thinking that I’m doing something wrong based on my number.”
Now that she’s receiving medication for the insulin resistance, she’s lost 15 pounds and has a normal weight BMI — and she’s glad.
Prestipino wishes the number on the scale wasn’t so important to her emotionally.
“We perseverate over the number, and I feel like if we didn’t maybe I wouldn’t have been so upset about my weight before or so happy now just because the scale is going down,” she said.