Can you refuse to be weighed at doctor check-ups? How is weight-centric healthcare often counter-productive and even dangerous? Is there a desire for holistic weight-inclusive medical care practices? In this podcast episode, Dr. Cristina Castagnini speaks about weight-inclusive patient care with Michelle May.


Dr. Michelle May is the award-winning author of the book series, Eat What You Love, Love What You Eat, which teaches mindful eating for yo-yo dieting, diabetes, binge eating disorder, bariatric surgery, and students. Dr. May is an Associate Professor at Arizona State University where she teaches Mindful Eating. She is a Certified Speaking Professional (CSP), the highest earned designation from the National Speakers Association. Dr. May founded Am I Hungry? Mindful Eating Programs and Training in 1999 to share her compassionate, constructive, and life-changing approach to eating through health and wellness professionals, corporate wellness programs, and community-based programs. Visit Dr. Michelle May's personal website, and see also Am I Hungry? Connect with Dr. May on Instagram and LinkedIn. FREEBIE: Read The Weight Inclusive Patient Care Practices pdf


  • Understanding causation versus correlation
  • New knowledge takes time to settle
  • Exercise should be recommended as healthcare, not punishment
  • A weight-inclusive patient care approach

Understanding causation versus correlation

There are a lot of conditions that are correlated with body weight or body size. Correlation does not mean that [the] body size caused those problems. (Michelle May)
For example, many people believe that larger body size causes type 2 diabetes. However, what causes type 2 diabetes is largely a heritable condition that is called “insulin resistance”, and this is almost completely asymptomatic for many years in most people that struggle with diabetes. Over time, as insulin increases in the body, weight gain is a normal bodily response to the increased presence of insulin.
At the end when someone is finally diagnosed with diabetes, then a researcher says, “See? People who are at a higher body weight are more likely to have diabetes.” Did the higher body weight cause the diabetes, or is it possible that insulin resistance caused both? (Michelle May)

New knowledge takes time

Many people are often harmed in the time that it takes doctors and scientists to welcome new data, practices, and research because people will instinctually reject what they do not know.
The idea that weight does not cause all diseases and weight loss does not cure all diseases goes against the current paradigm and it’s going to take time to change it. (Michelle May)
Physicians are busy people, and of course, they do read new research that gets put out, but they cannot reach everything in full and always stay up to date.
I’m not saying that physicians don’t read medical papers, of course they do, but many of them don’t have time to read everything [because] there are hundreds published every week, so they can’t read everything. So, unfortunately, they may be reading headlines or they may be ignoring things that don’t fit with what they already think or believe. (Michelle May)
Therefore, it takes a lot of time for new data to be integrated into medical practices, especially if doctors have been trained to teach people that weight gain is dangerous throughout their careers, or if they have always recommended weight loss for health.

Exercise should be recommended as healthcare, not punishment

If you’re saying to yourself, “Obviously being overweight is unhealthy”, that’s your paradigm showing. It is not obvious once you start to read the literature, and that’s what I needed to do to become so clear in my own mind about this. (Michelle May)
If everybody believes that weight is the primary problem, then it may not occur to teachers, and faculty in medical school, that they shouldn’t be endorsing weight loss, or dropping comments on weight gain. Exercise can be advised as a method for maintaining cardiac health, physical ability, lower blood pressure, improving mental health, and so forth. It should not only be recommended in the case of weight loss.
When a clinician, for example, recommends exercise with the sole purpose of losing weight, they’re completely missing the point [of providing healthcare] … so the patient may start an exercise program to try to achieve weight loss [and] when they don’t achieve the weight loss … they say, “Oh, exercise didn’t work for me”. (Michelle May)
Often, the illnesses connected with higher levels of weight are actually connected to weight cycling, which is the constant gaining and loss of body weight.

A weight-inclusive patient care approach

People will come to medical appointments in all shapes and sizes, and it is the clinician’s responsibility to look at them as individuals and consider all the different factors, of which weight is only one.
A weight-inclusive approach says, “We’re not engaging in these behaviors to lose weight, and we don’t measure the success of these behaviors with weight loss. We engage in behaviors that leave us feeling better”. It’s about well-being, it’s not about changing a number on the scale. (Michelle May)
How can you feel your best? It’s not about how you look, or the number on the scale, but about your mental, emotional, and physical well-being.



I am a licensed Psychologist and Certified Eating Disorder Specialist. While I may have over 20 years of clinical experience, what I also have is the experience of having been a patient who had an eating disorder as well. One thing that I never had during all of my treatment was someone who could look me in the eye and honestly say to me "hey, I've been there. I understand". Going through treatment for an eating disorder is one of the hardest and scariest things to do. I remember being asked to do things that scared me. Things I now know ultimately helped me to get better. But, at the time, I had serious doubts and fears about it. If even one of my providers had been able to tell me "I know it's scary, but I had to go through that part too. Here's what will probably happen...." then perhaps I would not have gone in and out of treatment so many times. My own experience ultimately led me to specialize in treating eating disorders. I wanted to be the therapist I never had; the one who "got it". I will be giving you my perspective and information as an expert and clinician who has been treating patients for over 2 decades. But don't just take my word for it...keep listening to hear the truly informative insights and knowledge guest experts have to share. I am so happy you are here!


Did you enjoy this podcast? Feel free to comment below and share this podcast on social media! You can also leave a review of Behind The Bite on Apple Podcasts (previously) iTunes and subscribe!

Podcast Transcription

[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Now, as I've mentioned before, if you go to my website,, you can send me a voice message on my new Speakpipe voicemail, or you can send me a private DM or message on any of my social media. I recently received a question by a follower asking me, "Hey, doc, why is it that each and every time I go in for a doctor's appointment, I need to be weighed? It makes me so anxious that I almost don't want to go. I always feel judged on how I look, and I always feel judged for whatever number pops up on the scale and I know that the short appointment I have will always be spent talking about me losing weight instead of what I'm really there for. Believe me, I've tried everything to lose weight and nothing works. What will happen if I refuse to get weighed and can I even do that?" Well, I am so glad you sent me this, but I am not going to be the one who's going to answer your question. This entire podcast today is focused on healthcare being weight centric and I am certain you will have your answer to this question by the end of it. The current paradigm in healthcare is weight centric, equating weight and health. This approach is not only ineffective, but has negative consequences on wellbeing, including weight cycling, disordered eating, weight stigma, and weight stigma in healthcare. Michelle May, MD is the co-author of a recent article reviewing the scientific evidence for why healthcare should ship to a weight neutral approach published in the peer reviewed journal, Nutrition and Clinical Practice. The article is The Consequences of a Weight Centric Approach to Healthcare: A Case for a Paradigm Shift in How Clinicians Address Body Weight, and is a review of the literature and presents a framework for weight inclusive patient care practices. Michelle May is here today, and I'm so thrilled. All right, Michelle, well, welcome to this show. It's great to have you back. [MICHELLE MAY] Thank you. I'm really glad to be here, Cristina, thanks for the invite. [DR. CRISTINA] Well, you have such a great topic. I know it is something that I get DMed about. I know it's something I talk with my patients about. That's just a small segment of the population, so I know listeners are going to be really getting a lot out of what you have to say today. Whether it's a medical doctor listening or a patient or a loved one the topic of when somebody goes into the doctors and maybe they are hesitant to go in because they're concerned about how they look their weight, talking about their health concerns, but not wanting it to be related to their weight, is that something that you're, that was, I guess, the motivation for you to write this paper or maybe if you could talk to us a little bit about like what motivated you to write this paper that you did? [MICHELLE] Yes I was a practicing family physician for 16 years, overlapping a bit with my work in mindful eating and like you in my work in mindful eating, the topic of weight kept coming up again and again, even though we never promoted weight loss or weight management. We did promote weight management early in the course of it, but we became a weight neutral or weight inclusive company. But that is a hard concept to swallow because our current culture is so weight focused and healthcare is incredibly weight focused. So it felt important to me to, first of all, familiarize myself with the research on this, so I read, I don't know, 150, 200, 250 papers on this topic and I prepared a presentation that I have given at a number of health professional conferences about why we want to make the shift from a weight centric to a weight inclusive approach. Then that led to the paper. So it really came from a place of passion and a place of need for my own clients and patients but it also, I thought was very important not to just have an opinion about this, but to make sure that the opinion that I have is evidence-based. I believe it is, unfortunately, the evidence is very slow to trickle down to the medical community and to our culture at large [DR. CRISTINA] That's frustrating for me too. Wow, that's a lot of articles you read. That's very telling too, that there's so much research out there and there's so much evidence and yet, to your point, it's so slow moving to get to the general public. [MICHELLE] Well, I'll tell you, this is one of the things that I came across in doing the literature review, is that there's so much bias toward a weight centric approach that it actually affects what studies get published and how their results are reported out. Lucy Alphamore did a review of articles that were published in a British nutrition journal, and they compared the description in the abstract or the conclusion the authors made with what the study actually showed and it would be, I won't give you an exact quote, but for example, it would be something like using a commercial weight loss program along with diet and exercise and a nutrition meal replacement is more effective than doing the same thing without the commercial weight loss program. So you read that and you think, oh, okay, good, a weight loss program is helpful. You go and look at the actual studies, and the difference might be 0.5 kilograms or two kilograms, which is only a couple pounds, three, four pounds and for many people, that is not a significant enough difference to make them say, oh, this is worth restricting my diet for the rest of my life. Further, a lot of weight loss research does not include all the dropouts. You and I know how many of our patients and clients have been through many weight loss programs. Well, people in a study who start a weight loss program and then drop out, don't go back to the researchers for follow up to be weighed again. So they're not counted in the data. So oftentimes we're only looking at, let's say, the 40% who's stuck with it and many research studies don't go out long enough to actually say whether this is meaningful, because the truth of the matter is diets do work temporarily. So if you don't measure people beyond six months or a year, or three years or five years, then you're measuring something that we already know gives you temporary results but that's not what we're looking for. We're looking for ongoing sustained improvements in health and so if you don't run the study for long enough, you don't really know what happened to those people. [DR. CRISTINA] I love that you just said that word health, because, isn't that really what this is about? Like why is it such a push for weight loss? Because I'm actually curious, in your findings, did you find that weight loss actually led to better physical health or that that is actually a treatment for any of the illnesses that doctors are saying, hey, lose weight and this will make this illness better? [MICHELLE] Well, so there's a really big scientific problem here, and that is the difference between causation and correlation. There are a lot of conditions that are correlated with body weight or body size. Correlation does not mean that body size caused those problems. Let me give you a really good example, the one that people often bring up to me and that is diabetes. They say, well, and we're talking about Type 2 Diabetes. It's a different condition than Type 1. Well, yes, but doesn't weight cause Type 2 Diabetes? Well, this is interesting because what we know causes Type 2 diabetes is largely a heritable condition that is called insulin resistance. Insulin resistance in most people is completely asymptomatic for many years and so for a very long time, a person's insulin is going up because their body is ignoring it. Over that same period of time, due to insulin resistance, we see weight increasing, because that's one of the things that insulin resistance does, is cause weight gain and we see increase in diabetes. So at the end, when finally someone is diagnosed with diabetes, then a researcher says, see, people who are at higher body weight are more likely to have diabetes. Did the higher body weight cause the diabetes or is it possible that the insulin resistance caused both? That's a simple example. In my clinical practice, I took care of many patients with Type 2 diabetes who did not have a higher body weight so we already know that that is not a direct link. I also took care of many of my patients who were in a higher body weight and did not have diabetes. So again, there's just so many assumptions that are made. The largest problem that we have here, Cristina, is that there is an assumption that body weight automatically confers poor health. You automatically will be unhealthy if you have a higher body weight. That is not at all what the literature shows. We see a bell curve of body weights, and we see a bell curve of different diseases. At the extremes, lower body weight and higher body weight, you do see an increase in certain conditions but for the vast majority of people in the middle including those that are defined by body mass indexes being overweight, or even, I'm going to use the O word here, obese, even in those situations you are not automatically unhealthy just because of the number on the scale. [DR. CRISTINA] So why do you think it's slow moving in terms of like getting rid of the BMI or the medical field, like using weight as a criteria for determining, okay, should I talk to my patient about losing weight so they'll be healthier? Because I think that is the message that most people walk out of the doctor's office with is, I need to lose weight so that I have better health or I just think that is the message and it's unfortunate. [MICHELLE] Yes, that is the message. Well, paradigms of any sort are very difficult to change. Once we have any a paradigm, and we, you and I see this in our practices as well, when someone has an established paradigm, it's very difficult for them to see through it, much less breakthrough. There was a Hungarian pediatrician back in the 1800s who discovered that if you washed, if the doctors washed their hands after working with a woman who had a severe infection after childbirth, you could decrease the risk of death. He studied this, he reported it to his colleagues, and his colleagues were appalled because they were gentlemen, they couldn't possibly be vectors of disease. It took a very, very long time for people to, physicians to accept that hand washing was an important practice to prevent infectious disease. Now, nowadays, that is so obvious, but back then it flew in the face of the paradigm, which was doctors or gentlemen, and they were men, by the way, the doctors were gentlemen, and they couldn't be causing disease. So many, many people were harmed by the fact that it took a long time for them to accept that data. I have other examples, but this Hungarian pediatrician, his name was Simul Weis, so this is called the simul vice reflex that we automatically reject any new information. Well, the idea that weight does not cause all disease and that weight loss does not cure all disease goes against the current paradigm, and it's going to take time to change it, which is one of the reasons we wrote this paper. We really wanted to lay out the data in a different way, because so often the research that is published is already biased because studies that get accepted are already about weight loss and they may report things that aren't actually supported by the evidence, but it goes along with the current paradigm. [DR. CRISTINA] Well, that's another thing. So I'm wondering, as you're talking about this paper and presenting it, are you getting a lot of I guess people who are just questioning it, saying, is this right or like some pushback? [MICHELLE] I have not seen any pushback. That doesn't mean there isn't. But remember this was a peer reviewed clinical review, meaning that we read other studies and reported out what we learned from those studies, and we included all of the references in the papers. So really, what should happen and mostly doesn't, is that if somebody questions something, all they need to do is look at the reference and go back and read the original paper. Now, where the problem comes in is that we're talking about very busy clinicians who don't have the time to read most of the medical literature. I had not read 100, 150 pages before I got interested in this several years ago. So most of the time, a busy clinician is going to read the abstract, the summary of the paper, or they may see something in a press release, something that may be released to one of the morning news shows and that may be all that they actually get. Now, I'm not saying physicians don't read medical papers. Of course, they do, but many of them don't have time to read everything. There's hundreds published all the, every week, so they can't read everything. Unfortunately, they may be reading headlines or they may be ignoring things that don't fit with what they already think or believe and so they don't end up changing their perspective on what we already, what they're already doing in their clinical practice. One other thing I will say is that a lot of clinicians have spent their entire careers promoting weight loss. It is very difficult to admit that you were wrong and that you may have actually caused harm. Especially if somebody's career is built around weight loss interventions, it's very difficult to say, okay, I was wrong and I shouldn't have said that or done that. So we end up bumping into a lot of reasons. I mean, I always like to say doctors are people too. As people, we resist change in general. [DR. CRISTINA] So do you think part of this is stemming from the lack of, I guess, education in medical school about all of this too? [MICHELLE] Well, again if everybody believes that weight is the primary problem, then it may not even occur to teachers in medical school, faculty in medical school that they shouldn't be teaching weight loss or shouldn't be dropping in these statements over and over again about weight. But let's take this one step further, so people listening may be saying, well, obviously it's unhealthy. If you are saying to yourself, obviously being overweight is unhealthy, that's your paradigm showing. It is not obvious once you start to read the literature and that's what I needed to do to become so clear in my own mind about this. It is not an obvious c conclusion and there are a few other flawed assumptions about this. One is, for example, that weight is under an individual's control. If you are in a higher body weight, and by the way, I am intentionally not using the words overweight and obesity, let me tell you why. Because the word overweight automatically assumes that there is a right weight to be, and you are over it, which is incorrect. Throughout history, human beings have fallen on a bell-shaped curve of weight. There has always been a diversity of body sizes and there's a diversity of body sizes in different races, in different cultures. So to assume that there is a right way to be really ignores natural human diversity and unfairly stigmatizes certain people who are already at a disadvantage in some ways. And further the word obese, it automatically becomes a medical term. It pathologizes a person's body size. The word obese comes from the Latin word obeses, which literally means having eaten until fat. The truth is that that is not the only thing that causes weight gain. It has a lot to do with genetics, it has a lot to do with social determinants of health. In other words, your zip code has a greater prediction on many health conditions than your body weight does. It has to do with other conditions like insulin resistance and so forth. So this idea that people who are in a larger body caused it or did it to themselves is incorrect. For example, another place where this is the incorrect conclusion that you and I work on all the time, is that when a person restricts and deprives themselves of nutrition and fuel, the body's natural evolutionary, protective mechanisms begins to shift their metabolism. So people will be in a larger body over time, the more that they have tried and regained lost and regained weight. Weight cycling in and of itself is a risk factor for certain health conditions, and it tends to increase body size. So this is odd because the solution that people are often told they should do, actually may contribute to the very issue that the clinician is saying needs to be changed. So my point in all this is that if we think, okay, all you need to do is eat less and exercise more, we're ignoring how complex body size really is. It has to do with various hormone levels and genetics and physical activity certainly, but all kinds of other things that are not under an individual's control, like social determinants of health. So you can quickly see how complicated this could be, and any clinician listening to this might be thinking to themselves, oh my gosh, it's just easier to tell people to lose weight. That would be fine if number one, it worked long term and number two, it didn't have problematic effects, if it didn't actually cause certain problems. So that is the follow up to this, which is does it work? No. Are there any problems with doing it anyway? Yes. [DR. CRISTINA] Well, so that's the other thing to this, if someone is told you need to lose weight, and maybe they don't have, I mean, much to your point, you said, we're working with people in larger bodies who didn't have an illness but there's that weight biased doctors tend to have, which is if you're not larger body you must have something wrong with you. So even if there's nothing, they say, well for your own health it's better to lose weight. That to me, creates a problem. Now you're putting somebody who's not, they have no illness, their body's just fine, and they're creating something where they're going to put them in a slippery slope where now you could create illness. Maybe their body's not meant to be in a smaller size or smaller rate. It's perfectly fine. Now, are you causing illness because this person's going to go do things to try to get into a body size they're not meant to be in? What happens? [MICHELLE] Really good point. So a few things here. The first is that weight is not a behavior. Behaviors are what we can work on as therapists, as dieticians, as physicians, as personal trainers and so forth. Those are the things that are subject to working on. Now, having said that, nobody is obligated to seek health. If they don't want to work out, they don't have to. I mean, the part of the problem with this whole weight centric approach is that it doesn't respect people's autonomy and choice to do what they wish to do. But as a clinician, it certainly is our responsibility to talk to people about evidence-based recommendations that will improve their overall wellbeing. We know that physical activity does that. When a clinician, for example, recommends exercise with the sole purpose of losing weight, they're completely missing the point. So the patient may start an exercise program to try to achieve weight loss when they don't achieve the weight loss they were told to expect, or they lose a little bit of weight and then gain it back they say, oh, exercise didn't work for me, or I didn't like it enough to keep doing it and they quit. What we know about exercise is that exercise is incredibly valuable for improving wellbeing at all body sizes. In fact, a person who is in a smaller body and doesn't exercise is going to be less healthy by and large than a person in a larger body who does. So we want to start separating weight and behaviors because the behaviors are the pieces that we really want to focus on because those are the ones that are going to make the difference in the long run. [DR. CRISTINA] Again, to your point, you're bringing up these great things. I think they had assumption as well that someone in a smaller body must be healthier, that's the other bias, looking at somebody saying, oh, you're in a smaller body, you must be doing something right. What are you people get asked that all the time, well, what are you doing? What are you eating? What are you, how are you exercising? To your point, they might not be exercising. They might be doing many, many things that are actually very detrimental to their health and wellbeing. That's really scary too. [MICHELLE] Well, so there was another study, well we didn't talk much about BMI, we've dropped that term a couple times here. So BMI (Body Mass Index) has become the gold standard for assessing a person's health based on their body size. Well, the truth is that BMI was invented by a Mathematician back in the early 18 hundreds. He was not a medical physician. He was trying to find a mathematical way to estimate the average size of a population. It was never intended to be used to assess a person's risk factors or health individually. There was another clinician back in the early 19 probably 1900s who decided that he wanted to take this number. He renamed it the body mass index and started using it to estimate body fat percentage. Well, it turns out if you measure a population, it's not bad for estimating the body fat percentage of let's say a town, but if you look at individuals, it doesn't do a good job of that at all. So then they ended up taking this BMI and creating these BMI charts. We've all seen them. They're hanging in every doctor's office, usually right over the scale with a red zone, a yellow zone, and a green zone. It doesn't account for whether you're male or female, it doesn't account whether you're a weight lifter or not. It doesn't account for whether you have cancer or an eating disorder or some other condition that may lead you to have a low body weight. So as you said, there's this assumption that people in a lower body size are automatically healthier. There was a group that looked at data from NHIH, which was a huge, huge nurse's study and they looked at these different body mass index categories. Interestingly, the normal body mass index category, let's, I won't do the exact numbers, but let's say it goes from about 18, 19 up to 25. That's considered normal weight. They compare that to the health of people in the low weight, the overweight, which is around 25 to 30 in the obese, the obese category up from there and up from there. Interesting, what they found was the highest risk category was in those, in the lowest category. The ones that were underweight had higher risk of disease even when they controlled for things like cancer than the people in any other body mass index category. The healthiest people happened to be the ones in the overweight category, the 25 to 30 range. What's interesting to me about this is, despite this evidence, nobody went back and remade the charts and said, no, this is the BMI that you want to get to because of weight stigma and weight bias. It's already believed that that is an unhealthy weight and you shouldn't be that weight and therefore, nobody wants to risk you gaining weight or thinking that you're okay or stopping your weight loss pursuit if you're in that overweight category because it's overweight. Again, it's just this idea that we have this established paradigm and it's very difficult to make the shift out of that. We just assume that it's right and we don't question it. [DR. CRISTINA] So when you're talking to your colleagues, I mean, you have much more clout in talking to doctors because you have your MD behind you than a I do, the Ph.D., I think and you've been in the field, so I mean, I think there is something to that, do you find that people are open to hearing what you have to say and that there's a shift? Or do you find that there's not really? [MICHELLE] Oh, such a good question. There is an increasing movement toward a weight inclusive approach. I believe this message is getting out there. I believe that clinicians, therapists and dieticians and researchers and medical physicians, there is an increasing number who are actually hearing this message and seeing the papers, reading. That's one of the reasons we published the paper was to help increase this shift. There are many who are very set in their ways and have every reason to say, oh no, this is not true. Everybody should lose weight or try to lose weight if they are overweight or obese. Well, let's talk a little bit about the potential harms here. First of all, weight stigma in and of itself is harmful. For example, if a person goes in to see their doctor for a sore throat and they are automatically weighed and their BMI is calculated and put on their medical record and it's flagged to call the clinician's attention to it, in the course of that visit for their sore throat, that clinician might say, "And by the way, I noticed that your BMI is high, you really should lose weight." So now we have shifted the attention from a sore throat to a person's body weight in probably what amounts to a 10 minute or less visit. There's no time to talk about the person's actual behaviors. No, there's no time to say, well, do you exercise? There's already the assumption you must not. We don't have time to ask, well what, how many fruits and vegetables do you eat every day? Do you, blah, blah, blah? We don't have any time to ask any of the actual behavioral questions. We just assume that their body weight is high, therefore they must be engaging in unhealthy behaviors and the solution is to lose weight. That is weight stigma in action. Now, let's take it one step further. Let's say that a person comes in with shortness of breath and they have a high BMI on their medical chart. The clinician, of course is going to listen to their heart and lungs, find out a bit bit more information. But if that clinician has weight stigma or weight bias, they may say, "I really think it's because of your high weight and if you lose weight, you'll be able to breathe better." They may not do appropriate testing, they may not do an EKG or they may not get a chest x-ray, or they may not refer this patient. There may be all kinds of things they don't do. Now, isn't that interesting? If this person actually has an underlying cardio respiratory problem that isn't diagnosed, and then a few years down the road they die, and then the research says, see, they were overweight and they died of cardiorespiratory disease. No, they died because their clinician didn't bother to do the appropriate testing until it was too late or never did it at all and there is lots and lots of anecdotal data that show that this happens all the time. All you have to do is post in your social media, has anybody experienced weight stigma at a doctor's visit? Have you ever had a doctor ignore your complaints and focus on your weight instead? Have you ever had a doctor tell you to lose weight when that wasn't even what you went in for? You are going to be flooded with examples of people who have experienced weight stigma in the medical field. And then other issues, of course, is that the most common result of any weight loss effort is not weight loss, it's weight cycling, weight loss followed by weight gain, weight loss followed by weight gain. Oftentimes, the weight gain is even more than the weight loss and the body composition skews higher and higher toward body fat and away from muscle every time a person goes through that weight cycling process. Then a third piece, which I know you are very familiar with, is that restrictive eating often leads to disordered eating and eating disorders or contributes, maybe not leads to in all cases, but at least contributes to eating disorders and disordered eating that is a problem and is a huge problem for many people. I often encounter people who are otherwise healthy, but have very disordered eating patterns that ultimately will lead to problems for them. [DR. CRISTINA] To your point too, actually, I was going to ask you, people ask like, what are the consequences of weight cycling? Because I hear that a lot too is like, that is actually the cause of more problems for people like with their health. [MICHELLE] This is a really hard study to do. I mean, I talked earlier about correlation versus causation. So part of the problem I have here is that it's very hard to do a randomized controlled trial where you cause some people to lose weight and keep it off forever and you cause other people to lose weight, gain weight, lose weight, gain weight. I mean, you can't, you can't control that. You can't do that because in fact, what happens to the majority of people is weight cycling. So this is where the studies are forced to look at correlation. For example, in a big study that was done in Australia that we talked about in that paper, they looked at women who had lost weight, gained weight, lost weight, gained weight compared them to those who had never tried to lose weight. That's hard to find because, lots of people do. They found higher rates of depression, higher rates of other cardiometabolic problems like blood pressure, et cetera. And if you think about this, a lot of times when we look at studies that say, oh higher body weight, that's not actually the words they use, those are my words, but obesity is what the, is what they'll say obesity causes all these health conditions. Well, first of all, those aren't randomized controlled trials so they can only say obesity is correlated with these other health conditions. But they don't often ask the question about weight cycling. In my practice, as you know I do workshops and coaching and retreats and things for people who have a disordered relationship with food, who want a healthier relationship with food, in my practice, I rarely meet somebody at a higher body weight who hasn't weight cycled, but they don't ask that question in the research. So we often, we don't even really know how many of these diseases that are presumed to be caused by weight are actually affected by weight cycling, because again, those two travel together almost all the time. [DR. CRISTINA] No, that makes sense. You can't do that study. That makes complete sense. It'd be really interesting just to study the people that have never tried to lose weight. I mean, looking at that, like what is it about them that they were not susceptible to the messages of society or anything else? Like that's a fascinating group right there. [MICHELLE] It is a fascinating group, and I know those studies have been done. I wish I could quote them to you off the top of my head, but consider this just as part of this is that oftentimes those are people who are already in a naturally lower body weight. So there can be a lot of factors. It could be genetics, it could be that they were raised in a family where food was not restricted and deprived, they were never put on diets. Maybe because of their naturally slim body, we call this thin privilege, so if you are privileged and if you have the unearned privilege of being in a smaller body, you were born this way, you were raised this way, you never went on diets, you never did the weight cycling that led to an increase in body weight, et cetera, then you may have a healthier relationship with foo, meaning in my world, and this is the name of my book series, you can eat what you love and you love what you eat. You don't obsess about it, you don't restrict, you don't deprive. You don't go on a diet every January 2nd. Instead, maybe you're interested in health, maybe you are more mindful of eating fruits and vegetables and that sort of thing or maybe not. But a person with thin privilege is automatically presumed to have created that condition. They are automatically presumed to choose healthier foods or automatically presumed to be healthier or have willpower when in fact many of them are don't. Those who do manage their body size through willpower and restricted eating oftentimes have disordered eating or even eating disorder behaviors as you well know. [DR. CRISTINA] Going back to what you said about people coming in and not getting tested for things, so the people you're talking about who you said white necking it, willpower, putting themselves in bodies that are smaller than maybe they're meant to be genetically, biologically whatnot, how often they get bypassed for getting EKGs or labs or things that they might need as well and that's a sad fact as well too. [MICHELLE] Oh, what a good point, Cristina. If you show up to a clinician's office in a smaller body, you're automatically presumed to be eating a balanced diet and exercising so they may never ask you the question or make recommendations or suggestions. They may not do certain testing lipid profiles or A1 hemoglobin A1C to screen for pre-diabetes or diabetes. They may not, you may come in, remember the example of chest pain that I was, or shortness of breath I was using earlier. You come in with shortness of breath and you're presumed to be healthy. So you don't get the EKG or the chest x-ray or the other testing either because now you are presumed to be healthy and that it certainly couldn't be a heart attack happening, especially if you're a woman, by the way. This is another way that weight stigma or weight bias shows up in the clinical setting. All of this is to say that I'm not saying that weight doesn't affect a person's wellbeing or that it doesn't influence certain conditions. Please don't misunderstand me. That's not what I'm saying. What I'm saying is that if we filter everything through a weight centered approach, then we're going to make a lot more mistakes than we need to, and we may actually cause harm. So what I promote is a weight inclusive approach so that what we're really looking at is that all people come to a clinical encounter in all body sizes, and that it is our responsibility as a clinician to look at them as an individual and to consider all the different factors. Weight might be one of those, but we may also, of course consider their blood pressure, their family history, their lipid profile. And by the way, lipid profiles aren't nearly as affected by a person's diet or weight as clinicians who were trained back when I was trained had been led to believe. It turns out that, again, this is another area where genetics is far more important. That doesn't mean you aren't going to benefit from improving the way that you eat and exercising, but to say that you need to lose weight to make those changes is a misdirection. Oftentimes, when they say, oh, but weight loss works, they don't separate out the fact that in order to lose weight, people change their diet, they change their exercise, they might go to a group support meeting, they might see a clinician frequently, they may be taking supplements or doing this or doing that, drinking water, sleeping, all the other things. So it's automatically assumed that it was the weight loss that caused the change, not all the behaviors that the person engaged in in order to lead to weight loss. Then when weight is regained, which it often is, and we didn't even talk about why that is, but it often is then people stop the changes in behavior because they figure it didn't work anymore. Or as you know restricting and depriving yourself of certain foods makes it really hard because eventually, you're craving those foods all the time. When you finally eat them, you binge eat them, then you go back on the diet. We call that the eat, repent, repeat cycle. That in and of itself does not lead to wellbeing. [DR. CRISTINA] Just to clarify too, what you didn't say, which was great, is that people didn't take on this restrictive diet and insanely like time consuming exercise program in the sake of like seeking health or wellness and then lost weight. It was, they tried to do things so that they were, well, that their bodies were, well, they were eating while they were like exercising for the whole purpose of their overall health, mental health and physical wellness. Then as a byproduct, their weight may or may not change versus maybe some people listening going, see, if you eat different and you exercise, you'll lose weight. But that's counter to what you're saying. [MICHELLE] That's right. So a weight inclusive approach, exactly what you just said, a weight inclusive approach says we are not engaging in these behaviors in order to lose weight and we don't measure the success of these behaviors with weight loss. We engage in behaviors that leave us feeling better. It's about wellbeing, it's not about changing a number on the scale. So it's an inside out approach, not an outside in approach. It's not me trying to follow the rules in order to change the weight. It's me figuring out how I feel my best. Well, okay, if I eat a third portion of X, Y, Z food and I don't feel good after now I know that that particular behavior doesn't lead to me feeling better and so I can begin to change that specific behavior, not to change my weight. It's not about being good, it's about feeling good and ultimately, that shift to how I want to feel makes all the difference in the world. [DR. CRISTINA] Which I know you promote very well in your program. I know you mentioned it, but I did want to give you an opportunity to maybe talk a little bit more about it before we end because I'm a strong advocate for your program. Obviously, I'm a facilitator for it, but I didn't know if you wanted to just introduce it a little bit for people listening to say, wait, she mentioned something, what is it? [MICHELLE] Yes, great. Thank you for that. So the company is called Am I Hungry, Mindful Eating Programs and Training. The company exists to provide a weight neutral, mindfulness based, non-diet approach to wellbeing. Now I'm purposely using the word wellbeing rather than health and the reason for that is because health has been co-opted or stolen by the diet industry to make everybody think that health and weight are related. We're looking for overall wellbeing. I don't mean related, but directly one causes the other. So in Am I Hungry, what we're really focusing on is teaching people the skills and mindset to lead to lasting behavior changes, literally changing the way they think about food in order to change their relationship with eating and their bodies. We do that a lot of different ways. We train people like yourself, other health and wellness professionals to offer programs in their practices or their communities or their companies. We offer books. I have a book series called Eat What You Love, Love What You Eat. I do support communities and virtual workshops and trainings and we do retreats. So there's all kinds of different ways that we do that and having people like you out there reaching their population is one of the very important ways that we do that. So the website is The homepage is designed to be a taster page, a freebie page. You can download the first chapter of Eat What you Love, Love What You Eat. You can sign up to get a free course. We're just trying to introduce people to the idea that what you've been doing for the last 2, 3, 4 decades of your life hasn't worked not because your weak willed, but because it doesn't work and that there is another way to think about food. [DR. CRISTINA] Fantastic. Yes, no great information on your website. So anyone, we're going to have the show notes with all the links, so thank you for that. I know you have also got, you sent out in a recent email to anyone who was a subscriber great. I guess idiograph for the topic we're talking about today, so we're going to also have a link to that. That's a great gift. Thank you, Michelle, for creating that for anyone listening. Any last --- [MICHELLE] I think that's really helpful. I think it does give people a paradigm, a new paradigm, a new way of thinking about this that will support your own shift in thinking. [DR. CRISTINA] Yes, and I think that is the challenge, is everyone needing to change the way they're thinking about this. It's going to, I think if, it's like you coming out and talking about this, it's getting people to think differently. It's hopefully going to make it from a very slow change to maybe you making it a little bit quicker, so really appreciate you. [MICHELLE] It does, it is the thing that gets momentum as more people are talking about it and questioning it. I think because I'm now in that paradigm, I see it all over the place. I see the changes happening so I'm optimistic that within my lifetime we'll have seen a big shift, but for now, we need to do the best we can to find clinicians who support that or who are willing to listen and learn and we need to advocate for ourselves as well. It's unfortunate, but if you feel that your medical concerns or your symptoms are being disregarded because of your weight or if you don't want to be weighed at an office, you have the right to refuse that, to say I have been diagnosed with an eating disorder and hearing my weight can be very triggering. I really don't want to be weighed today. I'll be happy to talk to the clinician about that and if that's a problem. Or knowing I'm not here for my weight today, I'm here for a sore throat and I really find that being weighed is a distraction and I really don't want to be weighed while I'm here today. [DR. CRISTINA] It's amazing to me how many people don't realize they don't need to get weighed or they get so nervous saying, oh gosh, I don't want to get weighed today. So great point. I think that's very helpful for people to know they don't have to see that number, they don't have to get weighed. [MICHELLE] That's right. I mean, there may be an advantage to being weighed once a year or there are a limited number of medical conditions where a weight is necessary for monitoring low weight, anorexia nervosa might be one of those conditions. There may be congestive heart failure that causes fluid retention where the weight may indicate an individual's fluctuations and might be important but for the rest of us it's not important data and it's being collected because of our weight centric approach to health. It's just one piece of data, it doesn't need to be done every time you go in. [DR. CRISTINA] Thank you again so much. You've given such great information. Anyone out there, please go to the show notes. Look at Michelle's website. She's got such great information on there, again, so inspiring. Really appreciate all the work you've done. That's a lot of reading and hopefully this is just going to spark on some more change as people keep talking. So thank you again. [MICHELLE] Thank you. Thanks for having me, Cristina and thanks for being out there doing the work. That's where that change really happens. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.