by Fall Ferguson, JD, MA
Practitioners of and advocates for weight-inclusive approaches, including Health At Every Size® (HAES) models, claim that their approaches are “evidence-based”. Indeed, the evidence base is growing, as documented in the peer-reviewed literature perhaps most comprehensively by Tylka, Annunziato, Burgard, Danielsdottir, Shumna, Davis, & Calogero in 2014 (“The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss”) and by Bacon and Aphramor in 2011 (Weight Science: Evaluating the Evidence for a Paradigm Shift”).
Advocates for weight loss and “obesity” prevention interventions, bariatric surgery, and other weight-based treatments and practices also claim their approaches as “evidence-based.” In a simpler world, one side would be 100% right and the other would be 100% wrong, but the world of evidence-based practice (EBP) doesn’t work that way.
As an individual patient who has suffered harm from weight-based practices, and as an advocate who believes in her cause, I tend to want to focus on the evidence for HAES approaches and to disregard anything else. As a former trial attorney, I know that “truth” is as much about one’s perspective as anything else. As a health professional, my ethical obligations require me to follow the evidence wherever it takes me, even if I don’t like the results. In general, the available research “takes me” to weight-inclusive practices, but it is not always as clear-cut as the advocate inside me would like.
One thing is clear – “evidence-based” is not simple. In fact, it’s a lot more complicated – messier, even – than it sounds.
What is EBP?
What do we mean when we claim to be “evidence-based”? Are we living up to what that concept means? Are the advocates of weight-based approaches? Is my health care provider? How can I know? Is it possible for both sides of the debate over weight science to legitimately claim to be evidence-based? Or, when two points of view diverge so completely, can only one be said to live up to the idea of EBP?
One of biggest misconceptions about EBP is that it is simply about critically examining the scientific literature. In fact, critical examination of the literature is only one facet of EBP. One of the widely cited definitions comes from Sackett et al.’s 1996 article in BMJ entitled “Evidence-Based Medicine: What It Is and What It Isn’t”:
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.
The concept has been broadened to include not just medicine but other health professions as well – thus the broader term, evidence-based practice. It’s common to see EBP represented graphically by a Venn diagram, showing the overlap of three key sources of information: external evidence; patient preferences and values; and clinical expertise.
EBP Takes Place in a Broader Context
Some experts suggest that there is even more to EBP than these three factors – clinicians should take into account the broader context. For example, The Survival Guide for Health Research Methods suggests that scientific evidence, patient values, and clinical wisdom need to be further “filtered” through both an assessment of what resources are available and the various professional, legal, and ethical frameworks applicable to the clinical interaction (pp. 8-9).
This broader context also gives rise to a number of impediments to EBP. Even the best-intentioned clinician must function in a world of limited resources, time, and access. I don’t claim this list as all-inclusive, but here are at least some of the reasons why practitioners may fail to meet an “evidence-based” standard:
- Lack of exposure to the best evidence
- Lack of time to investigate the literature
- Lack of ability to understand biases and errors in the literature
- Lack of time to reflect upon clinical experience and integrate it with scientific literature and patient choice
- Lack of time in the clinical encounter to determine patient values and preferences
- Lack of influence within the clinical setting to change the status quo (for example, less experienced practitioners)
- Lack of understanding of the nuances of EBP
- Financial incentives – for example, bariatric surgeons may be unlikely to give heed to literature that documents the dangers of weight loss surgery
- Influence of billing practices and structures of insurers and 3rd party payers
- Paradigm paralysis – for example, “everyone knows” the “dangers of obesity”
Working with the Idea of EBP
So, having defined some terms, now what? Should we – can we? – attempt to articulate a weight-inclusive EBP? As the HAES movement matures and gains momentum, it seems important for all of us – practitioners, advocates, clients, and patients alike – to understand what it means to say that a health practice is “evidence-based” and to be clear about our claims to that term for the HAES model. How can we get that clarity?
By the way, I am not asking these questions randomly. As Chair of ASDAH’s Public Policy Committee, I am earnestly asking all of you – the HAES community – where you think we should go with this. What would be a useful result? Let’s say we come up with guidelines for EBP – is it one set of guidelines, or are there several, such as (for example) one for higher weight patients/clients, one for patients/clients with eating disorders, one for working with children, and others that I am not even thinking of yet?
What about intersectional issues –should we create a separate set of guidelines on the nuances of working with various populations and how to honor multiple identities and cultures in a weight-inclusive approach, or do we build that into every set of guidelines (assuming we have more than one)?
What else comes up for you when you think about the challenges of EBP? What do practitioners want and need? What do non-practitioners think? Would you bring a set of EBP guidelines to your health care practitioner if there was one?
I hope this is the beginning of an ongoing conversation, and I look forward to the dialogue.
Fall Ferguson, JD, MA is the Program Chair of the Health Education Program at John F. Kennedy University in Pleasant Hill, California. She teaches courses on health policy, community health, health coaching, educational methods, and body acceptance, among other subjects. Fall served as the President of ASDAH from 2012 through 2015, and currently chairs ASDAH’s Public Policy Committee.