Expert by Experience: addressing healthcare inequalities through weight neutral programmes

Nutriri is a social enterprise working to improve access to healthcare, nutrition and movement without focusing on weight. They offer a hybrid (digital and in-person) workforce training and community learning methodology, which includes self-paced courses and working in the community. Rather than tracking weight change, they measure increases in engagement, reductions in disordered eating, and validated improvements in mental, physical and social health. Nutriri’s founder, Helen James, was invited to be an expert witness at the House of Commons inquiry for ‘Body image and its impact on physical and mental health,’ in front of a panel including Jeremy Hunt MP.

At Telescope, we believe it’s vital for policymakers to listen to the voices of frontline workers and those with lived experience of the services they’re legislating for, so we were delighted to talk to Helen about her approach to building a weight neutral service and how this influences the healthcare sector.

Nutriri aims to reduce health inequalities and improve wellbeing, without focusing on weight change as a measure of success. What inspired you to take this approach?

I set up Nutriri as an in-person meet up group after decades of attending weigh-in groups. I wouldn’t like to add up how much money I’ve spent while fluctuating my weight dramatically but never feeling much better around food, my body image and even getting active. I noticed that healthcare systems seemed to focus on BMI, with little regard for the mental health impacts of being constantly in pursuit of a different bodyweight. That lifetime of experience, and we all have a living experience of judgement and diet culture, but that’s what ultimately led me to think I could do this a bit better and I opened the meet-up group and went from there.

What do you think are the biggest drivers of health inequality in the UK?

In my opinion, the biggest driver is income level, and then, from a Nutriri perspective, we think that’s closely followed by barriers to access. One example of a barrier is uninvited weight talk, from within a system that is still relying on that arbitrary BMI data and ignoring that very real impact of weight centred patient interactions.

“I found this stat that the poorest 10% of UK households would need to spend, after their housing costs, 74% of their income on food in order to follow the government’s dietary guidance. And that’s compared to only 6% of income for the wealthiest 10% of UK households. And then if you consider the 80% of households in between, who are in a full-blown cost of living issue right now, it’s really quite stressful.”

And then, when we look at health inequalities, it’s very easy to go to protected characteristics and start looking at what impact that brings. There’s a lot of work around inclusion health groups and that tends to be lower socio-economic groups, Romany gypsy and minority groups. These groups have various needs that are not being met and that results in a lack of engagement with healthcare. If we really focus on that lack of engagement and then bake in that intersectionality with bodyweight, you can have any protected characteristic and have higher weight. That’s why Nutriri rates bodyweight as perhaps one of the most discriminated against unprotected characteristics.

How can we, as individuals, address these inequalities?

If you look at conversations around weight, they often occur in our own minds before our friendship groups, before our family groups, before we even get anywhere near a healthcare system, we self-stigmatise. And that’s the work we do at Nutriri: connect people up and share in community, the impact of inequity; while we’re waiting for a perfect system, we ask, what can we do?

And how could government or other public sector bodies help to address these issues?

“By first acknowledging that they exist. I think what we’re experiencing is that we get lots of nods and reassurance that our work is important, and then in the next breath they’re not integrating the knowledge into policy or change.”

We have to keep repeating ourselves or find that way that we articulate it with individuals. For me, with a long-ago sales background, it’s asking, what are the benefits of adopting working weight neutrally for the individual that we’re speaking to at the time? That might be – if we’re talking to social prescribing link workers, for example – we ask them what they don’t like about what they’re doing around weight. And then we help them find their own solution to that, which is that adoption of weight neutral understanding and actually paying attention to over 20 years’ worth of evidence that’s calling for it. We don’t have to adhere to BMI any longer because there’s new evidence that not adopting a weight neutral practice is actually going to continue to harm people.

You provide training for people on the frontline of healthcare including nutritionists, GPs and other healthcare workers. What are the biggest challenges in terms of changing the way that these services are delivered?

“What we’re experiencing is a frustration with the speed at which change can happen within a system that is undergoing its own structural changes.”

The transition towards integrated care systems that are closely linking the NHS with local government are happening at the same time that we’re expecting them to adopt the changes we’re talking about.

I did the NHS’s QI quality improvement course on large-scale change and was delighted to find they use an emotional learning model, so it’s finding that link to help people buy into it emotionally, as most people are, or know, someone who is experiencing weight talk in healthcare. We’re hoping for a domino effect for large-scale change.

You also work with local commissioners to drive change at a local level. How do these programmes deliver change, both at an individual and community level?

We’re part-workforce training and part-citizen community support platform, which link workers can refer patients to. Our work helps increase participation and patient activation, not only for nutrition and movement activities, but also for mental health providers, diabetes or cardiovascular support. The increase in engagement comes by not making it about weight. If it’s tagged to weight change, we find once that stops, often the beneficial behaviours are also stopped. But if we take weight monitoring out of the equation, the likelihood of any beneficial behaviours persisting and being sustainable goes way up.

If you look at traditional weight management services, their referral to enrolment to completion rate is around about 12%, with about 17% of those achieving a 5% weight loss. Even that tiny weight loss that’s monitored, it’s regained very quickly. But in comparison, Nutriri achieve – albeit on low pilot numbers so far – an 80 to 100% completion rate and satisfaction rate of our services.

What are the biggest barriers you encounter in your day-to-day work with people using your services?

We need to see the wider endorsement for weight neutral from statutory bodies, from the healthcare service. We want to see that so it can rebuild the trust that has eroded over time from a weight centered system. If you take an individual who has perhaps put off attending a GP appointment, or anything connected to their healthcare, for fear of having a ‘change weight’ diagnosis, there are lots of people that just don’t go and engage with doctors and other health professionals because of that. So, if they rebuild that trust, they can see it’s worth engagement in their own healthcare, once they learn that clinicians and practitioners understand weight neutral, that they’re going to then be offered support through social prescribing with their nutrition and getting moving more.

What process did you use when designing programmes that would work effectively for your clients?

I’m really proud of this. I started Nutriri out of my own lived experience and what I wanted to see change, but Nutriri is mostly built and co-created by everybody who has ever interacted with us.

Moving forward, we hope to get proper funding to create good spread and adoption. We’d really love to have a social franchise model that allows someone else to replicate what I’ve done using their own lived experience. If there’s someone who’s had decades of feeling low self-esteem, they can suddenly realise that all of that experience can help them to let go of weight as a marker of our value and health status and train to help themselves and those around them.

What challenges have you experienced in trying to influence policy in this area?

I think there’s that big misunderstanding that weight change for health gain is borne out in the evidence and the data, and that is really baked into healthcare and we’re blinkered to the barriers that it creates. We have to find better questions to help people move from the position that losing weight must be beneficial because we’ve been talking about it forever. But the data’s out there that this is not helping to engage people, so if we focus on access and look back at historical programme performance, then we can start shaming the performance data, because that’s where the stigma needs to be held. We’ve been wasting so much resource on a ‘weight management’. People entrench themselves because it’s in their training. We’ve got metabolic professors and molecular science experts who might think we (weight neutral) are resistant to what they are saying, but we’re not at all. We’re saying ‘so what?’, your metabolic health knowledge is going to waste if no one is accessing what you know. So as long as the system focuses on weight change for health the longer the access barriers are kept in place. 

And can you share an example of a conversation with a policymaker where you felt it went really well?

It was secondary to the inquiry conversation, and whilst the comments received were hard to read, they brought more clarity and urgency for change. When Jeremy Hunt asked what we thought of weight discrimination in healthcare, and I put the video out on TikTok afterwards, the comments on it, there are over 300 comments and they are heart-breaking. After all these years of doing the work, you get jaded, you think how much longer, what can we do to push this through, and then reading the messages and the comments on that video, it’s like, that’s why we’re doing it. It was a reconfirmation that there’s still work to do here.

What changes would you like to see policymakers implement to address health and wellbeing issues in the UK?

Redirect ‘weight management’ spending towards social prescribing for holistic care, for all sizes, that reduces inequalities to improve access. And Nutriri offers a part of the solution, with that part co-created by those who’ve been most affected by a weight-centered system. The individual has shouldered the burden of this for a long time: they’ve self-shamed. We’ve really absorbed the obesity crisis, the burden on the NHS, we’ve absorbed it and agreed with it.

That shame doesn’t belong to us. And we have an opportunity now, assisted by new design in integrated care systems, to change key conversations and re-engage ourselves in health, nutrition and movement without a weight focus.

To find out more about Nutiri’s work, visit their website.