What are the issues?

Public Health’s focus on “obesity” prevention has increased exponentially within the last few decades, and with it an increase in weight stigma and negative attitudes towards people in larger bodies. In the past decade, weight discrimination has increased by 66%, and is one of the only forms of discrimination actively condoned by society. Decades of research have shown that experiencing weight stigma increases one’s risk for diabetes, heart disease, discrimination, bullying, eating disorders, sedentariness, lifelong discomfort in one’s body, and even early death.

Additionally, “obesity” related public health approaches can be harmful because they are based on limited or poor quality evidence, they focus on preventing one outcome at the expense of another outcome, they lack community engagement and they ignore the root cause of problems. However, the public health field has not taken a critical look at this research, focusing on the narrative that weight is controllable and a personal responsibility. If the goal is to find the most ethical and effective strategies to achieve optimal public health, there needs to be an alternative to “obesity” and weight focused approaches and a shift in understanding of weight stigma as a social justice issue.

11 reasons why we should not use weight-based approaches to health

1.  The focus on body size is rooted in racism.

Around 81% of societies historically have favored people in larger bodies. Larger bodies signified wealth and prosperity while thinness signified poverty and weakness. However, this began to change due to racism and eugenics. Charles Darwin and other race scientists created a hierarchy of civilization, placing white men on top and people of color, specifically black people, at the bottom, considering them to be “less civilized.” Fatness and differing body characteristics were used to justify lack of civilization- fatness used as a marker of “uncivilized behavior” while thinness was “more evolved”. This idea was maintained throughout the United States in the 19th and 20th centuries, as a way to justify slavery, racism and classism, and control women through “temperance”. This ideology has perpetuated Desirability Politics- where thinness and whiteness are given more access to social, political and cultural capital.

2.  The BMI is flawed (and you can’t tell someone’s health by their body size).

The BMI was developed by Adolph Quetelet in the 1830’s, with the goal of finding the “perfect human.”  Quetelet was not in the medical field and did not intend for the BMI to be used for medical purposes. His sample population only included white French and Scottish men, thus, the BMI is not representative of the entire human population. It rose in popularity in the early 20th century when it was discovered by life insurance companies, who used it to set insurance premiums for their clients. The company found a relationship between weight and mortality, though the sample included only insurance company clients who self-reported their heights and weights. Nevertheless, it set off an interest in the use of the BMI as a tool to assess health. The BMI was determined to be the  best tool to assess health not for its accuracy, but for its ease of use in medicine and research. The BMI does not consider health behaviors (e.g. stress, nutrition, physical activity) or body composition (e.g. bone, muscle, and fat mass). Therefore, it does not give an accurate picture of health.

3.  Focusing on weight underdiagnoses thin people and misdiagnoses larger people.

A study of 40,420 U.S. adults using National Health and Nutrition Examination Survey (NHANES) data from 2005-2012 looked at health stratified by BMI and found: Nearly half of overweight individuals, 29% of obese individuals and 16% of obesity type 2/3 individuals were “metabolically” healthy

Over 30% of normal weight individuals were “metabolically unhealthy.”

If extrapolated to the US population, an estimated 74,936,678 US adults are misclassified as unhealthy or healthy if based on BMI alone. Another analysis of NHANES data showed that those in the overweight BMI category actually have the greatest longevity out of any BMI group, again contradicting the idea that BMI directly indicates health status.

When the medical system uses BMI as a health indicator, it can lead to misdiagnosis for people in larger bodies- with the risk of real medical concerns being overlooked as the focus is placed on weight or weight loss. Similarly, people in thinner bodies are often underdiagnosed due to an assumption of good health.

4.  Evidence shows that diets don’t work and weight loss research is problematic.

Short term weight loss studies indicate that participants lose ~5-10% of their baseline weight. However, long term studies indicate that regardless of initial weight loss, most people regain that weight after 2 years, with up to 2/3 of dieters likely to regain more weight than they lost on their diets. Intentional weight loss has a 90% failure rate (5). If it were any other drug, it would never be considered for use.

In addition, much of the weight loss data is flawed with many studies featuring: High attrition rates (up to 70%) that often are not reported. Much of the obesity research in the U.S. is funded by weight loss and drug companies, such as Weight Watchers and Abbot Laboratories- thus influencing the types of studies that are funded and published.

Multiple interventions (e.g., diet, exercise, smoking cessation) or rigorous (not realistic) interventions Short study length (many studies only last ~6 months)

5. Food restriction is harmful.

Food restriction (via intentional weight loss) has detrimental effects on our physiology. Our bodies, designed to keep us alive at any cost, do not understand the societal importance of dieting. Rather, our bodies interpret food restriction as starvation, and adapt resiliently to keep us from losing important stores. When we restrict food, we weaken our body’s natural hunger and fullness cues, making us more susceptible to outside food cues. In addition, our body’s hormones change in attempt to reduce weight loss, producing more hormones that make us feel hungry and increase our cravings for carbohydrate foods, and less hormones that make us feel full.

Ancel Keys’ Minnesota Starvation Experiment found that men who spent 3 months on a semi-starvation diet (1700 kcal/day) had (15): significant decreases in strength/stamina, body temp, heart rate, sex drive and mental ability, increases in fatigue, irritability, depression and apathy, obsession with food (dreaming/fantasizing about food, reading and talking about food nonstop)

6.  Weight cycling is bad for our health.

People who are dieting often experience weight cycling: the repeated loss and regain of weight.  Weight cycling is associated with increased all-cause mortality, mortality from cardiovascular disease, risk for heart attack, stroke, diabetes, high blood pressure, and suppressed immune function.

Weight cycling is more commonly seen in people in larger bodies, due to the societal expectations that they lose weight or be “working on their health.”  Despite weight cycling’s detrimental effects on health, it is often not considered as a confounding factor in research that investigates the relationship between body size and health. Therefore, it is hard to say for certain whether worse health outcomes in larger-bodied people are due to weight itself, or due to confounders such as weight cycling.

7.  Rates of eating disorders/disordered eating are increasing (and it’s becoming normalized).

Dieting is a strong risk factor for disordered eating and eating disorders. Disordered eating differs from an eating disorder in that it does not have a diagnosis. However, both disordered eating and eating disorders can have profound negative effects on mental and physical health.

Disordered eating is defined by characteristics such as:

• • Frequent dieting, including fasting, chronic restrained eating, restricting major food groups, bingeing, and/or using vomiting and laxatives Anxiety associated with specific foods or feelings of guilt and shame associated with eating
  • Chronic weight fluctuations
  • Rigid rituals and routines surrounding food and exercise
  • Preoccupation with food, weight and body image that negatively impacts quality of life A feeling of loss of control around food, including compulsive eating habits
  • Using exercise, food restriction, fasting or purging to “make up for bad foods” consumed
  • 68% of Americans have dieted in some form. 65% of American women ages 25-45 have disordered eating, and 10% have a diagnosed eating disorder.

U.S. children are 242 times more likely to have an eating disorder than Type 2 Diabetes, and by age 9, 50% of girls have considered restricting food.

People of color experience eating disorders such as bulimia and binge eating disorder at higher rates than their white counterparts, often as a mediating factor from experiencing racism or other acculturative stressors. However, they are more likely to be underdiagnosed, which can occur due to misconceptions about who gets eating disorders. LGBTQ+ individuals also have higher rates compared to cisgender, heterosexual individuals, most likely as a way to mediate stressors.

8.  Weight stigma is harmful to health ( and not controlled for in research).

Experiencing weight stigma not only increases one’s risk for negative health outcomes, it also leads to health care avoidance by people in  larger  bodies,  increasing  the  chances  that  they  do  not  receive  preventative  care  services  ( e. g.  cancer screenings).

In children, weight-based bullying is one of the most frequent types of bullying experienced in school. Often,  this type of teasing is a stressor children will face for years,  throughout their childhood and into adulthood.  Experiencing weight-based bullying often leads to coping though avoidance of physical activity and increased emotional or binge eating.

9. When we focus on weight, we’re not being trauma-informed.

Rates of eating disorders are often higher in people who have experienced trauma or Post Traumatic Stress Disorder (PTSD). People who have experienced trauma may use food as a safe and secure coping mechanism,  both to distance themselves from unsettling thoughts or to reduce their attractiveness as defined within a society that equates thinness with beauty.

Assessing the relationship between eating and trauma is essential.

10. Higher weight is not causal to worse health outcomes.

Overall,  there is a  correlation between higher  BMI and worse health outcomes, yet this does not imply causation. Research studies exploring this relationship should be assessed not only for quality in terms of study length and  attrition length,  but also whether they evaluate confounders including weight cycling,  weight stigma, and trauma,  factors often experienced by folks in larger bodies and which can have considerable impacts on health outcomes.

11. Focusing on weight ignores systemic injustices.

Though lifestyle factors such as nutrition and exercise are important,  it is essential to note the historical racism and injustices within our current food environment. As presented by Soul Fire Farm, the U. S. food system is built on stolen land using stolen labor from black and latinx indigenous people. Not only has this created a large-scale food apartheid and trauma for people  indigenous  to  this  land, but it has also caused a disconnection of indigenous people from their cultural practices and identities

Appreciate that bodies come in all different shapes and sizes, and that fat people can be just as healthy as thin people. Remember, you cannot tell someone’s health on the inside by looking at their size on the outside. It is the responsibility of those in public health to create environments for every person to thrive in whatever body they live in.

Use a Health At Every Size (HAES) approach.

When we call for weight loss, we shift blame onto individuals and make health and weight a “personal responsibility,” when often they are the result of uncontrollable genetic or environmental factors. The HAES approach rests on the evidence that while extremes of weight and health problems are correlated, evidence for the role of factors other than weight in people’s health is stronger.

• Focus on root causes of health and social determinants of health, to develop long-term, sustainable solutions to improved population health.
• Where possible, work to increase health access, autonomy, and social justice for all individuals along the entire weight spectrum. Trust that people move toward greater health when given access to stigma-free health care and opportunities (e.g., gyms with equipment for people of all sizes; medical facilities that do not weigh patients).
• Weight is not a behavior. Focus on behaviors that impact health, such as eating, movement, stress management, sleep, smoking cessation, etc.
• Don’t moralize foods (e.g., “You need to stop eating X”). Instead, promote eating for pleasure, hunger, satiety and nutrition, not weight. Evidence shows that people who eat more intuitively eat more nutritious foods and keep their weight more stable over time.
• Promote mindful movement focused on what brings people joy and connection, not weight loss. A meta-analysis of 16 studies found that regardless of BMI, mortality indicators improved with exercise, indicating that movement can be healthy without a goal of losing weight.
• Critically evaluate the evidence for weight loss treatments and incorporate sustainable, empirically supported practices into prevention and treatment efforts. Call for more research where the evidence is weak or absent.
• Have discussions about fatphobia and weight stigma in your classroom and in your research. Engage students and researchers in critical thought about how to best measure health, without using weight as a marker, and how using weight as a marker of health can be harmful.