Reprinted with permission from the British Medical Journal February 21, 2008
Debate About Fatness Increases
Debating whether the health risks of obesity are exaggerated seriously detracts from the real question: what should we prescribe for our health in any case? Weight loss or management is constantly recommended—disregarding the fact that weight is not a behavior, and as such it is not ours to select or “control.” Weight results from a multitude of factors, some of which are in our power to choose—how we eat, how active or sedentary we are—but many of which are internally regulated, and thus are not. A host of studies have now eliminated the age old mystery about why some sedentary folks can eat like horses and remain lean while their neighbors consume moderately, train for triathlons, and stay fat. If we limit ourselves to healthy means, the best anyone can hope for is to influence weight, not control it.
Genetic predisposition aside, it turns out that the most common advice for reducing fatness has made things worse. Research published over sixty years ago demonstrated how and why even a moderately restrictive diet is counterproductive for long term weight loss. New studies bear this out: weight can be lost on virtually any contrived plan to restrict calories or food groups, but between 85% and 95% of this weight is predictably regained, with over half of all dieters gaining more weight than they lost. If you doubt this, check the National Institute of Health for the data; then check your own observations: how many people do you know who have gone on a diet once? If dieting was effective why would it be a perennial activity, and why would most dieters be fatter today than before their first weight loss effort?
Aside from weight loss, what other unpleasant recommendation with a roughly 90% failure rate would still be prescribed? Even so too many health authorities persist in the belief that if we can make people feel bad or afraid enough about their weight they will “do something” about it. This flies in the face of a growing body of studies that document what many of us working in the trenches to reverse disordered eating have known for years: body dissatisfaction does not serve as a motivator for healthy behaviors. To the contrary, unhappiness about weight is a catalyst for disordered eating, poorer overall health, and weight gain. Worry about weight is a self-fulfilling prophesy. In light of this, how can we persevere like Sisyphus in unrelenting talk about the risks of fatness and the need for weight loss as if this will make people repent? In four decades the thinner we have tried to be the fatter we have become. But if weight stigma, fear of visible fatness, and efforts to lose pounds contribute to the problem, what is the solution?
The way out of this spiraling and dangerous problem requires the courage to ask the right question: fat or thin, what should we be doing for our health in any case? Few will dispute the evidence showing that fatter people who are well fed and fit are at lower risk for health problems than thin people who eat poorly and are sedentary. In light of this, what if instead of fear and loathing of fatness, public health initiatives pushed the value of as well as ways and means for wholesome eating and fitness for everyone—irrelevant of size? If instead of size or a BMI a sustainable, healthy lifestyle were the goal, then some people would remain fat, some would be thin, but virtually everyone would be healthier. Isn’t this the point?
It is troubling that so few leaders in health care cannot see the forest for the trees: that shifting the focus to how we live rather than what we weigh is an effective solution that empowers all people of every size and shape to be the best they can be. Who could argue that a fit and well-fed populous of diverse sized people would not be preferable to the status quo? Campaigns to support the development of healthy, realistic body images, wholesome, stable eating, and lifetime fitness habits regardless of shape, size, or weight could eliminate much of our population’s “weight problem.”
Competing interests: None declared
"The doctor of the future will give no medication, but will interest his patients in the care of the human body."
—Thomas A Edison
“Some people believe that stigma is helpful in motivating weight loss - that making it uncomfortable or undesirable to be overweight will somehow help people lose weight. But a large and growing body of research disputes this. Studies show that youth routinely cope with feeling bad about their weight by trying to lose weight in harmful ways (fasting, diet pills, vomiting, and chronic dieting) leading to binge eating and avoidance of physical activity - all unhealthy behaviors that can actually impede weight loss and reinforce weight gain… Confronting stigma, bullying and weight bias needs to go hand-in-hand with efforts to reduce the prevalence of obesity nationwide.”
–Nan Feyler, reporting for the Philadelphia Media Network, September 25, 2012, regarding the call from Yale’s Rudd Center for Food Policy and Obesity for weight-stigma reduction programs.