If you have ever been on a diet, you know the pure vulnerability of getting weighed at the doctor’s office. Standing on an old metal scale with your shoes off, you might avert your eyes, as if that would prevent the nurse from saying the number out loud as they write it down. But what if weight did not play such an active role in how you understood your health?
Some of the research presented in this show challenges a lot of what many folks have been told about health and their bodies...possibly even what they have heard from their medical provider. Linked at the end of this page are studies referenced in the show. This conversation is not a substitute for personal medical advice.
In this edition of our ongoing series Embodied: Sex Relationships and Your Health, we deconstruct diet culture by examining the holes in the science which props it up. The medical field has puzzled over the “obesity epidemic” for years with little progress. According to a growing field of doctors and health practitioners, weight is not the end-all-be-all indicator of health. Data shows that a higher body weight is correlated with diseases like osteoarthritis, cardiovascular disease and Type 2 diabetes, but correlation does not imply causation.
History of Diet Culture
Christy Harrison is an anti-diet registered dietitian, nutritionist and certified intuitive eating counselor. After spending much of her life engaged in disordered eating, she found her way out of diet culture. She calls it “The Life Thief” and defines it as a system of beliefs that worships thinness and equates it to health and moral virtue; promotes weight loss as a means of attaining higher moral and health status; demonizes certain foods and food groups and ways of eating while elevating others; and oppresses people who don't match up with its supposed picture of health and well-being.
In her forthcoming book, “Anti-Diet: Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating” (Little, Brown Spark/2019), she traces diet culture’s history as far back as ancient Greece and outlines society’s moralistic arguments against fatness.
“This was because of the belief system that ancient Greeks had about balance and moderation and all things being seen as a virtue,” she says. “So fatness was seen as an imbalance to be "corrected.”
Though that perspective fell out of vogue for centuries after the fall of Rome, it began to reemerge in the mid-19th century, still long before the medical world propagated put a large focus on weight as a central metric of health.
“Ideas about the value of different bodies and of different people was really in the foreground, and that started to lead to a demonization of fatness,” she says. “Early evolutionary biologists who are working around [the turn of the 19th century] started to point to fatness as a mark of "evolutionary inferiority" because people who had more fat on their bodies were supposedly women and people of color and groups that were being demonized at the time.”
Harrison says the societal association of fatness with disenfranchised groups like women and people of color attributed to the convergence of weight stigma and medicine. As patients increasingly demanded to be weighed by their doctors and be put on diets, medical professionals bent to their demands. She also points to the emerging life insurance industry as a factor in medicalizing weight stigma.
“The life insurance industry, of course, is geared towards making money and making sure that they're having people in their insurance pool who are going to live the longest. And so they're doing this research to determine who's a bigger risk. And they found from their early research in wealthy, white middle-aged men that it seemed to be the larger-bodied men were dying sooner. And so they started to relay this information to doctors. They started to kind of coalesce behind a campaign of telling people not to be fat and having people lose weight as a way of supposedly reducing health risks. The risks are really — it was about reducing monetary risks from the insurance industry.”
The ‘Obesity Epidemic’
The research these early insurance companies conducted relied on measuring body mass index, or BMI. The scale categorizes people as underweight, normal or healthy weight, overweight or obese. BMI is a person’s weight in kilograms divided by the square of height in meters. It was developed in the 1830s by an astronomer as a statistical exercise.
Dr. Louise Metz says it is a problematic way to categorize health. She is a board-certified internal medicine physician specializing in eating disorders and gender-related care. She founded Mosaic Comprehensive Care in Chapel Hill, and it is a weight-inclusive health center.
“[BMI] was designed for populations, not for individuals, and was not designed to define health in any way. And then moving on later to the modern age, it was used to begin to define health somewhere in the 1900s,” Metz says. “And then later on in the late '90s, what we found is that these arbitrary categories for BMI were suddenly changed. So the definitions of obesity and overweight were suddenly decreased, and 29 million people suddenly became "overweight or obese" overnight. And these changes really were not based in any research that shows that there was a direct link between these BMI categories and health.”
The measure is still used today to track changing body weight at a national level. Medical professionals and insurance companies use BMI as a measure of a person’s health. Harrison says this contributed to the declaration of an “obesity epidemic.”
“Many other researchers who are in the field of so-called obesity research are financed and funded by the pharmaceutical industry, [and] the pharmaceutical industry [is funded] by the diet industry,” Harrison says. “Many of them have their own diet plans and programs that they are selling and have this financing that's coming from people with a vested interest in making Americans fear weight gain and think that their body size is a problem.”
Weight and Health: Correlation vs. Causation
Still, the CDC links higher body weight to a range of health consequences like high blood pressure, Type 2 diabetes, coronary artery disease and osteoarthritis. There is ample evidence that weight is correlated with these health ouctomes, but Harrison and Metz caution against implicating weight alone.
“We don't have proof that it's the body size causing these health conditions. So there are several other mediators of that. One could be cardiovascular fitness. We have some data to show that that could be a mediator between body size and health,” Metz says. “There's one study that looked at this and found that in people who have low cardiovascular fitness levels, mortality rates were higher with higher BMIs. But [in] individuals who had higher cardiovascular fitness, we found that the mortality rates evened out across body size, and that in fact, people who are "overweight or obese" and were active cardiovascularly had lower mortality rates in those with a normal BMI who were inactive.”
For Type 2 diabetes, a disease widely believed to be preventable by avoiding weight gain, Metz says medical professionals are asking the wrong questions.
“There are assumptions behind those questions. It is likely not the body size that is causing diabetes, but there may be other mediators like genetics. So someone might be predisposed to have a higher body weight and have diabetes. And someone might be exposed to chronic dieting and weight cycling … As well as weight stigma [that] are increasing the risk of conditions like diabetes.
Why Diets Don’t Work
Harrison, Metz and any promoter of the Health At Every Size (HAES) movement will tell you that diets do not work. They are not designed to result in long-term weight loss, but instead trap people in cycles of weight fluctuation. This process is called weight-cycling, and there is evidence that it adversely affects health.
“Weight-cycling is this repeated cycle of weight loss and regain that people undergo when they try to intentionally lose weight,” Harrison says. “And we see in the research that up to 98% of the time when people embark on weight loss efforts, they end up regaining all the weight they lost within five years, if not more. In fact, up to two thirds of people who embark on weight loss efforts may regain more weight than they lost.”
People in larger bodies get started on weight-cycling sometimes as early as childhood. A lifetime of dieting, HAES practitioners argue, contributes to poor health. Our bodies are not designed to diet, and Harrison has an explanation as to why the vast majority of people gain back the weight they lost and sometimes more.
“Our bodies are wired to resist starvation. And they have all kinds of biological mechanisms that kick in in a situation of lack of food, because the body perceives that as famine,” she explains. “And so it will do things like turn down your fullness hormones so that you keep eating longer in the presence of food, ramp up your hunger hormones so that you're more likely to seek out food, turn down your body temperature so that you're not burning as much energy, reduce your reproductive function because that requires energy.”
To counteract this, Metz never recommends intentional weight loss to her patients. From the HAES perspective, it is more important to focus on things like metabolic levels and other vital signs. As part of the weight-inclusive model at Mosaic, patients are not routinely weighed. If deemed necessary, like in adolescent growth or prescribing weight-determined medication, practitioners will privately weigh the patient and turn the face of the scale away if the patient does not wish to know their weight.
Weight change could be a symptom, and Metz acknowledges its importance when patients bring it to her attention. But overall, she references HAES research in justifying the mostly weight-neutral approach at her practice.
“[The] study looked at women who were "overweight or obese" and assigned them either to a diet routine/diet plan or a non-diet Health at Every Size approach. And what they found in these two groups [is] that initially, at the six-month follow-up that they did see improvements in blood pressure, high cholesterol and an increase in engaging in exercise behaviors among both groups,” she says. “And they saw that weight went down in a diet group. But then if you followed them out to two years, we found that the folks in the diet group actually had all of those numbers revert back to their baseline, and they had no sustained health benefits from engaging in the diet. But in the non-diet group, we found that at two years, they had sustained improved health outcomes across the board, but no change in their weight.”
Navigating Diet Culture as a Fat Athlete
Not everyone has access to a HAES practitioner. For people in larger bodies, the weight stigma baked into the medical field can prevent doctors from seeing past their size and addressing underlying issues.
Mirna Valerio has experienced that firsthand. She is a former teacher-turned-sponsored athlete who runs marathons and ultramarathons. She gained some celebrity in the running community as a large black woman and avid trail runner. Even though she has been running regularly for more than a decade, some people still question her validity as an athlete. Her book “A Beautiful Work In Progress” (Grand Harbor Press/2017) traces her rise as an avid marathon and ultramarathon runner.
“Please do not ask me to exercise or to lose weight,” she writes on her doctors intake forms. “I'm a very, very active person. I run marathons, and I work out four to six days a week. I know I'm overweight and I've been working at slow and permanent weight loss for the past five years. Please actually read my chart before you start talking about these things. I would highly appreciate it.”
It works for her now, she says. Prefacing her appointments with that note will get most doctors to address her health concerns beyond weight. Still, people on the street question her health.
“I'm fat. You don't need to tell me. You don't need to tell me with your body language. You don't need to tell me explicitly or implicitly. I already know that. So it doesn't help me to keep pointing that out, whether I'm out on the trail, whether I'm out on the road, whether I'm just trying to sit and be me and exist in this world as I am.”
She has not weighed herself in years, but her body size has stayed about the same since she started running seriously.
Metz says everyone can take this HAES approach to their own doctors, like Valerio did.
“If you're going to your doctor, one thing is that you do not have to be weighed. It is your right to decline to be weighed,” she says. “And another helpful quote that we learned from Raegan Chastain — she will say that if the doctor is recommending weight loss for a condition that you have, and you don't think it's appropriate, you can ask: Well, what would you recommend for someone in a smaller body? What testing or treatment would you recommend for someone who's thin?”
On this edition of our recurring series Embodied: Sex, Relationships and Your Health, host Anita Rao talks with Harrison, Metz and Valerio about diet culture and the stigma larger-bodied people face from the examining room to the running trail.
Continued scholarly reading: