Conventional medical wisdom tells us three things about weight: First, that too many of us are too heavy. Second, that having a higher-than-ideal body mass index (BMI) is dangerous. And third, that slimming down is the solution.
Yet, despite all that we know about nutrition—and the $72 billion Americans spend on weight-loss efforts each year—our collective waistlines are still larger than they were 35 years ago. The way we’ve been fighting our “weight problem” doesn’t seem to be working very well. Some researchers and providers believe that a better alternative is to throw out the focus on size, and emphasize self-care and self-acceptance instead. One thing’s for sure: It’s complicated.
Humans Come in All Shapes
An initiative called Health at Every Size (HAES) is perhaps the most well-known approach to shifting the way we think about weight. One of the underlying principles of HAES and similar movements is that size diversity is normal, and that every person deserves respect. Higher BMIs in the United States are often blamed on a sedentary lifestyle and a diet built on convenience foods, but heavy people were around long before couches and potato chips: Stone Age sculptors created fat female figurines so detailed and realistic that anthropologists have concluded that obesity existed thousands of years ago.
Unfortunately, many fat people, particularly women, face an enormous amount of weight hate on a daily basis. (The word fat is used here as a judgment-free descriptor of body size. Many high-weight people and HAES advocates prefer the term.) According to a 2015 national survey run by the Rudd Center for Food Policy and Obesity at the University of Connecticut, almost 41 percent of participants say they’ve experienced weight stigma. Heck, author and body-image activist Jes Baker was called “landwhale” so often by internet trolls that she made it the title of her second book.
But it’s not just trolls who spread the stigma—women feel it even in comments from their own physicians. “I have patients come to me all the time who feel discouraged and hopeless because of recent interactions with a doctor,” says endocrinologist Jody Dushay, MD, clinical director at the Well Powered Weight Management & Wellness Program at Beth Israel Deaconess Medical Center in Boston.
Perhaps more concerning, some doctors can be unable to see past by a person’s size, chalking symptoms up to weight and skipping tests and effective treatments they would automatically offer a slimmer patient, says Lindo Bacon, PhD, a longtime weight researcher at UC Davis and author of Health at Every Size: The Surprising Truth About Your Weight.
Diets Don’t Work for Everyone
Another key tenet of HAES is that for most people—particularly high-weight individuals and those who have a history of yo-yo dieting or disordered eating—weight-loss plans don’t pay off as promised. We know from research that many who slim down on a diet put the weight back on later. A large review of 29 studies, for example, found that 80 percent of lost pounds were regained within five years.
“Our willpower is no match for our biology,” notes Christy Harrison, MPH, RD, author of Anti-Diet: Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating. Burning more calories than you take in triggers mechanisms in your body that lower metabolism and increase hunger, explains Bacon, which can ultimately increase your weight.
Of course, not everyone who loses a few pounds winds up bigger in the end: The set-point theory is that the body has a built-in comfortable weight variation of between 10 and 20 pounds where antistarvation processes won’t kick in, says Harrison. You probably know someone who has slimmed down a little and stayed that way. It’s a different story for someone who’s being told to lose 5, 10, 20, or even 50 percent of their body weight.
Some doctors who treat obesity have expressed worry that encouraging size-acceptance offers people an excuse to “give up.” But Harrison says that’s one of the biggest misconceptions about HAES. “It’s actually about supporting your overall well being, feeling great, and getting to a place where you can engage with nutrition, exercise, and other self-care behaviors in a way that’s not coming from fear or trying to shrink your body.”
The Health Factor
At the very heart of non-diet philosophies is the belief that a person’s BMI or the number on her scale doesn’t necessarily tell you about her health. This is also the most controversial aspect of these movements.
“You could have a BMI above the ‘obese’ cutoff and have no metabolic complications, eat a healthy diet, and move your body and I would say you are in very good health,” Dr. Dushay points out. That said, reams of research show a correlation between a higher BMI and certain negative health outcomes. “Obesity—in particular fat around the waist and deep within the abdomen around and inside organs—is commonly associated with metabolic diseases such as type 2 diabetes, high blood pressure, high cholesterol or triglyceride levels, and nonalcoholic fatty liver disease,” she says.
But as Harrison notes, those findings don’t prove that weight causes those outcomes. One of the basic principles of scientific investigation is that correlation is not causation. Harrison points to two factors that may impact the correlation between BMI and illness: weight stigma and weight yo-yoing—both of which are extremely common for people with a high BMI.
Research has found that people who experience weight stigma are prone to higher blood pressure and levels of C-reactive protein (an inflammatory marker linked to heart disease); they’re also more likely to avoid the gym and put off doctor appointments. A large 2015 study found that people who experience weight bias may have a shorter life expectancy than those who don’t, regardless of the number on the scale.
Weight yo-yoing has its own list of potential consequences: It’s also been linked to higher blood pressure, as well as chronic inflammation, muscle loss, osteoporosis, and heart disease, independent of BMI.
Many studies have found that dropping pounds is associated with better health outcomes—but claiming causation is tricky here, too, notes Dr. Dushay. Say there is a diabetes study in which a participant starts eating more nutritious foods, loses a little weight, and her blood sugar improves. “Was it the 8 pounds that helped, or was it that she’s eating a higher-quality diet?”
Some research suggests it could be the latter or a combination of both. In 2011, Bacon published a review of randomized, controlled trials of HAES-like health programs, which showed that the non-diet approach to health was associated with more physical activity and improvements in blood pressure, cholesterol, mood, and diet quality.
So where does all this leave us? “Ultimately, the way you approach weight and health in your own life should always be what’s going to work for you,” says Dr. Dushay. Has focusing specifically on weight loss been good for you, and are you physically and emotionally healthier now than ever before? If so, that’s great. But if repeatedly “failing” at weight loss has made you feel bad about yourself—or even develop disordered eating or exercise behaviors—it may be time to try something new, Dr. Dushay says. “I often advise patients to consider focusing less on, or even ignoring, the number on the scale. This switch of focus may be a relief and actually make you more likely to pursue healthy behaviors. Eating a highly nutritious diet and exercising every day are incredibly good for you whether they shrink the size of your body or not. Focus on what you do in these two areas, and you’ll be healthier for it, no matter what your BMI is.”