When discussing health, you’ll notice a trend between two approaches – weight normative and weight inclusive.

The weight-normative approach includes the many principles and practices that emphasize achieving a “normal” weight when defining health and well-being. This approach rests on the assumption that weight and disease are related in a linear fashion, with disease and weight increasing in tandem. Under the weight-normative approach, personal responsibility to make “healthy lifestyle choices” and maintain “healthy weights” are emphasized.  The approach prioritizes weight as a main determinant of health and as such, weight management (calories in/calories out) as a central component of health improvement and health care recommendations.

Instead of imagining that well-being is only possible at a specific weight, a weight-inclusive approach includes research-informed practices that enhance people’s health regardless of where they fall on the weight spectrum. Under this paradigm, weight is not a focal point of treatment or intervention. Instead the weight-inclusive approach focuses on health behaviors that can be made more accessible to all people. These are behaviors such as exercising for pleasure, eating when hungry and stopping when full.

So is one better than the other? We’ll look at three questions to figure that out:

1. What happens when people believe that everyone should reside within a certain body size / weight range?’
2. What happens when people try to reach that certain body size / weight range?
3. Does higher body weight / larger body size cause poorer health?

What are the effects of the belief that all people should reside in a “healthy” body size / weight range?

Bad things happen – weight bias, weight stigma, microaggressions and more.

The emphasis on achieving a “healthy” weight implies that there is a healthy or normal weight that each of us should be striving to attain and maintain, which gives credibility to cultural messages prizing leanness and weight loss. These socially prescribed ideals can become internalized – and when that happens, it’s connected to body shame, body dissatisfaction, eating disorders, and potentially harmful muscle-enhancing behaviors.

Emphasizing “good weights” and “bad weights” produces the opportunity for weight bias.

Weight bias and weight stigma refer to negative weight-related attitudes and beliefs that manifest as discrimination, stereotypes, rejection and prejudice toward individuals of any size. Common negative stereotypes about higher-weight people include ideas that they are lazy, stupid or worthless – and this results in behaviors targeting them including bullying, harrassment, pressure to lose weight, and weight related microaggressions.

Microaggressions are intentional or unintentional verbal, behavioral, or environmental indignities that communicate hostility or negativity toward people who hold less power in society. For example, a doctor recommending a diet for a patient who presented with an issue unrelated to weight would be a weight-related microaggression.

Complimentary weightism is another type of microagression. Some examples include an anorexic student hearing that she “looks healthy” after disclosing that she has an eating disorder. And really – anyone being told they are “looking good” puts the focus and importance on appearance. The compliment could unknowingly congratulate someone who is using problematic behaviors like vomiting or restricting calories to control their weight.

Another example of complimentary weightism is when thinner people are “hated” for their thinness –  “I hate you because you can eat whatever you want.”

Research shows that weight stigma is associated with increased calorie consumption, a pattern that challenges the common wisdom that pressure to lose weight will motivate overweight individuals to lose weight.

Instead…

When people believe that folks of all sizes and weights can be healthy, it results in less shame, increase trust and rapport, improved outcomes such as pro-health lifestyle changes and improved psychological well-being.

What happens when people attempt to reach a “healthy” or “normal” weight to improve their health?

Bad things – weight cycling, disordered eating and emotional distress.

The literature says that attempts to reach a healthy or normal weight rarely work. Research has repeatedly shown that dieting is not an effective means of weight management. No weight-loss initiatives have generated long-term results for the majority of participants. In fact, there are serious risks of dieting, including weight cycling, disordered eating, and emotional distress.

Weight cycling, or the repeated loss and gain of weight, is an almost inevitable result of dieting. Nutrition and fitness education interventions that focus on weight management are rarely effective long-term, as clients often lose weight and then gain it back.

Weight cycling alone may be enough of a reason not to recommend weight management because it is linked to adverse physical health and psychological well-being, including higher mortality, higher risk of osteoporotic fractures and gallstone attacks, loss of muscle tissue, hypertension, chronic inflammation, and various forms of cancer.

In order to maintain lost weight, formerly overweight dieters may need to consume fewer calories than their same-weight counterparts who were never overweight. During calorie restriction and weight loss, metabolic rate is often lowered, and folks may need to employ more rigid dietary habits or excessive exercise routines that may be deemed disordered.

“The best-known contributor to the development of eating disorders is body dissatisfaction.”- National Eating Disorders Association

Dieters are 12 times more likely to binge eat. A third of  “normal dieters” become pathological dieters, and of those, 1/5 – 1/4 develop eating disorders.

The weight-normative approach promotes the view that weight can be controlled easily through willpower and reduction of poor lifestyle habits. But there is ample scientific evidence that people have little choice about what they weigh due to the interplay between involuntary genetic and environmental factors. Recently, 97 regions of the human genome were identified as playing a role in the development of obesity, including the control of appetite and energy use.

Plus, multiple uncontrollable external factors impact weight. Socioeconomic status influences weight in numerous, complex ways. America’s obesogenic environment leaves many Americans with little access to high quality fruits and vegetables and ample access to addictive, engineered, intensely marketed processed foods.

People who are focused on achieving a “healthy weight” may struggle to reach their weight-based goals, in large part due to the external factors mentioned above. This struggle often results in a sense of learned helplessness. Any adopted healthy behaviors like being more physically active, getting better sleep, or eating more mindfully may be seen as futile if attempts to reach and maintain a specific weight continually fail.

Weight loss promotion and achieving a “healthy weight” may instill a sense of learned helplessness in the majority of people who are unable to achieve weight-based goals. If attempts to reach and maintain a “healthy weight” continually fail or are seen as impossible given available resources, the practice of healthy behaviors may be seen as futile. If I go to the gym for a week or two regularly and see no change in my goal of reaching a desired weight, I will likely learn that nothing I do helps.

Finally, it’s important to remember that when we attribute weight-related stereotypes to each other, it affects the well-being of ALL OF US. It makes even students who are at a normal weight terrified of gaining weight. The negative effects reach across the weight spectrum.

Instead…

The weight-inclusive approach focuses on the PROCESS – being active because it’s fun, and eating when hungry / stopping when full. In doing so, it results in reduction of risk factors (like sedentary lifestyle) and improved physiological measures (like blood pressure or blood glucose) in lieu of pounds or BMI. There are four decades of research proving the positive impact of weight-inclusive interventions. One study looked at folks over a 2 year span and included a “diet group” and a health-at-every-size group. Over the 2 years, 41% of the diet group left the study versus only 8% of the weight inclusive group. In the same study, the researchers offered 6 months of weekly interventions and 6 months of aftercare group support to a diet group and a weigh-inclusive group. The health at every size group members maintained their weight, improved in all outcome variables, and sustained improvements. Diet group participants lost weight and showed initial improvement in many variables but by the end of the study, the lost weight was regained and little improvement was sustained.

Longitudinal studies repeatedly indicate that freedom from weight bias along with body satisfaction correlate with reduced risk for all of the following: unhealthy dieting behaviors, sedentary behaviors, eating disturbances, and weight gain. These findings hold regardless of the participant’s actual weight. 

Does higher body mass index cause poor health?

Nope.

The weight-normative approach rests on the assumption that weight and disease are related in a linear fashion with weight and disease increasing in tandem. The belief is that to be healthy and avoid disease means achieving or being in pursuit of a lower weight if overweight or obese. A weight-normative approach believes that recommending weight loss to these individuals is not a function of weight bias but of health imperative.

But data does not support that a higher BMI causes poor health. A higher BMI is associated with various diseases, but causality is not well-established. Interestingly enough, when accounting for socioeconomic status, nutrition, physical activity levels, and weight bias, even the correlation between a higher BMI and disease is vastly reduced or disappears. The risk for all-cause mortality is lowest for people in the overweight category and highest in the underweight BMI range.

In 2013, Flegal’s very well-known and very-debated meta-analysis showed that the risk for all-cause mortality is lowest for people in the overweight category with the highest risk in the underweight BMI range. The U-shaped curve is a well-known image used to describe the obesity paradox.

Instead… Students can be fat and fit. A 2011 study found that metabolically healthy obese individuals had a lower risk of heart failure than normal-weight people who were insulin resistant. And what does “metabolically healthy” mean? Certain characteristics exist in people who were both obese and metabolically healthy: normal BP, cholesterol, and blood sugar levels, normal insulin sensitivity and good physical fitness.

Many studies show that obesity and healthy are not mutually exclusive. And culture is starting to agree. Joni Edelman, a registered nurse and writer, recently blogged about her own experience of losing weight and truly becoming obsessed with the calorie counting and incessant exercise necessary for her to achieve a BMI in the normal/healthy range. She is an example of someone who feels healthier and happier at a higher weight.

“There is a cultural belief that people have to be dissatisfied with their weight (or any aspect of their appearance) to be motivated to improve it. This belief has not found general support in the literature; in fact, the reverse is supported:  people are more likely to take care of their bodies when they appreciate and hold positive feelings toward their bodies.” Tylka et al, 2014

What should we do?

Emphasize self-compassion

Help your loved ones shift away from habitual appearance monitoring, which is associated with lower self-care and ignoring physical health, to attending to their bodies in more positive ways that emphasize self-care. People are more likely to take care of their bodies when they appreciate and hold positive feelings toward their bodies.

Remind your friends that you’re perfect just the way you are! That unconditional positive regard goes a long way in helping people feel supported and confident in their ability to make changes when THEY are ready.

Reframe body blame and shame as internalized weight bias that has little to with someone’s actual weight or size.

“What does your body provide your life that you enjoy?”

“Be gentle with yourself! You’re amazing!”

“I love you just the way you are. No matter what.”

Appreciate all bodies – don’t compliment them, just appreciate them.

Placing a focus on appearances is problematic. Avoid: “You look great!” “Have you lost weight?” “I can tell you’ve been working out!” “You look really strong!” Again – you don’t know what behaviors your comment is supporting. And on the flip side, negative comments just make people feel bad about themselves.

Some alternatives? If you can’t stop talking about how people look – focus on how they did their hair that day or compliment their shoes. But even better? Tell them what you’re feeling – or ask about their self-care.

Instead:

“I’m really glad I ran into you.”

“What’s new with you?”

“I could use some new ideas. What do you do to take care of yourself?” and then, “how does it make you feel? Has it impacted your sleep?”

Focus on behaviors

Instead of encouraging a friend to work out more or eat differently, do it with them and make it fun and easy!

“Do you want to go for a run with me?”

“Wouldn’t it be fun to bike to the quarry and go swimming this weekend?”

“Can I make you dinner?”

“Let’s go to bed early tonight so we can play outside all day tomorrow!”

Make it sustainable

Sustainable change means that the behavior is supported, easy, and fun. One easy way to incorporate more physical activity is to move as a part of other activities. If you’re running errands, actually run them (or walk, or bike). If you have to drive, park a few blocks away so you get to move a bit more. Try to eat intuitively and encourage your friends to do the same.

“What if you and I walked to dinner instead of taking the bus?”

“Will you be my lunch buddy?”

“Hey, I got you this water bottle! I’ve noticed how much more water I drink when I carry it with me and fill it up at each water fountain I go by. I feel so much better when I’m hydrated!”

“How can I help you reach your health goals?”

Encourage quality of life as an end goal

Avoid focusing on how exercise makes bodies look, or exercise as a way to “make up for” food choices. And avoid focusing on calorie counting. Help your loved ones reconnect with their bodies –  focus on internal body awareness rather than engage in external appearance monitoring. Consider how healthy behaviors make you and your friends feel.

“It feels so good to be outside, doesn’t it?”

“Endorphins are amazing!”

“I love how good I feel after eating a meal like that.”

“Whoa, I’m full. I love this yummy food but I know if I eat more I’m going to be uncomfortable. Let’s save some leftovers to eat for lunch tomorrow.”

Critically evaluate the evidence for weight loss treatments and communicate them

Reading this blog is a good start. Question what you see and hear about health. You’re going to see body-focused health messages everywhere! Start talking about them and actively work to change the culture.

“Did you see that article about achieving a “spring break body”? What a crock! All bodies are beach bodies! And it’s not possible to do something that is healthy and sustainable but changes someone’s body over the next two weeks. I wrote a letter to the editor to ask them not to publish misleading and body-shaming articles like that anymore.”

Work to increase access, autonomy and justice for individuals of all sizes

There are several body-positive groups at UNC and lots of simple steps you can take to advocate for more weight-inclusive practices on campus.

“I’m taking the Embody: Carolina training next month. Want to do it with me?”

“I noticed that my department’s offices don’t have chairs that would fit people of all sizes, so I asked the office manager to add a wider chair to the room. The next time I went in, there was a new, larger chair!”

Trust that people move toward greater health when given access to stigma-free health opportunities

UNC is a great place for this. Campus Rec, Campus Health, and Student Wellness staff have all been trained on body-positive principles. And our community offers so many ways to stay healthy!

Want to learn more?

• Health At Every Size (HAES)
• Wellness, Not Weight: Health at Every Size and Motivational Interviewing
• Intuitive Eating
• UConn Rudd Center

What do you think about this article? What ideas do you have to support health at every size on campus?

Sara Stahlman, MA, is a marketing and communication coordinator at the Campus Health Services at the University of North Carolina at Chapel Hill. She is also a member of the ACHA Healthy Campus Coalition and the ACHA Health Promotion Section.

Toni Hartley, MPH, RD, LDN, is a clinical nutritionist with Lutz, Alexander Nutrition Therapy. Antonia specializes in medical nutrition therapy for people with disordered eating patterns. She promotes Health At Every Size® principles both in her office and in her speaking engagements and practices a non-diet approach.

References

Bacon, L., Stern, J. S., Van Loan, M. D., & Keim, N. L. (2005). Size acceptance and intuitive eating improve health for obese, female, female chronic dieters. Journal of the American Dietetic Association, 105(6), 929-936, L., Stern, J. S., Van Loan, M. D., & Keim, N. L. (2005).

Bacon, L. (2010). Health at every size: The surprise truth about your weight. Dallas, TX: BenBella.Health at every size: The surprising truth about your weight. Dallas, TX: BenBella.

Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of allcause mortality with overweight and obesity using standard body mass index categories: a systemic review and meta-analysis. Journal of American Medical Association, 309(1), 71-82.

Leibel, R. L., & Hirsch, J. (1984). Diminished energy requirements in reduced-obese patients. Metabolism: Clinical and Experiential, 33(2), 164-170.

Locke, A. E. et al. (2015). Genetic studies of body mass index yield new insights for obesity biology. Nature, 518(7538) 197-206.

Mann T., Tomiyama J., Westling E., et al. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychology, 62, 220-233.

Neumark-Sztainer, D. (2005). Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents? International Journal of Eating Disorders, 38(3), 220-227.

Puhl, R. M., & Brownell, K. D. (2006). Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity, 14(10), 1802-1815.

Schvey, N. A., Puhl, R. M., & Brownell, K. D. (2011). The impact of weight stigma on caloric consumption. Obesity, 19(10), 1957-1962. impact of weight stigma on caloric consumption. Obesity, 19(10), 1957-1962.

Shisslak, C. M., Crago, M., & Estes, L. S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18(3), 209-219. 

Tylka, T. L., Annunziato, R.W., Burgard, D., Danielsdottir, S., Shuman, E., Davis, C., & Calogero, R.M. (2014). The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight-loss. Journal of Obesity, 2014(2014), 18 pages.