Supporting Healthy Bodies at UNC: Navigating Obesity, Eating Disorders, and Weight Bias

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

aha-screengrab
Screenshot from American Heart Association, 1/25/2015

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.

weightinclusive
Photo Credit: Prevention Magazine

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?

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Photo credit: Words over Pixels

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.

weightstigma
An image from Georgia’s problematic anti-obesity campaign, Stop Sugar-Coating It

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.

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Photo Credit: More Bad News About Weight Stigma in Health Professionals

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.”

complimentary-weightism
Photo Credit: Some eCards

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…

love-your-body
Photo credit: I Stand Against Weight Bullying

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.

weightcyclingWeight 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.

disordered-eating
Photo Credit: Unite Virginia

“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.

obseigenic
Photo Credit: American Nutrition Association

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.

learned-helplessness
Photo credit: I Stand Against Weight Bullying Tumblr

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…

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Photo credit: I Stand Against Weight Bullying Tumblr

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. correlationA 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.

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Flegal’s U-shaped Curve

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… fat-and-fitStudents 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.

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“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?

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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?

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.

How You Can Have a Healthier Relationship…with Food!

A healthy relationship… with food?

You’ve probably heard of a “healthy relationship” with family, with friends, or with a partner, but we talk less often about our relationships with food in terms of their health — beyond simply what we consume and when. A relationship with food is psychological, financial, social, and cultural as well as physical. Like any other healthy relationship, a healthy relationship with food is free of fear or the feeling of being controlled or out of control.

What impacts our relationship with food?

Our relationships with food are impacted by our life experiences and the systems around us. For example, the fad diet industry often uses body-shaming tactics and capitalizes on our desire to be “good” or “healthy” people in its mission to sell more products. These techniques often also promote the idea that some foods are inherently “good” and others are inherently “bad.” You’ve probably heard a friend say, “I’ve been so bad today — I ate (fill in the blank).”

However, there are no “good” or “bad” foods — and furthermore, what we consume can’t make us “good” or “bad” people! Just like eating kale all the time doesn’t make you somehow better or more moral, a bag of chips doesn’t suddenly make you a “bad” or “unhealthy” person. A healthy relationship with food involves knowing that your morality or value as a person is not determined by what you consume.

Our relationships with food can also be shaped by a desire to attain an (often unrealistic) “ideal” as portrayed on TV, in movies, or through other media. This ideal of “health” or “fitness” often depends on visible body shape/size, and provides a very narrow window of “healthy” shapes/sizes. However, research tells us that we cannot tell how healthy a person is — or how healthy his/her/their relationship with food is — by the size or shape of her/his/their body.

Overall, our bodies need different things at different times. Only you can determine what’s best for you based on your body, access to resources, and belief systems. One rule or set of guidelines does not apply to everyone in regards to diet, and people have many different ways of getting the nutrients we need.

Image from Pinterest

What can I do to have a healthier relationship with food?

  • Remind yourself that your value does not depend on what you eat, and that there are many more ways to be healthy than are shown in the media.
  • Listen to your body. To the extent that you are able, try to eat when you’re hungry and stop when you’re full. Don’t wait for your hunger or your fullness to “yell” at you – keep in touch with what your body needs to the best of your abilities based on your access to resources. This can take practice!
  • Don’t be so hard on yourself! Being rigid and restrictive about what foods you “allow” yourself to eat can be harmful to your body and your mind. Focusing excessively on what foods you have eaten, or counting calories obsessively, are often a sign of an unhealthy relationship with food.
  • Pick the foods that give you the energy to do what you do during the day. After all, that’s what calories are — energy! The more nutrients that come along with that energy, the better.

Find more information:

Balanced eating as a vegan or vegetarian

Finding balanced and nutritious foods on a budget

Eating intuitively

Nutrition resources at UNC

If you feel concerned for yourself or a friend, or want to talk more about your relationship with food, you can find more information and contact options here.

This article was originally published September 4, 2014, by Mary Koenig, a program assistant for Student Wellness. She was in the school of Social Work and Public Health at UNC Chapel Hill.

Being healthy is more about what you do than what you look like

This blog post was originally published on March 5, 2015.

If I asked 10 different people what physical health looks like, do you think I would get the same answer? My guess is I would actually get 10 different answers largely because there is no one right answer.

The purpose of this blog is not to try and change your mind about what it looks like to be physically healthy, but rather to suggest that using body image and weight as an indicator of health is misguided. Being healthy is not about how you look, but rather what you do. What you do in your everyday life often plays a very large role in determining your what the real important health indicators like blood sugar levels, triglycerides (fat content in blood), LDL cholesterol, and many others will be.

I think it is time that we start to shift our attention from what people look like to what they do when we think about health. There are so many factors that contribute to health and there are also many things out of our control, but what is in our control, at least somewhat, is whether you try and live a healthy lifestyle.

Body Snark Free Zone Sign by Treacle Tart (flickr creative commons)
Body Snark Free Zone Sign by Treacle Tart (flickr creative commons)

So what does this mean? This means that you cannot always tell if someone is healthy or not by just looking at them. But—and I say this with a big but– the majority of research shows that being extremely overweight or extremely underweight can be very harmful for your health. We also should maybe rethink how we look at individuals whose weight falls somewhere in between these two extremes and even reconsider what we would be considered overweight. I say this because last year, a large study showed that people that are overweight actually live longer than people who are “normal” weights. I also say this because in the middle of these two extremes is a very large group of people that could, or could not be very healthy but we really cannot tell just by looking at them. What it comes down to is that the deciding factor is what people do in their everyday lives (and genetics), not what they look like. I think if we started to be more concerned with things like how physically active people are, how much sleep they get, and the food they eat (in addition to many other things) instead of what they look like, we as a society could do a better job at not stigmatizing people for being either over or underweight.

I would like to emphasize that I am not saying to be whatever size you want because as I said earlier, there is very good evidence to show that this can be very harmful to health. What I am saying is let’s worry more about eating real food, food that has not been overly processed, and exercising in moderation among many other daily activities, and let’s worry less about what size we should be. This means that being “skinny” even if you can eat whatever you want without exercising, does not make you healthy. But it also means for people that get the recommended amount of exercise and eat real food in reasonable amounts, but still weigh more than society says you should, that’s ok.

I think the bottom line is we need to be real with ourselves, and stop using what we look like to determine our health. What we look like in a mirror is meaningless if we are not doing what we should be doing to promote physical health, and vice versa. Let’s start trying to live our lives in a healthier way and use that to measure our health instead of the numbers we see on a scale.