Jeanine C. Cogan, PhD
Obesity is commonly defined as a medical condition because of its associated health risks. The standard treatment is a form of restrictive dieting and prescribed activity with the goal of weight loss. For half a century, psychologists, physicians, nutritionists, other health professionals, and commercial weight loss organizations have directed the weight loss efforts of the obese and the not so obese. The federal government has spent millions of dollars on public health campaigns and other initiatives to alert the public about possible dangers of obesity, urging weight loss for all those who do not conform to specific weight standards.
And the public has responded. As many as 40 to 70 percent of the U.S. population is trying to lose weight.(1) More than 33 billion dollars is spent on weight loss products, commercial programs, and aids in the U.S. annually, not including the cost of medical and psychological interventions.(2) And yet the incidence of obesity has not declined, but rather continues to rise.(3)
The tendency to continue promoting weight loss in the name of health, even in the absence of long-term outcome data supporting effectiveness, reflects the “weight-centered approach toward health.” The monolithic focus on the elimination of obesity through weight loss has led to a high rate of dieting and other associated behaviors of concern for many health professionals. This concern stems from several areas of research. Evidence continues to accumulate that weight loss through restrictive dieting and other methods (1) has not cured obesity in a significant portion of participants and, in fact, is unsuccessful in producing even minimal permanent weight loss in the majority of cases; (2) may cause health problems; and (3) is not critical for improving health for those considered obese relative to exercise and healthful diet choices.3
Continued participation in weight loss programs is associated with repeated weight loss and regain, which may cause problems as weight fluctuation is associated with increased mortality and cardiovascular disease.4 Integral to the weight-centered approach is “thinness bias,” a prejudice rarely addressed by researchers and health professionals.5
Thinness bias
Bias is the systematic error introduced into the testing of phenomena and interpretation of results by selecting one outcome or answer over another. Thinness bias, then, is the error of seizing upon results that favor thinness or paying selective attention to thinness-promoting information. Content that does not support thinness as the optimal health standard is ignored or even attacked.
Thinness bias is pervasive in the U.S. today. Biases are not uncommon. In fact, it is difficult to avoid operating under a certain set of biases at any given time. Aesthetic biases favoring slender figures socially or in the media are deeply ingrained in our society. When such biases make themselves felt in the arena of health care and public policy, they move beyond the question of personal preference and can have serious consequences.
Outlining the problem
An unintended outcome of the current weight-centered approach toward health is that people are literally dying to be thin through weight-loss drugs (e.g., pulmonary hypertension after prolonged use of fen-phen), very low-calorie diets, stomach stapling, rapid weight loss, diet-induced nutritional deficiency (e.g., adult osteoporosis), weight fluctuation, and eating disorders.6
The costs of thinness bias are great, with a host of iatrogenic problems and casualties. Many people are scrutinized and shunned by peers and strangers for not fitting the ideal body size. Those considered obese are blamed for their “condition.” Women of all sizes and shapes suffer from body hatred. Millions of Americans have dieted unsuccessfully again and again, and they internalize their failure to maintain weight loss. Children are “afraid to eat” and afraid of being fat, of being teased and taunted.7 Anorexic teenage girls are at an increased risk of dying. Too many families have lost their daughters, sisters, or mothers to anorexia and diet drug-related deaths.6
The pursuit of thinness, therefore, is a growing social problem and public health threat. At a time when medical technology has made revolutionary advances, how is it that we find ourselves facing this new health problem? Advocates of a new health approach posit that the answer lies within the dominant approach toward health that considers obesity a dire public health threat in urgent need of treatment and prevention. This conceptualization of obesity and health is incomplete and therefore problematic.
Although fatness is believed to be synonymous with bad health, this conclusion reflects only selective interpretations of research. There is considerable need to reinterpret previous data that have been filtered through a thinness-biased lens. We need to reinterpret past conclusions built up from such assumptions.
A coalescence of multiple incomplete and inaccurate notions about weight, health, and dieting, each reinforcing the other and each widely accepted by professionals and the lay public, compels a shift of paradigm. The following are commonly misunderstood assumptions: (1) people can change their weight at will; (2) dieting works; (3) thinness equals health and fatness equals disease; and (4) dieting is good for you. Each will be addressed in turn.
Inherent in dieting, with its goal of a thinner self, is the belief that body weight is controlled through human behavior. Although logical, this does not account for the important role of genetics in determining body weight and size.
Both twin and adoption studies have consistently found that genetic factors are important in the etiology of obesity. For example, Stunkard and his colleagues found that fraternal and identical twins were likely to be similar in body weight regardless of whether they were reared together or apart.8
The genetic influences on obesity, in combination with the research on other biological determinants of body weight, such as differences in resting metabolic rates and individual set-point, suggest that body weight and size are not solely determined by individual behaviors and therefore are not easily changeable.
People diet because they believe they will lose weight. Most weight loss programs are successful at producing short-term weight loss maintained for a few months or a year. As time passes, however, there is surprising consistency in the research: weight that was initially lost is eventually regained. The longer the follow-up, the more weight is gained.9
Researchers first addressed the failure of dieting in the 1950s when it was reported that less than 5 percent of dieters were able to maintain their weight loss.3 Decades of research and dozens of critical
reviews reaffirm that restrictive dieting has this high failure rate for maintenance of long-term weight loss.
The idea that thinness equals health is perhaps the most widely held myth of all. Yet research shows that extreme thinness is associated with increased mortality, and that certain weight loss strategies can be life threatening. One epidemiological study, following 1.8 million Norwegians for 10 years, found that those in the lowest weight category were at highest risk for premature mortality. Women who were considered morbidly obese, weighing twice the recommended weight standard, had a higher chance of survival than women in the leanest weight category.10
Similarly, data from a number of long-term studies show both extremes of the weight continuum to be at greater risk of early death. Individuals in the lowest weight category were at highest risk, those in the highest weight category were slightly more likely to survive than the thinnest group, and those somewhat above average weight were at least risk.4
Additionally, as noted earlier, the effort to attain thinness can be dangerous, especially when people resort to more extreme weight loss strategies. Anorexia is the psychiatric disorder with the highest
mortality rate. According to one study, individuals with anorexia had an 18-fold increase in the risk of death over individuals who were not anorexic.11
A number of highly publicized deaths in young women due to primary pulmonary hypertension ended the popularity of dream diet drug fen-phen.
The risks associated with drugs must be weighed more carefully against the proposed benefit of curing the “disease” for which they are prescribed. This is often the justification for prescribing anti-obesity drugs with known adverse effects: the potential benefits outweigh the risks. Yet weight loss drugs have not been found to cure obesity or to improve the health of those taking such drugs.
Dieters often talk of a sense of euphoria and feelings of accomplishment upon embarking on a new diet. Yet researchers have found that dieting by restricting calories is associated with a host of negative consequences including adverse effects on cognitive performance and body image; negative mood and depression; preoccupation with food and eating; binge behavior; and the onset of eating disorders.12
Physiologically, restrictive dieting is also associated with nutritional deficiency, lowered resting metabolic rate, menstrual irregularity, and sometimes death. In the 1970s, a number of popular very lowcalorie diets such as the Cambridge diet were implicated in the deaths of more than 50 people.6 Unfortunately, there has been insufficient response from government agencies and other authorities to both document and prevent diet-induced deaths.
One cannot ignore the huge economic incentive for maintaining diet myths with a weight loss industry responsible for millions of diet products, weight loss clinics (often run by obesity experts), and new anti-obesity drugs. In such a context, it is difficult to debunk the myths of dieting and obesity so common in our public psyche and, therefore, the health of the American people continues to be compromised.
Accurate information is sorely needed about the genetic influence of body weight, the ineffectiveness of dieting, the negative consequences of restrictive dieting, the dangers of many weight loss strategies, the risks of being underweight, and the high psychological and physiological price of eating disorders. If we are to protect and promote the health of the next generation, more complete and accurate information on weight, obesity, and dieting must be made public. This is one of our greatest challenges within the current climate of the thinness bias.
Paradigm shift from weight to health
A logical conclusion when considering the flawed assumptions of the weight-centered model toward health is that there needs to be a paradigm shift. Centralizing health rather than weight is of special importance for the well-being of children and adolescents. Research shows that young girls in particular are dieting in large numbers and at early ages. Women and girls are disproportionately affected by eating problems. They are more likely to suffer obesity-related stigma and to be the consumers of diet products. Therefore, they are more likely to suffer the negative consequences of dangerous weight loss methods and eating disorders.
Additionally, although once considered more a phenomenon of white and higher socioeconomic groups, eating problems are becoming more common among African-American women and people of all socioeconomic classes. Given the higher prevalence of obesity in these groups, the health consequences of adopting risky weight loss strategies may be enormous.
By shifting to a more comprehensive approach toward health, we can prevent vulnerable groups from developing a loathing for their bodies and engaging in risky weight-loss behaviors.
Jeanine C. Cogan, PhD, is a social psychologist and research and policy analyst in Washington, DC. With Paul Ernsberger, she co-edited Dying to be thin in the name of health: shifting the paradigm, a special issue of the Journal of Social Issues, Volume 55, 1999.
References
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5. Cogan JC. Re-evaluating the weight-centered approach toward health. In Sobal J, Maurer D, eds. Interpreting weight: the social management of fatness and thinness. New York: Aldine de Gruyter, 1999; 229–253.
6. Berg FM. Health risks associated with weight loss and obesity treatment programs. Journal of Social Issues 1999; 277–298.
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8. Stunkard AJ, Harris JR, Pedersen NL, et al. The body mass index of twins who have been reared apart. N Engl J Med 1990; 1483–1487.
9. Garner DM, Wooley SC. Confronting the failure of behavioral and dietary treatments for obesity. Clin Psychol Rev 1991; 729–780.
10. Waaler HT. Height, weight and mortality. The Norwegian experience. Acta Med Scand Suppl 1984; 1–56.
11. Norring CE, Sohlberg SS. Outcome, recovery, relapse, and mortality across six years in patients with clinical eating disorders. Acta Psychiatr Scand 1993; 437–444.
12. McFarlane T, Polivy J, McCabe R. Help not harm: psychological foundation for a non-diet approach toward health. Journal of Social Issues 1999; 261–276.
This article is from the Health at Every Size Journal and can be cited as Jeanine C. Cogan, “Research on Weight Supports a Paradigm Shift” from Health At Every Size 14:1 (January/February 2000).
