Can You Really Be Healthy at Any Size?
While the weight loss and diet market contracted by 21% in 2020 due to the covid-19 pandemic, it’s expected to rebound in 2021, likely surpassing its record high of $78 billion in 2019. The problem? The entire industry is based on a false premise: that being overweight or obese is itself a health problem, even potentially a chronic illness. Even worse, the marketing for weight loss products and programs propels weight discrimination and stigma, which are vastly more harmful to a person’s health than being obese is in itself.
When I mentioned in a newsletter recently that weight was actually a pretty poor indicator of health, I received many replies that amounted to body shaming, which made me realize that it was way, way, way past time for a deep dive into the science on weight stigma and health at any and every size. It’s worth taking a moment here to remind all of my readers that I am always happy to engage in good-faith conversation regarding scientific evidence, and strive to create an informative, engaging, and supportive community. As such, I do not reply to messages that are not in good faith, and trolling and bullying will get you removed from my e-mail lists and blocked from my social media accounts.
Yes, it’s ingrained in our society to associate health with weight. So, let’s dig into the science demonstrating why we all would benefit from collectively ditching this mentality and instead adopting a weight neutral approach to health.
Don’t Conflate Overweight and Obese with Unhealthy
Many chronic diseases are associated with obesity, including heart disease, type 2 diabetes, nonalcoholic fatty liver disease, and cancer. But, correlation does not equal causation. A collection of important studies from the past 20 years have revealed that overweight and obesity themselves are not the risk factor, but instead are a symptom of an underlying health challenge (like chronic stress, gut dysbiosis, hypothyroidism or insulin resistance) and/or are an indicator of poor health-related behaviors (like sedentary lifestyle or poor diet quality), and it is actually these latter factors and not bodyweight itself that increase risk of chronic illness.
An important 1999 prospective study of over 25,000 men evaluated BMI relative to other risk factors for cardiovascular disease (CVD) mortality and all-cause mortality (a general indicator of health and longevity) over at least a 10-year follow-up period. While overweight and obese individuals, on average, had an increased risk of dying from cardiovascular disease (obese men had a 2.6X higher risk of dying from CVD) or from any cause (obese men has a 1.9X higher risk of dying from any cause), they were also much more likely than normal-weight men to be sedentary. When the participants were striated based on physical fitness in addition to weight, a very different picture of the true risks for mortality emerged.
Compared to fit normal-weight men, normal-weight unfit men had a 3.1X higher risk of dying from cardiovascular disease, overweight unfit men had a 4.5X higher risk, and obese unfit men had a 5.0X higher risk. But, physical fitness was incredibly protective at all sizes: overweight fit men only had a 1.5X higher risk of dying from cardiovascular disease, and obese fit men only had a 1.6X higher risk, compared to fit normal-weight men.
The difference was even more stark when comparing relative risk of all-cause mortality. Compared to fit normal-weight men, normal-weight unfit men had a 2.2X higher risk of dying from any cause, overweight unfit men had a 2.5X higher risk, and obese unfit men had a 3.1X higher risk. But here’s the kicker: fit overweight and obese men only had a 1.1X higher risk of dying from any cause compared to fit normal-weight men! The implication here is that, while fit overweight and obese men still had a slightly higher risk of dying from cardiovascular disease compared to fit normal-weight men, they had higher levels of protection from non-cardiovascular disease-related mortality in order to have near identical all-cause mortality risk.
|Relative Risk of Cardiovascular Disease Mortality|
|Normal Weight (BMI 18.5-25)||1.0||3.1|
|Overweight (BMI 25-30)||1.5||4.5|
|Obese (BMIT >30)||1.6||5.0|
|Relative Risk of All-Cause Mortality|
|Normal Weight (BMI 18.5-25)||1.0||2.2|
|Overweight (BMI 25-30)||1.1||2.5|
|Obese (BMIT >30)||1.1||3.1|
The authors concluded that low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors, and was of comparable, if not of greater, importance to diabetes co-morbidity, elevated serum cholesterol, hypertension, and smoking status. The only risk factor that was clearly more important than fitness was previously-diagnosed cardiovascular disease.
Overall, this study showed that sedentary people were more likely to be overweight or obese, and that it was the poor cardiorespiratory fitness that increased risk of all-cause mortality rather than being overweight or obese itself. In fact, obese individuals with at least moderate cardiorespiratory fitness had about half the mortality rate compared to normal-weight but unfit individuals. And, other studies (like this one and this one) have shown consistent results for both men and women, irrespective of whether BMI, body fat percentage, body fat mass or waist circumference is used to differentiate overweight from normal-weight individuals.
Furthermore, these studies show that, rather than exercise being protective because it is a weight-loss tool, living an active lifestyle is protective regardless of weight, which is why a 2004 editorial concluded “Physicians, researchers, and policymakers should spend less energy debating the relative health importance of fitness and obesity and more time focusing on how to get sedentary individuals to become active.”
Additionally, studies reveal that overweight and obesity are actually very poor proxies for measuring health and disease risk, and it would be much more helpful from a medical perspective to dissociate weight from the risk assessment and instead look directly and health behaviors, like activity.
A 2008 study showed that overweight and obesity were not synonymous with being metabolically unhealthy. This study evaluated cardiometabolic health of over 5,400 participants, and deemed them metabolically abnormal if 2 or more indices were elevated (including blood pressure, serum triglycerides, fasting plasma glucose, C-reactive protein, HOMA index [a measure of insulin resistance], and serum LDL “bad” cholesterol). Among overweight individuals, 51.3% were metabolically healthy; among obese individuals, 31.7% were metabolically healthy; and, among normal-weight individuals, 23.5% were metabolically abnormal. These data bust the myth that people who are overweight or obese are unhealthy and that people who are thin are healthy by default.
This study went further to evaluate risk factors other than—but striated by—weight for poor cardiometabolic health. Among normal-weight individuals, being older, male and physically inactive increased risk of metabolic abnormalities. And among overweight and obese people, being middle-age or older, male, and a race/ethnicity other than non-Hispanic Black, as well as imbibing more than two alcoholic beverages per day, smoking (current or ever), having a sedentary lifestyle, and having a high waist circumference each independently increased risk of metabolic abnormalities. Physical activity was the most protective for both normal-weight and overweight/obese individuals, the more metabolic equivalent tasks (MET; a measurement of the energy expenditure per kilogram bodyweight during physical activity, with 1 MET being roughly equivalent to burning 1 calorie per kilogram of body weight per hour) per day, the better (the most active group had >280 METs per day).
Not only does this study prove that you can be overweight or obese and be perfectly metabolically healthy, it also demonstrates that a substantial proportion (nearly one quarter) of normal-weight individuals have 2 or more metabolic abnormalities linked to increased risk of cardiovascular disease and diabetes that may go unrecognized because of the erroneous assumptions that normal weight equals healthy and overweight and obesity equal unhealthy. Making assumptions of health based on bodyweight does everyone a disservice, propelling weight stigma and the health detriments thereof for overweight people (we’ll get into this next), while also failing to identify risk factors for normal-weight people. In fact, a 2017 analysis concludes “It is not possible to determine a person’s health status on the basis of their weight.”
A quick aside on BMI: The body mass index, or BMI, which is calculated from height and weight, is the standard when it comes to describing body composition from a scientific perspective. While there are obvious limitations to this measurement for individuals (the classic paradox of the ultra-lean body builder who has an obese BMI, or someone who is “overfat” with a normal BMI), it’s a pretty good scientific tool for representing the average body composition of a group. In addition, many of the studies I’m referencing use secondary measures like waist-to-hip ratio, body fat percentage, body fat mass, or waist circumference.
I want to emphasize that I am not implying that being overweight or obese is automatically healthy, but rather that you can be healthy while overweight or obese because health behaviors and underlying conditions are driving chronic health problems rather than the weight itself. So, if you’re overweight or obese and eat a healthy diet, live an active lifestyle, manage stress, and get enough sleep, losing weight is unlikely to make you healthier. And, if you’re normal weight and eat junk and live the couch potato lifestyle, you may not be as healthy as society views you.
The Rise of Fatphobia, Weightism and Sizeism
The astute reader will have noticed that, in the study I discussed above, physically-fit overweight and obese people still had a 50% to 60% increased risk of dying from cardiovascular disease, and a 10% increased risk of dying from any cause, compared to equally fit normal-weight people, yet I have summarized the results focusing on physical fitness as the important contributor to mortality risk and not weight itself. The discrepancy here can be explained by the health detriment of weight discrimination and weight stigma—we’ll discuss how these impact health in the next section, but first, let’s talk about the history of and the ways in which weight stigma manifests.
If you’ve never been overweight, and especially if you do not identify as belonging to an underrepresented marginalized group, you may not understand the chronic social stress that comes from being judged constantly, even subconsciously via implicit biases. In my health journey, I lost over 100 pounds twice, once in my early-20s and once in my early-30s (I regained the weight back and more in between). Both times, it was remarkable to me to reach a threshold of weight lost where, all of a sudden, strangers would smile and make eye contact with me, hold doors open for me, or strike up a conversation while we were both waiting in line—I had lost enough weight to no longer be invisible. But, no matter how much weight I lost, no matter how fit I got, especially through the silent struggle to maintain that lost weight, the feeling of being less-than still haunted me, driven in part by the trauma of being bullied as a kid, but even more so by the persistent thousands of small ways society demonstrates value for thin people and lack of worth for everyone else.
Fatphobia can be traced to the early 1900s (when racist, xenophobic and religious influences combined to shift the previous association of fat with prosperity to instead associate it with the lowest social status and blamed on character flaws such as laziness, gluttony, or lack of self-discipline) and it has been ingrained in Western societies for a century. But, a 2019 examination of fatness as a social justice issue highlights a few key historical contributions, and the special interests behind them, to the current cultural assumptions that overweight equals unhealthy and that losing weight is simply a matter of trying hard enough. Of note, the collection of health professionals, government health officials and lobbying groups that began promoting the idea that obesity was a disease in the early 1980s (based on a collection of flawed, correlative studies) were financially supported by the pharmaceutical and weight-loss industries. The Shape Up America! Campaign and the “war on obesity” declared by the Surgeon General in 1995 were financially supported by Weight Watchers, SlimFast, and Jenny Craig. Also in 1995, the World Health Organization issued a report recommending that “overweight” be defined as having a BMI greater than 25 (because it’s a nice round number, not because studies showed this was a cusp for negative health effects), but a major contributor to writing that report was the International Obesity Taskforce, which was primarily funded by the pharmaceutical companies that made the diet drugs Xenical and Meridia (Hoffman-La Roche and Abbott Laboratories, respectively). It’s worth emphasizing that the presence of private funding and special interests doesn’t automatically undermine the credibility of a campaign or policy, but rather the confluence of undue influence from brands likely to benefit financially and lack of scientific foundation.
Throughout this time, well-designed studies continued to show a lack of causality between overweight/obesity and morbidity and mortality.
A 2005 study (which incidentally controlled for gender, age and smoking, which many other studies prior to that time did not do) found that individuals in the overweight category (BMI between 25 and 30) had lower mortality rates than people in the normal weight category (BMI between 18.5 and 25), while those who were underweight (BMI less than 18.5) had the highest mortality rate in the whole study. Further striating the data by age and smoking status was even more interesting. For example, in people over 70-years old, being underweight increased mortality risk by 1.69X whereas class II obesity (BMI greater than 35) only increased mortality risk by 1.17X—having a normal BMI or class 1 obesity (BMI between 30 and 35) were comparable in terms of mortality risk, and overweight had the lowest mortality risk. And in never-smokers aged 25 to 59, both overweight and class 1 obesity had lower mortality risk (36% and 23% lower, respectively) than normal weight individuals, but underweight and class 2 obesity had identical elevated mortality risk at 1.25X. This study is often quoted as the first evidence of the “obesity paradox”, but this study built on a body of research dating back at least to the mid-1990s. See also Using the Obesity Paradox to Inform Goals.
In 2013, the American Medical Association voted to label obesity as a disease, despite the fact that its own expert panel recommended against it. That same year, a meta-analysis of 97 studies, including more than 2.88 million individuals and more than 270,000 deaths (can we just get a collective “wow” for what a huge dataset that is?!), confirmed that class 1 obesity overall was not associated with higher mortality, and that overweight was associated with significantly lower all-cause mortality, compared to normal-weight individuals. Given that a BMI of 25 to 30 is associated with the lowest mortality, shouldn’t we redefine this as normal weight or healthy weight?! One interpretation of this data is that we have an epidemic of underweight, rather than epidemic of obesity (not to mention how this terminology pathologizes obesity despite the lack of scientific rationale for doing so, but I digress).
Studies now show that medical discrimination against overweight and obese people is a major problem. A 2017 analysis paints a disconcerting picture that aligns with my own experiences. When overweight and obese people go to the doctor, they’re likely to have their symptoms attributed to their weight, without diagnostics being performed, and instead be counseled (with more than a sprinkling of fat-shaming microaggressions) to lose weight. These common experiences lead overweight patients to delay seeking healthcare in order to avoid the stress of interacting with disrespectful and dismissive healthcare providers. The combination of assumptions by healthcare providers and hesitancy to seek medical care by overweight individuals leads to less preventative medicine than normal-weight individuals, as well as higher levels of undiagnosed or misdiagnosed health conditions. For example, a 2006 study of more than 300 autopsy reports found a 1.65X increased likelihood of obese patients, relative to normal-weight patients, having a significant undiagnosed medical condition (e.g., endocarditis, ischemic bowel, lung carcinoma), misdiagnosis, or inadequate healthcare that may have contributed to their death. It’s not that obesity increased the risk of these medical conditions, but rather that it increased the risk of dying from them due to inadequate healthcare.
The most common prescription for weight loss is dieting despite the fact that it has long been known that the majority (77%) of people who lose weight gain all the weight back (and often more) within five years.
Adapted from Am J Clin Nutr 2001;74(5):579–584.
This can be attributed to the concurrent rise in ghrelin (which increases hunger, see The Hormones of Hunger) and drop in basal metabolic rate that occur when we lose weight, especially quickly, which effectively means that the more weight someone loses, the more willpower they need to continue to maintain a caloric deficit. If losing weight makes us healthier, why does the body fight so hard against it? Even more problematic is yo-yo dieting because during weight loss, the body loses some muscle mass as well as body fat, but during the weight regain phase of yo-yo dieting, fat is regained more easily than muscle. The net effect is that yo-yo dieters have a greater risk for type 2 diabetes, cardiovascular disease, and non-alcoholic fatty liver disease than if they simply remained overweight or obese, in addition to having an increased risk of depression and eating disorders. See TPV Podcast Episode 353: Beach Body Yo-Yo
It’s also worth noting that scientific studies have not proven that intentionally losing weight prolongs life, and some studies even show the opposite! A 1995 study showed that women aged 40 to 64, who had never smoked and who had no pre-existing conditions, who intentionally lost over 20 pounds had an increased mortality rate during the follow-up period. And a 1999 study from the same research group showed that men without pre-existing conditions who intentionally lost over 20 pounds had a 48% increased risk of diabetes-associated mortality during the follow-up period, and men with pre-existing conditions who intentionally lost over 20 pounds had a 25% higher rate of cancer mortality. Both of these studies show that intentional weight loss can improve outcomes in some situations (for example, for type 2 diabetics), but worsen outcomes in others. A 1999 review summarizes “In view of the potential risks associated with weight loss and weight cycling, it is suggested that public health may be better served by placing greater emphasis on lifestyle changes and less attention to weight loss per se.”
Plus, weight discrimination isn’t just in the exam room. Overweight and obese people experience discrimination in education and employment, in addition to healthcare, along with frequent microaggressions and subliminal messaging in their daily lives. And, it’s considered socially acceptable in our culture to body-shame people for their weight, and to give unsolicited advice on weight loss. It’s probably no surprise that, over the same time period as the “war on obesity”, the prevalence of weight discrimination in the USA increased from 7% (in 1995-1996) to 12% (in 2004-2006). You may think that weight discrimination is always expressed as negatives (for example, a kid once shouted at me when I was out for a run “hey fatso, you’ll have to run faster than that to burn all that blubber off!”—incidentally, I was a normal BMI at the time), but even well-intentioned statements can propel weight stigma. For example, complementing someone on how great they look after losing some weight actually communicates that they had less value when they were heavier and more value now that they’re lighter. If that person struggles to continue to lose weight or maintain the weight they lost, they internalize that feeling of low self-worth.
In the next section, I’m going to dive into the science explaining how incredibly harmful weight discrimination and stigma are, but I hope that my readers are already willing to honestly reflect on their own behavior in this regard, and commit to no longer judging people based on their weight (I recommend taking Harvard University’s Implicit Association Test on weight). And, I can personally commit that, as I build my new website (subscribe to my newsletter to learn more), I will be updating all of my healthy weight loss content, including how I present my own health journey, to fully reflect this research because I acknowledge the contribution that weight loss success stories can have to propelling weight stigma.
Weight Stigma Is SUPER Harmful to Health
While obesity is often blamed for metabolic syndrome (that combination of risk factors including insulin resistance, inflammation, hypertension, elevated serum lipids, etc.), a variety of studies show that it is weight discrimination and weight stigma (a.k.a. fatphobia, weightism, healthism, body-shaming and fat-shaming) behind the increased risk of type 2 diabetes and cardiovascular disease, while lowering life expectancy. And, the magnitude of effect is high.
An important 2011 study of over 900 non-diabetic adults examined how weight discrimination affected blood sugar regulation, relative to BMI, waist-to-hip ratio, and waist circumference. Weight discrimination was assessed by asking the participants how often on a day-to-day basis (from never to often) they experienced:
- being treated with less courtesy than other people
- being treated with less respect than other people
- receiving poorer service than other people at restaurants or stores
- people acting as if they think you are not smart
- people acting as if they are afraid of you
- people acting as if they think you are dishonest
- people acting as if they think you are not as good as they are
- being called names or insulted
- feeling threatened or harassed
Similar questionnaires were used to assess perceived discrimination in the studies I’ll discuss below, too. Blood sugar regulation was assessed by hemoglobin A1C (HbA1C), which is a good indicator of average blood glucose levels over the previous 2 to 3 months. (High HbA1C [above 6.5%] is indicative of type 2 diabetes, and a recent study showed that, for every 1% increase in HbA1C above 7%, diabetic patients experienced a 21% increased risk for any cardiovascular disease event and a 37% increased risk of dying from cardiovascular disease.) While higher BMI, waist-to-hip ratio, and waist circumference were linked to elevated HbA1C, the study showed that weight discrimination exaggerated the increase, independent of other health behaviors like smoking, exercise, and fast food consumption as well as other covariates like age, race and gender. And, did you catch that important data point? Weight discrimination increased average blood glucose levels (indicative of insulin resistance) independent of exercise.
People with high waist-to-hip ratios and who also experienced weight discrimination had the highest HbA1C levels in the study. This is particularly interesting when you consider that high levels of chronic stress are strongly associated with increased waist-to-hip ratios (due to cortisol’s impact on abdominal fat deposition, see for example this study), and that stress reduces insulin sensitivity, see 3 Ways to Regulate Insulin that Have Nothing to Do with Food.
A 2014 study of over 7,000 participants showed that weight discrimination is also inflammatory. Similar to the previous study, participants were given a questionnaire to gauge their experiences with weight discrimination and systemic inflammation was assessed by serum C-reactive protein (CRP). While CRP did increase proportionally with BMI, participants who experienced weight discrimination had exaggerated CRP levels relative to BMI, with the exception of those with class III obesity (BMI > 40) where CRP was similarly elevated whether they experienced weight discrimination or not.
Another 2014 study in 45 healthy overweight to obese women showed that experiencing weight discrimination elevated oxidative stress, as measured by F2-isoprostanes, even after controlling for covariates including income, education, and global perceived stress. One thing that was really interesting about this study is that they assessed both exposure to and consciousness of weight stigma using a questionnaire that asked participants about 50 specific weight-stigmatizing situations. Weight stigma is harmful to our health, even when we’re not aware of it.
Given the results of the above-summarized studies, it’ll come as no surprise that weight stigma increases cardiovascular disease risk. A 2017 study of nearly 27,000 adults evaluated the link between cardiovascular disease and perceived weight, gender, and racial discrimination in the USA. Participants who experienced weight discrimination had a 2.56X higher likelihood of myocardial infarction and a 1.48X higher likelihood of minor heart conditions, after accounting for BMI, smoking, alcohol consumption, major depressive disorder, stressful life events, age, sex, income, education, and race/ethnicity. (Racial discrimination but not gender discrimination also increased risk of myocardial infarction and minor heart conditions, in addition to additionally increasing risk of arteriosclerosis). As you might expect, individuals who experienced multiple forms of discrimination had the highest risks of cardiovascular disease in this study.
A 2015 analysis of two different datasets (the Participants in the Health and Retirement Study, which included over 13,000 participants, and the Midlife in the United States Study, which included over 5,000 participants) revealed that weight discrimination was associated with a nearly 60% increased mortality risk, even after accounting for age, sex, race/ethnicity, education, BMI, subjective health, disease burden, smoking history, depressive symptoms, and physical activity. This study also found that, in general, mortality risk increased more in association with weight discrimination than for other forms of discrimination. The authors conclude “In addition to poor health outcomes, weight discrimination may shorten life expectancy.”
Why Is Weight Stigma So Harmful? Stress!
The most logical question to ask here is: Why? What explains the harmful effects of weight stigma, and with everything that we know about immune-modulating adipokines like leptin and adiponectin, how can science explain weight stigma, rather than adiposity itself, as the driver of increased disease and mortality risks?
Quite simply, stress.
As a 2014 review article puts it: “The fact that humans must eat to survive makes weight stigma unique, as eating itself may be a context for stigmatization, providing multiple, repeated, daily opportunities for experiencing weight stigma. There is no in-group favoritism among overweight individuals as they themselves tend to internalize weight bias, show implicit attitudes that prefer thin individuals to fat individuals, and typically do not glean positive esteem from their weight-based group identities. Moreover, the greatest weight stigmatization comes from family members and close friends – people who would typically be unconditional sources of social support and safety.” In plain English, we experience weight stigma every time we eat, we internalize that bias and believe it ourselves, and there’s no safe space.
The physiological stress response related to the psychosocial stressor of weight stigma has been measured in a variety of ways.
One very clever 2012 study of 99 young women who perceived themselves as overweight clearly demonstrated the stress response related to weight stigma. The study participants were asked to give a recorded speech, some were told that they would be viewed by an audience on a video recording while others were told that the speech was audio only. Throughout the speech, blood pressure was continuously monitored—mean arterial pressure is well-known to elevate in response to stress. Not only was mean arterial pressure higher among women who believed they were being video-taped compared to those giving what they believed to be an audio-taped speech, but the effect increased with BMI. Basically, the higher the BMI, the more self-conscious the women were about being judged, and the higher their stress response.
A 2016 study of 28 healthy young women (half normal-weight and half obese) evaluated heart rate variability (HRV; which is sensitive to changes in autonomic nervous system activity due to stress—stress lowers HRV) in response to monetary and social incentive delay tasks (which measure social information processing via first anticipated and then received positive, negative, and neutral outcomes in the form of money or facial expressions), relative to experienced weight discrimination assessed with a series of questionnaires. Women with obesity had lower HRV when experiencing negative social outcomes compared with normal-weight women, and this was exaggerated in women who had experienced weight-related teasing.
And a 2014 study showed that the experience of weight stigma, as assessed by questionnaires, significantly increased morning salivary cortisol, the cortisol awakening response (salivary cortisol 30 minutes after waking minus salivary cortisol at waking), and serum cortisol measured from fasting morning blood samples. This has also been shown in studies that experimentally manipulate weight stigma. For example, in another 2014 study, participants were shown a 10-minute video containing weight-based stigmatizing scenarios or a neutral video—those shown the weight-based stigmatizing scenario video exhibited sustained cortisol reactivity, independent of their bodyweight.
A 2017 study of almost 1000 participants showed that individuals who experienced weight discrimination had more than double the risk of having a high allostatic load, which is the cumulative maladaptation of multiple physiological systems (i.e., cardiovascular, sympathetic/parasympathetic nervous, HPA axis, immune, and metabolic) in response to chronic stressors. This was after accounting for covariates, including: age, race/ethnicity, household income, education, smoking status, and physical activity. And, those who experienced long-term discrimination (at least a decade) had a 3.36X increased risk of high allostatic load.
It’s worth noting here that chronic stress increases the risk of depression and anxiety, cardiovascular disease, obesity, diabetes, autoimmune diseases, chronic headaches, memory problems, digestive problems, and infections and is linked with poor wound healing. These effects are believed to be mediated by the activation of the hypothalamic-pituitary-adrenal axis (HPA axis) and the impact that cortisol and other adrenal hormones have on immune function. (See How Stress Undermines Health, How Chronic Stress Leads to Hormone Imbalance, and 3 Ways to Regulate Insulin that Have Nothing to Do with Food).
Plus, Weight Stigma Drives the Obesity Epidemic
There is a common perception that fat-shaming (whether framed positively or negatively, and whether by a well-meaning friend or your doctor) encourages overweight individuals to lose weight, but it actually has the opposite effect.
As summarized in a 2018 review article, experiencing weight stigma triggers behavioral changes linked to poor metabolic health and weight gain, including overeating, smoking, excessive alcohol consumption, and exercise avoidance. For example, a 2017 study showed that, when overweight and obese people experienced weight stigma at their gyms, they developed negative attitudes toward the gym, maladaptive coping behaviors, weight bias internalization, unhealthy weight control practices, and lower self-reported physical and emotional health—and here’s the kicker, all that was regardless of how frequently they went to the gym.
A 2017 study showed that weight-based teasing of adolescents (average age was 15) predicted higher BMI and obesity in adulthood at a 15-year follow-up (when the participants were 30 years old). On top of that, weight-based teasing during adolescence also increased risk of binge eating, chronic dieting, eating as a coping strategy, unhealthy weight control, and poor body image. Interestingly, this study striated by whether the teasing occurred from peers, from family members or from both, and found that, for women, teasing from family members increased risk of obesity more than teasing from peers (2.58X compared to 1.84X), but for men, teasing from peers but not family increased risk (2.44X).
Weight discrimination increases likelihood of obesity in adults, too. A 2013 study of over 6,000 participants aged 50 and over in the USA, showed that individuals who experienced weight discrimination had a 2.54X higher likelihood of becoming obese if they weren’t at baseline, and a 3.2X higher likelihood of remaining obese if they were at baseline, at a 4-year follow-up. This effect was independent of age, sex, race/ethnicity, education, baseline BMI, and other forms of discrimination. And a 2014 study of nearly 3,000 people over the age of 50 in the United Kingdom similarly showed that weight discrimination increased risk of weight gain and increased waist circumference, along with a whopping 6.67X increased risk of becoming obese at a 4 year follow-up (but no increased risk of remaining obese for those who were at baseline). The authors conclude “Our results indicate that rather than encouraging people to lose weight, weight discrimination promotes weight gain and the onset of obesity. Implementing effective interventions to combat weight stigma and discrimination at the population level could reduce the burden of obesity.”
The Evidence for Health at Any Size
If you are overweight or obese, it can be challenging to let go of years of social programming eroding self-worth and making you feel like you’re a failure (believe me, I’m still working on it). On the flip side, it can be challenging to let go of the privilege and esteem that comes with maintaining a svelte figure. But, that’s exactly what the scientific research supports. In fact, losing weight likely shouldn’t be the goal at all, nor should it be used as a metric of success. Yes, you can throw out your scale (or do what I did and put it in the garage with the luggage, just to use it to weigh suitcases for traveling post pandemic). It is far, far, far more important to instead focus on health-related behaviors, like eating a veggie-focused nutrient-dense diet, getting enough sleep, living an active lifestyle, and proactively managing stress (in addition to smoking cessation, moderating alcohol consumption, and addressing mental health challenges). A 2011 review article calls this way of thinking a “weight-inclusive approach (emphasis on viewing health and wellbeing as multifaceted while directing efforts toward improving health access and reducing weight stigma)… [which] rests on the assumption that everybody is capable of achieving health and wellbeing independent of weight, given access to nonstigmatizing health care.”
The 2008 study described in detail above shows that overweight and obese people absolutely can be metabolically healthy. The following studies show that obese people who aren’t metabolically healthy can measurably improve their health… without losing weight. Better yet, this weight-inclusive approach to health (also called weight neutral) shows lasting physical and mental health benefits when weight-loss centric approaches fall short.
A 2005 study in 78 obese women, aged 30 to 45 and who were chronic dieters, evaluated the efficacy of a program created by Dr. Lindo Bacon called “Health at Every Size” compared to a typical behavior-based weight-loss program for one year, with follow-up at two years. The principles of the Health at Every Size program are:
- “Accepting and respecting the diversity of body shapes and sizes.
- Recognizing that health and well-being are multidimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects.
- Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, appetite, and pleasure.
- Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.
- Promoting all aspects of health and well-being for people of all sizes.”
Even though the women in the typical behavior-based weight-loss program group lost an average of 5.2 kilograms (about 11.5 pounds), they didn’t see improvements in serum lipids or blood pressure. The Health at Every Size group, on the other hand, did not lose weight but had significant improvements in total serum cholesterol, LDL “bad” cholesterol and blood pressure (systolic and diastolic)! They also had reduced hunger and disinhibition (loss of control that follows violation of self-imposed rules), and an improved score in an eating disorder evaluation. Even better, 100% of the women in the Health at Every Size group had improved self-esteem, whereas the women in the traditional diet group had decreased self-esteem (53% of them expressed feelings of failure compared to 0% in the Health at Every Size group). These health improvements were maintained at two years for the Health at Every Size group, but the traditional diet group regained most of the lost weight by the two-year mark.
A 2009 study in 144 premenopausal overweight and obese women compared the Health at Every Size program to a social support group (small-group counseling facilitated by a registered dietitian and clinical psychologist) and a control group (instructed to follow their usual lifestyle habits) for a 4-month intervention period and a 16-month follow-up period. While the Health at Every Size group did lose an average of 2% of their bodyweight, the primary advantages were decreased susceptibility to situational eating, disinhibition, and hunger.
I think it’s worth emphasizing here that our diet and lifestyle choices are super important for our health—this research does not support the idea of giving up, doing or eating whatever we want, or not caring. Instead, the idea is to dissociate the desire to lose weight from the intention to improve health, and re-emphasizes the incredible health benefits we can experience with a nutrient-dense anti-inflammatory diet, active lifestyle, managed stress, and sufficient sleep. See The Importance of Nutrient Density, The Importance of Exercise, How Stress Undermines Health, and Sleep and Disease Risk: Scarier than Zombies!
If Not Weight, How Do We Measure Health?
So, if body weight isn’t a very good metric of health, how DO we measure health? It first helps to define being healthy more robustly than the typical medical definition of simply being free of disease.
I define physical health as:
- Being unburdened by symptoms of disease
- Having energy throughout the day (no “crash”)
- Enjoying daily movement and activity
- Sleeping well and awaking refreshed
- Having a sense of wellbeing (that’s both literal and a euphemism)
- Not needing “crutches” or willpower
- Having good mental health
And, I define mental health as:
- Generally feeling happy and enjoying life
- Having good mental clarity, problem solving, and memory
- Not having brain fog or cognitive challenges
- Having balanced and proportional emotional responses
- Communicating effectively
- Having the ability to cope in a productive (not destructive) way
- Enjoying play and engaging with others, laughing easily and genuinely
- Being comfortable with boredom
- Not needing “crutches” or willpower (yep, this goes on both lists)
When we combine these indices of physical and mental health together, they reflect the underlying biology. They are collectively the signs that we have no nutritional deficiencies and have well-regulated neurotransmitters and hormones, a healthy gut, healthy immune system, healthy cardiovascular system, etc. This is discussed more in TWV Podcast Episode 436: What Is Health, and How Do You Measure It?
While most of these metrics are subjective, it is possible to quantify some of them using biotrackers (for example, measuring HRV as a proxy for stress, or giving us a sleep score, or a miles equivalent for our activity level). For the rest, we can use semi-quantitative analysis approaches, like scoring a qualitative measure (like mood or energy level) on a scale from 1 to 10 or by measuring how frequently they occur (like how many headaches per month). And, we can track all the above metrics of health by keeping a simple journal, noting on daily basis:
- Energy levels
- Mood, malaise, emotional responses
- GI symptoms and stool quality/frequency
- Skin health (can also include things like fingernails, hair, etc.)
- Pain: headaches, body aches, joint, muscle
- Cognition (IQ boosting games that give a score are a fun way to track this)
- Sleep quality (subjective, or measure with a tracker)
- Stress, baseline and response (or measure HRV)
- Activity (or measure with a tracker)
- Any symptoms of health conditions
And, of course, a doctor’s exam is still beneficial! A doctor can add to our understanding of our health with a complete exam (which would include general appearance, heart exam, lung exam, head and neck exam, abdominal exam, neurological exam, dermatological exam, extremities exam, and male and female exams), measurements of vital signs (like blood pressure and body temperature), and various tests like fasting blood sugar and insulin, hormone profiles (stress hormones, sex hormones, etc.), a lipid panel, other blood work (like CRP and other inflammatory markers) and other tests (like gut microbiome analysis).
And, while the negative emotions I felt in response the aforementioned fat-shaming newsletter replies reveal to me that I still have some emotional work to do to reach body acceptance, I am committed to tuning out the body shaming that originates with an overly simplistic view of health, one based on bad assumptions that are contrary to the scientific evidence. I know that enjoying a spontaneous 3-minute dance party to goofy music with my kids and feeling good as I power up a hill on my morning walk with my dog are far more indicative of my health than whatever the number is on the scale or on the label of my jeans.
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