What public health gets wrong by focusing on weight

On Nutrition

As I was earning my master’s degree in public health a decade ago, I observed a certain level of what could be considered hypocrisy. On one hand, our eyes were opened to social determinants of health — which the Centers for Disease Control and Prevention defines as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of -life risks and outcomes.” On the other hand, we were lectured on the “obesity epidemic” and how to encourage fat people to eat less and move more would make them thinner and healthier. (I’m using fat as a neutral descriptor, like short, tall or thin).

Never mind that this form of “personal responsibility” rhetoric is dubious at best. For example, in 1992 a panel of experts convened by the National Institutes of Health determined that when people intentionally lose weight, “one-third to two-thirds of the weight is regained within one year, and almost all is regained within five years. ” A 2007 review from UCLA researchers found that one- to two-thirds of dieters regain more weight than they lost, and that “there is little support for the notion that diets lead to lasting weight loss or health benefits.”

I’ve heard more than one public health expert acknowledge all of this, then say something like, “Well, we still need to encourage people to keep trying.” Perhaps darker is the case of CDC researcher Katherine Flegal, who found herself on the receiving end of an aggressive smear campaign by a prestigious school of public health after she published research in 2005 concluding that being “overweight” was associated with fewer excess deaths than being “normal” weight. She detailed these attacks in her 2021 article, “The obesity wars and the education of a researcher: a personal account.”

For years, governments and public health departments have created “anti-obesity” task forces and public health campaigns. Unfortunately, these efforts have been more harmful than helpful, as the stigmatizing messaging used in many of these campaigns has fed anti-fat bias — or weight stigma — in all corners of society.

In their 2018 paper, “What’s Wrong with the ‘War on Obesity’?” Public health researchers Lily O’Hara and Jane Taylor wrote, “In a bitter twist of irony, there is evidence of a direct causal pathway from weight stigma to weight gain, with or without changes in eating behavior as a mediator, which demonstrates that … a fat hating environment makes people fat.”

Experiencing anti-fat bias increases levels of the stress hormone cortisol, which contributes to weight gain but also directly harms health. While the “war on obesity” can affect everybody by encouraging shame for being fat or fear of becoming fat, the greatest harms are to people who are already fat and experiencing hostility, discrimination and oppression while navigating a physical environment that’s designed for thin people. If you identify as a woman, as low income, as disabled or as a member of any other marginalized group, these effects are amplified, resulting in greater inequalities in health.

Fortunately, there are signs of change. One is a policy brief titled “Public health needs to decouple weight and health” from the University of Illinois Chicago School of Public Health Collaboratory for Health Justice, which stated, “If the goal is to find the most ethical and effective strategies to achieve optimal public health, there needs to be an alternative to ‘obesity’ and weight focused approaches and a shift in understanding of weight stigma as a social justice issue.”

That’s right. Weight stigma, or anti-fatness, is a social justice issue. Full stop.

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