But What About Health? The Relationship Between Weight & Wellness
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Diets don’t work. It’s a line you’ve surely heard before. Perhaps it’s a statement that’s even supported by your own lived experience. Maybe you are so burned out on diets that you are ready to consider giving up the pursuit of weight loss for good.
Except that, maybe you’ve also been told that weight loss is important for your health. You’ve been told your joints will feel better, your blood sugar will improve, your risk for X, Y, or Z diagnosis will decrease. Or maybe that you’re “healthy” now but if you don’t get or keep your weight “under control” it’s just a matter of time before you begin to experience those “weight-related” illnesses. Maybe you're fearful that if you do give up trying to control your eating you’re being reckless with your health.
So, you find yourself in a bit of a conflict. On the one hand exhausted by constant and usually unsuccessful, pursuit of shrinking or controlling your body, and on the other hand fearful of the consequences of letting go of that pursuit.
So, what are you supposed to do? How can you get off the diet culture roller coaster and still honor your health?
Oof. There’s a lot to unpack here.
What is “health” anyway?
This is where I often start when clients ask me, “but Dana, what if I *need* to lose weight for my health?” I ask them to think about, what is health anyway? How do you define it? What does it mean to you?
Usually when someone expresses concern about losing weight for their “health,” they’re referring to some measure of physical health – blood pressure, blood glucose, triglycerides, cholesterol, joint pain, etc. Yes, those are all measures of physical health. But, physical health is just one part of overall health. Health actually includes several domains – physical, mental, emotional, social, and spiritual. So, my question becomes, how does the pursuit of weight loss impact all of these areas? And how does food nourish all of these areas differently?
When we become so fixated on controlling food to control weight in an effort to prioritize physical health we may actually neglect these other very important areas of health. For example, how many social invites have you turned down because either it didn’t align with your diet, or you were worried about not having control over the food options? We are wired for connection and controlling our food in the name of “health” may lead to social isolation, which actually isn’t so supportive of our health at all. Or perhaps you do go to dinner, or to the party, and are so preoccupied with the food you can't enjoy yourself or engage in meaningful connection with the people around you. Maybe you exert every ounce of willpower you can muster to not eat the food offered only to binge when you get home, which takes a significant toll on your emotional wellbeing.
The point is health is about a lot more than just physical health, and when we reduce it to only that we compromise other important areas of our health—mental, emotional, social, and spiritual health. Consider the emotional drain of the frequent guilt, shame, and defeat we feel from never measuring up to diet culture’s expectations – whether it be deviating from the meal plan, or not seeing the scale move in a way that reflects your efforts, or feeling that your workout is never “good enough.” Or, the mental exhaustion from devoting so much of our energy to trying to “stay the course” with increasingly powerful feelings of deprivation. The real kicker here? Neglecting those other areas of health may negatively impact your physical health. For example, trying to control our food and body is stressful. Chronic stress is associated with adverse physical health outcomes.
“The point is health is about a lot more than just physical health, and when we reduce it to only that we compromise other important areas of our health—mental, emotional, social, and spiritual health.”
So, when we are thinking about how to nourish ourselves to support our health, we need to consider the big picture of what health really is.
But will losing weight improve my physical health?
It’s a great question and the short answer is, I don’t know. And even though this is a very common assumption and recommendation by providers, no one else can answer that question definitively either. Why? Because research to support that really does not exist.
What research does show?
When people in large bodies lose a modest amount of weight (i.e., approximately 5% of initial body weight) through lifestyle interventions (i.e., diet and exercise) we do observe improvements in some markers of physical health, at least temporarily.
People in smaller bodies have lower risk for certain health conditions than people in larger bodies.
However, from this research we cannot conclude that people in larger bodies should therefore be pursuing weight loss to improve health. Here are several reasons why.
Again, diets don’t work. What research shows is that people do lose weight when they participate in weight loss programs. That is, until they stop participating. Because research also shows that the vast majority of people regain all of the weight lost within 5 years of the program (1). This is even true of the most rigorous and highly controlled randomized controlled clinical trials where people likely have access to a lot more support than the average person going it alone. This has a lot more to do with how our bodies are wired for survival than it does willpower. So, we cannot say that if a person in a larger body loses weight via diet and exercise and maintains that weight loss indefinitely that they will have better health outcomes than if they remained at a higher weight all along because there hasn’t been a large enough population of people who have been able to do that to actually study.
Sure, we see that when people lose weight, they may also experience improvements in some markers or health. Temporarily, at least. But, we also can’t say that that’s because of the weight loss alone. Generally, that weight loss is accompanied by behavior changes like increased fruit and vegetable intake and increased exercise. But since the outcome we are measuring is weight, not sustained behavioral change, when the weight starts to return those behaviors are often abandoned because “what’s the point?” if we are no longer losing or are regaining weight anyway? We do know that engaging with health-promoting behaviors is supportive of overall health regardless of weight status and that behaviors are what we have most control over (2, 3). We also know that weight is not a behavior and that behavior change may or may not result in weight loss. So, if we can shift the focus from weight to behavior, we may have more success in helping people improve health outcomes, however that is defined for them.
A lot of the assumptions that we make about weight and health are based on the observation that lower weights are correlated with lower health risk. So, the belief is if people at higher weights can become people at lower weights then they will have reduced health risks, too. But, there are a couple of major problems with this assumption even aside from the fact that we don’t know how to make higher weight people lower weight people safely or effectively long-term.
We are not comparing apples to apples here. We cannot compare a higher weight person who becomes a lower weight person to an always-been-lower-weight person and assume they will have the same health outcomes as an always-been-lower-weight person.
CORRELATION DOES NOT EQUAL CAUSATION. Anyone who’s ever taken an intro level stats course may recall, this is one of the very first things you learn! Just because we see two things occurring in parallel doesn’t mean that one thing is causing the other. So just because a person at a lower weight seems to have reduced risk for certain health conditions, it does not mean that their weight is the reason. Likewise, for higher weight people appearing to have increased risk for certain health conditions, it doesn’t mean weight is the cause. Perhaps it is.But also possible is that a higher weight is a side effect of those health conditions so it is the health condition causing the weight. Or, maybe there is something else that is impacting both of those things simultaneously. For example, we see a correlation between increased ice cream consumption and death by drowning. No one is going to conclude that eating ice cream causes drowning, but rather eating ice cream and swimming are both more common in the summer. And finally, correlations are sometimes completely random, like the divorce rate in Maine correlating with per capita margarine consumption. Check out this website for some bizarre correlations where we are never going to conclude one thing is causing the other.
We also know that dieting behavior is a primary predictor of the development of eating disorders. So, while it’s unknown if it can have long-term positive impacts on health we certainly know it can have long-term negative impacts on health.
So, then what else, beyond weight, could be impacting the health of people at higher weights?
To answer this question, I think it’s helpful to start with the determinants of health. Goinvo provides a great visual for this. While individual behaviors (e.g., physical activity, dietary and sleep patterns), do contribute to health and is the area in which we have the greatest control (though the degree of “control” over these is still highly individual), it is but one determinant.
Genetics and biology, another determinant, account for approximately a quarter of health. This is where weight lives because weight is by and large genetically determined, which is part of why achieving long lasting weight loss is nearly impossible. We don’t get to choose our genes.
But what I think is SO important to consider here is the impact that both social circumstances and medical care have on health. Combined, the impact of these is essentially equivalent to health behaviors. So, what does that mean?
Social circumstances include things like social support networks (e.g., family, friends, community), income, education, occupation, race and ethnicity, gender identity, sexual orientation, and DISCRIMINATION. We’re talking about weight stigma and anti-fat bias here, folks. This can be described as negative attitudes and beliefs and discriminatory behaviors directed toward higher weight individuals.
Research on correlates of weight stigma and health reveal a relationship between weight stigma and disordered eating patterns, reduced physical activity, increased levels of cortisol, increased c-reactive protein (a marker of inflammation), increased hemoglobin A1c (a marker of blood glucose) and poorer glycemic control, elevated blood pressure, depression, anxiety, low self-esteem, and suicidality, among others (4).
The authors of a 2015 review study found that in all studies reviewed that controlled for BMI, the stigmatizing experience itself was independently associated with negative outcomes, suggesting that it may be weight stigma, rather than weight alone, that contributes to many of the biopsychosocial problems often attributed to higher body weights (5).
And, we can’t entirely separate this from medical care because weight stigma and anti-fat bias are rampant in healthcare. Examples of how this might show up include (6):
Providers over attributing a higher weight patient’s symptoms to weight and failing to refer the patient to appropriate diagnostic testing or considering treatment beyond recommending weight loss;
Providers spending less time with higher weight patients; and
Providers providing less health education, again, beyond weight loss recommendations;
Offices not having size-inclusive seats in the waiting, gowns, or blood pressure cuffs.
Providers may even hold beliefs that higher weight patients are lazy, lack self-control and willpower, are personally responsible for their weight, and are deserving targets of derogatory humor (4).
So, it may come as no surprise that higher weight individuals might hold off on seeking treatment as long as possible, thus presenting with more advanced disease states and have reduced trust in their treatment provider, and subsequently their treatment recommendations.
The bottom line
To say that weight equals health is a gross oversimplification, which generally reduces it to a single domain of health (i.e. physical), and neglects to account for the various other domains and determinants of health. Even then, physical health in and of itself is far too complex to reduce to a single determinant. Just because there is an association between weight and some measures of physical health does not mean that weight is at all or solely responsible for those measures. It’s worth noting, there is no illness or health condition that only people at higher weights get.
“To say that weight equals health is a gross oversimplification, which generally reduces it to a single domain of health (i.e. physical), and neglects to account for the various other domains and determinants of health.”
And even if there were a causal relationship between weight and physical health, weight is just not the controllable factor we believe it to be. This is supported by a substantial body of weight science literature that has repeatedly failed to find a safe, effective, and sustainable solution for shrinking bodies and has consistently shown that people cannot maintain even a modest weight loss for more than a few years.
Continuing to promote the idea that weight loss is within one’s control only serves to perpetuate weight stigma and anti-fat bias, which likely only worsens health outcomes of higher weight people.
If not weight loss, then what?
Letting go of the pursuit of intentional weight loss is not giving up on yourself or your health. It’s actually creating space for you to prioritize your whole health and wellbeing by shifting your focus from something that is largely out of your control to what is within your control. By that I mean health behaviors. This includes things like sleep hygiene, stress management, health supportive eating (which is *not* the same as dieting), and joyful movement. You can pursue all of these things without making the measure of success weight loss. In fact, you are probably far more likely to maintain these behaviors if you don’t make the measure of success your weight, but rather focus on how the behaviors make you feel.
I should also mention that pursuing health and engaging in health promoting behaviors is not a moral obligation and the degree to which participating in these behaviors is accessible to any one individual is highly variable. Your worth as a human being is unchanged by the degree to which you are able or choose to engage in such behaviors.
Given the fatphobic world we live in, it’s very understandable that you might desire to lose weight and that the idea of giving up that pursuit is a tough one to wrap your mind around. But if you are reading this, you’ve also probably witnessed and/or experienced the harms associated with the pursuit of intentional weight loss. While the hope of weight loss may be hard to let go of, know that it does not need to be your path to pursuing health.
Learn more
There are lots of wonderful non-diet and weight-inclusive resources that exist to support you on your health journey, here are just a few to get you started.
Weight and Healthcare, by Ragen Chastain
Health at Every Size 101, by Lindley Ashline
Maintenance Phase podcast , with Aubrey Gordon & Michael Hobbes
Resources:
Nordmo M, Danielsen YS, Nordmo M. The challenge of keeping it off, a descriptive systematic review of high‐quality, follow‐up studies of obesity treatments. Obesity Reviews. 2020;21(1):e12949.
Mensinger JL, et al. A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial. Appetite. 2016;105:364-74.
Clifford D, et al. Impact of non-diet approaches on attitudes, behaviors, and health outcomes: a systematic review. J Nutr Educ Behav. 2015;47(2):143-55.
Puhl RM, et al. Overcoming weight bias in the management of patients with diabetes and obesity. Clin Diab. 2016;34(1):44-50
Papadopoulos S, Brennan L. Correlates of weight stigma in adults with overweight and obesity: A systematic literature review. Obesity. 2015;23(9):1743-60.
Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. obesity reviews. 2015;16(4):319-26.
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