Intentional Weight Loss is Incompatible with Eating Disorders Prevention and Treatment – Even if Weight Watchers Disagrees

Studying the Studies

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A deeply misguided paper from January of this year was recently brought to my attention by a newsletter reader. This paper was published in the Journal of the Academy of Nutrition and Dietetics (a group you may remember from this transparently desperate attempt to cling to the weight-centric paradigm in spite of the evidence) which makes it fairly unsurprising that they published this article.

The short explanation is that this paper reads like a bunch of diet industry shills trying to co-opt the language of weight-neutral health in order to obfuscate the plain fact that intentional weight loss is incompatible with eating disorders prevention and treatment, so they can continue to market the same old failed “interventions” for “ob*sity”* and dodge responsibility for all the harm they create.

The paper is called “Patient-Centered Care for Ob*sity: How Health Care Providers Can Treat Ob*sity While Actively Addressing Weight Stigma and Eating Disorder Risk” and, as is my policy, I won’t link to it because of content that stigmatizes those at higher weights, and perpetuates harm, including eating disorders.

Content Note: The paper, which I’m quoting below for the purpose of analysis, is rife with weight stigma and triggering language. I’ve indented the quotes so that you can skip them, but make sure to take care of yourself, and of course feel free not to read, or to stop reading if it’s causing harm. If you want to read a shorter explanation of why this paper is completely misguided and dangerous without the triggering quotes, I wrote one here back in March.

Still here? Ok, let’s dive into this, begin with the study authors:

The lead author, Dr. Michelle Cardel is currently the Director of Global Clinical Research & Nutrition for Weight Watchers (or WW as I understand they’re calling themselves now) and is a consultant for Novo Nordisk, which you may remember, is the company borrowing every page they can from the Purdue Pharma OxyContin marketing playbook in order to market their dangerous new weight loss drug.

Faith Newsome is a Graduate Research Assistant who has accepted payments from Novo Nordisk. Her Twitter bio shouts out the Obesity Action Coalition, an astroturf organization that claims to advocate for fat people but whose main funding source is Novo Nordisk and which acts as a lobbying arm for them (again, straight out of Purdue’s Oxycontin playbook.)

Dr. Rebecca L Pearl has received grant funding from Weight Watchers, and has consulted for Weight Watchers and Novo Nordisk. She also runs what is called the Body Image and Stigma (BIAS) lab at the University of Florida. This is a lab that appears to espouse the harmful (but profitable for companies like Weight Watchers and Novo Nordisk) message that “we want to eradicate you and everyone who looks like you from the earth, and we’re willing to risk your life to do it, but, you know, not in a stigmatizing way” constitutes an anti-weight stigma message. (For the record, it does not.)

Dr. Emily Dhurandha is the chief scientific officer for obthera, whose stock and trade is selling direct-to-consumer weight loss. Per LinkedIn she was previously self-employed at Dhurandhar Weight Management where she provided “highly personalized eating plans for weight loss.”

While these are the only four authors who declared conflicts of interest, the other authors all seem to have pinned their finances and/or careers to the weight loss paradigm as well.

Now let’s look at the contents of the paper. They begin with the standard misleading claim:

Ob*sity is associated with adverse health outcomes…In addition, as severity of ob*sity increases, so does severity of health problems.

At this point, their credibility should be forfeit, as should anyone’s who says something like this without immediately being very clear that weight stigma, weight cycling, and healthcare inequalities are associated with the exact same health issues, and that as weight increases, so does exposure to all of those (including at the hands of researchers like these.) This type of correlation error (which should not be made by someone who is ten minutes into their first research methods class, let alone by people with this many letters behind their names,) harms and kills fat people.

They are also pushing to adopt a new definition of “ob*sity” that benefits those with a profit motive for classifying simply living in a higher weight body as a “chronic lifelong health condition”

 ob*sity as the state of excess adiposity that is associated with adverse impacts to quality of life or physical health

Notice what they did there – read carefully because it’s quite sly. No actual health (or even “quality of life”) issues are necessary for this diagnosis. The mere association of being higher weight with health issues (which the diet industry has worked so hard to push utilizing sketchy research…like this) is enough. Never mind that “correlation does not imply causation” is pretty much the first thing you learn in freshman research methods, and never mind that, again, these health and quality of life issues are just as, if not more, likely rooted in the weight cycling, weight stigma, and access inequalities that fat people face.

As Bacon and Aphramor explained, “Weight cycling can account for all of the excess mortality associated with ob*sity in both the Framingham Heart Study and the National Health and Nutrition Examination Survey (NHANES). It may be, therefore, that the association between weight and health risk can be better attributed to weight cycling than adiposity itself.” This is far from the only paper on the subject, you can find a partial list of other research here.  

The authors of this paper next attempt to gaslight us about their claims:

This new definition takes a health-focused rather than a weight-focused approach

No, it does not. It is still making weight a proxy for health, even though thin people get all the same health issues that fat people do (such that being thin can neither be a sure preventative nor a sure cure) and not all fat people get the same (or any) health issues. They are basing all of this on correlation and an aggressive refusal to fully investigate confounding variables (only giving them the slightest lip service later in the paper.)

The weight-neutral paradigm is actually health-focused and offers greater benefits with far less risk. What it doesn’t offer is tens of billions of dollars a year to the weight loss industry to sell interventions that have been failing the vast majority of the time since the 1920’s, so here we are. Still, co-opting the language that people who are fighting for true health-focused, weight-neutral, stigma-free care (many with far less privilege than these authors) have been using for decades, as the authors of this paper are doing,  is beyond disingenuous.  

Next they assert

BMI can still be complementary data when assessing whether someone has obesity

If you still think this paper has a shred of credibility, the fact that they continue to promote a measurement that is rooted in racism and anti-blackness* and that “assesses” people based on a ratio of weight and height regardless of their actual health status should burn that last shred to ash.

Next, they repeat all of the mistakes above, but in chart form.

Scroll through that, and we get to the meat of this paper, where they begin by trying to convince us that there is some sort of efficacy difference between “self-directed” intentional weight loss attempts and “supervised” intentional weight loss attempts.

To say that I am utterly unconvinced would be an understatement. They fail to provide any study where even a simple majority of subjects in these so-called “evidence-based supervised” attempts achieve anything close to what any reasonable person would consider significant long-term weight loss. (Instead, they fall back on the “5-10% weight loss creating health benefits” lie that we previously discussed in detail here.) They also ignore the fact that all of the benefits that they attribute to weight loss have been repeatedly shown in research to be achievable through weight-neutral health-supporting behaviors, with the same or greater (and much longer-term) efficacy, and far less risk (understanding, as always, that health is an amorphous and multifactorial concept that is not an obligation, barometer of worthiness, or entirely within our control.)

Then they move into a truly ludicrous attempt to suggest that intentional weight loss and eating disorder treatment have important commonalities. Don’t take my word for it, here’s a direct quote:

Shared components between supervised evidence-based ob*sity treatment mirror interventions for ED by including overall concepts of diet quality vs quantity, physical activity/sedentary activity, self-monitoring, and building a healthy body image.

This is dangerously misleading. As a reminder, intentional weight loss attempts are about manipulating food and movement (sometimes in combination with dangerous drugs or surgeries) in an effort to create a “negative energy balance,” which is to say that someone must give their body less fuel than it needs to survive, in the hopes that it will consume itself and become smaller (which has a long-term failure rate hovering near 100%.) An attempt to manipulate body size in this way is wildly incompatible with eating disorders prevention or treatment. In fact, intentional weight loss attempts are often precursors to disordered eating and eating disorders, and calling them “evidence-based” and “supervised” doesn’t change that, no matter how much the diet industry’s profits might depend on it.

They move on to:

Physical activity goals in obesity treatment include increasing enjoyable activities and reducing sedentary time, which parallels recommendations in ED treatment.

Another extremely misleading statement. Physical activity can be contraindicated for those with eating disorders, I know this from personal experience, as a big part of my ED was compulsive physical activity (and I was fat at the time.) I can’t tell you how many fat people I hear from who were encouraged to participate in physical activity in their ED treatment, even though thin people with the same ED symptoms/behaviors were restricted from physical activity. Why does this happen? Because so many ED practitioners’ work is rooted in weight stigma and the foolish belief that intentional weight loss attempts and eating disorder treatment can safely co-exist (sound familiar?) Also note that these researchers are making the “enjoyable activities” mistake, which is common when people are co-opting the language of the weight-neutral health paradigm with no actual attempt to understand it.

This one I had to read a couple times because I honestly couldn’t believe they tried it:

Self-weighing as part of obesity treatment leads to clinically significant weight loss without resulting in adverse psychological outcomes

I am almost speechless here. Frequent self-weighing can be a precursor to, or symptom of, eating disorders (which I would certainly consider an adverse psychological outcome,) so this amounts to, paraphrasing Deb Burgard, prescribing to fat people the same things that are treated in thin people. And, again, when they say “clinically significant weight loss” they mean a few pounds, which are typically not maintained long term, and which Tomiyama, Ahlstrom and Mann found were not the source of the health improvements. Not to mention that there is no proven causal mechanism between weigh-ins and even the small temporary weight loss that most people can expect (prior, of course, to the weight regain.) So the risks of engaging in self-weighing provide no real gain except, again, to the diet industry.

And right on time, here comes more gaslighting:

Finally, evidence-based obesity treatment encourages patients to participate in activities to reduce the overvaluation of weight and shape and promote self-efficacy, similar to ED interventions that promote these activities to reduce the risk of relapse

This from the same people who just tried to convince us of the “benefits” of self-weighing… You cannot be “treated” for a diagnosis based on being too fat, with treatment whose goal is to make you less fat, that involves self-weighing, and at the same time “reduce the overvaluation of weight and shape.”

You know what does do that? The weight-neutral paradigm!!! Just to reiterate, this entire paper seems to be another attempt by those representing the diet industry to co-opt the language of the weight-neutral paradigm to be able to continue to sell their snake oil to the tune of $70+ billion a year without admitting the harm and high failure rates of their products. Shame on them for all of this.

Their section on “patient-centered” approach starts

Given the multiple complications of obesity, withholding evidence-based obesity treatment from patients for whom it is medically indicated and who desire it is unethical.

This is a line straight out of the weight loss marketing playbook (which is not surprising since the lead author of this study is a Weight Watches employee) and is, perhaps, the most despicable in the entire paper (which is saying something.)

First, they are falling back on the correlation vs causation error. The treatment is never medically indicated as intentional weight loss’s high failure rate and the phycial and psychological harm it does mean that it doesn’t meet the criteria of an ethical, evidence-based intervention.

Moreover, the notion that if weight stigma and lies about the likely outcomes of weight loss and/or other healthcare being held hostage until weight loss is achieved have driven fat people to seek weight loss, then it should be prescribed to them regardless of the fact that the most likely outcomes are complete failure to produce long-term significant weight loss, or improved health and, in fact, frequently the outcome is harm.

As a queer person, the argument they are making is very familiar to me. It’s also commonly used by those who promote similarly dangerous and debunked so-called “conversion therapy” to “turn us straight.”

Their use of the term “unethical” to describe people not being given interventions that most often fail and cause harm is a hubris only achievable by those who are part of an industry that has spent decades being willing to do or say anything to increase heir profits and satisfy their shareholders (at the cost of the lives and quality of life of fat people).

If I seem angry, it’s because I am. The recommendations in this paper (dispensed by a bevy of people who have deep financial and career ties to the weight loss industry) will, if followed, harm and kill fat people. Worse, those fat people will likely be blamed for the havoc and harm the diet industry does. So, if you are uncomfortable with my tone, or you feel that my writing here is not polite or deferential enough, know that I hold fat people’s lives in much higher esteem than I hold politeness to those who profit from our suffering and deaths. We cannot let this continue unchecked, we must stop the parade and yell out, loud and clear, that the weight loss industry has no clothes.

In Summary

There is no evidence-based weight loss intervention. There is no study where even a simple majority of people achieve long-term, significant weight loss. The vast majority of people will lose weight short term and gain it back long term.  This experience of weight cycling will likely harm them physically and psychologically, and it’s absolutely unnecessary for(an, in fact, is the opposite of,) health-supporting behavior.

The existence of a conceptualization for “ob*sity” or any mechanism to pathologize higher weight is mutually exclusive to ending weight stigma, treating eating disorders, or providing ethical, evidence-based treatment to higher weight patients. The only thing it’s necessary or helpful for, is the continued hand-over-fist profit generation of the diet industry.

Promoting intentional weight loss requires that someone

1.       Ignore the near-complete failure rate of intentional weight loss

2.       Ignore the mountain of evidence that shows that weight-neutral interventions provide similar or greater benefits with far less risk

3.       Ignore the dangers of intentional weight loss which include weight cycling, disordered eating, and eating disorders.

4.       Ignore the ways that structural weight stigma and access inequalities create physical and psychological harm; and/or suggest that the solution to fat oppression is for fat people to change themselves to suit their oppressors.

That’s…a lot of ignorance.

The truth is simple:

The pathologization and medicalization of higher-weight bodies and the suggestion that they require “treatment” to make them weigh less is completely incompatible with the work of truly preventing, treating, and allowing for full recovery from eating disorders. It’s also completely incompatible with supporting the health of higher weight people.

No amount of paradigm straddling and co-opting the language of the weight neutral health paradigm, while recommending dieting and trying to gaslight us into believing it’s something else, will ever change that.

If we truly want to prevent eating disorders and support full recovery for people of all sizes, we have to leave the weight-centric model, diet culture, and the idea of “ob*sity treatment” far behind and adopt a weight-neutral health paradigm, even if the people profiting from the weight-centric model (and the harm it creates) have to find another line of work.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.