Paradigm Entrenchment in the Weight-Centric Paradigm

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I talk a lot about paradigm entrenchment, and I’ve had several readers ask me to dig deeper into it.

Before we talk about entrenchment, let’s talk about the weight-centric and weight-neutral paradigms within healthcare (there are many other ways that these paradigms can be applied, but for today we’ll focus on healthcare practice.)

Understanding that health is an amorphous concept, is not an obligation or barometer of worthiness, and is not entirely with our control:

There is the weight-centric (sometimes called weight loss) paradigm which in healthcare, at its simplest, says that being higher-weight is a health problem in and of itself, blames health problems on being higher-weight and believes that weight loss is the “treatment.”

There is the weight-neutral paradigm which in healthcare, at its simplest, says that there is a diversity of body sizes for many reasons and that the focus should be on supporting health directly and not trying to manipulate a patient’s body size.  

Entrenchment is about ideas becoming fixed and unchangeable.

So when I talk about paradigm entrenchment in the weight-centric paradigm, I’m talking about healthcare providers who consciously or subconsciously, are unwilling to consider anything other than the idea that being higher-weight is a health issue and that weight loss is the cure.

I want to be clear, paradigm entrenchment is not “I’ve examined the evidence with an open mind and I don’t agree with the weight-neutral paradigm.” Reasonable people can disagree and have productive discussions around this. Paradigm entrenchment is “I won’t examine the evidence.”

Now, healthcare providers didn’t come to this idea out of nowhere – in fact this is the basis of much of typical healthcare education. This includes continuing education, plenty of which is funded/conducted by the weight loss industry and including doctors within it.

I also want to note that people who are entrenched in the weight-centric paradigm may believe and profess that weight stigma is wrong. Still, their core belief is that higher-weight is a health issue/disease and that weight loss is the cure. This leads to an anti-weight stigma conceptualization that amounts to “fat* people shouldn’t be treated poorly, but the goal of healthcare should be the eradication of fatness and the prevention of future fat people from existing.” This is not, in fact, an anti-stigma position (though the weight loss industry, those who are taking payments from them, and their astroturf “advocacy” organizations have worked very hard to claim that it is.) No matter how well-intentioned or sincere, it amounts to giving lip service to anti-stigma work, and maybe even doing a bit of reduction of weight stigma, but always stopping just short of challenging their paradigm entrenchment.

Paradigm entrenchment leads to a lot of things. One is that for the last century, healthcare providers have been insistent that if higher-weight people would just eat less and exercise more they could lose any amount of weight and keep it off forever, despite a complete lack of research supporting that view and plenty of research refuting it. This, in turn, led many healthcare providers to assume that their fat patients were lying, were not trying, were not “smart,” were weak-willed etc. That impacted how those providers treat their higher-weight patients across the board and research tells us that includes giving them less respect, less time, and less information. That has led to patients getting subpar healthcare and/or disengaging from care.

I also want to say that this is not necessarily a conscious thing. The book “Mistakes Were Made, But Not By Me,” explains that when people experience something that clashes with their deeply held beliefs they can respond with self-justification and confirmation bias – even subconsciously.

The book explains that “What they see confirms what they believe and what they believe shapes what they see. It’s a closed loop”

My example of this around healthcare providers and weight loss is of providers who believe that all fat* patients don’t exercise enough and eat too much: I tell them to eat less and exercise more. Did my patient lose weight? Excellent, the advice I gave them was effective! Did my patient not lose weight? It’s the patient’s fault – everyone can succeed at intentional weight loss if they just eat less and exercise more. Did almost all of my patients regain the weight they lost? Does a century of research say that almost everyone regains the weight they lost? That’s because fat people eat too much and don’t exercise enough which is why my advice to eat less and exercise more would be effective if they would just follow it.”

The problem with paradigm entrenchment around the weight-centric paradigm isn’t just this closed loop (though that’s certainly an issue,) it’s that even if the loop opens, it’s still opening into a closed box.

Weight-centric paradigm entrenchment is the idea that weight loss is the right way to make higher-weight people healthier.  

So let’s say that a provider reviews the research and comes to the conclusion that that behavior-based weight loss interventions don’t create long-term, significant weight loss for the vast majority of patients and can do significant harm.

This could represent a real opportunity to consider a weight-neutral perspective. But if they are entrenched in the weight-centric paradigm, what is more likely (and what we’re seeing now, and what Novo Nordisk, Eli Lilly and others are exploiting) is that they will be looking for a different weight loss option. Since they are unwilling to consider a weight-neutral option, their only option at this point would be to consider an intervention that carries even more risk. In this way, these providers become willing to accept more risk for their higher-weight patients. And since they (often sincerely and without stigma or malice) believe that this is the only option, they use their position of medical authority to push more dangerous pharmacotherapies, devices, and surgical procedures on their higher-weight patients.

One current example is the shift we’re seeing, at least on the surface, in which providers are starting to admit that behavior-based interventions don’t create significant long-term weight-loss. Activists in the weight-neutral health and fat activism movements have been screaming this from rooftops and waving research around for decades, since before I was born. But this shift isn’t about that. Instead, it’s in response to the massive marketing campaign (in and outside of the healthcare system) that Novo Nordisk and Eli Lilly have spearheaded around their new weight loss drugs. They are finally admitting that behavior-based weight loss interventions don’t work but only as a way to sell the idea that higher-weight patients need more expensive and dangerous weight loss methods (their drugs.) I wrote about that in some depth as part of this series.

What can weight-centric paradigm entrenchment sound like? Here are some red flags:

·         Dismissing/scoffing at the idea of weight-neutral health as an abstraction/without engaging

·         Re-defining/ill-defining weight-neutral health and arguing against/dismissing it based on that incorrect definition

·         Refusing to discuss/consider the research supporting the weight-neutral paradigm

·         Refusing to discuss/consider the research questioning the weight-centric paradigm

·         Minimizing the risks of weight loss interventions (ie: “all drugs have side effects/these drugs are well tolerated” in lieu of an informed consent conversation)

·         Substituting weight loss sales pitches for informed consent conversations

·         False dichotomies – ie: claiming that someone speaking out against the weight-centric paradigm is just the same as a researcher taking money from the weight loss industry

I’ll say again here that this paradigm entrenchment and the things that come from it may be happening on a subconscious level, but that doesn’t do much, if anything, to reduce that harm that it does to higher-weight patients.

I’ll also say, including from a standpoint of personal accountability, that this is something all of us who work in these fields must do. It’s work that I do on a pretty much daily basis. Regular readers will know that I often analyze weight-loss research and guidelines on this page and I start out every one thinking “this may show that I am wrong.” I constantly try to remember that the evidence that I’ve reviewed over the last twenty years has led me to support the weight-neutral paradigm and so I have an even greater requirement to consider confirmation bias in my work for example I always ask myself “Am I cutting these weight-neutral researchers more slack than I would if they were weight-loss researchers?” Of course I’m not perfect but I am actively engaged in the work.

Here is an example in my own work -  one imbalance that I’m aware of and try to navigate delicately when it comes up in conversation or Q&As is that I’ve been studying the research around the weight-neutral paradigm (and the research around the weight-centric along with it) for over twenty years, whereas the person who is asking me the question may have just been introduced to the weight-neutral paradigm and research questioning the weight-centric paradigm in the hour talk I gave immediately preceding the Q&A we are having. So they are asking me a question that they are just forming for the first time, but that I’ve answered hundreds of times over two decades. It’s easy for me to start answering their question – out loud or in my head – before they are even done answering. It’s critical I don’t do that. My answer must not – and must not even appear to - dismiss their question without considering it – my goal is to listen fully and not guess/assume what the question is going to be, and then considered it and offer a full answer that often includes the fact that I, at some point, had that exact same question.

So what can be done about paradigm entrenchment.

I’ve written before about things that could change with research itself that would be helpful, like having weight-neutral comparator groups, long-term follow-up, and clear information.

From an individual perspective, it begins with having a willingness to consider a weight-neutral perspective. I’ve written before about the story that Galileo’s contemporaries simply refused to look through his telescope. They were so entrenched in their paradigm that they refused to even look at something that might challenge their beliefs. Perhaps especially for healthcare providers it can be understandable – not only is this going against what they’ve been taught, it would also be an admission that they have been giving patients bad advice and harming them. That’s a tough thing to deal with, but the alternative is - potentially at minimum -  to keep harming patients. The very first step, I think, is to say “there might be something I could learn that is different than what I have believed until now.” I have a research post here for anyone interested in a place to start. I also have a video workshop about understanding the research around weight and health (there’s a pay-what-you-can-afford option so money isn’t a barrier.)

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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’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.