Study's Questionable Claims About Eating Disorders and Dieting

AAP Guideline Deep Dives

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I was part of a project with WIND (Weight Inclusive Nutrition and Dietetics) to create a comprehensive response to the disastrous American Academy of Pediatrics (AAP) guidelines for higher-weight children. I was part of the team that analyzed the research that, the AAP claims, supports their recommendations, and I’ve been publishing my breakdowns here as well.

Today we have Patient-centered care for ob*sity: how health care providers can treat ob*sity while actively addressing weight stigma and eating disorder risk, by Cardel MI, Newsome FA, Pearl RL, et al.

This is a study that the AAP guidelines attempt to use to try to suggest that their (highly profitable) recommendation of putting kids as young as two on weight loss interventions won’t increase eating disorder risk.

Quick Guide:

• Written by a group of people who either take payments from the weight loss industry or work for them directly

• Most of the studies cited included only adults, and thus have very limited to no extrapolatability to the recommendations for children and adolescents that the AAP is using this study to support

• Consistently uses the blanket terms “EDs” or “eating disorders” when the research they cite only considers binge eating disorder

• Ignores common ED symptoms including food restriction and induced vomiting and diarrhea that are inherent in the weight management, pharmacotherapy, and bariatric surgeries that the AAP recommends

• Draw patently false parallels between ED treatment and “ob*sity treatment”

• Admits that a focus on weight and internalizing the thin ideal increases eating disorders, then recommends pathologizing bodies based on weight and recommending treatments focused on making people thinner

• Fails to provide any evidence that weight management actually results in long-term significant weight loss and/or health benefits (which are two different things.)

• The use of older, smaller, shorter, and lower quality studies indicates the likelihood of “cherry picking” data to support (rather than test) their hypotheses

• Cites multiple studies to support claims, most or all of which do not actually support those claims

Deep Dive:

Conflicts Of Interest

Dr. Michelle Cardel is currently the Director of Global Clinical Research & Nutrition for Weight Watchers International

Faith Newsome has accepted payments from Novo Nordisk. Her Twitter bio shouts out the Ob*sity 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.)

Dr. Rebecca L Pearl has received grant funding from Weight Watchers, and has consulted for Weight Watchers and Novo Nordisk.

Dr. Emily Dhurandhar 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, and would likely stand to profit from the recommendations of this study.

Claims and refutations

Quotes from the study are in italics

Ob*sity

“Ob*sity is associated with adverse health outcomes, including impaired daily functioning, decreased health-related quality of life, increased stress and increased risks of cardiometabolic disease and cancer. In addition, as severity of ob*sity increases, so does severity of health problems.”

Neither they, here, nor the studies cited, discuss or control for the impacts of weight stigma and weight cycling even though both are correlated with similar outcomes to those correlated with being higher-weight, and weight cycling is the most common outcome of the “ob*sity interventions” they are recommending.

“a new definition has been proposed with Canadian guidelines and the World Health Organization defining ob*sity as the state of excess adiposity that is associated with adverse impacts to quality of life or physical health (Figure 1). This new definition takes a health-focused rather than a weight-focused approach…”

The final sentence is, quite simply, not accurate. As long as the definition is pathologizing body size (even if it exploits correlation to health issues with no proven causation) and the “treatment” is weight loss, it’s still about weight and not health.

…allowing for improved sensitivity to the nuance of the relationship between weight and health status.”

This statement is inaccurate. What it actually does is encode correlation as causation in order to pathologize higher-weight bodies and obfuscate the impacts of weight stigma, weight cycling, and healthcare inequalities on the health of higher-weight people in order to recommend highly profitable but very rarely successful weight loss interventions.

ob*sity should be treated like other chronic conditions and afforded access to evidence-based and effective treatment options to improve health-related outcomes.

No. “Ob*sity” isn’t like any other chronic condition in that there is no shared symptomology or cardiometabolic profile. Each of the health conditions that are correlated with “ob*sity” happen to people of all sizes, and already have evidence-based and effective treatment options, so it does not make sense to pathologize some of the people who have those conditions based on their body size, adiposity, or height/weight ratio.

Figure 1

They list “prevalent health concerns” which is a list of things which are correlated with being higher-weight. They make no acknowledgment that they may actually be due to weight stigma, weight cycling, and healthcare inequalities. Also, some of the links they mention are tenuous at best – it is not clear that they had robust criteria for inclusion here.

While section that shows health issues that are correlated to “ob*sity” has a list of anything that is even vaguely correlated to being higher-weight, the section that shows health issues correlated with weight stigma section compresses this to “Cardiometabolic disease risk factors (eg, heightened inflammation)” obscuring how much overlap there truly is between the “ob*sity” list and the weight stigma list.

Both the weight stigma and eating disorders portion list “people with overweight and ob*sity” in the high-risk population, but this may well be more accurately expressed as “people who experience weight stigma and people who attempt weight loss.”

There is debate surrounding whether ob*sity or weight stigma might be the true cause of adverse outcomes related to ob*sity,4 and that the previous definition of ob*sity erroneously prioritized BMI and weight status alone as the diagnostic criteria for ob*sity. Further research is needed to better understand how to operationalize this new definition of ob*sity when doing population-level research and to examine whether this revised definition facilitates a decrease in weight stigma and bias.

There is a logic issue here, as well as a clear bias toward pathologizing body size. What they are saying is that they don’t know if body size or weight stigma causes negative outcomes, so they are going to subject higher-weight people to “treatments” (which have risks and negative side effects) to see if those so-called treatments “reduce weight stigma.” A less risky (but far less profitable to the weight loss industry) strategy would be to target the reduction of weight stigma (an intervention with few to no risks or negative side effects) to see if that reduces the incidence of negative outcomes. They also consistently ignore the fact that weight cycling is the most common outcome of the “ob*sity” treatments they are shilling for, and that it is independently linked with most of the health issues that are linked to “ob*sity” as well as to higher overall mortality.

Weight Stigma

Weight stigma increases the risk of high allostatic load, psychiatric and substance use disorders, and suicidality. Complicating these risks, more than one-half of health care providers attribute overweight and ob*sity to a lack of willpower, reinforcing negative stereotypes33 and dissuading people with ob*sity across the globe from seeking medical care.36 Rather than motivating healthy behaviors, weight stigma contributes to avoidance of health care, health care inequities, increased weight gain, and Eds. Therefore, preventing weight stigma should be prioritized in health care settings.

Here they are finally more honest about the risks of weight stigma and they pay lip service to the notion of preventing weight stigma, but ignore the fact that you can’t define the existence of higher-weight kids as an “epidemic” or “crisis” and suggest that they should be eradicated, while simultaneously reducing stigma against them. Here I’ll point out that researchers who contributed to this paper also put out so-called “weight stigma” research that is really little more than weight loss industry propaganda.

EDs

A childhood history of overweight or ob*sity and substantial weight gain during adolescence increase risk for EDs, with increased weight concerns as a mechanism.

Note that they are admitting that increased weight concerns increase ED risk while simultaneously trying to claim that putting mroe focus on weight management will decrease ED risk. By their own admission, their recommendation of pathologizing body size and focusing on manipulating it will likely increase the incidence of eating disorders.

It is also important to note that weight stigma is a known risk factor for disordered eating. Both children and adults who experience weight stigma have an increased risk of low self-esteem and poor body image. The impact of weight stigma on disordered eating can be seen in children as early as elementary school. Internalization of the thin ideal can moderate the relationship between experiencing weight stigma and disordered eating behavior. However, more work remains to be done to establish the link between weight stigma and anorexia nervosa, bulimia nervosa, and binge ED.

Again, they are admitting that internalizing the thin ideal can drive eating disorders while simultaneously suggesting that moving people toward the thin ideal should be considered a healthcare priority. Again, they are tacitly admitting that pathologizing being higher-weight and focusing on body-size manipulation “treatments” is likely to increase eating disorders.

Dieting vs Supervised Treatment for Ob*sity

The word diet has been used counterintuitively. In colloquial use, it describes self-directed efforts to lose weight by restricting the amount and/or types of food consumed.

This is a definition that they constructed. It is quite self-serving to their attempt to create some kind of separation between “dieting” and “supervised treatment.” It ignores the fact that most diets recommend changes in eating habits as well as increased movement and decreased sedentary behavior.

In contrast to self-directed diets, which often promote reaching an “ideal” body size by implementing overly restrictive changes, supervised evidence-based behavioral weight management encourages sustainable changes to promote long-term health

This is not accurate and seems to be trying to co-opt the language of weight-neutral health in order to promote intentional weight loss. The study they cite for this (Steinbeck et al. 2018) is clear that these strategies involved dietary change, increased physical activity, decreased sedentary behaviors (which parallel what they are calling “dieting.”) The study also recommends pharmacotherapy and bariatric surgery which are even more high-risk ways to attempt to achieve an “ideal” body size. The distinction they are trying to make here literally does not exist.

Current behavioral treatments for ob*sity typically produce weight losses of 5% to 10% of initial body weight, and improvements are observed regarding quality of life, body image, daily functioning and mobility, and modest reductions in depression and anxiety

There is no proof that even this moderate amount of weight loss can be sustained long-term. Even if it is, Tomiyama, Ahlstrom, and Mann 2013 explored the idea that 5-10% weight loss can improve health and found:

  “Across all studies, there were minimal improvements in these health outcomes and none of these correlated with weight change”

There were “a few larger positive effects” related to hypertension and diabetes medication use and diabetes and stroke incidence,] “In correlational analyses, however, we uncovered no clear relationship between weight loss and health outcomes related to hypertension, diabetes or cholesterol, calling into question whether weight change per se had any causal role in the few effects of the diets. Increased exercise, healthier eating, engagement with the health care system, and social support may have played a role instead.”

This level of weight loss may result in a state of weight suppression, which can increase the risk of EDs. Notably, the link between weight suppression and ED risk is mediated by increased drive for thinness, and interventions that increase body acceptance may prevent negative consequences of weight loss

They fail to provide any evidence here to refute the logical conclusion that you can’t simultaneously suggest that people take significant risks in order to become thinner and increase their body acceptance at the same time, especially if the weight loss attempt ultimately fails (as most do.)

Rarely, evidence-based ob*sity treatment can lead to, or exacerbate, pre-existing distorted or obsessive thoughts and behaviors around weight and food, which potentially increase risk of Eds

The first study they cite, Jebeile et al., 2019 (Treatment of ob*sity, with a dietary component, and eating disorder risk in children and adolescents) has similar author conflicts of interest in that most of the authors either take payments from, or are directly working in, the weight loss industry. Louise Adams wrote a letter to the editor explaining the issues with this (the published letter is behind a paywall but her full letter is available here.)

She summarizes it by writing: “The authors’ conclusion that ‘structured and professionally run ob*sity treatment leads to a reduction in the prevalence of ED, ED risk, and ED-related symptoms for most participants’ is extraordinarily misguided, given that (a) quality long-term data were available for only 7.5% of the sample, and (b) clear evidence of a subset of adolescents who developed ED symptoms was present in the longer term studies. Moreover, the high numbers of missing data due to adolescents lost to follow up is important to note and cannot be overlooked as a potential indicator of even higher risk.”

The other study they cite, Leite et al.  2017 only considers binge-eating disorder and only includes adults. (This is something that is common – looking at ED symptoms that would be reduced, at least short term, by following a “weight management” program while ignoring the ED symptoms that are prescribed by weight management programs including things like food preoccupation, food restriction, frequent weighing etc.) This study included only 24 volunteers, and was only a 32-week intervention.  They offer no proof that what they’ve captured isn’t short term compliance with a weight-management program that will be followed by longer-term return to, and possibly exacerbation of, disordered eating and eating disorder behavior.

Overall, however, participation in treatment for ob*sity has been associated with reductions in disordered eating behaviors

Here they re-cite Jebeile et al 2019 (Treatment of ob*sity, with a dietary component, and eating disorder risk in children and adolescents) analyzed above.

They also cite Jebeile et al 2019 (Association of pediatric ob*sity treatment, including a dietary component, with change in depression and anxiety: A systematic review and meta-analysis.). This does not actually examine eating disorder symptoms, but looks at changes in depression and anxiety. They find that “structured, professionally run pediatric ob*sity treatment is not associated with an increased risk of depression or anxiety and may result in a mild reduction in symptoms.” Note that the use of “may result.” Further, the studies offer follow-up between 2 weeks to 15 months which fails to capture the fact that weight regain from these programs typically starts around the 12-month mark, and fails to address (or even consider) what will happen to depression and anxiety symptoms during/after likely weight regain. I did a deep dive into this study here.

They also cite Grilo et al., 2020. This study’s lead author consults for Sunovion and Weight Watchers International. Again, this study only looks at binge eating disorder in adults and only on a 6-month intervention. Without long-term outcome data there is no way to know if “compliance” with this short-term intervention led to long-term development of EDs, nor how this impacted ED behaviors outside of binge-eating disorder.

Evidence-based ob*sity treatment is compatible with a patient-centered treatment approach, as these treatments focus on improving overall health rather than weight loss alone, and can reduce ED risk.

Neither the papers cited above, nor the papers cited here support the conclusion that these treatments can reduce ED risk (or that these treatments can lead to significant, long-term weight reduction and/or health improvement.)

The first paper they cite here is Wharton et al 2020. The authors take significant payments from weight loss interests including Novo Nordisk, Bausch Health, Eli Lilly, Janssen and more.  The study recommends pathologizing bodies based on size and offering treatments including medical nutrition therapy, physical activity, psychological interventions, pharmacotherapy and surgery, all focused on changing the size of the patient (and the latter two of which are sold by the companies from which the authors take payments.) This study makes no mention of eating disorder risk.

Next they cite Ryan and Yockey, 2017. This paper does not mention eating disorders.

Next they cite Webb and Wadden, 2017. This paper does not mention eating disorders.

Next they cite MacLean et al, 2015. This is not a study, but rather a working group report. This paper does not mention eating disorders.

It seems that by citing these papers they are trying to make the case that these recommendations are broader than just weight loss, however, the primary focus of the interventions is on pathologizing and subsequently manipulating body size, and none of these studies show sustained weight loss or health improvements at/beyond five years. In fact, most specifically show and/or discuss the very high rate of weight regain.

Many individuals regain weight after ob*sity treatment, leading to concern about weight cycling. Early research indicated patterns of weight loss and regain are associated with higher all-cause mortality and morbidity from cardiovascular disease; however, much of this research did not control for unintentional weight loss from underlying health conditions. More recent findings support that treatments for ob*sity produce significant and sustained physical and mental health improvements, despite potential weight regain, and challenge the notion that losing and regaining causes more harm than never losing weight. In fact, increased frequency of weight loss attempts when at least 5 lb were lost is associated with lower mortality than no attempt.

Here they made a small mention of the harms of weight cycling which they have heretofore failed to mention or discuss. Again, they are ignoring the research that finds that behavior changes, rather than weight loss attempts, are likely responsible for any health changes. I also think they are downplaying the risks of weight cycling.

The study Cardel et al cites to suggest that increased frequency of weight loss attempts was associated with lower mortality than no attempt is Willis et al. 2020. This is a study of AARP members, who are senior citizens. Remember that the AAP is using this study to support recommendations for kids as young as two. The study depended on a self-reporting of the patient’s memories of their weight loss attempts and exact weights over the previous 20 years.  In some cases, weight cycling predicted a high hazard ratio, and the study authors point out that “the benefit observed for frequent weight loss attempts may be because these individuals engage in healthy behaviors (e.g., exercise, healthy diet, etc.) over a cumulative longer time period than those who made no attempts” and “ One potential limitation of our study is that associations could reflect confounding by unmeasured or poorly measured confounders, including other unmeasured behavior changes.” They also point out that “Infrequent attempts with large volumes of weight lost provided no mortality benefit.”

Again, our study authors are working hard NOT to consider the (unprofitable) option of focusing on supporting the health of higher-weight kids directly, rather than trying to (profitably, but likely without success) manipulate the body size.

Robust analyses have demonstrated that treatment for ob*sity may reduce ED prevalence and risk

It is unclear what definition they are utilizing for “robust” but, based on the research they cite, it’s not a definition with which I am familiar.

They re-cite Jebeile et al. 2019 (Treatment of ob*sity, with a dietary component, and eating disorder risk in children and adolescents ) As a reminder, the issues with this study were summarized by Louise Adams above.

They also re-cite Grilo et al 2020 which we covered above.

Supervised behavioral childhood ob*sity treatment may have a protective effect via treatment carryover by addressing emotional eating

First, note the use of “may.”

They re-cite both Jebeile et al. 2019 studies. As previously noted, neither of these studies support this dubious claim.

Both meal planning and regular eating are components of ob*sity treatment that overlap with cognitive behavioral therapy (CBT) for EDs

The study they cite to support this, Sivyer et al. 2020, included only 130 adult subjects, lasted only 20 weeks, and looked only at binge eating disorder. The study examined four potential mediators of change in Cognitive Behavior Therapy on binge eating disorder (regular eating, weighing frequency, shape checking, and interpersonal problem severity.) The study found that only regular eating reduced binge-eating frequency. They did not study the impact of weight loss interventions which focus not just on regular eating, but eating with the goal of manipulating body size.

Again, Cardel et al. continuously write “eating disorders” when they are only providing information about Binge Eating Disorder, without making that in any way clear.

Meal planning ensures nutrient-rich foods are available when it is time to eat, mirroring efforts to identify and reduce triggers for disordered eating. Regular eating is prescribed to prevent excessive hunger, which contributes to dysregulated eating

The study they cite, Fairburn et al., 1993, again, only looks at binge eating disorder, I was not able to find a copy of the full text of this 30-year-old research. One wonders, if this is such a good idea, why research from this century could not be located.

This claim also fails to address the fact that intensive behavioral interventions for “ob*sity” focus on caloric restriction, and that the pharmacotherapy and bariatric surgery that are recommended by the AAP guidelines focus on disrupting hunger and satiety signals in order to induce patients to eat less food than they need to create an energy imbalance, which is the opposite of what is done in eating disorder treatment.

Regular weigh-ins represent another component shared between supervised evidence-based ob*sity treatments and CBT for EDs. Weekly weighing replaces too frequent or complete avoidance of weighing, either of which can perpetuate disordered eating. In individuals without EDs, self-weighing helps facilitate clinically significant weight loss without leading to ED symptoms.

They cite Gorin et al. 2019 which looks at self-weighing. It includes only a 4-month intervention followed by optional interventions with sporadic two-year follow-up. Many of their results failed to meet statistical significance. Both the frequency of weighing and the “general health” scores were compiled via a single question asked only once per year during follow-up (ie: How often do you weigh yourself: several times a day, daily, a few times a week, weekly, once a month, less than once a month to never.) The only disordered eating behaviors they captured (through self-report) were frequency of binge eating episodes accompanied by loss of control and frequency of compensatory behaviors including vomiting, diuretics, fasting, or exercising more than one hour to control weight.

They found that more frequent self-weighing was directly proportional to rigid control “characterized by an all-or-nothing inflexibility around dietary rules (e.g., strict calorie counting, with guilt following if calorie-dense foods are consumed)” which has been associated with more frequent and more severe binge eating episodes. They list two years of follow-up as a strength of the study but, in fact, may be missing eating disorders that develop over time if frequent weighing reinforces internalization of the thin ideal, and if rigid control continues and/or increases over time. They excluded those with eating disorders from their sample, which means that even if this research gives someone some “assurance”(and I’m not at all sure that it does,) that assurance would not apply to those with eating disorders.

Steinberg 2013 is a 6-month intervention that only included adults and so is not extrapolatable to pediatric populations. This study only measured weight loss, with no attempt to capture eating disorder signs or symptoms. In addition to not being extrapolatable to younger populations, concerningly, the intervention group reported lower body dissatisfaction which, since they were experiencing (at least short-term) weight loss, may indicate an internalization of the thin ideal that could lead to future eating disorders. They also experienced greater dietary restraint, if this restraint was rigid (which was not reported one way or the other,) it has been associated with more frequent and more severe binge eating disorder episodes. Finally, 6 months is likely not enough time to capture any adverse effects of self-weighing.

Here again, Cardel et al. are drawing a false parallel between legitimate ED treatment and “weight management” by failing to mention that the weigh-ins in ED treatment are to make sure that people are getting adequate food/energy, whereas the weigh-ins in “ob*sity” treatment are to measure the manipulation of body size toward a thin ideal, the internalization of which they, themselves, have admitted can cause eating disorders.

It should be noted that “clinically significant weight loss” is a term used for very small amounts of weight loss, and none of the studies cited by Cardel et al to support this claim show long-term (at least 5-year) sustained weight loss. It should also be noted that actual cardiometabolic health measurements were not included – they are only talking about weight changes, not health changes.

Among those with EDs, being aware of weight can counteract irrational beliefs that can motivate disordered behaviors or create ambivalence about treatment.

Again, Fairburn et al. is a 30-year-old study that only considered binge eating disorder. I was unable to find a copy of the study but Mountford et al (the next study they cite) seems to suggest that Fairburn et al.’s recommendation is that patients not weigh themselves?

Mountford et al. 2015 is not a study, it is a paper whose thesis is that patients with EDs should be weighed by practitioners during Cognitive Behavioral Therapy. It views weighing as a “safe” behavior and suggests labeling the desire not to be weighted as a “problem behavior” to which CBT can be applied, without engaging in the issues of placing weighing into the context of a society rife with weight stigma and internalizing the thin ideal or creating body dissatisfaction.

In fact, they take the view that while “undoubtedly” those with EDs “overvalue their eating, weight and shape as part of their self-worth more than non-sufferers…however, that condition is so normative (particularly among females in western cultures) that it is hard to see it as a defining characteristic of the eating disorders.”

Concerningly, this attempts to de-pathologize/normalize disordered relationships with food and movement on the basis that disordered relationships with weight and body have been normalized through (highly profitable) diet culture. Further, problematically this paper recommends that practitioners be “firm” in denying patients their right to informed refusal of a weigh-in. They offer no outcome data about this type of weighing, and no proof that weighing will not increase body dissatisfaction, investment in the thin-ideal, or disordered eating behaviors.

Sysko & Hildebrandt 2011 is a single-subject case study of Family Therapy and Cognitive Behavioral Therapy on an “underweight” 16-year-old with a diagnosis that no longer exists (eating disorder not otherwise specified (EDNOS)) whose symptoms included binging and purging and who had significant anxiety over seeing her weight, over 29 treatments. The study mentioned that use of in-session weigh-ins to decrease the subject’s anxiety about knowing her weight, but makes no causal connection between weighing in and a decrease in disordered eating behaviors. Obviously, this study has extremely limited extrapolatability, especially to weight loss contexts. Again, one wonders why the authors are using single-subject case studies to support recommendations for millions of vulnerable children.

Treatments for ob*sity also emphasize improving diet quality,86,87 suggesting a flexible eating style in which more nutrient-dense foods and fewer nutrient-poor, energy-dense foods are consumed, while moderately restricting caloric intake. No foods are prohibited and a balanced dietary pattern is recommended. This avoids triggering cognitive distortions linked to EDs, such as dividing foods into “good” vs “bad.”106 This approach is identical to that used in CBT for EDs.

The fact that they didn’t at least modify this to say “some treatments for ob*sity” is ridiculous. MANY so-called “ob*sity treatments” recommended in medical settings suggest a rigid eating style, prohibit specific foods, and divide foods into “good and bad.” This is ESPECIALLY true for children where the “red, yellow, green” and “whoa, slow, go” methods are common (and harmful.)

Bray et al, 2016 which does recommend a high-quality diet, but Cardel et al seem to be ignoring the fact that it recommends that in concert with “a minimum” of 150 minutes a week of movement which is an issue in ED treatment (where movement may also be contraindicated.) This study also recommends pharmacotherapy to disrupt hunger signals and surgeries that disrupt hunger signals and force malabsorption and extreme restriction, none of which parallels recommendations in ED treatment.

Looney and Raynor, 2013 only includes adults. They take the debunked position that “overweight” and “ob*sity” are simply a matter of energy imbalance. One group of participants were recommended low calorie diets (1200-1500kcal) which is not consistent with ED treatment. The other group substituted two meals a day with SlimFast. They only offer two years of follow-up which is not sufficient to capture the weight regain that research shows typically happens between years 2 and 5. They discuss various types of diet (low fat, low carb etc.) but always from a perspective of consuming fewer calories than the body requires which is at odds with ED treatment. The research also includes a significant exercise component.

Cardel et al.’s statement here (claiming that “ob*sity treatment” is identical to that used in CBT for EDs”) is patently false as “ob*sity treatment,” by their own admission, is based upon caloric restriction and CBT for ED does not include restricting caloric intake (in fact, it is one of the behaviors that CBT seeks to stop in the case of many EDs.)

The few studies examining ob*sity treatments that assess weight stigma have all shown modest yet significant short- and long-term reductions in weight stigma.

They cite Mensinger, Calogera and Tylka 2016 which does not support this claim. The study looked at impact of internalized weight stigma on adult [cis] women in a weight-management vs a weight-neutral healthy living program. They found that “Participants from both programs with low internalized weight stigma improved adaptive eating at 6 months, but only weight-neutral program participants maintained changes at follow-up.” (emphasis mine)

Durso & Latner 2008 is a study to develop an internal weight bias scale using an entirely adult population. They did not study the impact of “ob*sity treatment” on short- or long-term weight stigma and thus don’t support the above statement.

Lillis et al 2010 presented the weight self-stigma questionnaire, and only included adult participants. They did not study the impact of “ob*sity treatments” on weight stigma. They studied the impact of a “1-day mindfulness and acceptance-based workshop based on acceptance and commitment therapy that was designed to reduce weight stigma and increase quality of life.” It should be noted that this scale is, itself, rooted in weight stigma with terms like “my weight problems” and “overweight” as well as, ridiculously, classifying the reality-based, thoroughly evidence-supported view that one is very likely to regain weight after weight loss (which they admit in their own discussion section) to be a form of “self-stigma” which is roughly like saying that people are being self-stigmatizing if they say they probably can’t fly by jumping off their roof and flapping their arms really hard.

Pearl et al. 2019 only includes adults and does not support the above statement. They found that “Among participants in a weight loss maintenance trial, weight bias internalization did not change in relation to changes in weight.”

Lillis et al. 2019 included only adults and only had 24 months of follow-up. They did not study the impact of the weight loss program on weight stigma, they studied the impact of weight stigma on the amount of weight that was lost, hypothesizing only that “there may be potential for incorporating intervention methods targeting the reduction of self-stigma in order to improve weight loss outcomes.”

Behavioral and CBT interventions for weight often address negative cognitions that affect self-esteem and body image, which can minimize internalized weight stigma.

Look AHEAD studied adults who utilized meal replacement shakes and bars as well as weight loss medication. The study does not mention weight stigma, the only mention of self-esteem and body image is “Other new concepts presented in months 7 to 12 include coping with dietary lapses, improving body image and self esteem, and expanding exercise options.” They did not adequately measure the impacts to draw any conclusions.

The Diabetes Prevention Program Research Group studied only adults (average age: 51). The study doesn’t mention self-esteem, body image, or weight stigma.

The LEARN Program is a book originally published in 1997. Access to the text was not available.

For example, increasing self-efficacy by meeting behavioral goals enables a person to challenge and reject negative beliefs about one’s capabilities.

Pearl et al. 2020 (their citation 113) looked at just 72 adults over only 26 weeks and found only that “A psychological intervention for weight bias internalization produced short-term reductions in some aspects of weight self-stigma in persons with ob*sity.”

Pearl et al 2020 (their citation 114) is a follow-up on the above study group. 54 of the original 72 adults completed the follow-up assessment at 52 weeks (note that they lost 25% of their study population in just the first year.) They found that reductions in internalized weight bias did not differ between groups that were given the psychological intervention for weight bias internalization and behavioral weight loss and the group that was only given behavioral weight loss.

Further study of mechanisms for stigma-reduction are needed; still, these findings reveal internalized weight stigma reduces, rather than increases, with behavioral weight management treatment alone.

This statement is not supported by the research above for the long-term. The studies cited fail to follow-up during the 2-5 years when weight regain is highly likely, and thus fail to capture any impact on internalized weight stigma of the almost certain weight regain. Also, again, the studies cited are almost entirely adult populations, being used by the AAP to support recommendations for children.

The thing that this study constantly dances around is that all the benefits of focusing on health-supporting behaviors can be gained by ACTUALLY focusing on health-supporting behaviors (with fewer risks) than trying to sell intentional weight loss attempts wrapped in healthy behavior bow.

I have no idea about the true intentions or beliefs of the researchers, but I can’t help but notice that being clear about the benefits of a weight-neutral approach would not be a profitable message for the companies the authors work for and take money from (as we’ve seen with Weight Watchers - for whom, remember, this paper’s lead author is the Director of Global Clinical Research & Nutrition - who made a quick 180 from their utterly disingenuous “it’s about health” message to not just focus on weight loss, but actually start selling diet pills.

Of course, this is just my best guess, but having done a deep dive into this paper and the research that the authors cite to make their case, it seems to me that they had a very specific agenda and they created this study to (try to) support it. I don’t believe that this study in any way supports the AAP’s (profitable) claim that giving foisting behavior-based weight loss interventions on children as young as two constitutes the practice of ethical, evidence-based medicine, I also don’t believe that it supports the study title’s claims that “health care providers can treat ob*sity while actively addressing weight stigma and eating disorder risk.”

What’s truly despicable is the use of this research to try to silence/shout over/discredit the voices of higher-weight people who are very clear that these so-called “supervised ob*sity treatments” created eating disorders, exacerbated eating disorders, prevented full recovery from eating disorders, and caused relapses of eating disorders. The use of research like this to try to sway eating disorders professionals and other healthcare professionals to ignore the lived reality of higher-weight people (especially when it is one in the service of diet industry profit) is unconscionable, and we have to make sure that we are not fooled.

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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.