Outlook: Newsletter of the Society of Behavorial Medicine

Winter 2024

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Should the Field of Behavioral Medicine Move Away from Obesity?

Joanna Buscemi, PhD - SBM Member Delegate

In 2019, Society of Behavioral Medicine’s (SBM) past-president, Dr. Michael Diefenbach, challenged us to consider “provocative questions” in behavioral medicine.1 This initiative encouraged the generation of innovative ideas about what may push the field forward to address some of our “grand challenges.” While members of SBM pursue research across many areas, what brings us together is SBM’s mission to “improve the health and well-being of individuals, families, communities and populations.” As science and culture simultaneously evolve, the ways in which we approach this grand challenge of promoting health will undoubtedly shift as well. These shifts require an openness to reconceptualizing old ways of approaching health problems and bringing in new perspectives. In the spirit of continuing Dr. Diefenbach’s challenge, I present to you another provocative question, “Should the field of behavioral medicine move away from obesity?”

Growing up in the 1990s diet culture and then pursuing graduate training in behavioral medicine as a young adult, I was exposed to the pervasive message that the way to be “healthy” was to be thin to the point where I never considered any alternative way of thinking. At SBM’s annual meeting in 2021, Dr. Michelle May was one of the first to challenge my strongly held beliefs. She began her presentation by asking us all to be open to radically changing the way we think about weight. She challenged the concept that weight equals health,[2, 3] she described the significant limitations (and problematic roots) of Body Mass Index (BMI;) 4 and she talked about the harmful effects of calorie restriction and weight stigma.5 Importantly, she opened up my mind to what now seems like a simple concept. I had always paired food and exercise with weight, but in that moment, she encouraged us to unpair them.

It is entirely possible to promote health through increasing peoples’ access to a wide variety of nutritious foods and helping them find fun and sustainable ways to move their bodies without restricting calories and without even a single mention of weight.

It took me some time to wrap my mind around this unpairing, but once I did, it changed the way I thought about weight, wellness, health promotion and disease prevention. I began to critically evaluate the interventions commonly used in our field for weight loss, many of which involve extreme calorie restriction and have poor long-term outcomes for weight maintenance. [2, 6, 7] I began to ask myself some important questions: Is it time to think that perhaps the tools we have are not working and potentially causing more harm? 8 Is it possible that the weight cycling our interventions can cause may be perpetuating public health crises rather than addressing them? 9 Is it possible that there are much better tools to promote health and prevent disease that we are missing because of our hyperfocus on weight?

In 2022, SBM invited Dr. Sabrina Strings for a Master Lecture. In a wall-to-wall packed room, she talked about the racial origins of fatphobia and how weight stigma entered the medical field.10 Her talk challenged us to think more deeply about how fatphobia contributes to health inequities across chronic diseases, and how focusing on weight moves us away from more intentionally dedicating effort to environmental and social inequities that more definitively drive health outcomes across disease presentations. Given behavioral medicine’s central focus on promoting diversity, equity and inclusion, it is important to fully recognize that actively working to address weight stigma in our science and in our practices is an important part of those efforts, including attention to how weight stigma interacts with other intersecting marginalized identities.

Currently, the shift from weight-loss to weight-neutral interventions in behavioral interventions is slow but visible, and some SBM members have written pieces to raise awareness about the harms of weight loss interventions. [e.g.,11-12] However, we still have a predominant focus on obesity treatment methods involving significant caloric restriction, despite knowing this level of restriction is not sustainable [2, 6, 7] and potentially harmful.8 And while the overall goal with these efforts has been to reduce the rates of obesity nationwide, population level data show that the rates of obesity have nearly tripled since the beginning of the proliferation of behavioral interventions for obesity in the late 1980’s and early 1990’s,13 and health inequities for chronic diseases persist.14 These outcomes suggest that current strategies have not fully achieved their intended goals, indicating the need for a paradigm shift toward more sustainable, weight-neutral approaches to effectively address the complex public health issues at hand.

A shift away from obesity in behavioral medicine may seem radical to some and could challenge long-held identities among certain researchers. However, it is important to emphasize that this change wouldn't diminish our understanding of behavior change science, nor would it alter the well-established benefits of eating a variety of nutritious foods and engaging in regular physical activity. These evidence-based behavioral components, alongside nutrition and exercise science, have always been and will continue to be the cornerstone of our interventions to prevent chronic disease and promote overall health. By prioritizing these foundational elements, while also addressing the systemic factors that drive health inequities, we can maximize our impact on public health as scientists—reducing the harm associated with weight-loss interventions, moving away from a harmful focus on weight, and fostering a more inclusive, health-focused approach.

References:

  1. Diefenbach MA, Phillips A, Bullock L. Provocative Questions in Behavioral Medicine and the Acceleration of our Science. Annals of Behavioral Medicine. 2020; 54(12):920-923. doi: 10.1093/abm/kaaa087. PMID: 33416837; PMCID: PMC7791609.
  2. Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C, Calogero RM. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity. 2014; 983495. doi: 10.1155/2014/983495.
  3. Tomiyama AJ, Ahlstrom B, & Mann T. Long-term Effects of Dieting: Is Weight Loss Related to Health? Social and Personality Psychology Compass. 2014; 7(12), 861-877.
  4. Tomiyama, A. J., et al. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. International Journal of Obesity. 2016; 40(5), 883-886.
  5. Bacon L, & Aphramor L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal. 2022; 10(1).
  6. Wing RR & Phelan S. Long-term weight loss maintenance; American Journal of Clinical Nutrition. 2005; 82:222s-225s.
  7. Kraschnewski JL, Boan J, Esposito J. et al. Long-term weight loss maintenance in the United States International Journal of Obesity. 2010; 34:1644-1654.
  8. Levinson CA, Fitterman-Harris HF, Patterson S, Harrop E, Turner C,  May M, Steinberg D, Muhlheim L, Millner R, Trujillo-ChiVacuan E, Averyt J, Peebles R, Rosenbluth S, & Becker CB. The unintentional harms of weight management treatment: Time for a change. The Behavior Therapist; 2023; 46(7), 271–282.
  9. Tomiyama AJ. Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model; Appetite. 2014; 82:8-15.
  10. Strings S. Fearing the Black Body: The Racial Origins of Fat Phobia. Reprint ed. New York University Press; 2019.
  11. Steinberg, DM, Bohon, C., et al. Truly Reduce Weight Stigma and Eating Disorder Risk, We Need to Stop Promoting Weight Loss. Journal of the Academy of Nutrition and Dietetics. 2023; 123(3), 399 - 400.
  12. Frediani, JF, Woodruff, NH., Fowler, L.A.  What Does it Mean to be Weight Neutral? SBM Healthy Living Article. 2024: https://www.sbm.org/healthy-living/what-does-it-mean-to-be-weight-neutral?utm_source=informz&utm_medium=email&utm_campaign=mailing&_zs=Fjblo&_zl=B1i93
  13. Centers for Disease Control and Prevention. Adult Obesity Prevalence Maps. U.S. Dept of Health and Human Services; 2023.
  14. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 2, The State of Health Disparities in the United States. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425844/