Is there a new weight paradigm? – changing attitudes of body weight concept and role of health care professional in relation to body weight
Ellen S. Parham
TRADITIONAL VIEWS OF FATNESS
Sobal has described the evolution of models of fatness from the admiration characteristic of traditional cultures first to a moral model, to a medical model in the 1950s, and, more recently, to a political model. In Table 1, the moral and medical models are combined and identified as the traditional paradigm, which defines fatness as deviance, a problem to be corrected. The moral model considers the problem is one of weakness, laziness, and gluttony, fatness being the outcome of willful behavior of eating too much. The remedy is to exert will power to eat less. The medical model views fatness as a disease and emphasizes reliance on external control exerted by diet plans, exercise prescriptions, and other authoritative guidance. This agreement that fatness is a deleterious condition that should be avoided or corrected makes these traditional models variations of a single paradigm. They explain fatness as bad, unhealthy, and a threat to quality of life. The huge weight-loss industry profits from the perpetuation of these explanations.
[TABULAR DATA 1 OMITTED]
Even as the medical model has gained strength, the moral model has continued as an explanation of fatness (Table 1). The simultaneous existence of these two models contributes to a cycle of blaming that has fueled fat phobia. Because both models consider that the level of body fat is under voluntary control, those individuals who fail to slenderize are considered willful, noncompliant, and morally weak. Even well-meaning individuals may feel that their stigmatization of obesity is justified because of the assumption of major health risks accompanying the excess weight.
DISILLUSIONMENT WITH THE TRADITIONAL MODELS
As researchers and practitioners worked with obesity, many became disillusioned with the fit of the traditional paradigm to the realities they encountered. They began to ask some hard questions.
How Modifiable Is the Level of Fatness? Numerous reviews in recent years[2-6] have demonstrated the fallacy of the popular assumption that the human body can be resized at will. Most objective examinations of available interventions admit that, although there may be weight losses, rarely are these losses sustained.[2,5] In contrast to earlier statements of federal agencies and programs, the 1992 NIH conference on Methods for Voluntary Weight Loss and Control conceded that interventions currently in use meet with limited success.
Some reviewers optimistically note that increasingly painstaking research has led to improved interventions that are successful in producing modest losses that are maintained for considerable periods.[3,4] Others, less impressed with these outcomes, observe that the interventions are so extensive and demanding that their effects may be the result of screening out all but a very select group.[5,6] When surgical interventions, repeated and extensive hospitalizations for intensive dietary treatments, extended therapist contact, among other weight-loss treatments, produce follow-up weights only a few kilograms below starting levels among only some of those initiating treatment, we can hardly claim to have success in reversing obesity.
Brownell and Rodin suggest that if we had good data on the weight-loss experience of ordinary people, we would find that dieting is successful and would conclude that obesity is largely reversible. It is difficult to reconcile that suggestion with the increasing incidence of obesity in this country. Neither is it possible to explain this paradox by assuming that the obese people neither care about their fatness nor try to do anything about it. The numerous reports of widespread dieting clearly indicate much concern and effort.
Reports in the literature coupled with first-hand experience of practitioners have led to a major wave of disillusionment with our current ability to intervene effectively to reverse obesity among most persons. This is an important factor fueling interest in the new weight paradigm.
Does External Control Make Matters Worse? Diets are a means of establishing eating control external to the body’s signals of hunger and satiety. Those rare individuals who maintain weight loss through dieting become quite methodical about their eating. Indeed, writing from a medical model perspective, Kirschenbaum and Fitzgibbon advocate long-term programs designed to cultivate obsessive-compulsive self-regulation, accompanied by “supernormal” eating. Most dieters, however, are unable to achieve this level of control.
In fact, there are several indications that relying on external control is quite problematic. The human body has evolved with numerous powerful mechanisms to protect against starvation. These are not inactivated by a voluntary decision to diet. The external nature of diets contributes an on/off quality and perpetuates the fantasy that when one finds just the right diet, slenderness will follow. Diets exacerbate dieters’ strong feelings about food–it becoming their tempting enemy. There is a positive correlation between dieting and binge eating and, although to date no research has been applied to significant numbers of people using the design necessary to demonstrate causality, anecdotal evidence suggests that years of alternating between deprivation and guilt-laden eating contributes to the development of binge eating. Effective interventions with bulimia and binge eating usually involve stopping dieting.
What Are the Real Costs of Fatness? It is clear that fatness is negatively associated with health. The relationship, however, is complex and involves many unanswered questions, such as “Why aren’t all fat people equally affected? What is the impact of distribution of fat? What is the impact of weight cycling? To what extent are the health risks affected by behaviors and experiences secondary to obesity? By concentrating on the risks to physical health, are we exacerbating the psychosocial risks? Is it possible for a fat person to reduce health risks without losing weight?” These largely unanswered questions are quite compelling to those who have become advocates of the new weight paradigm.
Are the Obese a Homogeneous Population? For years, leaders in the medical model movement have noted the diversity among fat persons, referring to the multiple etiology of obesity, “the obesities,” and various classification systems. Yet most authors treat obese persons as a homogeneous group. For example, in discussions of the problems of fatness, rarely is there recognition of the existence of obese persons who are physically active and have full and satisfying lives. This type of overgeneralization slides easily into the perpetuation of negative stereotypes.
Who Is in Charge? The traditional weight paradigms view obese individuals as unable to take charge of their own behavior. Rather, they are dependent on others to design interventions that will produce better behaviors and to promote adherence to them. Although some authors laudably recommend that obese patients, as active partners in their own treatment, choose among several treatment options, most clinical practices are very limited in their ability to offer any real variety in interventions. Most problematic, however, is the absence for the option to decline to attempt to lose weight.
Advocates of the new weight paradigm have found these situations frustrating in the extreme. We lack interventions with a high likelihood of success, yet we demand that fat persons try them anyway. Our culture’s acceptance of the moral model of obesity persuades fat people that their shortcomings are responsible for the failure of the interventions. This situation is especially tragic in the case of fat persons who are experiencing a real health problem, but for whom the fixation with fatness may be a barrier to pursuit of treatments and behaviors that might be beneficial in spite of their weight.
The Call for New Approaches. As Sobal accounts, although the medicalization of obesity was first heralded as a blame-free alternative to the guilt-inducing moral model, the medical model was not value neutral. Individuals and groups with vested interests found it advantageous to join the medical bandwagon. Recognition that the medical risks of obesity were being used to justify preoccupation with dieting and body ideals far thinner than those consistent with lowest mortality led to the emergence of a third model, a political model. This model started as a “fat rights” movement that paralleled other rights movements of the 1960s.
This activist movement was at first a women’s movement fueled by the suspicion that pressures to be thin were really efforts to keep women so occupied with dieting and so convinced of their own ineffectiveness that they would not challenge traditional political structures. These leaders observed that a large woman was often considered a powerful woman and hypothesized that pressures to be slender were efforts to keep women small, occupying small spaces and threatened by the risk that fatness would impair their attractiveness. Carol Munter, who now with Jane Hirschmann heads the National Center for Overcoming Overeating, led a women’s group in the 1970s in which women dealt with these issues. Suzie Orbach’s 1978 book Fat is a Feminist Issue spread the questioning of the traditional views of fatness to readers across the country. Orbach’s work was followed by numerous books for the public promoting fat acceptance, pointing out that diets don’t work, and advocating various ways to improve quality of life. The National Association to Advance Fat Acceptance (NAAFA) was started in 1969 under the name National Association to Aid Fat Americans. Radiance magazine appeared in 1984 and continues to carry a message that fat women can be attractive and lead active, rewarding lives.
What started as an activist movement soon took on other forms. Susan Wooley initiated, in the 1970s, a string of articles that provided strong challenges to the moral and medical models of obesity. As early as 1976, Richard Keesey was publishing evidence of the existence of “set-point” weight regulation among laboratory animals. At about this same time, Janet Polivy and C. Peter Herman introduced the concepts of restrained eating and the boundary model of regulation of eating, offering some explanation of what clinicians were seeing in the field. Paul Ernsberger and Paul Haskew published in 1987 a thorough reexamination of the data linking obesity and health. Currently, there are more scientists and practitioners writing, speaking, and working within the new paradigm than can be mentioned here.
Leadership in the new paradigm movements originally came primarily from psychologists and counselors. Only more recently have other health care professionals made major contributions. Joe McVoy, a counselor and family therapist in Virginia, had a major impact in bringing together various disciplines to focus professionally on the new paradigm when he convened a conference in the spring of 1991. Out of this conference, the Association for the Health Enhancement of Large Persons (AHELP) was born. AHELP, like other groups related to the new paradigm, deals with eating disorders as well as obesity.
Not surprisingly, coming from a profession having the word “diet” in its name, involvement in a nondiet movement constitutes a stretch for some dietitians. Nevertheless, many have been able to make that leap. The American Dietetic Association has offered nondiet workshops at its two most recent annual meetings. In 1995, the Society for Nutrition Education chartered a new division related to the new paradigm, Nutrition and Weight Realities.
TWO NEW MODELS EMERGE
Advocates of the new weight paradigm are suggesting that in search for answers related to fatness, we are asking the wrong questions. Rather than ask “How can my client get and stay thin?” the question might be “What are my client’s real goals?” or “How can my client be healthier and happier?” Although there are a variety of answers advocated by leaders and researchers of the new paradigm, there are two main movements, size acceptance and nondiet.
Size Acceptance. The simplest of the new movements, size acceptance, provides the greatest challenge to the values of our dominant culture. Rejecting the concept that fatness is bad, some fat acceptance purists repudiate expressions such as “the problem of obesity” and challenge the idea that obese people have need of change. Size acceptance is the most unique part of the new weight paradigm and is a major factor in all approaches related to the paradigm. In fact, this author uses the presence of size acceptance as a criterion for determining whether a model, program, or approach is a part of the new paradigm.
The Nondiet Movement. The nondiet movement takes numerous forms that vary in the extent of focus upon change in fatness. Some advocate no change in body composition, instead focusing on adopting attitudes and behaviors that will enhance quality of life. Others encourage modest losses when physical or emotional health is threatened. None support the use of restrictive diets. Dietitians, nutrition educators, and other health care professionals tend to endorse the nondiet movement, rather than pure size acceptance, possibly because their services are more likely to be sought out by people who feel troubled by their fatness and are seeking some change (Fig. 1).
Nondiet Diets. Because the new weight paradigm has been addressed extensively in the popular literature, “nondiet” has become a buzz word that has been adopted by various commercial concerns. In fact, many of these programs and products have merely pasted new names on old approaches grounded in the moral and/or medical models.
COMPONENTS COMMON TO MOST APPROACHES
Although the new weight paradigm is not restricted to use with groups, the goals are long-term and usually require extensive programming in most cases, making groups a more efficient means of implementation. The components described here have been described by numerous authors.[13-20]
Self-Acceptance. For some, acceptance of oneself and one’s body is one of the most difficult components to grasp. Self-acceptance in the sense that is consistent with the new weight paradigm is a matter of knowing oneself and one’s body from many perspectives, enjoying one’s strengths and beauties, and objectively and dispassionately viewing the limitations and weaknesses. This view of acceptance reminds the author of the way children view their paintings. Unless they are taught otherwise, very young children are totally accepting, even delighted, with their own creations. Far from interfering with learning how to draw better, this acceptance is a foundation on which the child’s emotional growth and development builds.
Internal Control of Eating. New paradigm programs are especially helpful for binge eaters and others who feel their eating is out of control, guided by emotions rather than internal cues. The approaches recommended[13-19] to help to break away from these old responses and to develop new behaviors commonly have the following characteristics:
* Dieting is strongly discouraged.
* Participants are urged to consider all foods as “okay.”
* Heightened attention is given to signals of hunger and satiety and participants are urged to respond to these consistently.
* Participants learn to identify eating that is in response to emotions and to environmental factors.
* Alternative ways to meet emotional needs and to respond to environmental pressures are explored and practiced.
A variety of methods, psychoeducational, cognitive, and behavioral, might be used to facilitate these changes. Indeed, these programs are sometimes confused with traditional behavior modification approaches. One should bear in mind, however, that the techniques of the traditional approaches are designed to make it easier to sustain restrained eating or dieting, whereas the new paradigm approach has just the opposite goal.
Attention to the Quality of the Food Eaten. There is diversity of opinion as to whether it is appropriate to address the quality of food intake. Some leaders observe that obese people have been so besieged by dietary advice that attention to these matters would feel like a perpetuation of restriction and would interfere with new learning.
On the other hand, nutritionists and dietitians believe that food intake impacts health and well being and tend to be attentive to the nature of food selected. In fact, many suggest that some of the health impairments experienced by some obese persons are the result of the poor food intakes resulting from years of selecting foods on the basis of what would promote weight loss. These nutritionists advocate an attitude of taking individual responsibility for the quality of one’s intake, just as one takes responsibility for dental care or use of seat belts. When working with clients who have symptoms of health risk, they point out that there is some evidence that benefits in serum lipid profile and blood pressure levels may be realized in the absence of caloric restriction or weight loss.
Increased Physical Activity. New paradigm approaches urge that all participants find forms of movement that they enjoy and are within their ability. Physical activity is valued, not as a means of losing weight, but for its contribution to enhanced mental and physical health. Through their book Great Shape, Pat Lyons and Debby Burgard have been instrumental in refuting stereotypes about the exercise limitations of obese persons (Fig. 2).
THE NEW PARADIGM IN ACTION
In the professional literature there are relatively few reports of trials of new paradigm programs. Traditional weight control programs usually are evaluated on the basis of changes in weight or fatness, criteria inappropriate for most new paradigm programs. Because the paradigm emphasizes the value of individuals choosing their own goals and objectives and because programs usually utilize small groups, it is more difficult to design evaluative research. Nevertheless, it is incumbent upon those who offer services to demonstrate their value.
Hirschmann and Munter, in their recent book When Women Stop Hating their Bodies, included an analysis by Steinhardt and Nagel of a random sample of 750 of the 2700 returns of questionnaires included in Hirshchmann and Munter’s earlier book. A follow-up questionnaire was sent to this sample a minimum of 2 years after receipt of the first questionnaire; 64% returned it. Comparisons were made across time and between those who had stopped dieting and those who had not.
In general, mean scores on scales of eating preoccupation, body preoccupation, and emotional eating, tended to show improvement at the follow-up time. The changes were significantly greater among those respondents (75%) who reported that they had stopped dieting. Multiple regression analyses demonstrated that mastery of the main points of the book contributed somewhat to changes in each of the scales.
In interpreting the findings of this study, one probably can assume that the respondents who had stopped dieting represent a group who had engaged with the book and its curriculum and that, among this group, the book was helpful in reducing emotional eating and preoccupation with size and eating. The self-selection (to purchase the book and return the first questionnaire) and self-report of data obviously limit the extent to which the findings can be generalized. The findings are consistent with those of Omichinski and Harrison who found significant improvements in self-acceptance and other measures among more than 200 participants in the 10-week HUGS program.
Steinhardt also worked with Carrier and Bowman to evaluate the effectiveness of a worksite program based on the Overcoming Overeating philosophy. Designed to end dieting behavior, the program offers 20 class sessions over a 6-month period with periodic follow-up sessions. Data are reported from 79 employees followed for 3 years. Assessments were both quantitative (scales for eating style, dieting behavior, selfacceptance, self-esteem, and reports of physical activity) and qualitative (informal interviews).
Unlike the dropouts, participants showed improvement in selfesteem in the interval from program entry to follow-up. There were also significant improvements in self-acceptance, physical activity level, and in letting go of dieting, but these changes were enjoyed by the dropouts as well as the participants, a situation attributed to the exposure to information widely distributed by the wellness department. Participant groups reported increased mastery of an internally directed eating style with little or no evidence of diminution up to 3 years of follow-up.
Cilaska reported outcomes of the Beyond Dieting program designed to help heavy women who have chronically dieted in the past reestablish normal eating, improve self-esteem, and decrease body dissatisfaction. Cilaska randomly assigned 142 subjects to either an educational program, the experimental psychoeducation program, or a “waiting list” control group. Both the educational and experimental groups met weekly for 12 weeks. In contrast to those in the educational program using a lecture format, the experimental groups were smaller, had longer sessions, and used various strategies to change attitudes and behaviors.
An extensive battery of psychosocial and physical tests was used to assess participants’ characteristics initially, at the end of the program, and a follow-up times 6 and 12 months later. Although members of the educational group showed some improvement in self-esteem, the changes were significantly greater in the experimental group. At both follow-up dates, the experimental-group participants maintained their significant improvements in self-esteem and normalizing eating (diminished restrained eating scores), but their initial improvements in body satisfaction were not sustained at a significant level. None of the physiologic parameters (weight, blood pressure, blood glucose, and serum lipid levels) were changed in comparison to baseline values. The control group showed no significant changes in any of the parameters over 12 weeks.
Roughan et al. hypothesized that the quality of life of obese women could best be improved by identifying their problem as eating preoccupation and working to reduce this focus. They tested their hypotheses with 56 women completing 10-week programs offered in community mental health centers in Australia. The investigators report assessments made at entry and at 6 and 24 months after the end of program. A battery of psychosocial tests, including the EAT, was used at each assessment time.
Initial scores on the EAT and other scales confirmed that participants were, indeed, preoccupied with food and eating and had low levels of mastery, assertion, body satisfaction, and self-esteem. At the end of the program, all parameters except mastery showed improvement. EAT scores were significantly reduced at the end of the program and by the 6-month follow-up were within the range considered normal for the scale. At the 24-month follow-up, the significant changes were sustained. Mean body mass index (BMI) declined significantly from 31.7 initially to 31.0 at the end of the program, and finally to 30.7 at the last follow-up. The authors hypothesized that changes in eating preoccupation were the precursor of changes in the other psychosocial variables and in weight.
Like most reports in the literature, each of the program evaluations summarized here reports positive outcomes related to its particular goals. Weight loss was not a goal of most of the programs and; indeed, no program led to losses of major amounts of weight. Some programs assessed weight changes only to address the concern of some that abandoning dieting would lead to weight gain. There was no evidence that such occurred.
Most of the reports dealt with reasonably long follow-up periods and showed that many of the positive outcomes were sustained even at the most distant follow-up. The outcomes were achieved without the risks to physical and emotional health that accompany chronic dieting. The programs were low-tech and relatively inexpensive to operate.
Certainly there is need for more evaluative research. Given that the outcomes sought are rarely tangible, it is essential that this research utilize validated instruments to assess the changes. It should deal with the suitability of the various programs to various participants. Which persons are able to benefit from new paradigm programs? How can readiness be assessed? What improvements in physical health can be achieved among participants with health risks, such as hypertension or diabetes?
IS IT A NEW PARADIGM?
This article shows that, in contrast to traditional models based on the premise that fat is bad, there is a new, more neutral interpretation of fatness. This new paradigm rejects the notion that health and happiness can be achieved only through slenderness, but rather advocates a direct pursuit of those goals. All new paradigm programs advocate self-acceptance. Some are designed to bring about changes in behavior, and a minority work toward weight loss. Even those that aim for weight loss can be viewed as size accepting as the weight-loss effort is focused on the need to relieve health problems. New paradigm approaches should be evaluated, not by the weight-loss criteria of traditional programs, but rather by the extent to which the program’s unique goals have been achieved.
[Figures 1 & 2 ILLUSTRATION OMITTED]
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Ellen S. Parham, Ph.D., M.S.Ed., R.D., is professor of nutrition in the Department of Human and Family Resources, Northern Illinois University, DeKalb, IL, and adjunct counselor at the DeKalb County Family Service Agency. She is chair of the Nutrition and Weight Realities Division of the Society of Nutrition Education. Correspondence can be directed to her at the Department of Human and Family Resources, Northern Illinois University, DeKalb, IL 60115, or through e-mail to firstname.lastname@example.org.
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