Is every social media platform being indurated with some ideal body type or perfect way to obtain optimal health? Carbs are bad, thigh gap, blondes have more fun, ugh the list is endless. Do I contribute or fall into this trap myself, absolutely, who hasn’t? But this does not mean I am ok with this fanatical nonsense. Our cultural view on beauty, health and worth inhibit us from accepting ourselves, promotes self-destructive behavior and prevents self-compassion.
Where does it all begin?
Personally, I believe it begins and continues within the healthcare system. A major problem was created when the American Medical Association deemed "obesity" a disease, because clinicians began to diagnose individuals based on appearance alone. The medicalization of body weight has aided in the development of stereotypes, prejudice, and discrimination. When we evaluate a concerning rash on a patient, we get a history of present illness and consider associated symptoms before creating a treatment plan. Not only are we diagnosing someone based on appearance when it comes to ‘obesity’ much of the treatment focuses on improving the appearance, and data driven outcomes rather than the underlying issue(s). Also the 'treatment' DOESN'T WORK & is DISEMPOWERING!
Where does the definition of obesity come from?
The definition of obesity stems from body mass index also known as BMI. I HATE BMI, it’s a mathematical equation based on height and weight that measures physical appearance, not health. Athletes are subjected to the nemesis, 'BMI' constantly (e.g. severely low body fat but normal/high body mass can give false perceptions of health). Using terms such as obesity and obese only promotes prejudice and discrimination, which unfortunately, also increases disease. While it is recognized that obesity is associated with increased risk for many diseases, the true cause is not well established. Most studies do not consider other variables that have a role in governing health risk such as nutrient consumption, weight fluctuations, socioeconomic status, physical activity, genetics, and fitness. Among the studies that did regard these other factors the increased risk of disease disappeared or was significantly reduced.
We inhibit the ability to eating intuitively beginning in childhood.
We are born intuitive eaters so we are able to rely on our hunger and fullness cues, cravings, flavors, and texture perceptions. We begin creating a poor relationship with food during childhood. If parents pressure a child to eat more of this or less of that, or promote good and bad food categories, by using statements such as, ‘eat your broccoli and then you can have ice cream’, ‘you can have a sugar beverage only if you are outside playing’, or ‘cake is for birthdays’, the relationship with self and food begins to deteriorate.
As we learn about nutrition and health the advice often encourages consumption of a variety of food but more commonly counting calories, keeping track of portions, and regulating micro/macros using food labels and dietary guidelines is recommended. This leads to restriction and the idea that we should not trust our internal but rather external cues. These restricted values are perpetuated by the media and only continue to pester us throughout our lifetime.
Advertisements such as ‘enroll today to burn off those holiday pounds’, or statements such as ‘the freshman 15’, or ‘detox diet’, ‘eating clean or green’ ‘low-carb, low calorie, fat free, ‘asking if a food is ‘worth the extra calories’, finding ways to ‘speed metabolism’, how to get my ‘pre-pregnancy body’, I can go on and on. In adulthood we often see restriction of entire food groups. When someone removes meat from their diet, I can’t help but question if deletion of meat from their diet improved digestive symptoms and fatigue or did incorporating more fiber and nutrients from vegetables play most of the role? We sometimes get stuck in black and white thinking when most outcomes either good or bad are influenced by multiple factors, or what I like to call the grey area.
What is diet culture?
Christy Harrison defines 'diet culture' in her book Anti-Diet beautifully but this term has multiple definitions but most commonly it is a set of attitudes that worships specific body types and equates it with an individual’s health and worth. Our culture is governed by this narrow view of beauty and health. Even when flooded constantly with such messages, we can be oblivious.
There are so many cognitive distortions surrounding food and health. We tend to label foods as good or bad and then experience guilty feelings when eating foods on the “bad” list and pride when we eat foods on the “good” list. In actuality there is no right body shape, size, correct way to eat, or best method to exercise. We have a hardwired weight regulation system that is not entirely in our control. Body weight commonly fluctuates between a given set point in a 10-20-pound range
What defines perfection is based on inconsistent illogical opinion. This only creates a scaffold for personal failure because what is attainable for one person may not be for another. Not only does this lead to negative self-perception but it can cause us to judge others.
Examples of diet culture: for starters… BARBIE!
Filters on pictures posted via social media
Shapewear
Using the term ideal in relationship to appearance or heath
The concept of cheat days
Advice about diet such as, ‘drink water or eat something higher in fiber when you’re hungry as this may curb your appetite'
Weight loss programs
Endorsing pharmaceutical medications as weight loss treatment when developed for other reasons
Weighing patients at office visits
BMI and weight loss counseling being a metric in clinics to assess if we are providing quality care
Why is diet culture harmful?
Diet culture is psychologically and physically damaging to us all. It teaches us that our success, happiness and worth are based on our appearance. Plain and simple, there is no research supporting that weight loss programs or products improve happiness or achieve initial or sustained weight loss over a 2 to 5-year period. More than 98% of people regain the weight they lost with most regaining more than they lost. The message of diet culture is you are not enough, this is your problem and it is your fault. Even though 98% fail at weight loss, most people blame themselves so they find a new diet or program when they fail to lose weight and the cycle starts all over again.
Diet culture deviates our research, money and attention away from more important issues. The cost spent on obtaining some body ideal from supplements, programs, performance recording devices, to surgery is astounding. According to Market Research, the total U.S. weight loss market grew in 2018 to $72.7 billion and continues to rise. Refocusing our attention on more important issues like poverty and discrimination specifically weight-based discrimination which actually impacts access to jobs, healthcare, and education would be nice. We spend so much time discussing weight loss with our patients maybe we should consider teaching them self-acceptance and compassion, and refocusing personal wellness goals away from eating better and exercising out more?
Eating disorders are the leading cause of mortality among all psychiatric illness. With 1 in 7 people being affected by an eating disorder in their lifetime why are we not spending more of our time researching or training clinicians on this medical condition? Yes, eating disorders are a multifaceted illness but diet culture almost normalizes disordered eating behaviors making diagnoses and management that much harder not to mention a pathway for developing a clinical eating disorder.
What can we do to stop diet culture?
Embracing anti-diet culture can undo this tyrannical set of beliefs that precedes body shaming and stigmatizing behaviors. When I say anti-diet, I do not mean anti-well- being, rather communicating to ourselves, patients and the community that we should strive for a healthy body and mind not aim to modify our appearance.
Although some eating disorder specialists believe that a desire to look a certain way or focus on changing an aspect of one's appearance is pathological, I don't agree. I am a cis-female, who loves stilettos, fake eyelashes, lip gloss, botox and fashion shows, but I also enjoy going to the grocery store in my PJs, not looking at a mirror for months while climbing Mount Everest, and fighting for beauty equity. Christine Quinn, model, actress, and authors of the book How to Be A Boss Bitch says 'If you’re going to call me a bitch, I’m going to take it as a compliment.'
She owns her love for lip fillers, clothes and although desires a full figured body she has accepted her tall thin modelesque frame. Yes, I have a crush on her, not for her Barbie-like appearance but her ability to love herself and remain genuine; this is what has her oozing sex-appeal.
How do we break the barriers of diet culture?
There are many ways to advocate against diet culture.
Begin by being THE HEALTHIEST VERSION OF YOUR TRUE SELF! Understand that there is NO 'one' or 'right' way to live, look, eat, exercise, or sleep that is best for everyone. We are all different and thank goodness because if we weren't this world would be so boring.
HAES or health at every size is a movement that supports health while being compassionate, respectful to oneself and others regardless of body size. HAES embraces human and affordable access to health, provides social connection and diversity while dismantling an ideal body type or state of health.
The principles of the HAES movement emphasizes:
Weight inclusivity; reject the temptation to idealize specific body types
Health enhancement
Respectful care; this begins by acknowledging our own biases
Eating for well-being; food needs should be individualized, based on someone’s nutritional needs and desired taste while not being focused on weight control.
Physical movement should be enjoyable and focused on life enhancing skills not weight loss or similar
Intuitive eating was coined in 1995 by registered dietitians Evelyn Tribole and Elyse Resch and it is based on 10 principles. The general idea of intuitive eating is to promote the use of internal physical cues to decide what, when and how much to eat. The principles of intuitive eating encourage:
Rejection of the diet culture
Honoring hunger
Finding peace with food by not depriving oneself of cravings
Challenging the rules created around food but disregarding the idea of good and bad foods and appropriate times to eat.
Respecting fullness by being mindful
Allowing oneself to be satisfied by food and associated moments
Explore than regard feelings without using food since food does not fix problems or decrease emotions, but becoming self-aware and directly dealing with the concern does
Accept one’s body, this is the body given to us, learn to love it, use it and respect iExercise should instead be mindful movement, a time to connect the mind and body by shifting focus to how the body feels and moves rather than how many calories can be burned; stop checking and recording each and every step or activity, use this time to relax the brain and let the body function, spend time with a loved one or learn a new physical activity or skill
Honoring one’s health by eliminating the idea of perfection
Does this approach work?
Research has found that those who give themselves full permission to eat the foods they enjoy are more likely to rely on internal rather than external cures on hunger and fullness therefore are less likely to eat past fullness, including binge eating behaviors, experience less guilt with eating, have more positive self-esteem and a better body image. Research has found that intuitive eaters had higher HDL cholesterol and lower triglycerides in addition to a lower body mass index compared to unintuitive eaters and a lower overall cardiovascular risk as well.
If an individual's body size limits their mobility, worsens joint pain, causes obstructive sleep apnea, or contributes to the risk of heart disease, psychiatric disorders, hyperlipidemia, hypertension, erectile dysfunction, diabetes, etc or inhibits them from living the life they desire than lifestyle changes are critical. Changes should be made with compassionate guidance free from shame and disempowerment.
Are resources available?
There is a great deal of information available but the healthcare system is not doing a very good job at relaying these ideas or resources to the public. We all need to begin by understanding our own weight bias, when we are inundated with diet culture stereotypes, it is reasonable to develop prejudice and consequently discriminatory behaviors. Tools such as the Harvard implicit bias tests can be helpful.
Enhanced Cognitive behavioral therapy (CBT-E) specifically focused on body image helps to enhance the importance of other domains for self-evaluation and reduce the importance attached to shape and weight. Concepts such as body checking, avoidance, and comparison are addressed with CBT-E.
Help for negative body image can range from psychiatric programs to outpatient advice. Engaging in distraction and self-soothing techniques can improve body image distress, anxiety, and help to improve emotional regulation. I often have clients list behaviors or activities to engage in when they are experiencing disturbing body image. Examples include taking a bath, calling a friend, playing with their pet, or drawing. Learning to be mindful is key to almost any distressing emotional response. Mindful skills I have found to be successful include focusing on ones breath for a minute, listening to a calming song or sound, choosing something in the environment to observe intently for a minute, embracing a daily routine by placing attention on each activity for example thinking about brushing one’s teeth while the teeth are being brushed, or grounding by sitting in a chair and purposefully placing the feet on the ground which allows for the re-connecting of the body and mind.
Avoidance actually reinforces or increases negative body image so gradual exposure to these feared stimuli allows patients to increase tolerance of their bodies and improve body image. Some other techniques to assist with demolishing cognitive distortions include teaching patients to treat their thoughts as villains and use colorful language by making statements such as ‘who’s life is this anyway? The villain’s mind’s or yours?’ I am a dog-lover so my villains name was, Cruella de Vil.
What can clinicians do to help stop diet culture and weight stigmatization?
If we can shift the focus on health, not weight, or an unrealistic idea of beauty. Instead of ‘obesity prevention’ use the term “health promotion” and saying large or small bodied instead of overweight and obese to avoid weight-biased stigma. Health promotion should focus on all aspects including physical, emotional, social, occupational, intellectual, spiritual, and ecological. As physicians we need to promote self-esteem, body satisfaction, and body size diversity. Since weight is not a behavior it is not appropriate to target treatment interventions as behavior modifications. Nutritional and physical advice needs to be from a empathetic-centered approach that encourages self-care rather than as prescriptive sanctions to meet expert guidelines.
References:
Dockendroff SA, Petrie TA, Greenleaf CA, Martin S. (2012). Intuitive eating scale: an examination among early adolescents. Journal of Counseling Psychology, 59, 604-611.
Hawks S, Madanat H, Hawks J, Harris A. The relationship between intuitive eating and health indicators among college women. American Journal of Health Education. 2005;36:331-336.
Newburg D, Kimiecik J, Durand-Bush N, & Doell, K. (2002). The role of resonance in performance excellence and life engagement. Journal of Applied Sport Psychology, 74,249-267.
Polivy J & Herman P. (1999) Distress and eating: Why do dieters overeat? International Journal of Eating Disorders, 26, 153-164.
Tylka T. (2006) Development and psychometric evaluation of a measure of intuitive eating. Journal of Counseling Psychology, 53, 226-240.
Tribole E and Resch E. Intuitive Eating, 2nd ed. (1995, 2003), NY:NY. www.IntuitiveEating.org
Comments