Diet Culture vs. Anti-Diet Culture

Instead of picking a lane, I'd like to bring up what's good and bad about both sides. In doing so, I'll probably piss off literally everyone in the wellness space because the expectation is to pick a side and vehemently defend it. But then again, my jam is evidence-based practice. And both conflicting ideologies are conveniently ignoring evidence that doesn't support their dogmatic messaging.

Here's the gist of the whole "debate" in a nutshell from the two extremes:
Diet Culture: "Carrying extra body fat is always bad for your health. Being fat is 100% a choice. All diets (that create a calorie deficit) work if you stick to them."
Anti-Diet Culture: "Carrying extra body fat is never bad for your health. Being fat is 100% determined by things outside of choice (genetics, social determinants of health, environment). Diets don't work."

So, who's right? Both. And neither one. The truth is somewhere in the middle, as is often the case.

I know people on either side will feel like this is an attack, but the evidence is clear that excess body weight CAN be harmful to health in terms of predisposing towards illness and early death AND excess body weight CAN also be harmless in that it's not tied to negative outcomes for the individual. Both are true. It turns out that health is multifaceted.

In this post, I'll attempt to shore up the main arguments from both sides that are actually supported by evidence:

First off, the claim that excess body fat = "unhealthy" or poor health outcomes:

Obesity is strongly correlated with elevated risk of chronic health conditions such as heart disease, type 2 diabetes, hypertension, cancer, sleep apnea and other respiratory issues. Obesity is also associated with decreased life expectancy.

Studies related to poor health outcomes/decreased longevity linked to obesity:

• Hu FB. Obesity and mortality: watch your waist, not just your weight. Arch Intern Med. 2007;167(9):875-876.
• Guh DP, Zhang W, Bansback N, et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health. 2009;9:88.
• Bhaskaran K, Douglas I, Forbes H, et al. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5·24 million UK adults. Lancet. 2014;384(9945):755-765.
• Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366(9497):1640-1649.
• Gami AS, Caples SM, Somers VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am. 2003;32(4):869-894.
• Peeters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Intern Med. 2003;138(1):24-32.
  
• Caleyachetty R, Thomas GN, Toulis KA, et al. Metabolically healthy obese and incident cardiovascular disease events among 3.5 million men and women. J Am Coll Cardiol. 2017;70(12):1429-1437.

What all of this data points to is that obesity can negatively impact quality of life and longevity, and what many of these studies illustrate is that the highest levels of obesity are the most impactful on health outcomes.

On the flip-side: Let's look at the anti-diet claim that obesity has NO impact on health. I couldn't find much evidence that obesity has absolutely no impact on health... but, there is evidence that excess weight can be protective in some subsets of the population. This data is highly subject to specific scenarios and does not have the preponderance of data across subsets that the other argument (obesity is usually unhealthy on average) has. 

• Lavie CJ, De Schutter A, Milani RV. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol. 2015;11(1):55-62.
• Oreopoulos A, Padwal R, Kalantar-Zadeh K, et al. Body mass index and mortality in heart failure: a meta-analysis. Am Heart J. 2008;156(1):13-22.

There are what's known as "metabolically healthy" obese individuals who don't have the markers of metabolic syndrome that we often see in obesity. But, so far, there doesn't seem to be evidence that these metabolically healthy obese individuals will be protected long-term from the associated risks of obesity over a lifespan.

• Kramer CK, Zinman B, Retnakaran R. Are metabolically healthy overweight and obesity benign conditions?: A systematic review and meta-analysis. Ann Intern Med. 2013;159(11):758-769.
• Eckel N, Meidtner K, Kalle-Uhlmann T, Stefan N, Schulze MB. Metabolically healthy obesity and cardiovascular events: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23(9):956-966.

I think a much stronger claim from the Anti-Diet side of things would be: the act of dieting is, itself, injurious to an individual's health. Many studies have examined the harm of dieting on mental and physical health. This is, as always, an "it depends" scenario where dieting can be undertaken without negative health outcomes by some individuals and where dieting can be associated with poor health outcomes in others.

Dieting appears to be particularly harmful to health in yo-yo dieting/weight cycling individuals who are repeatedly gaining and losing weight.

• Montani JP, Schutz Y, Dulloo AG. Dieting and weight cycling as risk factors for cardiometabolic diseases: who is really at risk? Obes Rev. 2015;16 Suppl 1:7-18.
  
• Dombrowski SU, Knittle K, Avenell A, Araújo-Soares V, Sniehotta FF. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. BMJ. 2014;348:g2646.

Dieting can also be correlated with nutritional deficits and negative and even disordered behaviors and eating patterns when individuals engage in very restrictive eating patterns:

• Gabel K, Hoddy KK, Haggerty N, et al. Effects of 8-hour time restricted feeding on body weight and metabolic disease risk factors in obese adults: A pilot study. Nutr Healthy Aging. 2018;4(4):345-353.
• Madden AM, Mulrooney HM, Shah S. Estimation of energy expenditure using prediction equations in overweight and obese adults: a systematic review. J Hum Nutr Diet. 2016;29(4):458-476.
  
• Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc. 2006;106(4):559-568.
  
• Lowe MR, Thomas JG. Measures of restrained eating. In: Allison DB, Baskin ML, eds. Handbook of Assessment Methods for Eating Behaviors and Weight-Related Problems: Measures, Theory, and Research. SAGE Publications; 2009:121-161.

So, at the end of the day, when you look at the totality of all of this data (not just the side you most strongly agree with), it turns out that excess weight CAN be harmful to health and dieting CAN be helpful. But, also, excess weight CAN be benign or even protective and dieting CAN be harmful to health. It depends on individual circumstances.

I don't think I "like" anything from diet culture, but I guess what I like from general fitness culture is the emphasis on working with your body to try to improve your own health and wellness outcomes. My problem with diet/fitness culture is that it often misses the nuance of how each person's individual journey is a unique scenario. I like what the anti-diet crowd has brought to the table in terms of shining a light on individual differences and the natural spectrum of variety of bodies. I also like that we are now having a conversation about the negative impact of dieting on health. For many individuals, a healthier path may not involve dieting - even in individuals who are overweight and obese.

Wherever you fall on the continuum, I hope that you keep in mind the following:
Healthy lifestyle changes need not result in weight loss. Sometimes they do, sometimes they don't. There are things you can do that will improve your health like increasing your step count, engaging in weight lifting, adding some cardiovascular exercise, eating a variety of foods that meet your nutritional needs and so on. These things can improve health with or without weight loss. If you care about your health or the health of your clients - why not shift the focus towards that instead? Seems like a win-win!

​- Julie