The problem with weight loss outliers

weight loss outliersI recently had a rather heated discussion with someone near and dear to me about the alleged association between higher body weights (body mass indexes, or BMIs, in the “overweight” or “obese” ranges) and health problems. Let’s just say that if our walking route had taken us a little closer to Lake Washington, I might have tossed him in.

On his end, the discussion included the overused tropes about how “if people were just taught how to eat” and “if people had a little more willpower.”

On my end, I pointed out five problems with research studies that “associate” higher body weights with poorer health:

  1. Association does not prove causation.
  2. Even if we had proof of a cause-and-effect relationship between weight and health, given that 95 percent of attempts to lose weight end with weight regain—sometimes in excess of the pounds that were lost—advice to lose weight is highly questionable.
  3. Studies looking at weight and health fail to factor in the effects of weight stigma.
  4. Even if higher weights did cause poor health outcomes AND it was relatively easy for people to lose weight and keep it off, there’s no research showing that someone at a higher weight who loses weight has the same health risks (or lack thereof) as someone who has always been at a weight in the “normal” BMI range. (See the “Poodle Science” video at the bottom of the post.)
  5. People can be healthy or unhealthy at any body weight, so why should “eat right and exercise” edicts be directed only at people who weight more than the culturally accepted ideal. Why shouldn’t we help all people of all weights find the pleasures in nourishing food and enjoyable forms of movement?

And then we got to the outlier debate. Related to point #5, I shared some anecdotes from my clinical experience with patients (my debating partner/thorn in my side/devil’s advocate has no such experience).

I told him about two patients who have always been in smaller bodies, and were gobsmacked when they developed problems with blood sugar and high cholesterol. In each case, the patient expressed to me that they had never paid attention to what they ate or made a habit of exercising because they never “had to.” Translation: they never had a “weight problem.”

“Well,” he said, “those are outliers.”

I also told him about my patients who were in larger bodies who had perfect bloodwork and no notable health issues.

“Well,” he said, “those are outliers.”

Here lies the problem with weight loss outliers. How can we reasonably dismiss the healthy-in-a-larger-body “outliers” mentioned above (if indeed they are outliers…I think they are less outlier-ish than most people believe) but claim that we should all look to a different set of outliers (those 5 percent of people who diet to lose weight and successfully keep the weight off) as a model for our own behavior. When diets have a 95 percent failure rate, why should we expect people in larger bodies to try to be part of the 5 percent? Would you take a medication that had a 95 percent failure rate, coupled with side effects?

We shouldn’t. And as for my companion’s idea that people in larger bodies just need more nutrition education and more talking-tos by their doctors (I think steam came out of my ears at this point), well, they already have that. I don’t think more of the same is quite the answer. (As the saying goes, “The definition of insanity is doing the same thing over and over again and expecting different results.”)

It’s time for a new paradigm, and that paradigm is building momentum. Intuitive eating, health at every size, self-compassion, body positivity and social justice…those form the foundation for true whole-person health and well-being.

For more on Health At Every Size, see the blog series I did a few years ago based on interviews with Linda Bacon, PhD, author of “Health At Every Size” and “Body Respect,” and Lucy Aphramor, PhD, RD, her “Body Respect” co-author.

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