Weight-neutral approaches for better physical and mental health outcomes

In the past 40 years, chronic disease and obesity rates have dramatically increased, but so have weight loss attempts. Clearly, we are doing something wrong.

Weight loss interventions do not lead to long-term results

The evidence is clear, current weight-centric interventions are failing to produce long-lasting effects. Most people who lose weight after a weight loss program, gain the weight back within one to five years, and often even more than what they lost (1, 2).

Body weight is balanced by many factors, some of which are out of the individual's control. Some of the complex processes that regulate body weight include metabolic routes that sustain homeostasis; environment; behaviour; and genetics.

After calorie deprivation, the three most prominent routes that prevent any further weight loss, and promote weight gain, are:

1. An increase in hunger-inducing (i.e. orexigenic) hormones, such as ghrelin, and a reduction of satiety-inducing (i.e. anorexigenic) hormones, such as leptin (3).
2. A decline in total energy expenditure due to loss of body mass, and enhanced metabolic efficiency (i.e., ‘energy conservation mode’ in response to perceived food scarcity) (1).
3. Increased cognitive biases. Eg. hyper-focus on high-calorie food (4, 5).

In combination, these factors make it remarkably hard for a person to ‘keep off’ the weight they’ve lost after restrictive dieting. It's not willpower, it's biology.

So, the bad news is that it’s really hard to make people lose weight. But the good news is that we don’t have to.

Weight-neutral interventions have promising health outcomes

Epidemiological studies show that cardiorespiratory fitness and physical activity decrease and sometimes even eliminate the high mortality risk associated with obesity. Studies consistently show that increasing fitness levels causes greater reductions in all-cause mortality compared to weight loss alone (6).

Even more strikingly, evidence suggests that mortality rates are not any different amongst individuals who are physically fit, regardless of whether they fall into the normal weight, overweight, or obese category (7).

A large prospective cohort study showed that the adoption of four healthy lifestyle habits leads to a decrease in all-cause mortality risk regardless of BMI. These habits were:

• eating five or more portions of fruit/vegetables per day,
• limiting alcohol intake,
• not smoking, and
• moderate exercising (12 times per month);

This study found that in people with zero of these health-promoting behaviours, BMI does impact mortality risk at a significant level. However, adding even one health-promoting behaviour cuts the risk almost in half. Adding four of these behaviours completely eliminates any differences in mortality risk amongst BMI categories (8).

If the real goal is to reduce mortality risk and improve health outcomes, then why are we still focusing on weight loss?

Despite the clear benefits of adopting healthy behaviours such as physical activity, current weight-management programmes typically only recommend these behaviours as a way to achieve a negative energy balance and lose weight.

Let’s go back to our original and most important problem. People are developing chronic conditions that affect their quality of life and burden health care systems around the world. To tackle this problem, we have two options:

1. we keep focusing on weight loss despite decades of unsuccessful attempts (i.e. weight-centric approaches), or
2. we focus on lifestyle behaviours independently of weight (i.e. weight-neutral approaches)

Option 1. The weight-centric path: A never-ending loop

Decades of flawed scientific research have made us believe that weight loss is the only way to improve health outcomes. E.g. by attributing an increased risk of developing certain health conditions to weight alone, without controlling for confounding factors such as levels of physical activity, nutrition habits, and general lifestyle behaviours. Similarly, most weight-management studies showing improved health outcomes assume that weight loss is the cause of these improvements, without examining the effects of lifestyle behaviours independently.

As a consequence, weight biases amongst health professionals translate into suboptimal care compared to what people in thinner bodies are offered, leading to poorer health outcomes in people with a higher BMI (9).

What does remain clear, is that intentional efforts to lose weight inevitably lead to weight cycling. In fact, intentional weight loss has been shown to be a predictor of greater weight gain at a later point, compared to people who do not attempt to lose weight.

In addition to the physical health consequences, weight cycling leads to an increased risk of developing an eating disorder (10) and other mental health conditions such as depression and anxiety (11).

Option 2. The weight-neutral path: An overlooked opportunity

Weight-neutral approaches with a focus on behaviour change have the potential to be more effective than weight-centred interventions without the harmful consequences associated with intentional weight loss (12).

The benefits of taking the pressure off and ceasing to focus on body weight go beyond just physical health outcomes. Weight-neutral approaches lead to improvements in self-esteem and body satisfaction, a reduction of problematic eating behaviours, and an overall improvement in mental wellbeing.

At Holly Health we are playing our part toward shifting the paradigm by providing a weight-neutral service that coaches people to adopt consistent health-promoting behaviours. For those still trapped in weight cycling, or engaging in disordered eating behaviours linked to a weight-centric diet mentality, a crucial first step is to improve their relationship with food and with their bodies using a combination of science and self-compassion.

There is no denying that evidence for weight-neutral approaches and health outcomes is limited. But instead of considering this a roadblock, we should take it as an opportunity to conduct high-quality research and to develop innovative behaviour change interventions with the potential to shape the future of health care and public health policies.

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Written by Dr. Daniela Mercado Beivide, Director of content, research and UX at Holly Health

References

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2. Tomiyama AJ, Ahlstrom B, Mann T. Long-term Effects of Dieting: Is Weight Loss Related to Health? Social and Personality Psychology Compass. 2013 Dec;7(12):861–77.
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8. Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese individuals. Journal of the American Board of Family Medicine : JABFM [Internet]. 2012 [cited 2020 Apr 7];25(1):9–15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22218619/
9. Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review. Primary Health Care Research & Development. 2019;20.
10. Giusti V, Héraïef E, Gaillard RC, Burckhardt P. Predictive factors of binge eating disorder in women searching to lose weight. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2004 Mar;9(1):44–9.
11. Quinn DM, Puhl RM, Reinka MA. Trying again (and again): Weight cycling and depressive symptoms in U.S. adults. PloS One [Internet]. 2020;15(9):e0239004. Available from: https://pubmed.ncbi.nlm.nih.gov/32915921/
12. Lavie CJ, Ross R, Neeland IJ. Physical activity and fitness vs adiposity and weight loss for the prevention of cardiovascular disease and cancer mortality. International Journal of Obesity. 2022 Aug 20

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