Weight-Focused Public Health Interventions—No Benefit, Some Harm

“findings in these articles are consistent with literature on the adverse impact of weight stigma, which may be exacerbated by the increased focus on weight. Specifically, health promotion approaches that focus on obesity and target the individual perpetuate weight stigma and fail to address the profound inequities that drive disparities in health and weight. For example, BMI report cards, a widely used school-based childhood obesity intervention, inform parents of their child’s weight status and increase parents’ weight-related anxiety but provide little guidance about evidence-based health promotion strategies and offer no structural support for behavior change. Furthermore, weight-focused health promotion approaches fail to consider that behavioral changes made for the explicit purpose of weight control rarely result in health improvement or sustainable weight loss and are instead associated with disordered eating and greater weight gain.

[..] Weight perception has been a target of obesity-focused public health efforts for some time, predicated on the notion that individuals with elevated BMIs must have knowledge of their weight status to be motivated to engage in health-promoting behavior. However, this premise is not based on empirical findings; in fact, the opposite has been found in observational studies. In our own research, we found that youths with elevated BMIs who reported their weight to be “just about right” engaged in healthier behaviors and had fewer depressive symptoms, lower adoption of disordered weight control behaviors, and less weight gain from adolescence to adulthood. Others have observed similar patterns: a systematic review of weight perception and weight loss efforts found that individuals who perceived themselves as overweight were more likely to report weight loss attempts, but attempts were via unhealthy behaviors, ultimately associated with more weight gain over time. Public health efforts targeting weight perception are often focused on providing accurate knowledge about body size. However, the studies by us and our colleagues raise questions about what weight perception actually measures. Specifically, it is possible that weight perception also captures body satisfaction (ie, that individuals choose to report their weight status as “just about right” while knowing their measured weight status) rather than just inaccuracy (ie, not recognizing the category in which others might put their weight status). This is at least partially supported by the finding by Madsen et al that only 1 in 5 parents expressed surprise at their child’s BMI report cards; most parents recognized their child’s weight status without being told. We believe that this is similar to youths’ own self-assessments; few youths that we have worked with fail to recognize that their weight is considered too high. In fact, they are reminded of it relentlessly by those around them, and yet they continue to be satisfied with their body. Because body satisfaction is protective against so many adverse health outcomes, the continued push to correct weight misperception ignores these protective effects and may actually cause harm by inadvertently promoting weight stigma and weight discrimination.

The study by Madsen et al had concerning findings regarding unintended consequences of obesity-related public health interventions. There was an increase in weight-related talk and a decrease in body satisfaction among those whose BMIs were assessed compared with those whose BMIs were not assessed. Solmi et al found that the number of youths who perceived themselves to be overweight increased between the 1986 and 2015 cohorts. Perhaps more concerning, in girls who considered themselves overweight, the association with depression strengthened over cohorts. This is an important lesson because the focus on weight as the outcome often leads to substantial weight stigma in those targeted by the intervention, which perhaps counterintuitively predicts greater weight gain and less engagement in health-promoting behaviors. Alternatively, interventions that focus on weight-related behaviors (eg, reducing consumption of sugar-sweetened beverages and getting regular physical activity) have been found to be more effective when recommended for overall health rather than as a way to decrease weight.

The studies by Madsen et al and Solmi et al are important contributions to the literature because they illustrate the lack of benefit and the potential for negative consequences of weight-focused public health interventions. These studies illuminate the need for empirically driven interventions that not only show benefit but also limit harm to make better use of scarce public health resources. The studies also contribute to the growing literature that supports weight-inclusive approaches to health policy. The articles by Madsen et al and Solmi et al emphasize the need for health promotion efforts to empower, not stigmatize, those they are designed to benefit. This is especially important given that communities with low incomes and Black and Indigenous individuals and people of color systematically experience higher weights. Therefore, unintentional harm caused by obesity-focused public health interventions may incur double jeopardy, disproportionately and unacceptably further burdening Black and Indigenous individuals and people of color and low-income communities.”

Full editorial, Richmond TK, Thurston IB and Sonneville KR. JAMA Pediatrics, 2020.11.16