An Anti-Diet Antidote

The “anti-diet” movement, we are told- specifically by The Washington Post and The Examination- began with good intentions. 

Sharing DNA with the “health at any size” movement, the two aligned to protest the shaming and blaming of both bodies and diets, foods and choices.

Something certainly needed to be done; to this day, overweight and obesity remain the last bastions of socially acceptable prejudice. That is not to say, of course, that many other varieties of prejudice don’t prevail.  Sadly, they do- and since the advent of a particular occupant of the Oval Office, they have garnered enough acceptance in certain quarters to be altogether jarring.  But that is a topic for another day, column, and author. Obesity bias has prevailed all along, subconsciously, consciously, and without remorse or rebuke.  It stands apart, and needed to be knocked down.

The concept of “health at any size” was about striking that blow.  As you can likely tell, I fully support the assault on obesity bias.  We do not blame the victims of hypertension or diabetes, yet these, too, are overwhelmingly byproducts of lifestyle choices.  We do generally blame the victims of obesity, and have no business doing so.  Yes, of course, we all have personal responsibility for our actions up to a point; but the choices people make are subordinate to the choices people have.  Obesity has been propagated by the systematic promulgation of bad choices for big profits.

As for personal responsibility, while respecting its place in all this- we must be rational about that place.  We have rampant obesity among children; are we proposing that the current, global crop of kids has less innate “personal responsibility” than every prior crop?  Leaving aside the lack of scientific support, the notion is quite simply preposterous.  Obesity is pandemic among adults and children alike not because of rampant, inexplicable changes in human character- but because of rampant, entirely explicable changes in the food supply and modern environment.

Accordingly, I have been an ardent anti-obesity-bias crusader my entire career.  Even so, however, I found myself opposed to the “health at every size” contention, and at times, in direct and heated debate with its proponents.  This is simply because, as a public health physician, I was obligated to concede the truth: obesity was, and is, doing our health tremendous harm.

The evidence is overwhelming that other things being equal, obesity increases the risk for heart disease, diabetes, sleep apnea, dementia, disabling arthritis, and most other chronic conditions that plague modern populations.  Obesity markedly elevates the risk for a wide range of cancers.  Putting the fine point of recent and acute experience on all this, obesity greatly amplified the toll of the COVID pandemic, both directly and via its contributions to cardiometabolic disease; both in the U.S., and around the world.

The health of our children most decisively clinches the case.  When I went to medical school, the two varieties of diabetes mellitus taught were “adult onset” and “juvenile onset.”  The name changes to “type 1” and “type 2” were responsive to, and in my disgusted opinion a veil for, the transformation of “adult onset diabetes” into a widespread (and ever worsening) scourge among children, too. This travesty was driven entirely by the proliferation of obesity among kids.  I would be fine with “healthy at any size” if we actually were.  We are not, and neither are our children.

What about “fat, but fit”- a contention long championed by, among others, my former friend and colleague (sadly, he passed away) Dr. Steven Blair?  There is some theoretical merit to the concept; it is possible to be heavy, yet active and generally healthy.  But at the population level, few people are.  The things people do to be genuinely fit quite reliably make them less fat (consider the body mass and composition of endurance athletes as compared to the rest of us, for instance); the things people do to be less fat- at least the things that actually work (i.e., eating well and being physically active) are conducive to fitness, too.  Epidemiologic studies show that “fat, but fit” can occur, but that if we plot the two states this way - -in any real-world population, cell C is very large; Cell B is smaller but sizable; Cell D follows; and Cell A, fat but fit, is very small to negligible.  Once again, I support the aim of de-emphasizing and de-stigmatizing weight, but can’t support a reckoning of consequences that departs from the prevailing reality.

The Covariance of Fatness & Fitness

The reporting of the Post and Examination was less about this history, more about the present, in which the “anti-diet” movement, whatever its initial motivations, has fully devolved into industry obfuscation about junk where food ought to be.  The messaging about intuitive eating, freedom of personal choice, and “no such thing as a bad food” has been coopted by industry to paint lipstick on willful manipulation and chicanery, of which ever-rising obesity rates are just one among the devastating consequences.

Yes, there are bad foods; foods willfully engineered to be addictive at the expense of health are bad.  Yes, ultra-processing is generally bad, because it is often done expressly to maximize the calories required to feel full- and works exactly as intended.

From my point of view, “diet” is a perfectly good noun (referring to a pattern of food intake), and a very bad verb (as in “dieting”).  We diet alone, but live it together.  We diet briefly, but eat for a lifetime.  We enjoy eating, and suffer through dieting.  We dine with loved ones, and diet without them.  I am on record- international record at that- asserting that “dieting should die.”  But that refers to the death of the verb, not the noun.

Dietary patterns mater, and we would be hard-pressed to overstate how much.  How can we be “anti-diet,” when poor diet quality kills more than 500,000 Americans prematurely every year?  That is like being “anti-blood pressure,” except that the toll of poor diet is greater, even, than that of hypertension.  How can we be “anti-diet” when diet quality, measured objectively, is THE single leading predictor of premature death and chronic disease in the modern world?  How can we be “anti-diet” when diet quality was directly predictive of the severity of illness with infection by SARS-CoV-2?

We cannot be, unless we are dishonest.  We cannot be, unless we are complicit in some dubious agenda.

Which situates us between the horns of a dilemma.  How can we combat both obesity, and obesity bias?  How can we oppose the blaming of outcomes and the shaming of choices, while doing something meaningful to improve both?  What, in other words, is the anti-diet antidote?

First, we should prioritize health and vitality rather than weight.  Weight is a proxy for chronic disease risk; obesity is a canary in the coal mine of chronic disease.  But it is the ill health that is the enemy here, not size.  A focus on the pursuit of health for the sake of health, not the pursuit of size for the sake of size, should guide all efforts.

Second, we should focus on overall diet quality, measured in an unbiased manner, because as noted- it is the single leading predictor of death and disease in the modern world.  Gertrude Stein famously said “a difference, to be a difference, must make a difference.”  I hazard a corollary: if we are to make a difference, we must direct our efforts at what matters.  Diet quality matters, and must be addressed.

Third, we should direct our efforts to families, as well as individuals.  What is the message to children when their parents “go on a diet,” and leave them behind?  What is the message to those same children when their parents go on GLP1s instead of addressing health and lifestyle at the level of household?  We diet, we take medication alone; we share lifestyle practices, and in that unity, there is strength to support one another’s lifelong pursuit of the best possible health.

Why pursue health together?  Not as a moral imperative; not because some authority wags a finger and says you “should.”  But because health is the single best currency for procuring more years in life, and more life in years.  As goes health, so goes quality of life.  Other things being equal…healthy people have more fun.

Finally, we must hold to account the machinations of the medical-industrial complex.  Stated bluntly, we look on passively as one industry reaps enormous profits making us fat and sick, and another reaps enormous profits by treating conditions we never needed to get.  This calamitous feedback loop has long hidden in plain sight; the staggering costs of the GLP1 drugs have only recently further illuminated its ruinous potential.

I close with an analogy I have long used: obesity is not a disease, nor is it any kind of character flaw.  Rather, it is a form of drowning.  We are drowning in willfully addictive junk where food ought to be; we are drowning in labor-displacing technologies and activity-depleting schedules.

We don’t blame the victims of drowning; we resuscitate them, with all the tools and technologies at our disposal.  But we don’t wait for everyone to drown so we may resuscitate them at high cost to health and budgets; we preferentially direct our efforts at prevention.  We put fences around pools; practice parental vigilance; teach our children to swim; post lifeguards at beaches; flag riptides and close beaches.  Were we to treat drowning as we treat obesity, we would teach no one to swim; post no lifeguards; place no fences; encourage parents to look the other way; and put up signs that say “come on in, the water’s fine!” despite riptides and sharks.  As for the converse- how we might treat obesity and its consequences more the way we do drowning- I invite the exercise of your imagination.

There are bad foods making up bad diets that cause bad outcomes- and these all affect perfectly good people.  There are bad choices made by those who mostly bad choices have, despite perfectly good character.  Weight can matter because it matters to health, not because bathroom scales capture any measure of human worth.  Personal responsibility has its place, but it is not alternative to conscionable behavior by the body politic.  Health at any size is a fine concept, but in reality, “size” and health co-vary far more often than not.  Food choices need not be shamed to embrace the imperative of improving them if we are to safeguard years in life and life and years- and for that matter, biodiversity and planetary health.

These comprise an antidote for the pernicious distortions of what the anti-diet movement has become.