Author's Reply to "Readers Respond to '"End the War on Obesity: Make Peace With Your Patients'"

Linda Bacon, MA, PhD


March 06, 2007

To the Editor,

Resistance to my Webcast, "End the War on Obesity: Make Peace With Your Patients,[1]" is not surprising. It is considered self-evident that many of us are too fat; that excess weight contributes to increased morbidity and mortality; that weight loss is necessary, sustainable, and associated with significant health improvement; and that failure to deal with our obesity "epidemic" portends an unprecedented public health disaster. These beliefs are so deeply ingrained in our cultural landscape that most people view weight control as the normal, right thing to do, and, like Dr. Miller,[2] dismiss challenges without even considering the evidence. When we actually examine the scientific research, however, we find that all of these assumptions are flawed or at least highly exaggerated. My proposal -- that we practice evidence-based science -- hardly seems heretical.

Dr. Miller chose to ignore many of the arguments that I presented; in particular, he did not acknowledge my statement regarding confounders marring the epidemiologic research. He falls for a common error in interpreting epidemiologic research, assuming that association means causality. I'd like to add an additional example of a confounder not provided in my initial piece -- that physicians' prescribing weight loss may play a larger role in causing all of the concerns that he lists than the adiposity itself. For example, it is well documented that prescriptions for weight loss frequently result in weight cycling,[3] and that weight cycling increases risk for cardiovascular disease.[4,5] Numerous studies have documented that obese women face negative attitudes from physicians,[6,7,8] and physician attitudes toward weight are a chief barrier to obtaining healthcare.[9] Women report avoiding or delaying medical care to steer clear of being weighed and given a weight-loss lecture.[10] All of these contribute to a higher rate of medical concerns.

A short primer on some of the obesity myths, complete with references, called the Health at Every Size Manifesto, is available for free download from my Web site: Numerous other extensive exposés have been written, among them Fat Politics by Oliver,[11]Diet Myth by Campos,[12]The Obesity Epidemic by Gard and Wright,[13]Big Fat Lies by Gaesser,[14] and Diet Nation by Basham and colleagues.[15] I also have a book on this topic forthcoming.[16]

Regardless of one's willingness to challenge assumptions, I expect that many are in agreement with the most damning criticism against the "war on obesity": It just isn't working. Fortunately, there is another alternative that is effective. A randomized clinical trial, conducted by my colleagues and me at the University of California, Davis, found remarkable benefits to supporting body acceptance and healthy behaviors as opposed to promoting weight loss and dieting. Our results showed that "obese" women can learn to enjoy their bodies; trust and respond to their appetites; and see marked improvements in eating and activity habits, self-esteem, blood pressure, LDL [low-density lipoprotein], and more -- even in the absence of weight change.[17] This is in sharp contrast to the results seen in the control group dieters. Consistent with hundreds of other studies, the dieters' short-term weight-loss and health improvements were reversed over time -- and their self-esteem plummeted.

As has been said many times before, the road to health and happiness is wide enough for everyone. I urge physicians to challenge their most basic assumptions about weight, to stop prescribing weight loss, and to support all patients in adopting healthy lifestyle habits, regardless of their size.

Linda Bacon, MA, PhD

Readers are encouraged to respond to the author at or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email:


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