Many of us have been there: We look at someone’s body size and assume their health status.
This isn’t surprising. Whether in a magazine, at the doctor’s office or with friends, we receive messages that weighing more is always “bad” and means someone is “unhealthy” in their eating and exercise habits.
In reality, health is more complex than weight; weight doesn’t tell the whole story. And ignoring that can cause issues. However, most people ― and even some doctors ― are quick to associate a person’s body size with their overall well-being.
Here’s what people are missing when they make that assumption:
A person’s health encompasses way more than their physical appearance.
First, health is more than physical. The World Health Organization constitution notes that health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
But even in the context of physical health alone, weight wouldn’t play a huge role.
“There are many medical conditions that are minimally impacted by weight if at all, so it is not useful to make weight the sole measurement to define a person’s health,” said Dr. Rebecca Berens, a family physician with Vida Family Medicine.
Additionally, correlation doesn’t mean causation (though weight loss advertisements try to convince you otherwise).
“I have patients across the size spectrum with all endocrine conditions … diabetes, thyroid, PCOS and osteoporosis,” said Dr. Gregory Dodell, a doctor with Central Park Endocrinology who’s board-certified in internal medicine and endocrinology, specializing in diabetes and metabolism.
“Some of the most health-conscious patients I have ever seen are those who are struggling with obesity,” Berens said. “They are doing everything ‘right’ and yet receive judgment or are outright disbelieved when they seek care.”
Factors outside a person’s control can also affect weight and health.
Weight and health aren’t always (or even often) directly correlated — and research shows that, too.
Tanya Hargrave-Klein, a registered dietitian nutritionist at Equip, a virtual eating disorder care program, points to a health policy brief. “Research shows that social and economic factors explain about 40% of health outcomes, access to care another 20%, individual behaviors 30% and the physical environment accounts for the rest,” she said.
These components are also known as the social determinants of health (SDOH). The SDOH can include geographic location, economic context, discrimination, educational access and more.
“Many health outcomes (including, for some, higher weight) are additionally strongly causally correlated with multiple social determinants of health including poverty, experience of minority stress, discrimination and weight stigma,” said Dr. Jennifer L. Gaudiani, founder and medical director of the Gaudiani Clinic and an internist who specializes in eating disorders.
‘Weight cycling’ can be more of an issue than a person’s actual weight.
With many myths about weight and health ever-present, many people go on diets or restrict themselves. In fact, 25% of American men and 45% of American women are on a diet on any given day. That leads to “weight cycling” for 20% to 55% of adults.
According to Hargrave-Klein, that’s a real concern.
“The repeated pattern of losing and regaining weight leads to changes in blood pressure, heart rate, blood sugar and cholesterol,” she said. “Those repeated changes increase stress on the heart and increase long-term health risks. When we only look at the scale, we miss the bigger picture of what drives health.”
Weight regain after weight loss is common: As many as 90% of people who lose a considerable amount of weight regain it.
“Human bodies strongly resist long-term weight loss efforts due to strong physiological responses to inadequate nutrition that we evolved over millennia,” Gaudiani said. “Therefore, focusing on weight loss as a health endpoint … is futile, and for many, is psychologically and medically harmful.”
In other words, it’s not necessarily the weight that’s the problem, but weight cycling.
The complications don’t end there.
“This ‘weight cycling’ actually amplifies the metabolic harm of obesity, as the weight lost is often both fat and lean mass, but the weight regained is often primarily fat — worsening overall body composition and contributing to more insulin resistance and inflammation that we see with obesity,” Berens added.
Weight stigma and stress negatively affect health outcomes as well.
Weight stigma, another contributor, is bias or discrimination against someone because of their body size.
According to a 2021 research article in PLOS One, almost half of adults experience it. Experiencing weight stigma can look like doctors providing poor health care because they dislike or distrust you because of your size, or even discrimination in the workplace that leads to a lost job opportunity, and then not being able to afford a variety of foods with a variety of additional nutrients.
The health ramifications of the judgment and stress are real.
“What happens immediately is that the body’s stress response activates,” Hargrave-Klein said. “Cortisol levels rise, blood pressure goes up and blood sugar spikes. When that stress response is triggered again and again, it increases the risk for chronic conditions, like heart disease and diabetes.”
It’s important to note that this holds for stress in general, whether it’s about work or money, for example. Chronic stress (of any kind) is associated with muscle tension, digestive problems, headaches, weight changes, trouble sleeping, heart disease, cancer susceptibility, high blood pressure and stroke.
Weight stigma and discrimination can also lead to other health concerns, she continued, such as depression, low self-esteem, substance use concerns and disordered eating.
In this case, weight isn’t the problem — weight stigma and the stress that it causes are.
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Weight and health are always directly linked, but there are other nuances to consider before assuming it’s affecting a person’s health.
Weight stigma negatively affects health outcomes indirectly, too.
“Individuals at higher weights often experience bias when seeking medical care,” Berens said. “Any symptom is assumed to somehow be related to their weight … and therefore they may not be given the same evaluation and treatment … diagnoses may be delayed as the patient’s weight becomes the main focus.”
Those negative experiences add up. Hargrave-Klein said that after enough of them, people will delay or avoid care altogether. Then, health conditions can worsen.
“When they do seek help, providers who aren’t aware of weight stigma might assume every health concern is caused by weight, which means the real issues go overlooked or are praised,” Hargrave-Klein explained.
Regarding the former, Berens has seen patients who were told to lose weight when seeking care for an ear infection or for an ankle injury sustained while exercising.
Weight discrimination also shows up in the workplace and housing, which affects someone’s well-being, financial health and more — all of which contribute to physical health.
“For every 6 pounds an American woman gains, her hourly pay drops by about 2%,” Hargrave-Klein said. “Weight-based discrimination is legal in all states but Michigan.”
The BMI is used to measure health, but it’s a B.S. metric.
We can’t discuss weight without mentioning body mass index (and its considerable shortcomings). The BMI is inherently racist and sexist, and just not that accurate.
“It is not able to assess the body composition of the individual (lean mass versus fat mass), and the population it was based on is not reflective of the diversity of racial and ethnic backgrounds that it is now applied to,” Berens said. “Individuals who are metabolically healthy at a higher weight, based on their genetics and body composition, are being diagnosed with obesity, and those who may have metabolic dysfunction at a lower weight are not being diagnosed.”
Further, the “body roundness index,” aka the “new BMI,” has many of the same problems.
Weight loss isn’t always the answer to various health concerns — even the ones you’d expect.
You read that right: Some health conditions that are often associated with weight, such as high blood pressure, can be effectively addressed without touching weight. For example, Hargrave-Klein said reducing your salt intake can lower blood pressure. That could mean opting for low-salt chips or swapping your fries for apple slices at McDonald’s.
Mindfulness-based stress reduction programs are another way to lower hypertension, she continued, regardless of body size. This could entail meditating or slowing down.
Exercise is an activity that can improve cholesterol, sleep, depression symptoms and blood sugar levels, Hargrave-Klein said. Further, exercise doesn’t have to be a stressful, moral-laden chore; it can mean playing a recreational sport with friends or going to a dance class.
Even adopting the Health at Every Size (HAES) movement (which is a lot like it sounds) has a positive impact.
“A review of over 300 studies found that HAES interventions improved cardiovascular risk factors, body image and mental health outcomes over the long term without changing weight,” Hargrave-Klein added.
So, what role does weight play?
Gaudiani asserted that weight loss can mitigate some concerns, like hypertension, insulin resistance and metabolic dysfunction.
But don’t be fooled: She “does not assume pathology in higher body weight, honors body diversity and does not track body weight as a primary outcome.” Her treatment focus isn’t weight loss, but other health-promoting modalities.
“Understanding that higher weight can contribute to cardiometabolic health conditions while absolutely refusing to focus on weight loss as a primary outcome goal actually strengthens my position as both a weight-inclusive and fat-positive provider,” Gaudiani said. “I actually believe the number one medical complication of being in a larger body is the inferior medical/surgical care that these patients receive due to weight stigma.”
And again, dieting or restricting yourself can lead to weight cycling, which puts you right back at risk for medical conditions.
When Gaudiani focuses on weight, it’s to support growing children, pregnant people and people who are being monitored during nutritional rehabilitation.
Dodell is a weight-inclusive provider, too. “Weight-inclusive medicine recognizes the negative mental and physical impact of weight stigma, and therefore, aims to eliminate this far too common component of people’s medical care and health experience,” he said.
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Berens also believes weight is a factor (one of many) in only certain contexts, such as when it could signal an endocrine or metabolic condition. But again, that’s not about placing moral judgment or blame on the patient. She also considers and addresses all factors rather than prescribing an unsustainable diet or unrealistic goals.
With all of this information, what do we do? Gaudiani’s take is clear: “We concentrate on scientifically rigorous and psychologically beneficial solutions that do not involve seeking weight loss as a primary health endpoint.”
