Teaching Mindful Eating from a Weight Inclusive Paradigm

I had previously written a piece on Why Mindful Eating is Weight Inclusive. Among other feedback, I received requests to clarify some concepts or elaborate on the rationale for some of the statements in it,  particularly for newcomers to the Health at Every Size® approach or the weight inclusive paradigm. Although what follows is by no means an extensive review or discussion on the topic, it is my hope it is clearer, while providing additional references for a deeper exploration.

As a doctor, I was trained in a weight centric paradigm (1). This aligned with the weight bias and healthism (2), rampant in our culture, which I had internalized.

As human beings, we have what is called a cognitive bias, which means we tend to assimilate new learning into what we already believe to be true. So, for most health providers, as we learn mindfulness and mindful eating, we simply incorporate that as a new ‘skill’ viewed from the lens of the paradigm we have been socialized and trained into.

From a weight centric and healthist paradigm, it makes sense to lodge the responsibility for pursuing a “healthy” lifestyle that leads to a “healthy/normal” weight within the individual. And mindful eating is adopted and interpreted as a strategy to help people manage their weight, and to measure the outcome of said strategy in terms of how well their bodies conform (or don’t) to the normative idea of health. This normative idea is heavily influenced by racism, ableism, dominant binary gender identities, esthetic standards and a very narrow understanding of health as determined by metabolic or cardiovascular parameters. And the fact that most mindfulness / mindful eating teachers are individuals with highly privileged identities who have, for the most part, conforming bodies (i.e. white, cis-gendered, able-bodied, with thin privilege), also contributes to how these practices are transmitted and adopted.

As my dear colleague Caroline Baerten has pointed out in a blog post, many people are trying to be what they think they should be, and when a teacher reinforces an oppressive inner monologue by using an outcome driven approach, mindfulness becomes a form of violence.

In essence, we have the practice of mindfulness and mindful eating, which are intended to promote liberation, coopted by oppressive paradigms and structures.

If, as mindfulness / mindful eating teachers, we have not examined our internalized biases – both subtle and not-so-subtle – we will keep holding the belief that weight / a person’s body is a problem to be fixed, that mindfulness / mindful eating is the antidote or solution to the "problem" of "overweight" and "obesity’" We will keep expecting that if a person does this practice in the "right" way an inevitable outcome will be weight loss / weight management. And we will keep doing harm.

So how then do we shift from one paradigm to another? One way is to review the values, assumptions, and claims of the dominant paradigm. Another is to privilege different forms of knowing, such as the lived experiences of marginalized populations – including people living in larger bodies -, and to cultivate discerning wisdom about the harms, risks and caveats of continuing to promote the dominant paradigm.

In examining my own biases, it has been necessary for me to grapple with the grief of the realization that I too have done harm. I too have practiced and taught from a weight-centric paradigm. Even having transitioned to a Health at Every Size® approach, I catch myself using oppressive language, or notice thoughts and behaviors that come from internalized bias and stigma. I try to cultivate compassion towards myself, and towards others who are coopting mindfulness or mindful eating for a practice focusing on weight loss / weight management or who are still straddling both paradigms. Some days I am more skillful at this than others.

Below you will find some of the biases and beliefs I have found important to examine (beliefs are italicized and a brief explanation follows). A detailed discussion of each of them is beyond the scope of a blog post, so I have included several references at the end of this text.

  • That body size is relational to one’s physical and mental health. Yes, but not in the way we are usually taught. Living in a larger body makes a person a target of body oppression and marginalization, with a huge impact on health. This is particularly damaging in children and teens who are too often prescribed a number of actions intended to bring about weight loss, aka dieting behaviors.
  • That we can tell about someone’s behaviors and/or lifestyle based on their weight. In reality, assumptions we make about someone just by looking at them are only an indication of our own weight bias.
  • That "obesity" is an eating disorder (or a marker of one). The core issues and symptoms of eating disorders are in the realm of ideation and behaviors. Weight is not a behavior.
  • That "overweight" and "obesity" are neutral descriptors, or words that can be re-appropriated. These terms do harm. They are etymologically wrong and oppressive and have been created and centered by a system that pathologizes and marginalizes certain bodies (3). The creation of the "overweight" and "obesity" categories was based on
    • the Body Mass Index, a statistical measure that was never intended as a marker of individual health;
    • the assumption that above a certain BMI category all bodies are unhealthy and that the BMI is causally linked to health and/or longevity, which is not supported by a critical review of the science;
    • the financial interests of the diet industry, including manufacturers of weight loss drugs.
  • That a focus on weight as an outcome or reliable proxy for health is compatible with a weight inclusive / weight neutral approach to health. The focus/emphasis on weight (even when considered as a desired outcome of health related behaviors) continues to enhance a weight-centric paradigm, which engenders negative judgments onto higher weight individuals by promoting the view that they are unhealthy and a burden on society, and that weight can be controlled through will (so that if a person is fat, it is due to poor choices and lifestyle habits).
  • That a weight-centric approach is compatible with mindful eating. This is weight bias and diet mentality at work. Until we are able to leave weight out of the equation (having truly understood that it is not something that can be modified, managed or controlled at will; and ceasing to use it as a reliable proxy for health and wellbeing) we won’t be able to truly support someone in listening to their needs and getting comfortable in caring for those needs consistently, letting go of the outcome.
  • That a weight inclusive / weight neutral approach is synonymous with being against any and all weight loss, or that it glorifies/promotes "obesity". A weight inclusive approach advocates for social justice, and for the right of every person to receive respectful care. It seeks to disrupt weight stigma, and celebrates the diversity of body sizes and shapes. A weight neutral approach is not in favor or against of weight loss, it simply rejects the deliberate pursuit of weight loss, and advocates for trusting that each body will take care of the question of weight when a person cultivates sustainable self-care and wellbeing in different realms - this can be anywhere along the weight/BMI spectrum. This rejection of the deliberate pursuit of weight loss is grounded in ethical concerns as well as scientific ones.
  • That it is irresponsible to ignore the "serious consequences of weight". Although we know weight correlates with certain health risks, correlation is not the same as causation. And it is not weight, but our cultural fixation on it and the behavioral consequences of this fixation, that most often bring about adverse consequences to health. Stigma, discrimination, shame and oppression harm our physical, emotional and social health.
  • That weight is the problem and mindful eating the antidote, fix or cure. As stated above, mindfulness is not about fixing or controlling outcomes. Mindful eating is about healing our relationship with food, body and movement, not about fixating on a specific outcome.
  • That health is lodged within the individual. Contrary to this belief, what the science tells us is that – depending on our level of privilege – 15-25% of health related outcomes are a consequence of individual behaviors. The rest is a function of social determinants of health.
  • That health is a matter of individual choice. The biological reality of living in a body is that all of us will have different health conditions throughout our lifespan. And intersecting systems of privilege and oppression that impact every aspect of our life, including access to health services, are crucial determinants of health. This is not up to the individual.

We need to reframe our teachings to make room for humans of all sizes and levels of health to be nourished in mindfulness and compassion, without expecting bodies to change externally as a marker of success, progress or healing. We need to advocate for the right of all bodies to be held in radical acceptance, respect and trust.

We need to honor the ethics of our practice to create a more just, kind and compassionate society in which we are not colluding with weight bias, body oppression, and diet culture.

We need to stop promoting / selling weight bias, sizeism, ableism, healthism, and nutritionism disguised as mindfulness / mindful eating / compassion. 

Teaching about restraint and moderation in the context of mindful eating needs to be nuanced, taking into consideration that our teachings are received in the context of a culture and society in which the dieting mind is pervasive and rampant. We need to be accountable not only for our intention, but for the impact of what we say and do – or what we fail to say or do. Weight inclusivity and weight neutrality need to be incorporated explicitly into our teachings.

It is crucial that, as mindful eating teachers, we consider the paradigm and stance in which our practice and teachings are rooted and the biases and internalized stigma that inform the way we practice and teach. It is necessary that mindful eating be transmitted as a practice for liberation, not as yet another oppressive intervention or a strategy coopted by the diet mentality and culture or other oppressive structures and discourses. To this end, it is useful to learn from the fields of intersectional feminism, social justice, trauma informed care, cultural-relational theory, critical theory, and critical dietetics.

Un-learning and re-learning is a process, and it takes time.

May we all hold our mistakes in compassion and offer ourselves, and each other,

patience as we continue to examine and challenge internalized bias and oppression,

and resist oppressive structures and discourses on the path to collective liberation.

What are your beliefs and internalized biases around weight? How do they influence and impact the way you practice or teach mindful eating?

 

(1) The weight centric paradigm, also known as the weight-normative approach, centers weight in discussions about health. It includes the views that the body mass index (BMI) categories of "overweight" and "obesity" are a problem, that BMI is reduced limiting caloric intake and increasing energy expenditure and that there is an "obesogenic" environment. This paradigm rests on the assumption that weight and disease are causally related in a linear fashion, and emphasizes personal responsibility for “healthy lifestyle choices” and the maintenance of “healthy weights”. On the basis of these beliefs, it focuses on weight loss and weight management to prevent and treat a myriad of health problems. A range of agents is then engaged in socially constructing fatness as a correctable health problem.

(2) Healthism is a term likely first used by the political economist Robert Crawford, who in an essay titled “Healthism and the Medicalization of Everyday Life” wrote “Healthism situates the problem of health and disease at the level of the individual. Solutions are formulated at that level as well. To the extent that healthism shapes popular beliefs, we will continue to have a non‐political, and therefore, ultimately ineffective conception and strategy of health promotion. Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well‐being.” In this view, healthism entails seeing health as an individual matter, a primary value, a choice and a moral index.

Crawford was responding not only to the dominant medical model, but also to the various movements for self‐care, holistic care, and alternative medicine. Although those movements were reacting against conventional allopathic western medicine, they are also arguably part of a longer historical shift toward medicalization as a way of managing populations, toward thinking about everything in terms of whether it's healthy or unhealthy, pretty much synonymous with good and bad.

According to Petr Skrabanek, healthism begins when the government uses propaganda and coercion to establish norms of health and attempts to impose norms of a "healthy lifestyle". All human activities are weighed in the balance of their real or imagined effects on health: all human activities are deemed responsible and irresponsible based on this measure.

Following Skrabanek, Nikolas Rose has described healthism as a doctrine that links the "public objectives for the good health and good order of the social body with the desire of individuals for health and well-being". But while Skrabanek criticizes state interventions as coercive, according to Rose, the capitalist society finds coercion unnecessary. Since people want to be healthy, the apparatus of advertising and other means of capitalist persuasion lead people to internalize the message of healthism without state intervention. Rose's view represents an extension of Michel Foucault's theories.

(3)  From a weight-inclusive paradigm, the terms we use are larger body, higher weight, and fat, advocating for reclaiming the word fat as an adjective without negative connotation.

 

About the author

Lilia Graue is a physician, psychotherapist, coach and teacher. She works with brave humans to counter performative health, among other oppressive discourses, to do the compassionate healing work necessary to collectively create a culture of body justice and liberation, so that we may all become Fiercely Embodied.

 

References:

Aphramor L. Terms of belonging: Words, weight and ethical autonomy. NHDmag. 2018; 131: 41-45. http://lucyaphramor.com/dietitian/wp-content/uploads/2018/02/NHD-Feb-2018-Obgobbing.pdf

Bacon L. The body manifesto. 2017. https://lindabacon.org/wp-content/uploads/The-Body-Manifesto_Bacon.pdf

Bacon L, Aphramor L. Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight. Dallas, TX: Benbella Books, Inc.; 2014.

Bacon L, Aphramor L. Weight science: Evaluating the evidence for a paradigm shift. Nutr J. 2011; 10:9. doi: 10.1186/1475-2891-10-9

Berman MI. The ethics of helping clients with weight loss in psychotherapy. [Web article]. 2017. http://www.societyforpsychotherapy.org/weight-loss-psychotherapy 

Brady J, Gingras J, Aphramor L. Theorizing health at every size as a relational-cultural endeavor. Critical Public Health. 2013; 23(3): 345-355. Doi: 10.1080/09581596.2013.797565

Crawford R. Healthism and the medicalization of everyday life. Int J Health Serv. 1980; 10(3): 365-388.

Gingras J, Asada Y, Fox A, Coveney J, Berenbaum S, Aphramor L. Critical dietetics: A discussion paper. 2014; 2(1): 2-12.

Gotovac S, LaMarre A, Lafreniere K. Words with weight: The construction of obesity in eating disorders research. Health. 2018. doi: 10.1177/1363459318785706

Meadows A, Daníelsdóttir S. What’s in a word? On weight stigma and terminology. Front Psychol. 2016; 7: 1527. doi:10.3387/fpsyg.2016.01527

O’Hara L, Taylor J. What’s wrong with the ‘War on obesity?’ A narrative review of the weight-centered health paradigm and development of the 3C framework to build critical competency for a paradigm shift. SAGE Open. 2018; April-June: 1-28. doi: 10.1177/2158244018772888

Pearl RL, Puhl RM. Weight bias internalization and health: a systematic review. Obes Rev. 2018. doi: 10.1111/obr.12701

Skrabanek P. The Death of Humane Medicine and the Rise of Coercive Healthism. Suffolk, UK: The Social Affairs Unit; 1994.

Tylka T, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014. doi: 10.1155/2014/983495.

Wikipedia. Healthism. https://en.wikipedia.org/wiki/Healthism

* If you'd like a pdf copy of any of the research articles listed, or of the book by Petr Skrabanek, drop me a line.

Lilia Graue