THE ANTI-DIET MOVEMENT: AMORALIZATION OF FOOD, BODY, AND HEALTH
Dr. Gabrielle Fundaro, CISSN, CHC
Prologue
Depression Era Dieting: A Freedom from Want
Though President Hoover’s food conservation and international relief efforts levied the United States as something of a global benefactor during World War I, he was unwilling to involve the federal government in the distribution of food on American soil during the Great Depression. [1] After WWI, the US economy expanded rapidly for just over a decade until the most devastating stock market crash in history set off a subsequent decade of economic downturn. After the crash in 1929, severe droughts in 1930 forced farmers to abandon their fields while dust storms and starvation ravaged areas of the mid- and southwestern states. Hoover philosophized that federal feeding might set a dangerous precedent; instead, he relied on non-profit agencies like the Salvation Army and the Red Cross to provide aide. Inspired by the actions of private charities, Hoover suggested that wealthy men might also provide a solution in the form of five- or ten-million-dollar donations. Both Hoover and the Red Cross inculcated individualism and self-help as American values, so while the Salvation Army expanded its efforts, the Red Cross refused to act until 1932 when it conceded to pressures from Congress and eventually distributed flour to over 5,000,000 needy families. Reverence for personal responsibility and rational eating that emerged 20 years before the Great Depression led many social workers and home economists to believe that that malnutrition was the result of ignorance rather than socioeconomic status. Thus, rather than distribute surplus food to the needy for free—which would have serious implications for the market—home economists of the US Department of Agriculture distributed brochures. Earlier food conservation propaganda stigmatizing the ‘hoarding of food on one’s anatomy’ was refurbished, and demonstrations of ‘cheap extravagance’ became haute social events. The idealization of self-control, rational eating, and thinness that emerged from the intersection of progressivism, nutritional science, and food conservation a few decades earlier provided a solid foundation for the wave of Depression Era dieting.
Depression Era dieting is anomalous because beauty ideals historically reflected the appearances of individuals with wealth and thus access to an abundance of food.1 One might assume that the expansive threat of poverty and malnourishment would once again tip the scales of body ideals back in this direction. During this period, however, the thin ideal persisted, perhaps in part due to its new association with health. In contrast to centuries prior, members of the upper and middle classes—females especially---pursued weight loss intentionally while many Americans faced real scarcity. The message of abundance had been replaced, perhaps, with a message of privilege and security afforded by higher socioeconomic status. The wealthy could ignore abundance and practice their civilized restraint to cultivate a specific aesthetic that represented, “…a freedom from want.” [2]
Salisbury Steak and Regular Enemas
One might also assume that advancements of nutritional science would have stymied the perpetuation of fad diets and snake oil sales, but this was not the case, either. Though the popularity of fad diets waned temporarily, the Great Depression paradoxically re-ignited interest in their utility for weight loss, or ‘reduction.’ In 2010, the Pennington Biomedical Research Center produced a factsheet to increase consumers’ awareness of fat diets. [3] They noted that fad diets generally exhibited several the following characteristics:
· Elimination of food groups
· Promises of quick results
· Claims that certain foods offer advantages for weight loss
· Lists of foods that must be eaten and/or eliminated
· Personal testimonies as proof of unrealistic results
· Celebrity endorsements
· Promotion of pills or supplements as part of the plan
· Claims that weight loss will be attained without physical activity
· A lack of peer-reviewed scientific evidence to support the claims
· Rapid gain and loss of popularity
· Sounding ‘too good to be true’
Today’s fad diets bear a striking resemblance to their predecessors of the early 20th century, and one has even evolved into a familiar eating pattern with empirical evidence supporting its health benefits.[4] Until the mid-1910’s—at which point Americans were becoming fluent in calorie-counting—fad diets were a means to explore and rationalize the mysterious physiology of the human body. The Salisbury Diet might be considered an ancestor of the current Carnivore Diet. Comprised of nothing but meat and hot water, it was meant to improve chronic flatulence, arthritis, and gout. Practitioners of ‘forced feeding’ engaged in regular bingeing episodes followed by what they described as an ‘abundance of energy.’ Fasting, in contrast, was a popular method of ‘resting’ the digestive organs, thereby reserving energy for other tasks (a claim shared by the Salisbury Diet as well). Other fad diets claimed that mixed meals were harder to digest, so foods needed to be eaten in isolation or specific combinations. Myths about specific foods and cooking methods abounded, as well: white bread and sugar were imperative to health, chocolate lubricated the intestines, oatmeal required cooking for at least four hours to be considered nutritious, and deep frying was the most healthful method of cooking. While iterations of these fads unfortunately (though humorously) persist over 100 years later, one might come as a surprise. Vegetarianism—maligned as an affront to the patriotism of meat-eating in 1910—evolved from a niche fad to a generally prudent and potentially healthful dietary pattern with the empirical support of nutritional science.
The new wave of Depression Era fads, however, might appear even more familiar for a few reasons: food manufacturers began marketing foods for ‘reducing’ purposes, greater awareness of metabolic physiology gave rise to fears about ‘acidosis,’ and medical doctors were increasingly developing and promoting fad diets.1 The promotion of reducing diets and foods by manufacturers was a new phenomenon as highly-processed foods were more common by the 1930’s, but these energy dense foods required sly marketing. It would be decades before labeling laws came into effect, so manufacturers made ludicrous claims that grape juice would burn fat and bread that was ‘slo-cooked’ would provide longer-lasting energy. Both the grapefruit-centric, 600-calorie Hollywood Eighteen-Day Diet and a doctor-developed bananas and skim milk diet were promoted by fruit companies. A slew of diet drugs—now illegal or available by prescription—contained thyroid, laxatives, dinitrophenol (DNP), and even hydrogen peroxide and bleach. These food combination diets Dr. William Hay developed a food-combining diet that prohibited eating proteins and carbohydrates together, recommended eating ‘alkaline’ fruits and vegetables separately, and called for a daily enema. Not to be outdone, Dr. George Harrop of Johns Hopkins University developed the bananas and skim milk diet, which was regarded as 1934’s most popular way to reduce. Perhaps one of the most alarming and, unfortunately, familiar events was a weight loss ‘derby’ supervised by Chicago’s municipal health commissioner, Dr. Herman Bundesen, in 1934. He supervised three young women who collectively lost 32 pounds at the end of their three-month bananas and skim milk diet. Dr. Bundesen’s message to the public stated, explicitly, that “”…every pound lost is health gained, beauty added. Dieting to reduce is dieting for health.””1
To Diet or Not (to Die Yet)?
Beginning in 1925, Mount Holyoke College handbook warned students: "Beware of eating between meals. Freshmen traditionally gain ten pounds so patronize the 'gym' scales."2 Lowe (1995) points out that the message internalized here is not restricted to the thin ideal alone, but also, “…the perception that a normal relationship to food and the body included dieting.” The appearance of the female body—and the ability to manipulate it—became ever more synonymous with the character and value of its inhabitant.
Counterculture, however, was slower to evolve. In October 1924, Smith College Weekly (of Smith College, a private liberal arts women’s college in Massachusetts) published a letter to the editor titled, “To Diet or Not to Die Yet?”. It warned that the college would, “…become notorious, not for the sylph-like forms but for the haggard faces and dull, listless eyes of her students,” if some measures were not taken to prevent extreme dieting practices on campus.2 Just over 10 years later, Dr. Carl Malmberg, the Public Relations Advisor and Information Specialist for United States Public Health Service and Chief Investigator for U. S. Senate Subcommittee on Health and Education, authored Diet and Die.[5]In it, he criticized food manufacturers, unscrupulous medical practitioners, and the media for promoting the ‘slimness craze’ and fad diets which he referred to as ‘ODSAA’: “One Damn System After Another.” In the chapter entitled, “Better Be Fat Than Dead,” Malmberg (1935) wrote, “No single subject, with the probably exception of religion, has had grow up around it a larger body of error, misinformation, and plain buncombe than has the subject of diet.”
Thus, for at least 100 years, many Americans have been counting calories and following fad diets to ‘reduce,’ ostensibly in the name of health and beauty. For at least 80 of those, relatively fewer individuals have been challenging the beliefs about body size, health, and weight loss, or the fad diets and quack supplements sold to manipulate them. Origins of the body positivity and fat acceptance movements are complex, as they intersected with other activist movements challenging sexism, racism, classism, ageism, imperialism, and capitalism.[6] They likely emerged as unique movements in the late 1960’s after a serendipitous connection between Lew Louderback and a reader of his The Saturday Evening Post article “More People Should Be Fat!” [7] After reading Louderback’s article, Bill Fabrey reached out to collaborate, and in 1969 they founded the National Association to Aid Fat Americans (NAAFA), now known as the National Association to Advance Fat Acceptance. (Fabrey went on to establish the Council on Size and Weight Discrimination in 1991, and currently operates the non-profit organization alongside familiar activists in the HAES and fat acceptance movements, including Miriam Berg, Regan Chastain, and Lynn McAfee.[8])
The next three decades looked something like an arms race between fat acceptance activism, the dieting industry, and dissenting perspectives within the medical field. Psychologists, sociologists, medical doctors, obesity researchers, therapists, dietitians, and feminists (none of which are mutually exclusive) authored books, diet and non-diet programs, dissertations, epidemiological studies, presentations, and consensus statements. A true consensus, however, was lacking in a practical sense; though the National Institutes of Health (NIH) declared obesity a, “…complex multifactorial chronic disease,” in 1998, just 11 years prior, the Healthcare Financing Administration asserted that it was not a disease (perhaps to deny coverage for obesity-related care.) This decision was reversed in 2004, and in 2013 the American Medical Association resolved to recognize obesity as a disease in order to, “”…help change the way the medical community tackles this complex issue.”” The implications of this decision span from individual, internalized weight stigma to institutional changes in the coverage and reimbursement of obesity-related medical care.
Healthy at Every Size?
Far from providing a conclusive stance, the categorization of obesity as a disease seems to have sparked greater debate about the association between health and body size as well as the implications of intentional weight loss. On one hand, epidemiological data illustrates high rates of diet recidivism, as most individuals regain most of their lost weight after one year, and after five years, some gain more than they had lost. [9],[10] That said, other data indicate that the 20% (or fewer) of individuals who diet and maintain an average reduction of 2-7% of their initial bodyweight do experience improvements in physical health biomarkers, such as LDL cholesterol and A1c levels. [11] Other data question the validity of body mass index (BMI) to indicate health status, considering that overweight or obese classifications confer protection against some chronic diseases and mortality.[12] This phenomenon—known as the Obesity Paradox—supports the notion that BMI is limited as a standalone health metric since it fails to represent body composition, fat distribution, physical activity levels, duration of current adipose level, and other lifestyle factors that mediate the relationship between bodyweight and health. Importantly, a large body of evidence has shown that weight stigma—or negative beliefs and attitudes about body weight—leads to psychological distress, eating pathology, mood disturbances, body dissatisfaction, and low self-esteem. [13]
Weight-focused approaches—those that track weight change as the primary outcome—often include an emphasis on healthful habits such as physical activity, social support, and increased fruit and vegetable intake. However, some may stigmatize certain foods or body sizes, and the attachment to a specific weight outcome goal may overshadow the importance of a safe and sustainable approach. Perhaps the most extreme example of a weight-focused approach would be the concept of ‘diet culture’: a set of beliefs and practices centered around the attainment a specific aesthetic and the moralization of both food and body size. The National Eating Disorders Association (NEDA) explains that diet culture conflates body size and health, pathologizes or idealizes certain body sizes, and moralizes body size such that fat people are viewed as less valuable and thinness is privileged. In pursuit of this thin privilege, diet culture requires the use of external rules and food moralization to dictate eating habits. Additionally, physical activity is utilized solely as punishment for, or prevention of, becoming fat.[14] EDRDPro Sara Upson provides a number of specific beliefs and practices within diet culture, such as the moralization of food choices, feeling anxious or guilty about eating certain foods, avoiding social situations due to food anxiety, exercising for compensation or punishment, feeling the need to justify eating, and feeling worthy based on body size.[15] According to Upton, “Diet culture says you should lose weight and keep it off, live a lifestyle of forever dieting, hate yourself and your body, talk bad about yourself and other people of size, feel worthless unless you are dieting or trying to lose weight.” Christy Harrison, dietitian and author of Anti-Diet, explains that diet culture promotes weight loss as a means of attaining higher status and greater perceived moral virtue, thereby oppressing people who don’t adhere to the healthy ideal.[16] This ideal physique is attained only through vigilant adherence to a morally-superior way of eating and living. Some people, according to Harrison, spend their lives pursuing it with the unshakable fear that they’re broken in some way for not having achieved it.
Considering the effects of weight stigma, rates of diet recidivism, and complex relationship between body size and health, it is reasonable to surmise that a traditionally weight-focused lifestyle intervention might not be appropriate for everyone. Weight-neutral approaches encourage a change in behavior to increase healthful habits as well—the very same things that might be utilized in a weight-focused approach. Rather than seeking the outcome of weight loss, however, the process is the purpose; the outcome and the process are one: increased health-seeking behavior. Whether weight change occurs or not is a byproduct rather than the goal. (Read up on the similar long-term outcomes of weight-focused and weight-neutral interventions here!) A weight-neutral approach in isolation doesn’t spark a great deal of debate, but the social justice movement and trademarked name associated with a version of this approach certainly has. Health at Every Size™ (HAES) is the title of Lindo Bacon’s well-known 2008 book, but the name was actually developed by the Association for Size Diversity and Health (ASDAH), whose first conference took place in 2006. ASDAH is a membership-based, professional organization of HAES-aligned providers who share the mission of dismantling weight-centered and/or oppressive health policies and practices. ASDAH chose to trademark Health at Every Size™ between 2011-2012 to protect and conserve its use and applications.
As a movement, Health at Every Size™--no, not healthy at every size or healthy at any size—aims to enhance both information about, and access to, resources that promote health and wellbeing. As an approach to client interactions, it calls for practitioners to recognize the social determinants of health that affect their clients, provide respectful care to individuals in all body types, and focus on behaviors rather than weight loss outcomes [17]. Contrary to popular belief, the HAES website does not claim that individuals are healthy at every or any size. Rather, it emphasizes the importance of both personal behaviors and external factors that influence health and wellbeing. Their perspective suggests that pathologizing certain body sizes while idealizing others is harmful, and if a person is experiencing a health concern, focusing on behavioral rather than weight-focused interventions is more effective and less harmful. Additionally, they advocate for individual freedom to choose not to pursue health. Though the focus on behavioral intervention is hardly a contentious topic, many appear to take issue with the ideas that body weight and health aren’t mutually exclusive, or that individuals should have the freedom to choose an ‘unhealthy’ behavior with impunity.
Can We Bridge the Gap?
According to psychologist and professor Mary Lamia: "If you want to affect change, you have to institute some mutual effort to reach higher levels of understanding… Once we are able to understand someone else's perspective, we are more likely t o engage in productive dialogue that actually drives change.”[18] In response to a recent Instagram post questioning whether weight-neutral and weight-focused approaches can coexist, I wrote, “…if we are going to meet clients where they are, we need to be informed about weight-neutral and weight-focused approaches…within an entire profession or practice, the two must coexist because [one] is not going to be appropriate for every individual.” A client-centered approach requires that we meet the client where they are, creating an atmosphere of acceptance, collaboration, trust, and respect as we guide them to their self-determined goals. It is likely in everyone’s best interest to seek awareness and understanding of both weight-focused and weight-neutral approaches and philosophies, irrespective of what we choose to practice or believe to be true. Rather than picking an ideological side of the diet debate, we can choose to side with our clients. Likewise, the history of our industry provides valuable insights and lessons in humility, lest we take our current practices too seriously, only to see them revealed as fads in 50 years. Rather than repeating history, we can collaborate for a better future.
[1] Levenstein, H. A. (1993). Paradox of plenty: A social history of eating in modern America. New York: Oxford University Press. [2] Lowe, M. A. (1995). From Robust Appetites to Calorie Counting: The Emergence of Dieting among Smith College Students in the 1920s. Journal of Women’s History, 7(4), 37–61. https://doi.org/10.1353/jowh.2010.0517 [3] Roy, H. (2010). Fad diets defined. Pennington Nutrition Series, 89(89), 2–4. [4] Veit, Helen Zoe, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013 [5]Malmberg C. Diet and Die,. [New York]; 1935. Accessed February 9, 2021. http://hdl.handle.net/2027/coo.31924003489162 [6]The Rebellious History of the Fat Acceptance Movement - Center For Discovery. Accessed February 10, 2021. https://centerfordiscovery.com/blog/fat-acceptance-movement/ [7]History of the Health At Every Size® Movement, Part 1 | ASDAH. Accessed February 10, 2021. https://asdah.org/history-of-the-health-at-every-size-movement-part-1/ [8] Bill Fabrey – Council on Size and Weight Discrimination. Accessed February 10, 2021. http://cswd.org/bill-fabrey [9] Rena R Wing, Suzanne Phelan, Long-term weight loss maintenance, The American Journal of Clinical Nutrition, Volume 82, Issue 1, July 2005, Pages 222S–225S, https://doi.org/10.1093/ajcn/82.1.222S [10] Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 2001 Nov;74(5):579-84. doi: 10.1093/ajcn/74.5.579. PMID: 11684524. [11] U.S. Department of Health and Human Services. (2013). Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel. National Heart, Lung, and Blood Institute, 501. [12] Donini, L. M., Pinto, A., Giusti, A. M., Lenzi, A., & Poggiogalle, E. (2020). Obesity or BMI Paradox? Beneath the Tip of the Iceberg. Frontiers in Nutrition, 7, 53. https://doi.org/10.3389/fnut.2020.00053 [13] Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018 May;74(5):1030-1042. doi: 10.1111/jan.13511. Epub 2017 Dec 8. PMID: 29171076. [14] Recognizing and Resisting Diet Culture | National Eating Disorders Association. (n.d.). Retrieved July 28, 2020, from https://www.nationaleatingdisorders.org/blog/recognizing-and-resisting-diet-culture [15] It’s Time To Drop Out of Diet Culture – EDRDpro. (n.d.). Retrieved July 28, 2020, from https://edrdpro.com/its-time-to-drop-out-of-diet-culture/ [16] What Is Diet Culture? — Christy Harrison - Intuitive Eating Dietitian, Anti-Diet Author, & Health at Every Size Advocate - Food Psych Programs. (n.d.). Retrieved July 28, 2020, from https://christyharrison.com/blog/what-is-diet-culture [17] The Health at Every Size® (HAES®) Approach | ASDAH. (n.d.). Retrieved October 17, 2020, from https://asdah.org/health-at-every-size-haes-approach/ [18] Why Shame And Social Progress Don’t Mix. (n.d.). Retrieved July 28, 2020, from https://www.forbes.com/sites/laurencoulman/2020/04/27/why-shame-and-social-progress-dont-mix/#dd5870573fdc