When I read an intake form for a new patient and she requests help with weight loss, I pause and I take a deep breath. The territory is full of landmines. On one end of the spectrum, we have diet culture, touting crash diets or unrealistic body-size standards or the latest miracle weight-loss supplement. On the other end, we have the fat acceptance movement, started in the 1960s, aimed at reversing discrimination in the public domain, work environment, and doctor’s offices. Author Sarai Walker defines fat acceptance as believing that “bodies come in all shapes and sizes, and that all bodies have equal value. Fat activism is a political movement that advocates for the rights and dignity of fat people.” From the fat acceptance movement sprang fat positivity—a reaction to fat shaming—and ultimately body positivity, an evolving social movement that opposes narrowly defined beauty standards. Advocate Jameela Jamil, an actress from The Good Place, started a meme on Instagram called “I Weigh,” which Jamil describes as a “movement… for us to feel valuable and see how amazing we are, and look past the flesh on our bones.” What I seek with my patients is the judgment-free zone in the middle, focused on metabolic health, for reasons that I’ll explain in this article.
The Rise of #IWeigh
Body positivity has gained traction in recent years, and for good reason. I’m sensitive to the harms of diet culture, especially young women though it affects women of all ages, as we internalize the messages of female thinness and obedience at all costs. I’ve written a few New York Times bestselling books aimed at addressing metabolic health, and always, there’s a push/pull with publishers who want diet books that become a commercial success. I love the #iweigh community on social media, where Jameela Jamil is a critic of the Kardashian sisters and how they promote unproven and potentially risky products though we all know they have trainers and surgeons to help them achieve their enviable body size and shape.
Jameela Jamil did something bold on her I Weigh Instagram account after being disgusted by an image of the Kardashians and Jenners that displayed their weights captioned over their bodies. She comments in her popular podcast and online community that the moment was a line in the sand for her—that these women were being reduced to numbers from the bathroom scale and not any of the attributes that define them. And, obviously, this type of reductionism doesn’t happen to men.
In an BBC interview, Ms. Jamil said, “If there are any numbers written across those women’s bodies, it’s how much money they have brought to the table, which is a significant amount.” On Instagram, Ms. Jamil posted a photo of herself, describing what she weighs in everything except kilograms. It’s a powerful counternarrative.
The overarching goal of my work with the majority of my patients who request help with weight loss is to steer this complicated and divisive topic toward one that I believe is much more important: metabolic health.
What Is Metabolic Health?
In medicine, we define metabolism as an aggregate measure of the biochemical reactions in the body, including those related to your hormones, that dictate how you feel and determine how fast or slow you burn calories. Metabolic health is defined as optimal levels of blood sugar, insulin, triglycerides, high density lipoprotein (HDL) cholesterol and function, blood pressure, and waist circumference, usually without using medications. These biomarkers relate to your risk of metabolic problems, including heart disease, prediabetes, diabetes, and stroke. An optimal metabolism is the foundation of your health, today and tomorrow.
Here’s where things get interesting. You cannot tell from looking at someone’s weight whether they are metabolically healthy. I see patients at a normal weight or body mass index who are metabolically unhealthy, and conversely, I see patients fall into the overweight and obese range who are metabolically healthy. In my 40s, I was at a normal weight but I was developing hidden conditions that we correlate with obesity, including insulin resistance, rising blood pressure, and prediabetes. I was heading toward coronary heart disease, maybe a heart attack, but you couldn’t tell unless you checked my metabolic health. I wasn’t alone. Only 12 percent of Americans are metabolically healthy. Certain demographics and lifestyle factors affect metabolic health. Better metabolic health is more likely to be found in women, people under age 40 who are physically active, nonsmokers, and have some college education. Latinx race and people 60 and older are less likely to be metabolically healthy.
Fortunately, there are simple actions that improve metabolic health—eat a food plan rich in vegetables, with a healthy dose of prebiotic fibers that feed your benevolent microbes in your gut, plenty of color to support immune function, and with the right dose personalized for you of whole-foods carbohydrates, moderate and clean protein, and mostly plant-based fat. Exercise regularly and quit smoking. Schedule regularly destressing activities, and sleep 7 to 8.5 hours every night.
Medical Discourse vs. Toxic Media Tropes
In the polarizing conversation between “diet culture” and “body positivity” is the conflation of two approaches: the health discourse, based on scientific evidence from the medical profession; and the media and advertising industry discourse, wherein a thin body is promoted as ideal. The health discourse defines health based on the metabolic standards that I’ve just described. They are objective and tests that are readily available from a health care professional. The second discourse tends to laud unrealistically thin women and features images of women who are genetic outliers, like Kendall Jenner, Giselle Bundchen, and Kate Moss. It is a central part of body image issues.
We need to keep these two levels of discourse separate. I operate and see patients within the health paradigm. Fat acceptance, fat positivity, and body positivity aims to dismantle the fat shaming quality of toxic media messaging.
What occurs in the body and our judgment about it are two separate things. As a physician, I help with the first part, guiding patients to understand what is occurring in the body in terms of metabolic health. Our judgment about body weight and fat mass, and how it looks under someone else’s distorted gaze, is the creepy dynamic that we need to understand and dismantle, particularly in marginalized groups.
I get it. I suffered privately myself over my weight for too many decades. I met criteria for disordered eating in high school and in my twenties. I tried too many diets that failed in the long run. I read Naomi Wolf and other feminist texts, trying to find my way. I jumped on the intuitive eating bandwagon, rejecting chronic dieting and attempting to nurture my body rather than restricting my book. It didn’t work because I needed more boundaries. I was a member of a 12 Step food program for 13 years, which was very healing but also too restrictive. It didn’t work because I needed fewer boundaries. What has worked best for me is to focus on metabolic health.
That’s just me, but it’s what I bring to the table when I’m counseling patients about their weight. I have my own biases and blind spots, but I also know that we each have our own arc when it comes to how to create the type of health we most want—and it’s highly personal.
In my opinion, when it comes to metabolic health, I encourage my patients to find the middle path.
The Middle Ground: Metabolic Health
For me, the middle ground is somewhere between diet culture and body positivity. I define that space as metabolic health, and to promote healthy metabolism in a way that correctly and inclusively portrays bodies. We can understand and seek metabolic health separate from the toxic media tropes that promulgate unhealthy body image and create a toxic environment, especially for younger, vulnerable women.
Just as diet culture polarizes people and can cause harm, body positivity can also be polarizing and leave women feeling silenced about wanting to improve their metabolic health. That’s why we need to separate sound medical advice from misleading and potentially exploitative advertising hype.
What’s the downside to accepting one’s own body and the changes it undergoes? While the goal is to overturn the toxic notion of body image, and I support that 100%, there is a risk of ignoring the health discourse while trying to change or overcome the diet trope.
In a New York Times opinion titled, “The Problem with Body Positivity,” Kelly deVos writes about her weight and embrace of body positivity: “It took me years of hard work to learn to accept myself, but I finally embraced the idea that my body was healthy at any size… However, the past few weeks had cast those beliefs into doubt.” She was diagnosed with a severe infection requiring hospitalization with intravenous antibiotics, likely related to a new diagnosis of Type 2 diabetes.
I have two daughters and want to model for them how to eat for health, when to eat, and how we are far more than what gets measured on a bathroom scale. I continue to recover from disordered eating and sociocultural pressure to be as thin as possible. And I’m careful to normalize body fat. We need it to make hormones, and we need healthy fat in our diet to build hormones. Having cholesterol levels that are not too high (and not too low) can drive hormonal, mental, and physical health. Eating healthy fat does not make us fat. On the other hand, visceral fat is part of that worsening continuum from metabolic flexibility to inflexibility—that’s why I measure it in all of my patients. This is not about body shaming, it’s about metabolic health.
On the other hand, embracing body positivity wasn’t as healing for me as I had hoped. I tried accepting my growing waistline but that set me up for disappointment too. Meanwhile, my metabolic health continued to decline. I was diagnosed with prediabetes, worsening vascular function due to insulin problems, and high diastolic blood pressure while exercising. I tried intuitive eating, and gained more weight. I needed to find the middle path.
Importantly, I want you to define metabolic health for yourself, and to charter the best path for you to be the healthiest version of yourself. It may be through body positivity, and that’s totally fine. Or it may be through learning more about your metabolic health and hormones—and if that’s the case, I’m here to help you.
What do you weigh? I weigh…
- Two wise daughters
- One happy marriage
- One extraordinary labradoodle, my teacher in life
- 22+ years of education
- Board certification since 2001
- About 28,000 patients seen over the past few decades
- Financial independence
- Five published and bestselling books (the latest, Women, Food, and Hormones, is out now)
- Two academic positions, on at the University of California at San Francisco, and currently as Clinical Assistant Professor at the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University
- Two research grants on metabolic health
- A deeply fulfilling job with kind and collaborative colleagues as Director of Precision Medicine at Marcus Institute of Health at Thomas Jefferson University, where I see patients, perform research, and teach physicians and medical students about integrative medicine
Jamil posted next to the Kardashian image her own version of what she weighs on the I Weigh platform, “Lovely relationships, Great friends, I laugh every day, I love my job, I speak out for women’s rights, I like my bingo wings, I like myself in spite of EVERYTHING I’ve been taught by the media to hate myself about.” Amen.
