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The American Dietetic Association's position on weight management calls for a multifaceted approach to working with clients to achieve weight management (1). The goals of this approach include a healthful diet, moderate physical activity, reduced focus on weight, improved selfesteem, a more positive body image, and a functional support system. The purpose of this article is to review the rationale for promoting a positive body image or size acceptance and to present some body size acceptance strategies that are appropriate to dietetics practice with emotionally healthy adults.
Body dissatisfaction related to real or perceived fatness is widespread among women in North America (2,3). Although body dissatisfaction has been found among both black and white women of all sizes, white women seem especially vulnerable to this discontent (3). Other ethnic groups have not been studied adequately. Most studies have found that negative body images occur among women regardless of their body mass index, but there is a higher prevalence among those who are obese (3-7). Body image is closely related to self-esteem, especially in women (7,8). Not only does preoccupation with thinness contribute to unhappiness, it also interferes with the development of rational eating and exercise behaviors, either by promoting extreme behaviors or by making goals seem so inaccessible that the person is discouraged from trying to lose weight.
Body dissatisfaction is related to body image disturbance, which is one aspect of serious mental disorders, especially eating disorders (9). Although this article will draw on the research related to body image disturbance, its purpose is not to encourage dietitians to engage in psychotherapy but rather to help them encourage body acceptance among their weight management clients. The expression "body size acceptance" will be used to describe the goal of helping clients to challenge and replace the "normative discontent" (10) that has become characteristic of North American women. The article has 3 sections: an examination of the concerns that discourage dietitians from promoting body size acceptance; a review of the role of such acceptance in weight management programs; and a description, critique, and examples of 3 strategies for prorooting size acceptance.
Is Size Acceptance Advisable?
Health professionals and their clients often have serious doubts as to the advisability of size acceptance. The desire to be slender is so strong and so widely held that dietitians have become accustomed to using it as a means of motivating behavior changes. Size acceptance may be viewed by some as turning away from the goals of slenderness and health. Thus, doubts about the appropriateness of size acceptance must be addressed before dietitians can effectively work to decrease body dissatisfaction. Following are some of the typical doubts along with facts and perspectives that may be useful to challenge them.
"How can we deny the health risks of obesity?" Those who espouse size acceptance do not view it as denial of the health risks of obesity (8,11-19). Clearly, the risk of certain chronic health problems is directly related to the extent of body fatness (20). Using those risks to justify body dissatisfaction is problematic for several reasons: not all people who are overweight are at risk (20), weight-loss interventions have a poor success rate (21), and awareness of the risks does not consistently lead to improved behaviors (22). Fear is a tricky motivator, often producing irrational and/or erratic behaviors or a feeling of being overwhelmed. A study of almost 20,000 Canadians found that the presence of diabetes, hypertension, or hypercholesterolemia was unrelated to weight-loss attempts (22).
Lacking widely effective and lasting means of weight-loss intervention, it may be more appropriate to help clients find ways to cope with the health risks, either by reducing the risks through means other than achieving slenderness or by accepting the risks. Loss of relatively small amounts of weight may produce substantial improvements in risk factors (23), but will not produce, in most clients, the slenderness that is the cultural ideal. Research has shown that for most heavy clients attractiveness is usually a more pressing goal than improved health (24,25). To be satisfied with a 5% to 10% loss of weight, improved fitness, greater strength, or other achievements requires a change in their acceptance of a heavy body for most clients.
"If you relieve the pressure, won't people gain weight?" For the most part, the idea that body dissatisfaction provides the momentum necessary for lasting weight loss is an untested hypothesis. Studies commonly combine size-acceptance work with dieting and exercise interventions making it impossible to separate the effects. In an unusual study, Rosen and his colleagues (26) worked with obese women to improve their body image without any intervention for weight change. More than two thirds of the women became significantly more accepting of their size and there was no evidence of weight gain. Cilaska (12,27) also showed that short-term gains in body satisfaction were not associated with weight gain.
Pressure to be slender seems to be effective in increasing the prevalence of dieting, although not necessarily among those who are most overweight and evidently without a lasting effect on the prevalence of obesity (21). On the other hand, there is no evidence that pressure for slenderness is an effective public health means of reducing the incidence of obesity. The past few decades have been characterized by severe pressure for slenderness, widespread participation in dieting and other weight-loss strategies, and a major increase in the incidence of overweight. Data from the Third National Health and Nutrition Examination Survey, which showed a sharp upturn in the incidence of overweight, was collected in 1988-1991 (28), a period that was immediately preceded by a peak in the prevalence of dieting (29). The author of this point-counterpoint monitored weight changes and self-reported efforts to lose weight in a convenience sample of approximately …