Gut feelings and lived experiences: a qualitative study of ‘anti-diet’ dietitians’ and psychologists’ motivations and experiences regarding the weight-neutral approach

ABSTRACT

This paper examines whether the motivations and experiences of ‘anti-diet’ dietitians and psychologists represent a paradigm shift in healthcare. We conducted four 2-hour, discipline-specific focus groups with a total of 16 female participants residing in Australia. Our reflexive thematic analysis generated four themes that we consider to be stages of a weight-neutral paradigm shift: (1) a recognition of a mismatch between one’s weight-centred training and one’s lived experience of diet culture, which subsequently informs (2) gut feelings that influence their decision to reject the weight-centric paradigm, thereby leading to (3) exploring the anti-diet knowledge base and then subsequently (4) promoting or advocating for the weight neutral paradigm. Our findings represent a four-stage paradigm shift in action; emphasising the significance of lived experience in the weight-neutral turn, as well as differences in symbolic power between health professionals. Future research should focus on potential ruptures or conflicts within the weight-neutral paradigm itself, and look more deeply into the experiences of other health professionals who are critical of the weight-centred approach.

KEYWORDS:

• Weight-neutral
• anti-diet
• psychologists
• dietitians
• paradigms

Introduction

This study explores the motivations and experiences of ‘anti-diet’ dietitians and psychologists, and investigates whether they represent a paradigm shift in healthcare. Western health and medical discourses position the ‘obesity epidemic’ as a threat to population health and wellbeing, supporting the promotion of weight-loss via dietary, surgical, and pharmaceutical means to address varied health problems (Hunger et al., 2020; Talumaa et al., 2022). Over the past 20 years, however, studies have also shown that focusing on weight-loss can exacerbate maladaptive eating behaviours (e.g. weight cycling, disordered eating), contributing to healthcare avoidance (O’Hara & Taylor, 2018; O’Reilly & Sixsmith, 2012), and the social stigmatisation of people with larger bodies (O’Hara & Gregg, 2010). ‘Anti-diet’ health professionals have raised concerns about the impact of dieting as a health practice; instead, promoting health behaviours and emphasising that bodies naturally come in diverse shapes and sizes (Tylka et al., 2014). These perspectives have broadly been referred to as ‘weight-neutral’ or ‘weight-inclusive’ (O’Hara & Taylor, 2018), and predominantly been advanced by dietitians and psychologists (Bessey & Lordly, 2020; Calogero et al., 2019).

Some have referred to the change of focus from weight-loss to weight-neutrality as a paradigm shift in the weight sciences (Bacon & Aphramor, 2011; Tylka et al., 2014). While an emerging body of literature discusses the shift from weight-centred to neutral practice based on reviews of the existing academic research, to our knowledge, no studies have explored the motivations and experiences of ‘anti-diet’ dietitians and psychologists, and whether their resistance to weight-loss discourses constitutes a paradigm shift. Drawing on Kuhn’s (1962/1996) theory of paradigms and paradigm shifts in the natural sciences, this study investigates ‘anti-diet’ dietitians’ and psychologists’ motivations and experiences aligning with weight-neutral approaches while working within weight-focused systems. Our analysis of health professionals’ discussions about diet culture provides a snapshot of how and why a paradigm shift in healthcare might occur. Before embarking on this analysis, however, we introduce Kuhn’s (1962/1996) notion of paradigms to contextualise its relevance to discussions about weight and healthcare.

Paradigms and paradigm shifts

Paradigms have played an important role in scientific and medical revolutions for centuries (Bhatia & Rifkin, 2013; Kuhn, 1962/1996). Broadly characterised as ‘collection[s] of ideas, concepts, values, and beliefs that form the foundation of the approaches and techniques used by members of a scientific community’ (O’Hara & Taylor, 2018, p. 1), paradigms are informed and developed by a combination of evidence, experience, and gut feelings (Fricker, 1995; Kuhn, 1962/1996). In The Structure of Scientific Revolutions, Kuhn (1962/1996) popularised the term, arguing that the consensus engendered by a shared commitment to ‘rules and standards for scientific practice’ defined and promoted ‘normal science’ (p. 11). Kuhn disrupted the long-held belief that science produces ‘one linear, continuous, cumulative, unified story’ about knowledge, arguing that the field has been ‘beset by discontinuities, incommensurabilities, and disunities’ (Nickles, 2003, p. 5). While dominant paradigms become widely accepted in scientific communities with a shared worldview, the emergence of new and competing ideas disrupts entrenched ways of knowing (Anand et al., 2020).

Kuhn (1962/1996) referred to this disruption as a paradigm shift; a term increasingly used to describe shifts in how we understand weight and healthcare. A paradigm shift is typified by a period of scientific crisis, where a shift away from old ideas, rules and criteria elicits strong resistance from those immersed in the dominant paradigm, who have come to rely on pre-established rules to guide their thinking, and may believe that the paradigm is in fact the ‘truth’. By contrast, those contributing to a paradigm shift rely less on these rules – sometimes questioning their legitimacy – and draw on a combination of their professional training, intuition and life experiences to inform new hypotheses. Fricker (1995) emphasises the role of intuition and experience in the development of innovative ideas and the emergence of new paradigms. When a scientist or health professional constructs a hypothesis outside of the dominant paradigm based on a gut feeling, this is said to exemplify their capacity to make educated guesses based on relevant professional experience (Fricker, 1995; Kristensen et al., 2022). Once this hypothesis is justified, it assumes the ‘usual law-like form of scientific theory’ (Fricker, 1995, p. 236). From this perspective, intuition and reason are not opposed but unified in the establishment of a new paradigm. As paradigm shifts take ‘a long time to gain acceptance’ (Bhatia & Rifkin, 2013, p. 461), proponents must highlight the conflicting ideas that those still using the dominant paradigm ultimately reject, often through advocacy (Bhatia & Rifkin, 2013).

Weight paradigms of health

Some researchers argue that health professionals’ understandings of weight have undergone a paradigmatic shift in the last five decades (Tylka et al., 2014). This shift has emerged, in part, due to voices of those with lived experience in the ‘anti-diet movement’, comprised of feminist activists and researchers, fat liberationists, and some health professionals who draw attention to the harms of weight-loss diet practices (Jovanovski & Jaeger, 2022).

Health professionals, public health experts and policymakers have addressed the ‘obesity epidemic’ using the dominant paradigm – the weight-centred (or weight-normative; Calogero et al., 2019; Tylka et al., 2014) approach. This paradigm views body weight as fundamental to health (O’Hara & Taylor, 2018). It is characterised by the beliefs that having a higher weight is associated with excess disease and early mortality, and that losing weight will improve health (O’Reilly & Sixsmith, 2012). Proponents of this approach recommend weight-loss dieting and, in certain situations, pharmaceutical and surgical interventions, to improve health outcomes (Hunger et al., 2020; Talumaa et al., 2022). While this paradigm has been broadly promoted by the mainstream media, and widely adopted by the medical community to address population weight and health, it has come under increasing scrutiny for its often rigid and prescriptive ideas about both.

An emerging weight-neutral or weight-inclusive paradigm (Tylka et al., 2014; Zafir & Jovanovski, 2022), focusing on body-acceptance and the promotion of health behaviours for people of all shapes and sizes, has drawn attention to these limitations (O’Hara & Taylor, 2018). This paradigm ‘decentre[s] weight from health’ and is ‘based on the principles that health and wellbeing are not fixed, and that it is important for people to have access to equitable and non-stigmatising healthcare’ (Zafir & Jovanovski, 2022, p. 359). While it is gaining traction in the academic literature, it is still at the margins of health discourses, and has received less research attention compared to the weight-centred approach (Zafir & Jovanovski, 2022). For the purposes of this paper, weight-neutral and weight-inclusive will be combined (e.g. weight-neutral/inclusive paradigm) when describing health professionals’ anti-diet views.

Research on the weight paradigms of health

Most of the current literature on the weight paradigms of health – aimed specifically at health professional audiences – reviews existing research and policies, developing recommendations and frameworks for furthering a weight-neutral/inclusive perspective (e.g. Bacon & Aphramor, 2011; Bessey & Lordly, 2020; Calogero et al., 2019; Hunger et al., 2020; Talumaa et al., 2022; Tylka et al., 2014; Zafir & Jovanovski, 2022). Health practitioners’ experiences of weight neutral approaches are not strongly represented in this literature, other than through discussions of ethical principles (e.g. Romano, 2018) and professional responsibilities (e.g. Calogero et al., 2019). Tylka and colleagues (2014) offer a theoretical framework based on their review of the literature on both paradigms, which focuses on helping health professionals minimise weight stigma in their practice (see also Calogero et al., 2019; Talumaa et al., 2022). O’Hara and Taylor (2018) propose a framework through their review of the weight-centred literature, which is intended as a heuristic to build competency in researchers to critique weight-centrism in healthcare. Others have clinically evaluated both approaches, finding that participants in their weight-neutral program reduced LDL cholesterol levels to a greater extent than participants in their weight-loss program, despite not losing any weight during the trial (Mensinger et al., 2016).

Some researchers have focused more broadly on recommending changes to public health interventions and health promotion campaigns. O’Reilly and Sixsmith’s (2012) discourse analysis on weight and health policy texts revealed that many of the discussions surrounding ‘obesity’ were ‘unnecessarily inflammatory, evoking an emotional response that fuels moral panic’ (p. 102). The authors recommend four weight-neutral policy options for existing public health interventions, focusing specifically on developing guidelines so that health measurements account for variables other than weight (e.g. health behaviours, weight cycling, etc.), replacing weight-centred terms with weight-neutral ones, providing government sponsored training to health professionals on the harms of weight stigma, and further testing and establishing the efficacy of Health at Every Size® (HAES) as a health promotion tool. Hunger and colleagues (2020) reviewed the medical, epidemiological and social scientific literature on weight and health. They identified weight-centred assumptions about weight and health, subsequently advocating for a weight-inclusive approach to health policy and promotion. These existing analyses of weight science literature delineate weight-focused and weight-neutral healthcare. The experiences of weight-neutral/inclusive health professionals – and the proposed form of the paradigm shift in weight sciences – are absent from the existing evidence base. Literature reporting the process or experience of paradigm shifts in medicine or healthcare, more generally, is scarce. This study therefore aims to contribute to our understanding of how and why paradigm shifts occur in healthcare.

The importance of health professionals’ motivations and experiences

The motivations and experiences of health professionals may offer important insights into how they manage holding anti-diet views in weight-centred professional contexts. Kristensen et al. (2022) argue that a combination of personal and professional experiences influence the ‘gut feelings’ of health professionals, and that these feelings ‘develop with practical experience in a certain field of specialization” (p. 574). Experienced dietitians and trainee counselling psychologists have been shown to rely on their ‘gut feelings’ in clinical encounters (e.g. Rest, 1984; Vo et al., 2020). While Kuhn’s (1962/1996) theory centres on the natural sciences, health professionals also draw on intuition, values, and experiences to make educated judgements about people’s health and advocate on behalf of their profession. These judgements often play a part in paradigm shifts. However, the role of motivations and experiences in shaping the views of health professionals who adopt an anti-diet, weight-neutral/inclusive stance is unclear. Understanding these motivations and experiences will add context to the emerging weight-neutral/inclusive paradigm and may provide empirical evidence of a paradigmatic clash.

This study aims to explore the motivations and experiences of ‘anti-diet’ dietitians and psychologists. Specifically, we aim to understand their perspectives in the context of what some researchers are calling a ‘paradigm shift’ in the weight sciences: from a weight-centred to weight-neutral/inclusive perspective.

Research questions include:

1. How do the motivations and experiences of anti-diet dietitians and psychologists shape their professional practice?

2. In what ways do these motivations and experiences point to a paradigm shift in the weight sciences?

Method

Participants

We used online advertisements disseminated via weight-neutral/inclusive communities (e.g. HAES® Australia), and snowballing to recruit a purposive sample. Dietitians and psychologists who identified as having challenged diet culture, who were not currently diagnosed with/receiving treatment for an eating disorder, and residing in Australia, were eligible to participate. Sixteen female participants were recruited across four discipline-specific focus groups (Dietitians: Focus Group [FG] 1, n = 4; FG 2, n = 5; Psychologists: FG 3, n = 4; FG 4, n = 3) on the harms of diet culture. A total of 4 dietitians and 6 psychologists working in private practice, 5 community dietitians, and 1 population mental health researcher participated.

Data collection

As part of each session, the lead researcher (Author 1) gave a brief presentation on the literature surrounding diet culture. Participants then discussed their perspectives on the content presented. Participants were invited to share their views on the origins of diet culture, and the strategies they have used as a health professional to challenge it. All focus groups were conducted via Zoom (2021) and were video- and audio-recorded to enable transcription.

The data included in this study were collected as part of Phase 2 in a larger project examining the experiences and strategies of women, activists and health professionals who have challenged diet culture. We designed our focus group protocol in collaboration with a project advisory group comprised of social and political scientists, health professionals and senior health policy advisors, and anti-diet activists. Focus group questions included ‘How would you define diet culture?’ and ‘What are some of the ways you have tackled diet culture as a health professional?’

Participants were given a detailed plain language statement and required to return a signed consent form before taking part. We provided a comprehensive list of support services in the event participants became distressed at any point during, or following, their participation. Participants were reimbursed with a $50 AUD Coles supermarket/Coles–Myer gift card. The project received ethical approval from The University of Melbourne Human Research Ethics Sub-Committee. Pseudonyms are used in reporting the findings.

Analytic approach

Authors 1 and 2 transcribed the data verbatim, which were then analysed using reflexive thematic analysis (Braun et al., 2019; Braun & Clarke, 2006; Terry et al., 2017). We applied a critical realist framework (Bhaskar et al., 2017) to interpret the data, enabling a discussion of how diet culture – and its resistance – is socially produced in relation to participants’ experiential realities. Participants’ professional and lived experiences were examined at both semantic and latent levels.

Data analysis was primarily inductive, beginning with authors 1, 3, and 4 familiarising themselves with the data through reading and re-reading. Author 1 led the analysis, liaising with the co-authors throughout the process. Primarily inductive codes and sub-codes were generated based on the semantic and latent content of participants’ discussions. One broad code, ‘resistance and paradigm shift’ included sub-codes related to ‘change in culture/progress’, ‘intuition’, ‘community’, and ‘courage/using one’s voice/strategies’. Through reading the coded data, further themes were generated, focusing specifically on participants’ relationship to their discipline or to others within the discipline. This included participants’ personal and professional reflections on the harms of weight-centrism; the role their intuition played in challenging weight-centrism and adopting a weight-neutral stance; their exposure to resistant messages from those within their community engaged in weight-neutral/inclusive advocacy; and their own role in educating the public about the benefits of weight-neutral care.

Results

The four themes generated in our thematic analysis track different stages of a weight-neutral paradigm shift. Participants reflected on the mismatch between weight-centrism and their lived experiences of diet culture (Theme 1), described the role of intuition in their professional experience, as informed by their personal experiences, and how this influenced their decision to reject a weight-centric paradigm (Theme 2), explored their experiences transitioning to embrace the weight neutral paradigm (Theme 3), and described advocating for it (Theme 4).

Dangerous and evangelical: reflecting on the harms of weight-centrism personally and professionally

For many women, the first negative exposure to weight-centrism was in their personal lives, where they were surrounded by a pervasive culture of weight-loss diet messages:

I never had a diagnosed eating disorder, but I had serious diet culture messages growing up. (Melinda, Focus Group 2, Psychologist)

I think just being a woman with friends who engage on social media, um, I’m surrounded by diet culture. (Joanna, Focus Group 3, Psychologist)

Participants described that even before starting their careers, living in a society that normalises dieting in women influenced their views on what it means to be healthy.

This adherence to diet culture even encouraged some women to become health professionals. Annie, a dietitian, argued that weight-centrism in her university degree exacerbated disordered eating and existing bodily insecurities among women in her student cohort:

[…] I could now say with confidence that the disordered eating was rife in my [university] cohort. Um, and so now I think about that with, you know, working with eating disorders for the last 20 years with a totally different set of eyes … If you think about what’s attractive about that, it’s talking about calories, it’s learning about the nuts and bolts and really getting stuck into that for two years. You’re going to love that if you have disordered eating! You know, it’s like that – it was almost, I hate to say the word, but, um, evangelical. It was almost that cult-like behaviour. (Focus Group 1, Dietitian)

Annie points to the ‘evangelical’ and ‘cult-like’ practices of weight management experienced during her dietetics degree, arguing that they are attractive options for people struggling with their bodies and eating practices. For Annie and many other participants, weight-loss diet practices presented in universities or through popular culture were virtually indistinguishable.

Some participants identified weight-loss and a fixation on thinness as a principal reason for their decision to become a health professional, and formative of their professional identity:

I guess, prior to becoming a dietitian, you know, the first 21 years of my life, I was enmeshed in diet culture, and thinness was definitely part of my identity and dietetic training absolutely reinforced that. (Anastasia, Focus Group 1, Dietitian)

Personally, I was quite disordered, um, before becoming a dietitian, which was why I chose the career. (Karmela, Focus Group 4, Dietitian)

I guess my interest sort of started off [with] body image issues, which sort of affects all females – including myself – in this culture. (Hilary, Focus Group 2, Psychologist)

Some participants talked about a blurring of societal pressures around thinness and health professional teaching focused on weight-loss dieting as a health practice, indicating that healthism, or the ‘preoccupation with personal health as … the primary focus for the definition and achievement of well-being’ (Crawford, 1980, p. 368), and the beauty norms accompanying health messages (Jovanovski, 2017; Jovanovski & Jaeger, 2022), travel across systems and institutions to become mutually reinforcing and embedded in women’s personal and professional identities (Jovanovski, 2023).

Some participants described rigid and prescriptive ideas about weight and health being reinforced throughout their degrees and their adoption of these practices in day-to-day interactions with clients. Upon reflection, some could see the potential harms caused by these approaches that they previously understood to be best practice. Rosa reflected on her experience working as a dietitian in a bariatric clinic:

I didn’t have enough time, I had just 20 min per patient, really. It was nothing. Um, and I fe[lt] like a dietitian machine. Like, ah, press play and repeat. Play, repeat. And I felt like that, but I thought that I was doing a ‘good job’ because I was in – in the mindset that they need to lose weight, they need to follow the diet plan, even though I thought I was flexible because I never was the dietitian saying, ‘ah, you never can eat, um, chocolate. Or you can never eat this’ … I thought I was … flexible. But then when I realised the other side [weight-neutral approaches] I was in shock … and I felt bad because … maybe [I contributed to] some harm to so many people, but on the other hand, of course, I wasn’t aware. (Focus Group 1, Dietitian)

Similarly, Melinda reflected on her early experiences of studying psychology and the message that certain food habits or exercise routines will treat complex mental health issues:

I was thinking about perhaps more of my early experiences when I was studying and um, you know, first getting into this kind of area. I was noticing this message about um, you know, your food and your exercise will, you know, like fix your mental health [laughs]. So, you know, ‘eat this certain way and do exercise, you know, for your mental health’. But that becoming a slippery slope. Um, and I think, you know, if I hadn’t found this message [weight-neutral approaches], I could have been one of those people pushing that out there. So, you know, I think that message was really dangerous. (Focus Group 2, Psychologist)

As Rosa and Melinda explain, their early experiences as health professionals involved a rigid focus on weight loss and restrictive eating practices, with both women reflecting on the potential harm caused by these approaches. Rosa compared her role to that of a ‘dietitian machine’ churning out weight-loss advice; Melinda described ‘dangerous’ messages about food and eating beyond the scope psychological practice. The personal and professional often intersected, with many expressing that disordered eating was rife throughout their training and colleagues’ behaviour. It was often in these moments of professional reflection that participants first criticised the weight-centred approach.

Gut feelings: the transition from weight-centrism to weight-neutrality

Many participants’ concerns about the weight-focused aspects of their discipline started as a gut feeling; a hunch that preceded cognition, but was informed by their lived experiences. This finding is unsurprising, as Kuhn (1962/1996, p. 94) himself stated that paradigms ‘can never be unequivocally settled by logic and experiment alone’. As Rosa demonstrates: ‘I wasn’t aware. I was feeling unhappy in the job in the bariatric surgery [clinic] but I wasn’t sure why’ (Focus Group 1, Dietitian). For others, this initial feeling was coded as a mismatch between one’s professional values and those of the wider weight-focused discipline. Amanda reflected on her experience attending a presentation on child growth and measurement scales facilitated by a dietitian, and feeling uncomfortable about the focus on weight at the expense of other important health variables:

I just remember now doing this presentation many, many years ago and just thinking at the time – you know how you have these gut feelings? Things are not necessarily sitting well with you, but it was ‘important to educate around the new growth charts’ (Focus Group 4, Dietitian)

It could be argued that Amanda’s sense of discomfort – or ‘gut feeling’ – was evidence of what Kristensen et al. (2022, p. 566) refer to as the ‘sensory and tactile modes of … communication’ that sit alongside scientific evidence for health professionals. As an already established dietitian, Amanda subsequently used her gut feeling about the presentation as an opportunity to examine the evidence base, explore alternative approaches to improving children’s nutrition, and follow-up with the speaker. Much of the literature on health professionals using their intuition has focused on clinical reasoning and decision-making, and interactions with patients/clients (e.g. Kristensen et al., 2022; Vo et al., 2020). Vo et al. (2020, p. 618) describe that, in an experienced dietitian, clinical reasoning is ‘automatic and complex involving … inductive reasoning approaches that involve pattern recognition, sensing, intuition and “gut feeling”’. In Amanda’s case, this ‘gut feeling’ was directed at another health professional, and the discipline more broadly, rather than at a client.

Some participants were motivated to change because something did not ‘feel right’ early in their careers. Anastasia expressed that being on her very first placement made it harder to express concerns or assert authority to explore alternatives:

The fact that we’re fresh out, but even we can see that referrals coming through from bariatric surgeons for people that are getting bariatric surgery, honestly, at quite low weights … and us kind of supporting them because that’s what we thought we needed to do. You know, Optifast and all that. That’s what we were doing for this other dietitian. And it just didn’t feel right. Like, even we could see these clients have disordered eating if not diagnosable eating disorders and they’re getting bariatric surgery, and even just having [my colleague on placement] there and being able to reflect with her that it didn’t feel right. (Focus Group 1, Dietitian)

Anastasia’s hunch that patients exhibited ‘disordered eating’, and her sense that prescribing weight-loss diet products ‘just didn’t feel right’, indicate that her sensory and tactile reading of clients’ experiences identified potential problems. Her lack of seniority – regardless of her personal experience of disordered eating – prevented her from acting on her concerns.

While gut feelings often signified something wrong, they were also generative for many participants. Gut feelings can trigger a ‘sense of alarm’ in health professionals or a ‘sense of reassurance’ that what they are perceiving is right (Stolper et al., 2009, n.p.). As Olivia explains, ‘I suppose it was early in my career that I went and did [weight-neutral] training and I had already started down that path. It just felt intuitive to me that that was just the right message’ (Focus Group 2, psychologist; emphasis added). The ‘gut feeling’ that weight-neutral approaches are the ‘right’ way to practice healthcare was reinforced through alternative professional viewpoints, which some referred to as ‘lighting a fuse’.

Lighting a fuse: exposure to lived and learned experiences as key turning points

Some participants’ personal experiences with diet culture and their professional exposure to alternative points of view, ‘lit something’ (Ciara, Focus Group 2, Psychologist) in them and influenced the way they understood health. For some, exposure to other health professionals’ different understandings of weight sparked their motivation to further explore anti-diet perspectives:

My professional interest in the non-diet approach probably started in the early 2000s when I got to know Dr [name anonymised] very well, and was assisting him in running some of his training for health professionals, which was like lighting a fuse in my brain and it hasn’t sort of stopped ever since. So, yeah, I just feel like this is such an important area of body liberation and um, helping people find more freedom in their lives on the most deeply personal level. (Melinda, Focus Group 2, Psychologist)

Melinda’s exposure to a weight-neutral evidence-base influenced her research and awareness of viewpoints outside of health. While most participants were not exposed to alternative perspectives about weight throughout their degrees, there were some exceptions. Anastasia attended a lecture on health professional perspectives critical of weight-loss dieting during her undergraduate degree:

To be honest, like, the more I think about it, the more grateful I am that I trained in the past, you know, 5 years. Like, I mean, sure, I only got one lecture from [a dietitian] … that was the thing. Yeah, it planted the seed, right? I heard the lecture, I was like, ‘wow, this is different!’ (Focus Group 1, Dietitian)

Anastasia later reflected that this experience may have ‘planted the seed’, but it took longer for her to adopt weight-neutrality in her work. Further exploration and work was needed to address the clash between her immersion in diet culture, weight-centric training, and respect for weight-neutral/inclusive health practices, but that ‘growing sense … that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature’ – a significant part of a paradigm shift in action – was present in women’s accounts (Kuhn, 1962/1996, p. 92).

Some participants discussed the role of health advocacy in promoting weight-neutral/inclusive approaches, and reflected on the importance of listening to health professionals with both lived and learned perspectives on weight:

I’d say one of the most, um – one of the most powerful ways I’ve seen is for people who are both health professionals and have lived experience … there’s been a couple of, um, eating disorder symposiums that I’ve been to where they’ve had, um, lived experience advocates who are also counsellors or therapists, um, in a HAES space and to hear them talk about the effects personally of diet culture on – on them, um, I think is really powerful and really moving because it’s that sense of: it’s not just a theoretical proposition. Um, someone is talking about the real danger that this presents to mental health and someone’s development and ability to feel happy in their body. (Joanna, Focus Group 3, Psychologist)

For Joanna, a combination of lived and learned experiences with diet culture bridged the theoretical with the experiential; one where she emphasises the perceived lack of lived experience found in weight-centric healthcare. This form of advocacy showed that there is ‘real danger’ in focusing on weight loss, and that health professionals embodying both worlds can powerfully articulate this danger.

Dropping seeds: community-building and weight-neutral care

For our participants, being an advocate and spreading knowledge about weight-neutral/inclusive approaches was seen as an extension of their responsibility to ‘do no harm’. This involved speaking to students, other health professionals, clients, and people in their everyday lives. For some, this was a relatively new process, but others described it as a decades-long project that was only now beginning to reach a groundswell. Participants used generative language, describing their advocacy efforts as ‘little seeds that [they’re] constantly dropping’ (Jamila, Focus Group 1, Dietitian). This process was multi-dimensional, whereby anti-diet messages were spread ‘at different levels. There’s the interpersonal stuff in my personal life, in my professional life, with individual clients’ (Jamila, Focus Group 1, Dietitian).

Rather than producing seismic shifts, dietitians and psychologists saw their contributions to the broad weight-neutral community as slow and subtle. These actions were often opportunistic:

For me, it’s those subtle shifts. That’s the little part I can do. The big part I can do, I guess, is when I get an invite to speak to child health nurses about, um, intro to solids for kids, I say, ‘I’d really like to talk about body image and diet culture in that ‘cause it starts when kids are little’. (Annie, Focus Group 1, Dietitian)

Annie described incidentally mentioning the harms of dieting and body dissatisfaction to child health nurses, where she couched the issue alongside broader discussions on childhood nutrition. She went on to explain that her incidental advocacy in educational settings has resulted in nurses changing their interactions with children from being appearance- to health-focused.

Others talked about slowly introducing weight-neutrality to students on placements, or health professionals joining their team:

We just run students through the way we work, and I feel like we try not to ram it down their throats, but we open it up and maybe they’re ready to hear it but maybe they’re not. Maybe they come back to us a few years down the track and maybe they don’t, but I feel like we use it as a way to plant the seed. (Karmela, Focus Group 4, Dietitian)

Karmela went on to describe this dynamic with new colleagues joining her team:

I think all the little things build up to a bigger message from us. Like, we had a new person start recently and we had to go around and kind of introduce ourselves and [one of my colleagues] said, ‘we work in a weight-inclusive way. Let me know if you would like to know more about that’ … inviting that conversation but not pressuring someone if they’re not familiar with it or not on board with it. They can take it or leave it. (Focus Group 4, Dietitian)

Participants often introduced weight-neutrality to others in subtle and gentle ways. It is important to note, however, that some health professionals expressed ambivalence even raising the topic subtly, often due to differences in symbolic capital. For some, this ambivalence centred on their own body size, with Olivia explaining, ‘I’ve had the pushback of like, “well, you’re just making excuses for yourself because you’re in a big body”’ (Focus Group 2, Psychologist). For others, it was about being new to their health professional role and finding their own voice in the anti-diet community, with Hilary saying, ‘I have sort of felt that sense of … [I’ve] gotta be perfect with what I say’ (Focus Group 2, Psychologist). The stress of not fitting in – of having a larger body or being new to the paradigm – was expressed by some women as a deterrent to their advocacy and further exploration.

Some even discussed conflicts that may arise when weight-neutral ideas are introduced without people – particularly clients – having a chance to critically unpack the ideas themselves. For this reason, women discussed giving clients time and space to process their feelings around food and their bodies:

Sometimes it’s worth putting the energy in ‘cause it drops the little seeds, and you see the people come back eventually and go, ‘oh! You talked about stigma, and you talked about this. Now this person’s talking about it’. Or, again, [with] clients, you’ve talked to them, and they come back years later and go, ‘wasn’t ready then, I’m ready now’. And it surprises you how much those seeds actually get sown. (Jamila, Focus Group 1, Dietitian)

Some participants used advocacy in their relationships with clients, producing a slow rather than seismic shift, which often needed to be delivered to clients patiently to avoid resistance. For others, it also involved establishing a clearly denoted weight-neutral professional practice. As Olivia reflected in relation to Melinda’s practice:

The fact that … clinics like yours that are founded on those notions … that is such a powerful thing … I’m seeing actual places that are defined by these principles, which is so good to see. Like, I, you know, work just in a generalised practice. I don’t have a, you know, that banner, but I think it’s so great that we do. You know, that there are now actual practices that that’s what they do. Um, and that’s the – the values they align with. And it’s very clear from the outset. (Focus Group 2, Psychologist)

In response, Melinda reflected on the slow process of building up the courage to explicitly define her practice as weight-neutral, emphasising that change is gradual rather than sudden, and that adopting practices outside of the dominant paradigm places even the most experienced health professionals at-risk of exclusion.

Discussion

In this study, we explored how the motivations and experiences of ‘anti-diet’ dietitians and psychologists inform their professional practice, and found four stages of a weight-neutral paradigm shift. Specifically, health professionals’ experiences of diet culture – via everyday life, clinical practice, personal experience, or vicariously through the negative experiences of family and friends – precipitated their ‘gut feelings’ about the harms of the weight-centred approach. These personal experiences and intuitions motivated health professionals to look for alternatives that ‘do no harm’, such as weight-neutral approaches, which contributed to their advocacy in the field.

The significance of women’s lived experiences shaping their learned experiences as health professionals is not new. Jovanovski (2023) traces the emergence of ‘anti-diet’ health professionals and argues that those who adopt weight-neutral views are products of both feminist and fat liberationist activism, which both found their way into higher education curricula through Women’s Studies and Fat Studies. In some instances, health professionals have a direct lived experience of diet culture rather than merely an intellectual curiosity. In these examples, lived experiences shape the learned experience of curricula; a finding that was reinforced in the early stages of the weight-neutral paradigm shift documented in this study.

While health professionals were aware of their minority status in their respective fields, pushing back against the ‘truth’ of the dominant weight-centric paradigm was more difficult for some women than others. Health professionals with a larger body or among those who just recently entered the health field (or anti-diet space) reported a sense of ambivalence about their position in the movement, indicating that the social, cultural and symbolic capital of being a health professional does not uniformly privilege all weight-neutral health professionals. However, those with extensive experience in their respective fields were able to draw on their lived experiences and gut feelings more confidently, thereby advocating more confidently for the emergent paradigm.

Overall, our findings provide a snapshot of a subtle paradigm shift in action. Supporting Bhatia and Rifkin’s (2013) observation that paradigm shifts happen gradually over time, the health professionals in our study reported embarking on a slow journey from weight-centric to weight-neutral practice, drawing on a combination of evidence, experience, intuition, and advocacy to inform their healthcare practices. Their values – simultaneously personal and professional – were central to shaping this process. Gallagher and Little (2017) found that doctors’ personal values played a more important role in shaping their advocacy efforts than their professional commitments. Doctors with previous experience working with a particular population tended to engage in ‘supraclinical advocacy’ to drive systemic change addressing the social determinants of health (Gallagher & Little, 2017). Our participants saw ‘doing no harm’ as a personal and professional responsibility. Based on their observations of disordered eating in clients, colleagues, and themselves, most engaged in some form of advocacy to ‘drop seeds’ for the next generation of health professionals. Our findings echo research criticising weight-centrism, which shows that weight-neutral approaches are informed by evidence and advocacy, especially from those with a lived experience of weight stigma or disordered eating (Bacon & Aphramor, 2011; Calogero et al., 2019). Most existing research is predominantly theoretical, focusing on what characterises weight-neutral approaches (e.g. Tylka et al., 2014). Our study adds empirical evidence that weight-neutral health professionals are motivated by their experiences, gut feelings, values, and other health professionals’ advocacy.

As some participants reported being influenced by one-off lectures on weight-neutral approaches in the university context, leading them to further explore these concepts often later in their careers, these findings also underscore the need to expand dietetics and psychology curricula to incorporate and address the significant concerns that (often female) health professionals have about practices in their field. Public health researchers McPhail and Orsini (2021) call on clinicians to ‘fatten’ up their understandings of health, or actively engage with critical fat scholarship to question their often pre-existing and simplistic assumptions about weight and health. This also includes questioning their pre-conceived notions of weight and health, which may involve exploring their own experiences of diet culture. Given health professionals’ significant concerns about weight stigma and disordered eating, our findings suggest it is vital for them to discuss weight-neutral approaches in educational contexts, and address the pervasiveness of diet culture in everyday life.

To our knowledge, this is the first empirical study exploring the weight-neutral paradigm shift in practice. As such, our findings have significant implications for researchers seeking to understand the motivations and experiences of health professionals adopting an ‘anti-diet’, weight-neutral stance. This study also traces what a paradigm shift looks like in practice, and the processes that drive and sustain weight-neutral advocacy among dietitians and psychologists. It was, however, limited by the use of a relatively small sample of Australian dietitians and psychologists. Future research should focus on support for weight-neutral approaches across health disciplines and countries to understand the true scope of resistance to the weight-centred health paradigm. Additionally, while appearing relatively infrequently in our data, future research may benefit from exploring whether there are any ruptures in the weight-neutral paradigm, as those adopting any given paradigm often display a rigid adherence to its rules. Future research would benefit from conducting a large-scale examination of ‘anti-diet’ health professionals in Australia, including those concerned about dieting but not connected to these broader communities.

Conclusion

This qualitative study explored the motivations and experiences of ‘anti-diet’ dietitians and psychologists, and investigated whether a paradigm shift was occurring. Our findings show a paradigm shift in four stages: (1) recognising a mismatch between one’s weight-centred training and their lived experience of diet culture, which (2) contributes to developing an intuitive relationship with weight-neutral forms of care. For many, this sense of intuition led to (3) listening to the voices of other concerned health professionals and (4) engaging in advocacy. Much like Kuhn’s (1962/1996) hypothesis that factors such as experiences and intuitions drive paradigm shifts, our findings show that health professionals used their experiences and gut feelings to ‘do no harm’ by not prescribing weight-loss methods to clients that may contribute to further health issues. Our findings represent a paradigm shift in action; one where health professionals question the dominant weight-centric paradigm and use their experiences – as individuals and health professionals – to inform their healthcare decisions. Future research needs to explore the motivations and experiences of ‘anti-diet’ health professionals across professions and countries to enrich our understandings of what paradigm shifts look like in healthcare.

Conflict of interest

Dr Jovanovski is an unpaid/volunteer member of the Academic Advisory Network for The Embrace Collective, an organisation that brings together global leaders and advocates working on improving body image.

Additional information

Funding

This project was funded by Dr Jovanovski’s Discovery Early Career Researcher Award from the Australian Research Council [grant number: DE200100357].