After the first public health school was established at Johns Hopkins University a century ago, the interdisciplinary practice has found a home in universities nationwide. Without a doubt, public health researchers and professionals have led the charge in understanding what a healthy society might look like, while simultaneously striving to create it. Here at the University of Michigan, the School of Public Health is one of the best in the nation. This doesn’t come as a surprise. What does come as a surprise from a university that champions itself as the “Leaders and the Best” is its perpetuation of diet culture and fatphobia via the weight-normative curriculum it bolsters. The lack of awareness around how these roots contradict its mission of promoting public health needs to be addressed.
Fortunately, within the School of Public Health, a professor is pioneering a public health approach that forgoes beliefs born out of diet culture and fatphobia, opting instead for a weight-inclusive approach which encourages healthy behaviors irrespective of one’s weight. Dr. Kendrin Sonneville, Sc.D., R.D., is an assistant professor in the Department of Nutritional Sciences whose research focuses on eating disorder prevention. To say her background and current work is impressive is an understatement.
Sonneville is one of a handful of public health faculty members that align themselves with the Health at Every Size framework, and to her knowledge, she is the only faculty member at the school who explicitly orients herself as a weight-inclusive researcher. She teaches a Weight Bias & Health course — the first and only freestanding class on weight bias at any public health school — and the work she does with her team at the Sonneville Lab for Weight-Inclusive Nutrition & Eating Disorders Prevention is monumental.
Sonneville is undoubtedly leading the charge here at the University’s School of Public Health to transform the foundation of public health into one that is weight inclusive and challenges misconceptions surrounding weight — namely that from weight alone, you can come to conclusions about one’s health status. She shared her thoughts on the state of the school’s curriculum and mainstream public health while providing suggestions on where to go from here so that relevant programs can move closer to achieving their mission.
Despite being a bit of an outsider within a department where most faculty members conform to the weight-normative model — for example, holding the belief that people classified as “overweight” or “obese” under existing standards must lose weight to become healthier — Sonneville has been met with curiosity and open-mindedness from colleagues and students intrigued by her approach.
“Even though my approach may feel relatively radical within a department of nutrition,” she said, “I think there’s an interest in understanding this paradigm, so even though people aren’t necessarily identifying as ‘all-in,’ there is a curiosity that comes from my presence.” Students in particular have been receptive to the HAES approach and her classes continue to draw more curious minds in.
It’s not lost on Sonneville that she has been able to venture into new territory with classes and research focusing on weight bias and eating disorders prevention and treatment due to support from her department chair and the school as a whole. For that, she is grateful.
“I do think that the support my particular teaching and research program is getting speaks volumes about our School of Public Health,” she said. The department’s approval of her courses, which are nonexistent in other places, has been their best decision yet.
Moreover, alumni of Sonneville’s courses have gone on to do meaningful and highly demanded work in the eating disorder space. They are the ones changing the public health landscape from weight-normative to weight-inclusive — and for the better. Alyson McAdams, M.P.H, RDN, graduated from the School of Public Health in 2017 and has established a career around the HAES framework. As a registered dietician working in pediatric primary care, McAdams credits Sonneville for her exposure to this weight-inclusive framework. At the same time, she also acknowledges that the University as a whole didn’t provide enough education on this approach or eating disorders, instead putting too much of an emphasis on weight normativity and solving the obesity epidemic.
Even when faculty and other students acknowledged that intentional weight loss diets do not work in the long run for a majority of people, when I interviewed McAdams, she said the framing of larger-bodied people as a problem in need of a solution remained. The escape from this message for McAdams was Sonneville’s courses.
“Kendrin’s class was definitely the only place where I felt like weight-inclusive language and practices were more overtly talked about,” McAdams said. Even those around her who saw weight stigma as a problem were missing the point.
“For many of us, we were still stuck in that lens of, ‘weight stigma is a problem because it contributes to weight gain, and weight gain and larger bodies are a problem,’ ” McAdams elaborated. Thus, further development is needed in the curriculum so that students can detach from the assumption that weight gain is inherently negative.
Addressing weight stigma as a factor contributing to weight gain while still viewing weight gain as inherently in need of a solution misses the point entirely. To dismantle weight stigma means to reject the belief that efforts targeted at improving health need to be targeted at lowering one’s weight.
McAdams also confirmed that the bulk of the required curriculum, specifically for the dietetics track of the Master’s in Public Health program, was extremely weight-normative and fatphobic.
“For example, we had a pathophysiology of obesity class that was required, but the eating disorders class was an elective,” McAdams said. Now in practice, she is bewildered by this. “Eating disorders and disordered eating show up all the time, and at the beginning of my practice, that was something I had to immediately seek continuing education about.”
McAdams’ own initiative to self-educate on the topic is applaudable, but soon-to-be-dietitians ought to already have this knowledge and a quality skillset surrounding eating disorders, given their prevalence in society. And, unfortunately, few dietetics professionals are as proactive as McAdams. On the whole, the dietetics field is saturated with providers who spew harmful, fatphobic messages about food and the body, not to mention many actively struggling themselves with their own disordered relationship with the two. These messages are detrimental to all who seek out their professional services, but for those going to these dietitians to recover from their eating disorder, it can be traumatic and a major setback in their pursuit of recovery.
Clearly, there is still plenty of room for profound changes in the curriculum. Only when such changes are made can the School of Public Health truly and accurately self-identify as a leader in the public health field. These changes will be no easy feat. With diet culture beliefs about weight as embedded in the research on health as they are today — both in public health and medical research — major shifts are needed in both spaces and our broader culture before any substantial improvements can be made.
Luckily, Sonneville has tangible first steps in mind that are feasible with the support of her department chairs, who are influential players in curriculum development. She finds that integrating the weight-inclusive framework into core curriculum rather than requiring classes that are solely HAES aligned may be most effective because it would not cast this framework as some niche field of its own. Incorporating it into the existing weight-normative curriculum also replicates the context in which many graduates will be working: one where weight stigma will be present, and weight will be valued as an independent health indicator. Exposure to both frameworks will equip graduates with the critical thinking skills needed to assess both paradigms and ask the right research questions.
The time constraint present by virtue of the M.P.H program being only two years long is another factor to account for. There is only so much you can require in such a short program, so Sonneville is more interested in how paradigms of weight-inclusivity and HAES can be incorporated into existing core classes. And she has already taken the initiative to do this. As an instructor of the required Nutrition Counseling course for second-year dietetics students, she uses the space to talk about weight inclusive approaches.
“More integration into core courses would be an exciting development within public health,” Sonneville said. “I would love every class that discusses social determinants of health to talk about weight bias; it is important that everyone gets baseline exposure to this incredibly important topic, not just those students who seek out that content. Doing a deep dive into this topic in my elective course Weight Bias & Health is an exciting opportunity, but the topic shouldn’t be reserved just for specialty classes.”
McAdams fully agrees, adding that the neglect of eating disorder education from the core curriculum is the only disservice to her education at the School of Public Health.
“If you’re doing nutrition counseling,” which she acknowledged a lot of alumni of the program end up doing, “disordered eating and eating disorders are going to come up, and we needed more information and more skills in that specifically.” The current curriculum separating eating disorders into optional electives is leaving many holes in the nutrition education graduates take away.
“If you’re eating, it can become disordered very quickly, for most people it is, and so that’s the only area I wish had been melded a little bit more,” McAdams shared.
So, where do we go from here? Sonneville’s suggestions for immediate next steps are a great start. Introducing the HAES and weight-inclusive framework into required classes should take place immediately. Beyond that, a wider cultural shift is needed, and the contemporary rise in the anti-diet movement leaves us with hope that change is possible. Like most movements for social change, its fate lies in the hands of the young thinkers and activists pursuing it; specifically, the current and future students of public health dietetics. Sonneville believes we can begin to tackle the challenge now.
“I think it will be really hard to dismantle all weight-normativity from schools of public health because that is how most of us were trained,” Sonneville said. “People who are already working in public health aren’t getting as much exposure to alternative paradigms as I would like.”
Once established in your public health career, especially as a research faculty member, it’s easy to remain in your own field. For many, that field is obesity-related research, so Sonneville is turning to the students.
“I think my hope is that students continue to demand use of respectful language, respectful terminology, challenge interpretations that are rooted in the anti-fat attitudes, and so I think change will come from within,” she said.
I share this hope, and look forward to watching public health schools evolve into inclusive spaces leading the pursuit of holistic population health.
Nyla Booras can be reached at firstname.lastname@example.org.
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