Lentis/The Weight Loss Industry in the United States

Americans spend tens of billions of dollars each year on weight loss products and programs, despite increasing evidence of physical harm or ineffectiveness. The weight loss industry is riddled with controversy and is highly influenced by the media, legal action (DSHEA) and participants such as the Federal Trade Commission. This article aims to look at the weight loss industry at the interface of society and technology.

The weight loss industry in the U.S. has dramatically expanded over the past century into a $61.6 billion market^[1] with an estimated 75 million dieters in 2010.^[2] The growth of the industry is fueled by both vanity and health-related motives to lose weight. The rate of obesity in the U.S. doubled between 1980 and 2000 and continues to rise.^[3] Obesity has been declared a disease by the American Medical Association as of 2013,^[4] and can also increase the risk of developing other diseases such as type 2 diabetes and heart disease.^[5] The rise of the obesity epidemic has expanded the weight loss industry to include a greater number of people attempting to lose weight for health reasons.

A U.S. Department of Health and Human Services study in 2009-2010 concluded that 68.8 percent of American adults are considered overweight or obese.^[6] This statistic is highly underrepresented by the modeling industry because companies rarely seek overweight or obese individuals to market their products. Most models today weigh 23 percent less than the average woman, a figure that has increased by 15 percent since the 1970’s and is incongruous with the simultaneous increase in the average weight of an American woman.^[7] In addition, models in advertisements are often retouched with the use of editing programs to eliminate even their smallest imperfections.^[8] Thus, the flood of ads from the internet, magazines, and television not only market popular products, but also an unrealistic body ideal. In addition to advertising, clothing companies use other methods to increase the value of their brand. One strategy employed by over 75 percent of high-end brands is to offer only sizes 12 and smaller, alienating the 72 percent of women in the United States who wear a size 12 and above.^[9]

More recently, some companies have countered the glorification of thinness with initiatives emphasizing health. Nike's Women Campaign is characterized by ads with declarations such as "I have thunder thighs. And that's a compliment because they are strong and toned and muscular."^[10] Dove has joined this movement with their Real Beauty Campaign whose mission is to help women "imagine a world where beauty is a source of confidence, not anxiety."^[11] All commercials and advertisements that are part of this campaign feature real women of average proportions rather than ultra thin models. Because of Barbie's unattainable proportions, many believe that the doll negatively affects young girls' body image.^[12] Artist Nickolay Lamm responded to this concern by recreating Barbie using the proportions of the average 19-year-old woman. Despite these efforts, 80 percent of women are still dissatisfied with their appearance^[13] and willing to go to great lengths to become thin. This phenomenon, referred to as the "thin at all costs" movement,^[14] explains much of the success of the weight loss industry.

1903 advertisement for La Parle obesity soap and 1953 advertisement for Domino sugar

Advertisements for diet fads and products promoting the "latest and greatest" weight loss solutions appeared in magazines as early as the 1900s. For example, Norwood Chemical Company sold "obesity soap" in 1903 for $1 per bar. Other popular 1900s products include weight reducing garments, toning belts, "Bile Beans," and self-improvement tapes.^[15][16] In the 1950s, there was a series of advertisements produced by Domino, which claimed that sugar was a healthy replacement to many foods because it contained less calories than an apple or an egg.^[17]

While nutrition science has grown over the past several decades and people are more aware of balanced diets and exercise, advertisements for quick and easy weight loss solutions are still prevalent, and no less deceiving, today. A recent study conducted by the Federal Trade Commission revealed that 40% of weight loss advertisements make at least one false claim.^[18] Furthermore, an additional 15% of these ads make at least one claim that lacks scientific evidence.

Today, weight loss solutions are marketed to consumers by magazines, newspapers, television and the Internet. Although the solutions range from diet supplements to meal plans, such as the Atkins diet, to exercise equipment, many weight loss advertisements have several distinct features in common:

1. they make losing weight appear effortless;
2. they claim immediate results, such as “you will lose x pounds in 2 weeks!,” without supporting evidence;
3. they say that you will see an increase in energy in addition to weight loss; and
4. they show pictures of a supposed participant of the given weight loss program from before they started and after a period of time.

Before and after photos are commonly used in weight loss advertisements to convince the consumer of fast and drastic results. However, several fitness trainers have shown how easy it is to fake the 'amazing results' in these photos. Melanie Ventura, a trainer from Australia, showed two pictures that were taken only 15 minutes apart but with seemingly significant weight loss. Her secret was to apply fake tanner, change into more slimming clothes, adjust her stance and hairstyle, change a few camera settings, and put on a smile.^[19] Andrew Dixon from Los Angeles performed an identical transformation. His method included doing a few push ups and chins ups in between photos as well as adjusting the lighting and sucking in his stomach.^[20]

The media is full of commercials for weight loss products and programs. Hollywood's portrayal of weight loss and the ideal body type can falsely shape one's own opinion of weight loss and how fast weight can be shed. The public tends to be easily persuaded by celebrity endorsements, giving admired celebrities the power to sway their audience toward a weight loss product or program, regardless of its effectiveness. Some of the most famous faces that have served as spokespeople for weight loss companies are: Jessica Simpson for Weight Watchers, Kristie Alley for Jenny Craig and Organic Liasion, Valerie Bertinelli for Jenny Craig, Jennifer Hudson for Weight Watchers, Marie Osmond for Nutrisystem, Jason Alexander for Jenny Craig, Mariah Carey for Jenny Craig, and Charles Barkley for Weight Watchers.^[21]

Under the revised 2009 Final Guides Governing Endorsements, the Federal Trade Commission requires that advertisements clearly disclose the results that consumers can generally expect.^[22] Additionally, the revised Final Guides Governing Endorsements state that "both advertisers and endorsers may be liable for false or unsubstantiated claims made in an endorsement - or for failure to disclose material connections between the advertiser and endorsers."^[23]

Reality shows are a fairly new development in the media's portrayal of weight loss. Reality shows in which contestants compete to lose the most weight show amazing transformations over the course of just a few weeks. These weight loss reality shows have clearly tapped into the American obsession with losing weight, as more than 200,000 people a year submit audition videotapes or attend open casting calls for programs.^[24] Weight loss reality shows also create and market their own products, with the unspoken promise of similar weight loss success for you at home.^[25] Some of the most popular weight loss reality television shows include the following: Thintervention with Jackie Warner, Heavy, The Biggest Loser, Celebrity Fit Club, I Used to Be Fat, and Extreme Weight Loss.

These shows highlight the difference between the pursuit of engaging television and the sometimes frenzied efforts of contestants to win, even at the risk of their own health. Doctors, nutritionists and physiologists have expressed doubt about the regimen of severe caloric restriction and up to six hours a day of strenuous exercise, which can cause contestants to lose more than fifteen pounds per week.^[26] Medical professionals advise against losing more than about two pounds per week.^[27] Rapid weight loss can cause many adverse health problems, including a weakening of the cardiac muscle, cardiac dysrhythmia and dangerous reductions in potassium and electrolytes.^[28] Additionally, numerous contestants have come forward and confessed to using dangerous weight-loss techniques, including self-induced dehydration.^[29]

The Better Business Bureau (BBB) and the Federal Trade Commission (FTC) are two groups fighting back against false claims in weight loss advertisements. The BBB holds advertisers accountable by pushing its Code of Advertising, which states that “advertisers should be prepared to substantiate any claims before publication, and … that claims about performance, efficacy, and results should be based on recent and competent scientific data.”^[30] The FTC targets consumers by providing a useful website that contains tips for avoiding fraudulent weight loss packages and also an outlet for reporting these scams.^[31]

The United Kingdom takes a similar approach, where the Committee of Advertising Practice (CAP) combats false ads by providing a set of guidelines for advertisements called the Advertising Codes. Section 13 of the codes has rules for weight control and slimming ads.^[32] Failure to comply with the codes is met with various sanctions such as alerting media companies about problem advertisers or referring them for legal action from the Trading Standards Institute or Ofcom.^[33]

Quackwatch, an organized group founded in 1969, aims to inform the public of health-related fraud or “quackery”. They attribute the public's susceptibility to quackery to:^[34]

1. Lack of suspicion: Some people believe that if advertisements are permitted to run on television, in newspapers or in magazines, then they have to be true. Additionally, personal testimonies that often appear in weight loss advertisements tend to curb people's suspicion because they believe and trust their peers' claims.
2. Belief in magic: People want to believe that there is a solution to their problems. When an advertisement offers an easy, cheap and quick solution to weight loss, consumers tend to focus on what they want to believe rather than any evidence against the product or program. This behavior is also coined "confirmation bias".
3. Overconfidence: Quackwatch asserts that “some strong-willed people believe they are better equipped than scientific researchers and other experts to tell whether a method works”.
4. Desperation: The idea of a solution that finally works outweighs any potential harms or costs. This can be especially true for people with serious health issues such as obesity because "the more persistent the condition, the more susceptible the sufferer may be to promises of a 'cure'".
5. Alienation: People who have an extreme distrust of science or medicine tend to opt for "alternative or natural methods" of weight loss. Products such as Hydroxycut are often advertised as such, which can entice these consumers.

The United States Food and Drug Administration (FDA) is primarily responsible for regulating the dietary supplement industry for safety. The FDA has limited power to regulate supplements because, under the Dietary Supplement and Health Education Act of 1994, they are considered "food."

The FDA considers dietary supplements as a type of “food” as long as it contains specific ingredients and is not promised to be a cure or a treatment for any condition. Products offered as cures or treatments are considered drugs under the law and are subject to more rigorous FDA regulations. Because they are considered food, dietary supplements do not have to be evaluated for efficacy. The manufacturers are responsible for evaluating the safety of their products themselves; however, after they are put on the market, the FDA can take action if the supplements raise safety concerns.^[35]

The first time the FDA took legal action against a major dietary supplement manufacturing company was in November 2011. The FDA filed a permanent injunction against a Pennsylvania fitness company, ATF Fitness Products and Manufacturing ATF Dedicated Excellence, for distributing over 400 products that violated the Good Manufacturing Practices (cGMP) passed in 2007. They also allegedly sold unsafe, misbranded and adulterated products. The injunction took effect in March 2012 ^[36] and since then the FDA has taken a more active role against dietary supplement companies. In 2012, they forced Venus Pharmaceuticals to cease production of their supplement for also failing to comply with cGMP requirements.^[37] They also fought against companies misbranding their supplements as treatments for certain ailments. For example, in 2012 the FDA requested U.S. Marshals to seize products from Syntec Inc. and filed an injunction against manufacturer, James G. Cole Inc.^[38][39] This increased legal action will most likely continue, considering that an estimated 70% of dietary supplement companies violate cGMP requirements.^[40]

Risk homeostasis theory (RHT), or risk compensation , “posits that people at any moment of time compare the amount of risk they perceive with their target level of risk and will adjust their behavior in an attempt to eliminate any discrepancies between the two.”^[41] Risk homeostasis may be present among consumers in the weight loss industry, promoting dietary weight loss supplement sales as a result of FDA regulation misconceptions.

Dietary supplement manufacturers are responsible for ensuring the safety of their products under FDA regulation. The FDA will only take action if a dietary supplement on the market is deemed unsafe.^[42] As of March 2011, the FDA has found nearly 300 fraudulent products (many of which were promoted for weight loss) containing hidden ingredients which can cause serious injury or death.^[43] The existence of these dangerous products should increase the consumer’s perceived level of risk, but the FDA’s discovery and removal of these supplements from the market may actually decrease perceived risk. Research has shown people are unaware of the FDA’s regulatory role of the dietary supplement industry^[44] and dietary supplement users show a low risk perception.^[45] RHT asserts that this diminished perception of risk would make consumers more likely to purchase and use dietary supplements. In 2010, consumers spent $2.69 billion on diet pills and meal replacements not approved by the FDA,^[46] indicating that dietary supplements are still popular despite the risk involved.

Eating disorders are a group of psychiatric disorders that cause serious disturbances to an everyday diet. The rate of incidence of eating disorders has been increasing since 1950.^[47] In the U.S., 20 million women and 10 million men suffer from a clinically significant eating disorder at some point in their life, including anorexia nervosa, bulimia nervosa, and binge eating disorder^[48] Eating disorders can have serious consequences on one's health, productivity, and personal relationships.

Anorexia nervosa is an eating disorder that causes people to obsess about their weight and the food that they ingest. People with anorexia nervosa attempt to maintain a weight that is far below normal for their age and height.^[49] To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively. In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients that it needs to function normally. A review of nearly fifty years of research confirms that anorexia nervosa has the highest mortality rate of any mental disorder.^[50] For females between 15 to 24 years old who suffer from anorexia nervosa, the mortality rate associated with the illness is twelve times higher than that of all other causes of death.^[51] As the number of anorexia nervosa diagnoses continues to grow, the utilization of pro-ana websites has become increasingly popular. Pro-ana websites feature thinspiration (or thinspo) images or video montages of emaciated women to motivate other women towards further weight loss.^[52]

Bulimia nervosa is an eating disorder in which a person binges on food or has regular episodes of overeating and feels a loss of control. The person then uses different methods (such as vomiting or abusing laxatives) to prevent weight gain.^[53] The incidence of bulimia nervosa between females 10 to 39 years of age has tripled between 1988 and 1993.^[54] The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.^[55]

Binge eating disorder is an eating disorder in which consuming an unusually large amount of food becomes a regular occurrence and is usually done secretly.^[56] Binge eating disorder often results in many of the same health risks associated with clinical obesity, including the following: hypertension, hypercholesterolemia, cardiovascular disease as a result of elevated triglyceride levels, type II diabetes mellitus, and gallbladder disease.^[57]

Weight loss advertisements have been found to be highly misleading and the products themselves are often ineffective or harmful. Despite evidence of this, the weight loss industry is booming with revenues of over $60 billion.^[58] This disjuncture can be explained by the “Barbie Effect” –a cognitive bias created by social pressures to be physically ideal. This effect can also be applied to other industries such as fake tanning and plastic surgery where people knowingly put themselves in potential harm in order to improve their appearances.