Health At Every Size in Professional Healthcare

“Is it possible to consider approaching “health” from a perspective other than weight and BMI, taking into consideration the roles of social inequity, psychology, genetic variance, and flawed science, in order to create a less demonizing, and more integrative and holistic approach to nutrition and public health?”

Last year, I posed the above question in a graduate level Community Nutrition class, and found myself grappling with the reality that a shift in the paradigm of health and body size may be more difficult than I thought. I was met with a myriad of silent crickets, angry stares, and nervous and confused glances (and 1 or 2 victory smiles and thumbs up), before the comment was dismissed and the next slide introduced, which showed pictures of “overweight” individuals aggressively smashing fast-food into their faces. Across dietetics and nutrition programs, the conversation being had about the value of a Health at Every Size and other weight-neutral approaches to health care is practically nonexistent. 

 

Health at Every Size is an approach based on the premise that the adoption of healthy lifestyle behaviors results in an improvement in overall health, regardless of weight changes. HAES addresses issues of policy, access, social justice, and diversity in relation to health, and supports healthy decision making for individuals in their unique situation without pushing a weight-loss agenda.  

 

The Health At Every Size® Principles are:

  • Weight Inclusivity: Accept and respect the inherent diversity of body  shapes and sizes  and reject the idealizing or pathologizing of specific weights. 
  • Health Enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs. 
  • Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
  • Eating for Well-being: Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.
  • Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.

 

While some argue that a weight-neutral approach is a step in the right direction, the majority of health professionals strongly disagree. HAES isn’t gaining popularity anytime soon within the medical community, the general public, or even within the world of integrative and holistic wellness. However, there is continually mounting scientific evidence to support the beneficial outcomes of a weight-neutral approach in regards to improving health and wellbeing.

So why, then, are individuals and institutions alike, so terrified of adopting a new perspective that holds the key to the lock they have been trying to pick for years? Isn’t it obvious that after only a few generations of fearing fatness, we as Americans have downwardly spiraled into a very sick and unhappy society? Can’t we admit that the more energy we put into “fighting the obesity epidemic”, the more it seems to prevail? Perhaps we are viewing the “problem” all wrong. To call “overweight” and “obesity” the problem is like blaming a house fire on the remaining smoldering ashes. Maybe obesity, and weight gain like smoldering ash, is simply evidence of a greater destructive force beyond the control of that which it affects. Maybe the problem is not “obesity”, but rather our deeply rooted societal attitudes regarding health and size, and our inability to wrap our minds around alternative, albeit improved perspectives.

 The number one prescription in response to chronic disease, larger body size, and continual self-loathing continues to be weight loss, via caloric restriction and increased physical activity. There is a strong misconception that weight loss (and in turn health) can be achieved through the simple mathematic equation of calories-in < calories out. But diets don’t work. Period. Time and time again, all dieting has failed to show lasting results in any population. In fact, the majority of dieters gain all of their weight (and often more) back within 2-5 years. Many studies have demonstrated that weight and BMI are not accurate indicators of health and a 2014, 36-study meta-analysis found evidence to support the controversial claim that excess weight is actuallyprotective in the presence of cardiovascular disease. Even aside from CVD (the number one killer in the US), individuals with a BMI number in the overweight and obese range live longer have lower rates of morbidity when compared to those classified as underweight and normal weight. The BMI scale has been shown to be an inaccurate and invalid measure of health, yet it is still the single driving force in determining everything from quality and focus of medical care, to health insurance rates, to whether or not a Whole Foods Market employee receives their full discount. BMI, and weight-focused approaches to health have also encouraged increasing rates of eating disorders. In fact, the recent edition of the DSM-V included several new diagnoses for disordered eating behavior, including binge eating disorder, which is currently the most common eating disorder in the US. Yo-yo dieting and weight cycling have been implicated in the development of binge eating disorder.

Where has dieting gotten us then, if not to a thinner, and healthier population? Continually obsessing over, and working towards an unattainable thin ideal has manifested itself as an unrelenting prejudice, resulting in distress, isolation, and unequal access for individuals living in larger bodies. In fact, sizeism is one of the last socially acceptable and unacknowledged forms of oppression in the United States. A research article that was recently published in the Journal of Obesity concluded that the stigmatization of and hyper focus on weight is actually perpetuating increases in weight gain and inabilities to lose weight. In a 2009 study, only 2% of dietetics students demonstrated a neutral or positive attitude towards fatness, while up to 81% demonstrated moderate, high, or very high levels of fat phobia. Most of the students in this study reported that “obese individuals tend to overeat, and are unattractive, slow, insecure, and inactive”. Weight discrimination has increased 66% over that last decade, even though rates of weight gain also continue to rise.

Unfortunately, these attitudes extend beyond the field of dietetics, and are typical of the majority of health care practitioners. Health care then, has become blindly directed at “treating obesity”, regardless of whether or not a person’s weight is a health issue. This results in over-treating healthy individuals with larger bodies, and failure to treat those in need who, based on their body size appear healthy. According to Linda Bacon, author of Health at Every Sizeand Body Respect, “rather than take responsibility for our failed paradigm, we blame our patients for failed weight loss attempts, and don’t consider the well documented biological resistance to weight loss or other challenges”. This is in direct opposition of the “First, do no harm” tenet of medical practice.

So how can nutrition students and professionals take part in shifting the paradigm of health from a failing weight-focused approach to an inclusive and progressive health-centered approach? To begin, you can always continue to educate yourself, seek out opportunities for information and experience, attempt to see the whole picture, and do your best to reevaluate the “problem” and challenge the proposed “solutions”. Most importantly however, speak up in opposition of the accepted norm. Validate your patient’s current healthy lifestyle practices and utilize alternative markers of health (cholesterol levels, blood pressure, quality of life) to assess progress. Reconsider the recommendations “you should lose weight”, or “weight loss will improve your health”, and instead, encourage patients to adopt healthy lifestyle behaviors such as incorporating more whole foods into their diet, finding enjoyable ways of moving their body, practicing good sleep hygiene, and taking time each day to love and appreciate their body exactly as it is. Finally, understand, raise awareness of, and advocate for the concept that health is not one-size-fits-all.


Resources:

1. Bacon L. Health at Every Size: The Surprising Truth about Your Weight. BenBella Books; 2010.

2. The Body Positive, website. 2015. www.thebodypositive.org

3. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009;17(5):941-64. 

4. Wildman, R. P., Muntner, P., Reynolds, K., McGinn, A. P., Rajpathak, S., Wylie-Rosett, J. & Sowersk M. R. (2008). The Obese Without Cardiometabolic Risk Factor Clustering and the Normal Weight With Cardiometabolic Risk Factor Clustering: Prevalence and Correlates of 2 Phenotypes Among the US Population (NHANES 1999-2004).  Archives of Internal Medicine, 168(15): 1617-1624.

5. Amigo I, Fernández C. Effects of diets and their role in weight control. Psychol Health Med. 2007;12(3):321-7.

6. Hansel B, Roussel R, Elbez Y, et al. Cardiovascular risk in relation to body mass index and use of evidence-based preventive medications in patients with or at risk of atherothrombosis. Eur Heart J. 2015.

7. Sharma A, Vallakati A, Einstein AJ, et al. Relationship of body mass index with total mortality, cardiovascular mortality, and myocardial infarction after coronary revascularization: evidence from a meta-analysis. Mayo Clin Proc. 2014;89(8):1080-100.