What About ‘Health At Every Size’?

HAESThis is a tough one. It’s about Health At Every Size (HAES), a movement based on the book by researcher Linda Bacon, PhD, that emphasizes body positivity and self-care. It de-emphasizes the importance of body weight and the effects of certain foods on health. It focuses on setting holistic lifestyle goals rather than enforcing strict diet rules. Nothing at all wrong there, right? I credit it and similar intuitive eating movements with bringing major change to weight loss counseling. National obesity rates are not dropping, so clearly providers including dietitians are not doing something right. I agree with many of their concepts and that too many people have a tortured view on diets and losing weight. I always evangelize self-care because I believe that everything else falls apart without it.

Then why do I struggle each time I read another article or blog post from a HAES supporter? Many of those supporters are fellow dietitians. After thinking and thinking, I realized that HAES is not as straightforward as it appears.

What’s unsettling about HAES:

  1. The consistently driving tone expressed by HAES proponents, which is one of judgement and justification that their way is the only correct approach to weight loss. It is a condescending tone that bashes social media posts from people who post about their gym workouts or photograph their meal prep for the week. Their favorite hashtags #nondiet and #ditchthediet condemn diet plans of any type, even if those lifestyle choices empower people to feel better. They denounce these folks as fueling the diet culture and being obsessed with their physical appearance.
  2. Preaching from personal experience and not being able to see a client from an unbiased view. I’ve observed that dietitians or health coaches who promote HAES concepts often have had personal experiences with an eating disorder, so they are approaching clients from a biased view. Founder Linda Bacon shared her personal struggle with an eating disorder. Maybe they have found peace by following HAES concepts or are still struggling with their disorder. But I think it’s important for every licensed, credentialed health provider to be unbiased in their practice. That means guiding clients and patients towards the best possible plan for them, not what has worked best for their provider. It’s important to provide individualized guidance based on extensive research, best practices, and the client’s unique situation, not based on a provider’s personal experience.
  3. In some cases, the HAES model may be the best plan. But not necessarily in every case. This is where HAES becomes too limiting. Every client I see has a different plan of action because there are a million and one pathways to improve one’s health that accounts for their age, lifestyle, personal preferences, medical conditions, social environment, etc. etc.! I don’t understand how HAES’s “one size fits all” approach could possibly meet the complexities of the human being. I’m trying to picture counseling every patient who is looking to lose weight with the same mantras that are solely focused on giving self-care and positive affirmations about their body…it just doesn’t register. What about teaching them what is happening physiologically in their bodies, and the foods and nutrients that will reduce inflammation, stimulate immune function, cause healing to diseased cells, etc. versus foods that cause harm when eaten in excess in the setting of other unhealthy behaviors (sedentary, high stress)?

What I believe:

  • I believe that HAES has an important place in nutrition counseling particularly when working with clients who have a history of disordered eating behaviors and an unhealthy relationship with food. That could mean a diagnosable eating disorder such as anorexia or bulimia nervosa, or a lifelong history following extreme restrictive diets with weight cycling. They have neglected to listen to and care properly for their bodies. They need to relearn physiological hunger and satiety signals that have been ignored for too long, and to find a plan that resonates with their entire being—mind, body, and soul.
  • I believe that if someone with a body mass index (BMI) over 30, defined as obesity, is free of disease and joint pain and they are happy at that weight, I completely support them without judgement. I have never initiated weight loss to a client. Even if a patient arrives in the clinic requesting weight loss, I ask why they want to lose weight and is there a medical reason in which their current weight is directly causing harm (prediabetes, osteoarthritis, heart disease)? If they say it’s mainly because they want to reach their college weight despite years of yo-yo dieting, I’d learn toward a HAES approach because they are displaying disordered eating patterns.
  • I believe that when someone is trying to achieve weight loss, the body thrives on structure and routine, such as with a meal plan and an exercise and sleep regimen. It works with kids, and most definitely with adults! I make people accountable for their choices that lead to negativity. I think the HAES approach leans toward the opposite extreme of relying too much on “doing what you feel” and overlooking one’s personal accountability in making harmful decisions.
  • I believe the main problem is not diets. The root problem in our country is too-easy access to too much food that causes weight gain that causes dieting. So if you only address stopping diets, you don’t address the root problem. Even if you engage in self-care and stop the diet mentality, you are still faced daily with an environment that encourages overeating. If you do not implement some type of discipline and instead simply guide your behaviors based on “eating whatever you feel,” because of our ubiquitous steady access to calorie-dense foods and an overeating environment, weight gain will happen. Then, if you consistently eat more food than needed, there is a complex interplay of hormonal changes. Our bodies adapt to (and crave) larger amounts of food…further supporting a heavier weight. Maybe at that point HAES followers won’t care because their principles preach acceptance of whatever body shape they have. But for some, it could lead to frustration if they develop new health problems or physical disability from having a larger body.
  • I believe there is a place for diets. And I don’t mean “diet” in the faddish term. I define diet as an eating plan that considers one’s entire makeup that first promotes mind-body health; sometimes weight loss follows. My clients who follow an eating plan do not use it 100% of the time nor do they need to follow it forever. The plan is simply like training wheels that redirect them to a healthy eating pattern as they learn. I have a unique perspective as an outpatient dietitian in that I follow some people for years in a clinical setting that provides results of their blood work and medical tests after following a prescribed “diet.” They become healthier on the inside and therefore feel physically better, much happier, and less anxious overall.

The reality:

  • Obesity is defined as having a BMI of 30 or greater. I strongly agree that BMI should not be the main measure of health, because it is only based on height and weight, and not total body composition (a common example cited is a body builder with less than 5% body fat but who is classified as obese). But in general a higher BMI is associated with a higher prevalence of chronic diseases.
  • Obesity is a major risk factor for almost every chronic disease: diabetes, certain cancers, cardiovascular diseases, gout, gallstones, nonalcoholic fatty liver disease, osteoarthritis, and gastrointestinal disorders like reflux. I’d estimate that 90% of patients who are referred to our clinic with these conditions are overweight or obese due to poor lifestyle habits. Even if one does not have these diseases, carrying around 30+ extra pounds can be tough on the joints and depletes energy levels.
  • HAES often showcases a 2013 JAMA study to support their movement, which found that people who were overweight lived longer than those who were at a healthy weight or thin. However the study was flawed because it compared healthy obese/overweight people with “normal” weight people who were heavy smokers, patients with cancer or other conditions that caused weight loss, and frail elderly people who had lost weight due to declining health. Who do you think came out on top? See this commentary and this one for a scientific breakdown of the study.
  • Weight loss if obese improves disease outcomes. This is not only confirmed by research but I see it over and over again in the clinic. With even a modest weight loss of 10-15 pounds, high blood glucose levels drop to normal, cholesterol levels drop to normal, blood pressure drops to normal. Even digestion improves. And usually the more weight lost, the more dramatic the internal changes.
  • It is very difficult to lose weight. I identify three key factors: 1) internal motivation and readiness to change, 2) a support system in place from many levels—home (spouse, children), immediate environment (supportive friends, health and wellness initiatives in the local community and workplace), national public health measures that support healthy lifestyles like the MyPlate guide, and 3) a skilled health coach, dietitian, or physician who can educate and guide a person to change.
    • The 3rd is a tough one. Motivating people in the long run is a highly prized skill that an otherwise skilled dietitian might not have. I think I’m getting better at it but I doubt I’ll ever master it. Sometimes I wonder if lacking this skill has fueled the HAES movement. It’s far easier to coach someone to set goals like accepting your body shape or doing one good thing for yourself every day… than to lose pounds. When a client can’t lose weight or has regained lost weight, they feel that they’ve failed. But so does the dietitian. In these cases, I don’t think the answer is to say that diets don’t work; that’s a cop-out. It’s more likely that the plan wasn’t a good fit so the client stopped following it. Maybe instead we can practice resiliency—learning from setbacks and finding better approaches or a more holistic strategy on how to successfully guide the client to lose weight, remembering that each client will have a unique path. It takes more perseverance and patience with this route, but one I’m willing to travel.

My two cents is that HAES has insightful nutrition points that providers can use for specific clients after screening their history and needs, but it’s important not to discount the health value that reducing body weight offers some people. Although the HAES movement is well-intentioned, I fear their practitioners may be doing more harm than good. They are practicing from personal experiences and beliefs, not based on science. They are clearly not actively reading published scientific research about obesity (or else they would not be ignoring the harm caused by generally encouraging health at any size). They are likely in private practice because they realize that solely using HAES concepts would never be embraced or effective in a clinical practice where clients with obesity often have other medical issues that require a complex nutrition plan that is not “one size fits all.”

What do you think? Are you a full-on supporter of the HAES movement or does it not quite sit right? Isn’t there room for some kind of middle ground? These researchers summarized what I feel is a balanced view on future directions for HAES:

Penney TL, Kirk SFL. The Health at Every Size Paradigm and Obesity: Missing  Empirical Evidence May Help Push the Reframing Obesity Debate Forward. Am J Public Health. 2015 May; 105(5): e38–e42.

10 thoughts on “What About ‘Health At Every Size’?

  1. Georgia King says:

    ^ agree with everything you just said!!! I couldn’t have said it better myself! I too see the value in HAES in some cases, but there are definitely some major flaws that are being used regularly in our culture! Thanks for sharing!

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  2. Heather Caplan RD says:

    Hi Nancy,

    I agree that it’s disappointing to see the dietetics field so divided on these points. I think we all know we’re in this field to help people, promote health behaviors when applicable/accessible, and provide guidance and expertise to clients in all practice areas (not just private settings). But what’s most unsettling is a misunderstanding, and often misrepresentation, of these concepts, and the general philosophy. Also, it seems, a general misunderstanding of how these concepts can be used across the spectrum of dietetics. I would love to chat with you about this, if you’re open to it! I have a podcast (RD Real Talk), but am also working on a series of events that focus on weight inclusivity in dietetics, and are designed to have open discussions just like these. 🙂 (Weightinclusiveconference.com)

    That said: I’m wondering why you’ve linked to James Fell’s post on his own blog about his distaste for Dr. Bacon as evidence that HAES is “not based on science.” I’m wondering if there is research, or peer reviews, suggesting HAES is an ineffective approach? (As an aside: I found his post in such poor (and arrogant) form—’prove to me I’m right about how she’s wrong’ isn’t getting anyone anywhere, and based on the transcripts he provided, he did, in fact, take many of her statements out of context. He must have felt insecure about it if he felt the need to write the post and provide exact transcripts.)

    Anyway, thanks for opening up a place for discussion. I hope we can get in touch and have a conversation, since I know many of these internet interactions can be easily misread or an argumentative tone inferred. Don’t mean to argue, just want to keep the dialogue open! 🙂

    Liked by 1 person

    • Nancy says:

      Hi Heather, thanks for your insights and time! I really appreciate differing points of view. I agree there is likely misunderstanding about HAES concepts. From what I’ve read, I agree with some of their points – especially about the harm (emotionally and physically) that some diets can cause. What I have most difficulty with are statements (from Linda) such as… most epidemiological studies on longevity have shown that overweight people live longest, and continuing to cite the unfounded statistic that 95% of diets fail (I’d tried desperately to find the original source for this when giving a nutrition talk 5 years ago and came up empty). Because I’m not only a dietitian but in a nutrition research setting, I am constantly exposed to studies — and whether new or old — they have a pretty consistent message: overweight and obesity are tightly linked to an endless number of chronic diseases and negative metabolic changes in the body. These are clinical trials as well as epidemiological studies. I’m not trying to promote any particular point of view but just reporting what I’m seeing. HAES has not been around long enough that there is published research on its effectiveness. But I would be extremely interested to see if a HAES model in a controlled trial (maybe compared with a traditional weight loss approach with calorie-controlled meal plans) using participants with obesity/overweight and one other condition such as prediabetes, type 2 diabetes, or heart disease could improve these latter health conditions without any weight loss. That’s the key question for acceptance of the HAES model in clinical practice: is it effective to treat the negative health outcomes that are caused by excess body fat? Also remember that I’m strictly speaking from a clinical perspective and practice. In the general outside world, I completely support body positivity and am against weight stigma and fat shaming. I do not address overweight/obesity unless it becomes a health issue.

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  3. Nancy says:

    I’m sorry you did not like the James Fell blog post. I agree that linking it to “based on science” was inappropriate as it was just a journalist sharing his experience in writing the article.

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  4. Bite Me Blogs says:

    I am not a dietician. I am a woman with a lifelong history of an eating disorder that finds I cannot maintain a “healthy” weight without engaging in disordered behaviors. I studied clinical mental health at the graduate level for three years, but didn’t finish my master’s degree.

    I am 100% behind HAES for many reasons. I appreciate that your view is fair and balanced. But my big question to anyone, with any degree of skepticism is towards HAEs is: why encourage weight loss in clients if permanent, significant, intentional weight loss is the exception and not the rule?

    Maybe the adage that 95% of people who lose a significant amount of weight regain within 5 years isn’t as accurate as it is believed to be. But what evidence is there to the contrary?

    Just for example, I am skimming a New York Times article that is insisting the commonly spoken fact that only 5% of people lose weight are able to keep it off is “just lore.” But apparently there hasn’t been substantial research to prove or disprove it. The number could be higher or lower. (I realize this isn’t peer reviewed research, I was just looking for an example.) https://www.nytimes.com/1999/05/25/health/95-regain-lost-weight-or-do-they.html

    But if a significant number of people are unable to maintain weight loss, I feel like that says a lot more about human biology than it does about dangers of obesity.

    I think food security, eradicating food deserts, and universal healthcare are more pressing health issues, that may combat “obesity”, as well as the health problems that are commonly associated with it. Focusing on “obesity” as a public health issue increases weight stigma and bias, and can be a contributing factor to eating disorders.

    There is a National Weight Loss Registry. But it is not well managed. It includes people who have maintained weight loss less than 5 years, and people in the registry have come forth stating they are still on it even though they have gained the weight back, and the registry is no longer accurate.

    It also astounds me how few people understand that binge eating disorder is usually fueled by periods of restriction. MOST (but not all) people with binge eating problems don’t binge eat out of nowhere. They developed this problems from periods of restriction and/or chronic dieting, quite often in pursuit of weight loss.

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    • Nancy says:

      Thank you for taking the time to share your thoughts! I found myself nodding to all of your points. I truly don’t disagree with anything you said.

      I think it is hard to know exactly how many people have lost weight and kept it off. Studies and registries only capture people who participate and are followed long term. Even the national weight loss registry is voluntary so it doesn’t capture everyone. In my clinic I only see people repeatedly with weight regain, but there are some who have lost weight and don’t come back (I should probably track better). Weight loss maintenance is super hard and that’s what we mostly hear about in the media (also because the commerical weight loss industry is a billion dollar industry) not so much the successes.

      I agree about addressing the wider scale health issues. I mentioned above how the real problem starts with easy access to too much of the wrong foods, especially in food deserts. But the point can’t be ignored that obesity definitely is associated with greater risk of and worse outcomes for many diseases. Not everyone who carries excess fat develops health problems but it is still definitely a public health issue.

      I also believe that calorie restriction can lead to bingeing. But in my opinion it is caused by over-restriction. The lower the calories, the greater the binge. And after a binge, you severely restrict calories to make up for the thousands you ate, right? And the vicious cycle continues. How many people (mainly women) I’ve seen who believe they can only lose weight if they eat 800 cals a day! This is an old school way of thinking from Jenny Craig days. I don’t use calories in counseling. It’s about eating real food that matches your natural metabolism and truly satiates you. Regarding the BED, food restriction may often be the trigger, but it is a mental health issue. There are other existing deeper problems but the person uses food as therapy/distraction/comfort…or punishment!

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  5. Alisha Carlson says:

    I’m just reading the book, so I can only speak to a bit about the book. However, in observing some of the movement’s biggest advocates I do have to say I disagree with some of the attitude that HAES/ Intuitive Eating is ‘giving’ permission to eat whatever you want and completely disregard self-control. There are extremes to every side, and both ends of the spectrum seem to leave out major points. It would be great to find the middle ground.

    I love that with both IE/HAES the focus isn’t necessarily on the amount of weight lost, but rather on the healthy habits formed. Speaking of, that is another thing that is kind of irritating with some of the HAES community–anything done in the sake of health seems to be scrutinized.

    Anyway, I appreciate you sharing your thoughts on HAES as well as offering some differing opinion too.

    As a lifestyle coach, I have opted to move away from the diet mentality. However, ultimately it’s my job to help my clients live their best life and sometimes that might include weight loss.

    Thanks again!

    Liked by 1 person

    • Nancy says:

      Hi Alisha, thank you for your insights – I agree! Just this week I had two new clients referred for obesity with a history of damaging diets and weight cycling, yet wanted another diet plan. I opted to use the intuitive eating model that caused them to open up about their childhood and emotional hurt caused by family/physicians. I didn’t take any body measurements or offer an eating plan, as we decided to work first on the negative emotions. Each approach to a client will be different so I’m glad to have the IE model available.

      I see your insights about HAES as well. When you dig deeper, it seems to be an anti-everything-you-know-about-health. I saw recently a HAES advocate write about how it’s perfectly fine to eat when you’re not hungry or to eat beyond fullness if you choose (going against the traditional IE model). I’d agree with this for a “normal” eater but not necessarily for someone regularly eating out of control. It’s basically saying f*** you, I can do whatever I want when I want. It suggests that when people change their weight to be healthier, they are only doing it for appearance to fit the media mold of thin and pretty. This is the main point I believe that HAES is fighting. It’s not about health, it’s about women’s rights, which is fitting in the era of #MeToo and Trump.

      Anyway, thank you for what you do as a life coach. It’s such a valuable and important field. I’ve found tremendous benefit in my practice using motivational interviewing, which I’m guessing life coaches are experts in.

      Liked by 1 person

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