Health at Every Size: A Sound Approach to Behavior Change
Dieting has failed us. Let's try another solution for obesity and chronic disease.
Apr 18, 2018
The correlation between obesity and chronic disease is well established (Bacon & Aphramor 2011; Bombak 2014; Penney & Kirk 2015). Causality, however, is not so clear (Bombak 2014).
For decades, efforts to fight chronic disease have focused primarily on obesity—encouraging dieting as the best way to lose weight. But even as the U.S. weight loss industry has grown to $58.6 billion annually, we haven’t seen significant improvements in rates of chronic disease (Bacon & Aphramor 2011).
The weight-focused paradigm’s failure to produce lasting results underscores the need to try new approaches to chronic-disease management. One such tactic is Health at Every Size®, a weight-neutral outlook that is showing promising results (Bacon & Aphramor 2011; Penney & Kirk 2015).
Diets Don’t Deliver
Dieting (eating less and moving more) has two goals: losing weight and improving health. Unfortunately, dieting fails on both counts.
Studies have demonstrated that sustained weight loss is an extremely rare outcome of dieting. More than 90% of diets result in weight regain (Bombak 2014; Ikeda et al. 2005; Bacon & Aphramor 2011). Even worse, dieters tend to regain more weight than they initially lost (Bombak 2014; Tribole & Resch 2012). This happens because the human body evolved a mechanism that protects against famine, which was a constant threat to our ancient ancestors.
Dieters often find that achieving short-term weight loss is relatively easy. But that creates a misconception of weight loss success that all too often ends in weight regain. Soon, the dieter embarks on a new diet, launching a round of weight cycling that wreaks havoc on the body and causes many problems routinely blamed on obesity. For example, weight cycling increases inflammation and raises the risk of hypertension, insulin resistance and dyslipidemia (Bacon & Aphramor 2011). These parameters are characteristic of type 2 diabetes, hypertension and cardiovascular disease.
The relationship between dieting and health outcomes is a bit more complex. In the short term, dieters strictly adhere to healthy behavior changes that may stabilize blood sugar, improve energy levels and reduce joint pain. All too often, weight loss gets all the credit for these health improvements, when other factors may be more important. It may well be that behavior change—independent of weight—is driving many of these improvements.
Furthermore, the detrimental impacts of weight cycling make it clear that the long-term effect of intentional weight loss is more harmful than beneficial to health. As studies have shown, dieting can produce immediate health gains that overshadow long-term damage.
Why Lost Weight Returns
Why is weight loss from dieting so hard to maintain? Research suggests the answer lies in the body’s hormonal response to dietary restriction. In short, eating less than the body needs triggers endocrine system changes that actively promote weight regain, reducing satiety after eating and increasing hunger (Bombak 2014). These effects can last for a full year after intentional dietary restriction. In addition, dieters develop a lower resting energy expenditure, so they require less food to maintain their weight compared with nondieters (Bombak 2014). Thus, weight-cycling dieters prime themselves for long-term weight gain.
For all its failures, dieting remains a cornerstone of chronic-disease management. Addressing this challenge requires a new paradigm in health promotion.
Embracing Health at Every Size
Nutritionists and other dietary authorities have been developing alternatives to dieting for decades, but the vast majority of these alternatives have been founded in the weight-centered paradigm. Lately, many of the efforts have coalesced around Health at Every Size, a weight-neutral approach to chronic-disease management that encourages healthy behavior change.
HAES is based on research suggesting that people who are classified as obese can improve their metabolic fitness and reduce their risk of chronic disease by eating more nutritious meals and increasing their physical activity—independent of changes in weight (Ikeda et al. 2005; Kennedy, Lavie & Blair 2018). By contending that weight is not an indicator of health, this method shifts the conversation away from weight management and toward health promotion (Bacon & Aphramor 2011; Bombak 2014). Weight change may or may not be a side effect (Bacon & Aphramor 2011).
“[Health at Every Size] rejects a focus on an individual’s weight, or change in weight, as a measurement of health,” says Jennifer McGurk, RDN. McGurk says HAES “stands for the right that all bodies deserve respectful healthcare, regardless of size.”
HAES promotes healthful eating, body acceptance, and attention to internal hunger and satiety cues (Bacon & Aphramor 2011; Robison 2005). It also promotes active engagement in enjoyable physical activity (Bacon & Aphramor 2011; Bombak 2014). HAES does not suggest that everybody is living at a healthy weight. Rather, it contends that behavior changes can stabilize weight at a healthy level (Robison 2005). This stabilized weight may or may not fall into the arbitrary “ideal body weight” range.
The HAES model does not ignore health risks and medical issues, but it does try to shift the focus away from prescribing weight loss as the solution (Robison 2005). After all, intentional weight loss has proved to be unsustainable and harmful to long-term health.
Research on HAES has been promising, showing substantially higher overall weight loss retention than dieting (Bacon & Aphramor 2011; Penney & Kirk 2015). This is especially noteworthy considering the common issue of weight regain over time with dieting. Since HAES does not encourage weight loss, it also avoids the harmful process of weight cycling.
Note that current research on HAES practices is limited to primarily overweight and class I obesity participants, excluding obesity class II or class III participants (Penney & Kirk 2015). More research is needed to reveal the effectiveness of HAES in this population.
The Anti-Diet: Intuitive Eating
A natural complement of HAES is intuitive eating, which encourages internal regulation of the eating experience (Bacon & Aphramor 2011). Unlike many traditional diets, intuitive eating encourages people to listen to and honor their internal cues for hunger and fullness. It also discourages food judgments that some foods are “good” and others are “bad.”
Rather than having people try to override specific food cravings in order to follow strict diet rules, intuitive eating embraces the body’s natural ability to regulate food intake. Intuitive eating promotes gentle nutrition in a weight-neutral manner, which is consistent with the HAES approach.
The principles of intuitive eating encourage people to observe, without judgment, the way foods make them feel. That includes honoring hunger and satiety cues, noticing energy levels and identifying when food is used for comfort (Bacon & Aphramor 2011; Tribole & Resch 2012). While diets promote feelings of guilt and shame from failure, intuitive eating embraces the flexibility of the human experience. The goal of intuitive eating is not to eat perfectly, but rather to support a more comfortable relationship to food (Tribole & Resch 2012).
The intuitive eating model is based on studies indicating that children choose foods that meet their nutritional needs without external guidance (Bacon & Aphramor 2011; Bombak 2014). This body of research suggests that intuitive eating enhances nutrient intake, reduces eating-disorder symptoms and does not cause weight gain (Bacon & Aphramor 2011; Tribole & Resch 2012). The lack of weight gain that occurs with intuitive eating is worth noting, because it’s a point that has drawn concern from critics.
Taking Weight Off the Table
The failure of the weight-focused paradigm requires that we find better ways to address chronic-disease rates. HAES shifts the story from focusing on weight to focusing on healthy behavior changes. Working from this approach supports both physical and mental health while being inclusive of clients of all body sizes who want a healthy lifestyle.
Bacon, L., & Aphramor, L. 2011. Weight science: Eval┬¡uating the evidence for a paradigm shift. Nutrition Journal, 10, 9.
Bombak, A. 2014. Obesity, Health at Every Size, and public health policy. American Journal of Public Health, 104 (2), e60-e67.
Ikeda, J., et al. 2005. The National Weight Control Registry: A critique. Journal of Nutrition Education and Behavior, 37 (4), 203-05.
Kennedy, A.B., Lavie, C.J., & Blair, S.N. 2018. Fitness or fatness: Which is more important? Journal of the American Medical Association, 319 (3), 231-32.
Penney, T.L., & Kirk, S.F.L. 2015. The Health at Every Size paradigm and obesity: Missing empirical evidence may help push the reframing obesity debate forward. American Journal of Public Health, 105 (5), e38-e42.
Robison, J. 2005. Health at Every Size: Toward a new paradigm of weight and health. Medscape General Medicine, 7 (3), 13.
Tribole, E., & Resch, E. 2012. Intuitive Eating: A Revolu┬¡tionary Program That Works. New York: St. Martin’s Griffin.
Weight-focused talk is not just psychologically damaging. Research suggests that it may be physically damaging as well. Thus, clients could benefit from a more weight-neutral approach to conversations. Here are a few ways to do that:
- 1.Move beyond weight. This won’t be easy, because weight loss is a primary motivator for so many clients. Jennifer McGurk, RDN, suggests steering the conversation toward behaviors, thoughts and feelings rather than arbitrary numbers on a scale. She also cautions against celebrating weight loss or restrictive eating. Try to shift toward celebrating healthful behaviors.
- 2. Avoid triggering words. Clients don’t need to hear words that shame them or that encourage restrictive behaviors. McGurk discourages the use of words like and Try not to dwell on data points like calorie counts and pounds lost or gained.
- 3. Treat everybody as equals. Don’t assume