This 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:
- 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.
- 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.
- 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.! I don’t understand how HAES’s “one size fits all” approach could possibly meet the complexities of the human being. I cannot picture counseling every patient with the same mantra of just focusing on self-care and positive affirmations; this is important but not enough. What about teaching them what is happening physiologically in their bodies, and the foods and nutrients that will help reduce inflammation, stimulate immune function, and cause healing to diseased cells versus foods that cause harm when eaten in excess, especially in the setting of other unhealthy behaviors (being sedentary, high stress, lack of sleep).
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 or been unable to listen to and care for their bodies. They may need to relearn physiological hunger and satiety signals that have been ignored for too long, to gain trust in their bodies, and to find a plan that resonates with their entire being—mind, body, and soul.
- I believe that if someone carries excess weight, is free of disease and joint pain, and they are happy with their weight, I completely support that without judgement. I have never initiated weight loss with 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 because they want to reach their college weight and have lost and regained the pounds from years of yo-yo dieting, I’d lean 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 think the HAES approach leans toward the opposite extreme of relying too much on “just do what you feel” and overlooking personal accountability when making decisions that are based on a fleeting feeling of the moment. An example is cravings. Cravings are caused by myriad of factors, and it’s important to understand their source before automatically succumbing to them.
- 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. Mindful eating is a key component. My clients who request 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 help 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.
- Obesity is defined as having a BMI of 30 or greater. I strongly agree that BMI should not be a major 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). BMI is more useful when looking at populations and seeing trends; in general a higher BMI in a population is associated with a higher prevalence of chronic diseases.
- Carrying excess weight is a major risk factor for almost every chronic disease, because extra fat increases inflammation, potentially leading to diabetes, certain cancers, cardiovascular disease, gout, gallstones, nonalcoholic fatty liver disease, osteoarthritis, and gastrointestinal disorders like reflux. 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.
- Significant weight changes rather than carrying longtime excess weight appears to be more problematic. Losing gained weight can improve 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 pounds, high blood glucose levels drop, cholesterol levels drop, blood pressure drops. Even digestion improves. Usually if the starting weight is excessive, any weight loss causes dramatic internal changes.
- It is very difficult to lose weight. I identify three key factors needed: 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 and compassionate 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. It’s more likely that the plan wasn’t a good fit so the client stopped following it. Or maybe there was too much focus on scale weight and not enough on psychological factors that still needed healing. Maybe instead we can practice resiliency—learning from setbacks and discovering a different approach or 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 clients after screening their history and needs, but it’s important not to discount the health value that reducing body weight offers some people and which they may request. Although the HAES movement is well-intentioned, there is a range of beliefs and approaches within their practitioners. Some simply use an intuitive eating and mindfulness approach. Others are practicing from personal experiences and beliefs, not based on science. They are 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 not embracing clients who have 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.