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Healthy At Every Size (HAES): the debate

Pick up any magazine today and you will find an article on the Non-Diet or HAES paradigm to healthier eating.

This focuses more on body acceptance and making changes focusing on health improvement rather than weight loss.

As the number of overweight or obese people in the world now roughly equals the number of underfed it is clear that how we view our weight issues needs to change not only for good health but also the sustainability of life on this planet.

As obesity has been linked with a range of chronic diseases, including type 2 diabetes, hypertension, coronary heart disease, gall bladder disease and stroke, it is the key target for public health action around the world as current treatments and management methods for these conditions are subject to intense scrutiny.

How do we currently measure obesity?

While the use of Body Mass Index (BMI) i.e. weight divided by height / m 2 to measure obesity has many flaws, it remains one of the few tools used globally and by the World Health Organisation to measure weight range and the health risks in an adult population. See Table 1 1

Having a high BMI does not mean someone will get a long-term health condition such as Type 2 diabetes, but they are at greater risk of getting this condition than someone who has a BMI within the acceptable range.

 Table 1: The upper range of BMI

Category Class Risk BMI Range
Overweight 25-29.9
Obese 1 low 30-34.9
Obese 2 moderate 35-39.9
Obese 3 high >40

Debate is now divided between the view that obesity should be measured in this way and managed with dietary intervention and sceptics who advocate a movement away from concern about body weight, shape and size. This is the HAES or Healthy at Every Size paradigm.

A report by researchers Penney and Kirk in the American Journal of Public Health2 2015 looks closely at this debate and makes some important observations:

The Core beliefs of HAES

Proponents of HAES encourage a fulfilling and meaningful lifestyle that strengthens health-giving behaviours, builds self-esteem, eating according to internally directed (intuitive) signals of hunger or satiety and encouraging a sensible level of exercise at every size.

By shifting the focus from weight to a health focus HAES challenges the traditional assumptions that:

  • Adiposity poses significant morbity or mortality risk
  • Weight loss will prolong life
  • Anyone determined to lose weight can keep it off with appropriate diet and exercise
  • The pursuit of weight loss is a practical and positive goal
  • The only way for people living with obesity is to lose weight
  • Obesity related costs places a large burden on our economic and health system that could be corrected by focusing attention on obesity treatment and management. 3

Instead HAES proposes that we:

  • Encourage body acceptance
  • Support intuitive eating
  • Support active embodiment 3,4

Focusing on positive feelings and body acceptance

The principles governing the HAES philosophy evolved in the early 2000’s. They argue that the traditional approaches of dieting and restriction causes physical, emotional and spiritual distress. This occurs especially when adherents “fail” to reach their weight goals and that these “failures” can make individuals feel that they are unable to be healthy unless they reach some narrowly defined and socially constructed body size. Such feelings can lead to discrimination, prejudice and fat shaming directed at people experiencing obesity and may further propel behaviours that contribute to disordered eating or excessive exercise 5,6

Proponents of intuitive eating encourage people to respond to internal cues of hunger and satiety rather than specific meal times or events in an effort to prevent negative body image or disordered eating.7

Studies have found that rather than using BMI to predict a woman’s body appreciation, the acceptance of her body by significant others and society has proven to be more empowering.8

Similar studies that focused on body function rather than form or shape resulted in improved body appreciation and success at intuitive eating 9

Does the HAES approach work?

Studies have shown that being part of a HAES group can help members to maintain weight and improve metabolic fitness (blood pressure and lipids). HAES group members maintained energy expenditure, positive eating behaviour and improved psychological scores (self-esteem, depression and body image) and susceptibility to hunger for up to a year when compared with a diet group.10

Diet groups tended to lose more weight than the HAES groups but did not maintain this at followup at one year. However improvement in longer term weight maintainance was achieved when the diet groups were also given social support.11

While HAES may not lead to weight loss (as this is not its goal) it does lead to a psychological and potential physical benefit. This is particularly important in respect to women who experience disordered eating or chronic dieting behaviour alongside issues of overweight and obesity. Valuing bodies at any size does offer social support for body acceptance and may help individuals to regain their feelings of self-worth. 2

Limitations with the HAES research

 In a summary of their HAES research Penney and Kirk noted: 2

  • Studies using HAES methods are small-scale and have tended to choose people with BMI’s in the overweight and class 1 obesity range. While any help given to enable people to reduce obesity should be applauded, it does not help people with obesity in the class 2 and 3 which are the fastest growing groups around the world. 12
  • By focusing on behaviour the studies have failed to address environmental influences and have focused  mostly on white female participants with a history of binge or chronic dieting. In Western culture this approach may not be appropriate for people with genetic predisposition to weight gain and resistance to weight loss or people of differing ethnicity.
    Nor does it value a weight loss of 5-10% which has been shown to provide greatest health benefit to class 2 and 3 obese.13
  • By framing obesity as a disease in itself HAES is ignoring the role that obesity plays as a risk factor in other diseases.
    As a dietitian I have observed that people are more successful in reducing their weight when they can also measure other physical benefits linked to dietary change. As part of assessment and review it is important to look at measures outside weight such as reduced blood pressure, blood glucose and better lipid control or improvements in mobility, sleep quality, respiratory function and feeling happier.
  • Removing weight from the obesity discussion could marginalize individuals who want support from the health system for weight management particularly where co-morbidities are an important health factor that may be contributing to their weight loss problems and additional support is needed. 14
  • While the HAES paradigm encourages individuals to respond to their own cues to eat and physical status, it doesn’t address the need to change the obeseogenic environment we all live in which favours supersizing nutrient poor foods that are low-cost compared to healthier foods. For many people intuitive eating is a privilege they feel unable to afford. By focusing just on the individual to treat obesity, this approach misses the point that for many weight gain is a result of social, economic and physical barriers that feed the problem. There needs to be a broad social and political will for change to support individuals and bring about long-term environmental change that also benefits public health. 15,16,17

There is no one size to fit all

We are all humans who need key nutrients to live and think and adapt to our changing environment.

There is now good evidence that the brain needs key nutrients in order to think clearly (and develop mindfulness). At Lea Stening Health, we prioritise a mental well-being and functional approach to all our dietetic work.

As well as looking at personal goals, weight loss experiences, learning styles etc, we begin with a nutritional assessment of a persons current diet to identify any nutrient deficiencies verses his/her body needs.

By looking at the big picture of a person’s health e.g. their work, activity and sporting commitments, their interests, culture and eating patterns, family commitments and budgeting constraints etc, it is possible to view weight issues alongside the mental and physical risk factors that people face.

We focus on the suppression of hunger as this, along with exercise and portion control improves energy levels. Management of hunger helps the development of intuitive eating and an understanding of the cues to eating. As people gain better control over their energy status clients report that they feel less tired and depressed and their self-esteem and happiness grows along with their sense of empowerment.

As nutrition science advances and people’s lifestyles and circumstances change the need for on-going nutritional support and education is an important part of building long-term health and fitness.This is why we maintain our website articles, monthly newsletter and our community activities

There are many people who can benefit from aspects of the HAES paradigm which is why dietitian’s are studying its effects. Rather than concentrating on a polarising debate regarding the removal of weight from the obesity equation I believe that we need to seek common ground, working together to improve the health and well-being of everyone.

To find out how we can help you contact us today.

For more articles by Lea on a similar topic:

Our attitude is the key to better health
Brain food part 2:Thinking food
Feeling full is the secret to weight loss
Unlock your potential with food
Stay in ‘the loop’ for a brighter future

References

1.Martin LJ. Health risks of obesity 2017 Medline Plus. US National Library of Medicine

2.Penney TL, Kirk SF. The health at every size paradigm and obesity: Missing empirical evidence may help push the reframing obesity debate forward. American Journal of Public Health May 2015, Vol 105, No. 5 Framing Health Matters e41

3.Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9.

4. O’Keefe JH, Vogel R, Lavie CJ, Cordain L. Achieving hunter-gatherer fitness in the 21(st) century: back to the future. Am J Med. 2010;123(12):1082-1086.

5.Miller WC. The weight-loss-at-any-cost environ- ment: how to thrive with a health-centered focus. J Nutr Educ Behav. 2005;37(suppl 1):S89–S94.

6. Robison J, Putnam K, McKibbin L. Health at every size: a compassionate, effective approach for helping individuals with weight-related concerns—part II. AAOHN J. 2007;55(5):185-192.

7.Miller WC. Fitness and fatness in relation to health: implications for a paradigm shift. J Soc Issues. 1999; 55:207-219.

8. Augustus-Horvath CL, Tylka TL. The acceptance model of intuitive eating: a comparison of women in emerging adulthood, early adulthood, and middle adult- hood. J Couns Psychol. 2011;58(1):110–125.

9. Avalos LC, Tylka TL. Exploring a model of intuitive eating with college women. J Couns Psychol. 2006; 53(4):486-497.

10. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105 (6):929–936.

11. Provencher V, Bégin C, Tremblay A, et al. Health-at- every-size and eating behaviors: 1-year follow-up results of a size acceptance intervention. J Am Diet Assoc. 2009;109(11):1854–1861.

12. Katzmarzyk PT, Mason C. Prevalence of class I, II and III obesity in Canada. CMAJ. 2006;174(2):156– 157.

13. Wing RR, Lang W, Wadden TA, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34(7):1481-1486.

14. Kirk SF, Price SL, Penney TL, et al. Blame, shame, and lack of support a multilevel study on obesity management. Qual Health Res. 2014;24(6):790–800.

15. Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. BMJ. 1997;315(7106): 477-480.

16. Blundell JE, Gillett A. Control of food intake in the obese. Obes Res. 2001;9(suppl 4):263S–270S.

17. Peters JC, Wyatt HR, Donahoo WT, Hill JO. From instinct to intellect: the challenge of maintaining healthy weight in the modern world. Obes Rev. 2002;3(2): 69-74.

About the author View all

Lea Stening

Lea is one of New Zealand’s leading paediatric dietitians and also specialises in Sports Nutrition. She has specialised in Paediatric Nutrition for 31 years and in 1985 was the first paediatric dietitian to enter private practice in New Zealand. Lea helps families through her private consultations, public lectures, newspaper and magazine articles as well as television and radio interviews. Read more »

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