Tuesday, February 8, 2011

The Science Behind Health At Every Size (HAES)

Regular readers of these pages will recall my past criticism of the use of BMI in individual counseling, my introduction of the Edmonton Obesity Staging System (which classifies obese patients not by how “big” they are but rather by how “sick” they are), and the many previous posts that recommend avoidance of weight gain rather than obsessing about numbers on the scale. In fact, I have gone on record with a previous post asking the question whether or not advising ALL patients to lose weight may in fact be unethical.

Without reiterating any of my past arguments, I would like to point readers to a paper by Linda Bacon (University of California, USA) and Lucy Aphramor (Conventry University, UK), just published in the Journal of Nutrition, which addresses the science behind the Health at Every Size (HAES) movement.

For readers who may be unfamiliar with the HAES paradigm, the underlying assumption, based on the high rate of recidivism seen with weight-loss efforts, as explained by the authors, is that:

“…this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination.”

Proponents of the HAES movement challenge the value of promoting weight loss and dieting behavior and argue for a shift in focus to weight-neutral outcomes.

So what supports this seemingly radical idea?

For one, as reviewed by the authors, a comprehensive search of the literature reveals at least six randomised controlled trials indicating that a HAES approach (focussing on promoting health behaviours and size acceptance rather than weight loss) is associated with statistically and clinically relevant improvements in physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, eating disorder pathology), and psychosocial outcomes (e.g, mood, self-esteem, body image). None of these studies found adverse changes in any variables.

The authors then discuss the literature underlying the common assumptions regarding the relationship between excess weight and mortality (e.g. weak relationship over a wide range of BMI; better survival in patients with chronic diseases at higher BMIs) or excess weight and morbidity (unresolved causality questions – e.g. does insulin resistance cause obesity or does obesity cause insulin resistance?), confounding positive effects of behaviour changes (e.g. improved diet and greater physical activity) and/or negative effects of weight cycling).

They also challenge the widely held assumption that anyone who is determined can lose weight and keep it off through appropriate diet and exercise, by pointing out that most people will regain any weight lost (and often more), and that there is little support for the idea that (weight-loss) diets lead to lasting weight loss or health benefits.

They point out that rather than being a practical or positive goal, the pursuit of weight loss generally does little more than promote weight cycling, psychological stress, and expose the body to high levels of persistent organic pollutants (POPs), which accumulate in adipose tissue and are released during weight loss. In addition, evidence from the eating disorder literature indicates that an emphasis on weight control can promote eating disordered behaviours and body dissatisfaction, which in turn is associated with binge eating, lower levels of physical activity, and increased weight gain over time.

In contrast to the widespread assumption that the only way for overweight and obese people to improve health is to lose weight, the authors point out that most health indicators can be improved through changing health behaviors, regardless of whether or not weight is lost.

Finally, the authors even challenge the assumption that obesity leads to higher health care costs by arguing that increased health care costs in obese individuals may be due to confounding variables such as (lower) physical activity, (poorer) nutrient intake, history of weight cycling, degree of discrimination, or simply due to the negative consequences of weight focus, which may include eating disorders, diet attempts, weight cycling, reduced self-esteem, depression, and discrimination. In addition, health care costs for people with higher BMIs may be artificially inflated because these individuals are subjected to more medical testing and treatment.

In several instances, the authors also address the issue of weight stigma and point out that when studies compare people of similar age, gender, education level, and rates of diabetes and hypertension, their body image appears to have a much bigger impact on health than their body size.

Although both authors declare their conflict of interest in that they both identify themselves as “HAES” practitioners, the paper is largely well-balanced and referenced.

One notable exception, however, is the brief passage dealing with the assumption that weight loss can prolong life. Here they rightly point out that liposuction (i.e. simple surgically removing fat) does not improve metabolic markers or health, but fail to mention the increasingly robust evidence that bariatric surgery (at least in patients with severe obesity) not only dramatically improves quality of life and reduces comorbidities but also significantly increases life expectancy (although the authors may well argue that patients, who have had bariatric surgery experience these health improvement because they eat healthier, are more physically active, and probably feel much better about themselves, rather than due to the actual weight lost).

With regard to the ethics of public health interventions to reduce obesity, the authors state:

“Policies which promote weight loss as feasible and beneficial not only perpetuate misinformation and damaging stereotypes, but also contribute to a healthist, moralizing discourse which mitigates against socially-integrated approaches to health. While access to size acceptance practitioners can ameliorate the harmful effects of discrimination in health care for individuals, systemic change is required to address the iatrogenic consequences of institutional size discrimination in and beyond health care, discrimination that impacts on people’s opportunities and health.”

The article closes with “guidelines”, which the authors state are supported by the Association for Size Diversity and Health (ASDAH), to assist professionals in implementing HAES strategies into practice:

  • Interventions should meet ethical standards. They should focus on health, not weight, and should be referred to as “health promotion” and not marketed as “obesity prevention.” Interventions should be careful to avoid weight-biased stigma, such as using language like “overweight” and “obesity.”
  • Interventions should seek to change major determinants of health that reside in inequitable social, economic and environmental factors, including all forms of stigma and oppression.
  • Interventions should be constructed from a holistic perspective, where consideration is given to physical, emotional, social, occupational, intellectual, spiritual, and ecological aspects of health.
  • Interventions should promote self-esteem, body satisfaction, and respect for body size diversity.
  • Interventions should accurately convey the limited impact that lifestyle behaviors have on overall health outcomes.
  • Lifestyle-oriented elements of interventions that focus on physical activity and eating should be delivered from a compassion-centered approach that encourages self-care rather than as prescriptive injunctions to meet expert guidelines.
  • Interventions should focus only on modifiable behaviors where there is evidence that such modification will improve health. Weight is not a behavior and therefore not an appropriate target for behavior modification.
  • Lay experience should inform practice, and the political dimensions of health research and policy should be articulated.

Obviously, this line of reasoning will find its strongest critics amongst the “weight-loss industry” as well as the many, who may have personally experienced health benefits from losing weight (although HAES enthusiasts will likely argue that these benefits result from the accompanying lifestyle changes rather than from the actual weight lost).

Personally, I plan to keep a very open mind on this issue (as reflected in many of my posts).

In my own practice, I routinely counsel patients, who pursue unrealistic and unsustainable weight loss goals, to focus on improving health behaviours rather than obsessing about numbers on their scale.

On the other hand, I also routinely recommend and discuss realistic weight-loss targets with patients in whom I see severe health problems that can likely be ameliorated or reversed by weight loss (or, as HAES practitioners may argue, the behaviour changes that lead to this weight loss).

I also routinely recommend bariatric surgery to patients who I believe will benefit, while (almost as often) discouraging other patients from considering surgery when the risks appear to outweigh any potential benefits.

As so often in medicine, I believe that the best approach probably lies in finding the middle ground between the two extremes of either automatically recommending weight loss to all patients with a BMI over 30 or simply accepting any amount of excess weight irrespective of its impact on health or quality of life.

Perhaps this is where clinical practice becomes more of an art than a science?

AMS
Edmonton, Alberta

Hat tip to Catherine for pointing me to this article

Bacon L, & Aphramor L (2011). Weight Science:Evaluating the Evidence for a Paradigm Shift. Nutrition journal, 10 (1) PMID: 21261939

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24 Responses to “The Science Behind Health At Every Size (HAES)”

  1. Anonymous says:

    In their spare time these people can extol the benefits of smoking cigarettes.

  2. AcceptanceWoman says:

    I think your closing statement is the key, and probably what makes you a fantastic doctor.
    A patient-centered approach, one that seeks to understand what the person sitting in front of you wants out of life, is going to need multiple strategies in that kit in order to meet the needs of individual patients.

    I’m a proponent of HAES — but not to the exclusion of a weight-loss focus for those who want it. I want a paradigm shift away from a single strategy toward people with “excess weight” — but not a pendulum swing away from other opportunities.

    My understanding about you and Dr. Freedhoff (and other bariatric doctors) is that people come to you wanting to lose weight, so you are working with them to determine what’s realistic, possible, healthy in terms of weight loss. But people going to their primary care physician for a cold or back pain or sprained wrist aren’t necessary looking to be lectured about weight loss at that visit.

    I am in favor of a HAES approach as a “first line” one — first, if you want to improve health and you think losing weight is the way to do it, first try to improve eating habits and find joyful movement rather than focusing on weight. Health and overall well-being may improve with no negative consequences as long as the changes made can be maintained (and if they can’t — no blame there from me — life can throw us all curves). If someone makes all the changes they can maintain to their lifestyle and they still want to lose weight — I think looking more closely at what’s going on — metabolically, psychologically, environmentally — makes sense for that individual and their provider. I’m in favor of people calling the shots themselves about what approach will work best for them. But I also want people to know that even though the long-term data aren’t good about maintaining weight loss — improving health through changing lifestyle is possible whether or not weight is lost. There are many other measures of health that can be tracked besides weight loss — waist circumference, blood glucose, lipids, and of course, subjective measures like “how do you feel?”

    Thank you so much for this post!

  3. Christina RD says:

    The HAES paper is a must read for all health professionals who provide weight management counselling. You can read the full paper at
    http://www.nutritionj.com/content/pdf/1475-2891-10-9.pdf

    Research shows that self-esteem level can greatly influence self-care including healthy lifestyles. If your self-esteem is poor how can you place a high priority on taking care of your self?

    There is a lot of value in people feeling good about themselves at their current weight. The mood boosting effects of healthy, regular meals and regular exercise enhance quality of life outside of any influence on weight. People who make changes with the only motivation being to lose weight are at risk of dropping all efforts if results do not meet expectations.

  4. Bill Moe says:

    We at Athletica Sport and Fitness are making a new consultation program for our clients. I think this is a perfect concept to advocate at our gym. We consistently have clients wanting to adjust their weight through exercise and diet. The diet cycling is very evident as they mention such fads as the Grapefruit Diet and the Zone. There is a consistent battle convincing clients to accept who they are with slow gains and slight changes after reaching the floor in the direction of their goals.

    Thank you Dr. Sharma

  5. Anonymous says:

    If weight is insignificant for health, why all the fuss about the obesity “epidemic”?

    If weight isn’t a health problem, it’s just a cosmetic problem, and as such the public health system shouldn’t be involved in weight management.

    If someone does need bariatric surgery for MEDICAL reasons, MSI should cover treatment.
    Otherwise, weight is a cosmetic issue, and it should be left to individuals to get private treatment, like they do with liposuction, botox, or other cosmetic treatments.

    As you mention , there is no medical treatment (other than bariatric surgery) which is effective anyway, so commercial programs are just as good and are available for those wanting cosmetic weight loss.

    HAES means there is no place in a public health system for treatment for weight management, unless it is related to real medical problems.

  6. fredt says:

    More people missing the primary problem again.

    The primary problem is hyperinsulinemia. When your diet addresses hyperinsulinemia, the weight will take care of it’s self as it is secondary.

    Until you learn to control insulin and blood sugar, your body will obligate you to eat, and likely gain weight.

    For the short course see the heart scan blog

    But do I know.

  7. catherine walsh says:

    Thanks so much for reviewing and summarizing this article, Arya. In my practice with people who are trying to manage their weight, many of the patients I see express their appreciation of simply being supported, which is indeed part art and part science. The art might include developing a relationship with people and motivating through compassionate care as the article “guidelines suggest”. Gathering more evidence around this relationship building would be a great start in looking closer at a paradigm shift. I think that Diane Finegood spoke so eloquently around this in her recent presentation Weight Bias and Discrimination Through a Complex System Lens provided at the CON Summit on Weight Bias and Discrimination. If you haven’t had a chance to watch her presentation, it is worth watching and if you did see it then the rerun is worthwhile as well.
    http://hosting.epresence.tv/obesitynetwork/1/page/Published.aspx

    Catherine

  8. Linda Bacon says:

    Thanks for airing these issues, Dr. Sharma, and for the private heads up. I just wanted to quickly address your note about our differing view of bariatric surgery. (Note to other readers: I’m one of the co-authors of the review that is discussed.) I can certainly understand why you have come to your belief about bariatric surgery, as there is much published research espousing its benefits. Someday I’d like to do an academic review of the topic parallel to the myth-busting about a weight focus that I did in this publication. Whenever I study the published reports on bariatric surgery, it becomes apparent to me that the conclusions don’t match the data. One of the most common manipulations, for example, is that the follow up is only on a small subset of the population (which we can presume are the successful ones), and we don’t get reporting on the vast numbers of people who have negative outcomes. I am quite concerned that the data are frequently manipulated to show positive results when there is actually a lot of evidence that when people are followed long term, health declines, weight is regained, and quality of life deteriorates. I wrote about this in my book, Health at Every Size (www.HAESbook.com); you can read a download of that section here: http://www.lindabacon.org/HAESbook/pdf_files/HAES_Bariatric-Surgery.pdf. It includes a discussion about how little accuracy and integrity there is in research or reporting on the topic.

    Thanks again for bringing up these issues. People struggle so much with weight concerns – we really need to change the discussion from fear and guilt to a more positive one of making friends with our bodies – which allows us to move on and take good care of them. I appreciate the work you do in this regard.

    Anyone wanting to learn more about Health at Every Size can find plenty of free information on my book’s website (www.HAESbook.com), my personal website (www.lindabacon.org), or the free HAES Community Resources (www.HAESCommunity.org). Professionals can also find great support and community through the Association for Size Diversity and Health (www.sizediversityandhealth.org).

    All best, Linda Bacon

  9. Barbara Berkeley, MD says:

    Dear Drs. Sharma and Bacon,
    As a physician who has specialized in obesity management for twenty years, I found this discussion very interesting. I certainly agree with the basic premise: we are abysmally ineffective at helping people to lose weight permanently. Despite this, we continue to give the message that it’s all very simple. If an overweight person would just eat less and exercise more, his problem will be solved. Size acceptance couple with healthier habits would seem to be an excellent alternative, and a kinder one. Except for one very important catch.

    One of the key principles I’ve learned in my years of clinical practice is that it’s near to impossible to ask people to take positions that oppose cultural norms. This is why weight loss doesn’t work. Permanent weight loss requires eating habits that fall far from American norms. Even the best intentioned are generally defeated by the endless exhortations to eat, the billion dollar marketing of food, the ubiquity of food sources and the cultural celebration of foods that bear no resemblance to nutrients our genes understand. Similarly, we love to tell parents that THEY control their children’s eating habits. At the same time, these kids swim in a cultural sea that believes that eating whenever and whatever we want is a basic human right. This is an overwhelming ocean that sweeps them away.

    In the same way, size acceptance has a problem. We live in a culture where overconsumption of “fake foods” is the norm yet its consequence, obesity, is disdained. The moral judgments that are attached to obesity are societal and enormous. Despite our relentlessly growing size, we are not a single step closer to accepting overweight as healthy or attractive than we were 30 years ago. Thus, in asking people to accept their size and become healthier, we are asking them to oppose a cultural tsunami. This is a losing proposition for most people.

    The patients who come to see me are frankly less concerned with their diabetes, hypertension and elevated risk of cancer than they are with a sense of unhappiness about their personal plight. They feel badly about themselves, out of control, frustrated and often self-loathing. Once they have achieved reasonable weight loss, I generally enter a long “bargaining period” with each of them during which I have to convince them that their body has done enough, they have improved their health, and they should stop trying to fight for additional loss.

    So which cultural war to fight? Of course, it probably depends on the individual. But I have a personal bias. While I don’t have the power of clinical trials behind this statement, I can only say that it is my personal experience that the patients I treat who lose weight and successfully maintain by significantly changing their approach toward eating (no small feat) are the happiest and healthiest ones. In my view, as poorly as we instruct people in weight loss, we do a hugely worse job at teaching people about maintenance. We are giving up this battle before we even explore the possible tools that might help patients maintain. Is there a drug to use after weight is lost that might stabilize patients until they solidify new habits? Are there better behavioral treatments? Should we focus more on research into weight maintenance and less into the minute biological triggers of fat loss?

    I’m not ready to give up the maintenance fight.

  10. Barbara Berkeley, MD says:

    Just wanted to add my website, which supports those who want to specifically work on weight maintenance: http://www.refusetoregain.com
    Barbara Berkeley, MD

  11. Rachel says:

    What a great discussion! In my view the way out of the cultural contradiction problem, which I agree is a VERY difficult one, is to ‘do the right thing’. The right thing is to love yourself as you are right now even if the rest of society thinks you are repugnant. Internalizing the loathing and trying to loose weight at any cost is no path to freedom. Thin people live in fear and horror every day of getting fat. Have you ever hear someone say “I’ll kill myself if I ever get fat”? I have. The only way out of this trap is to fight to end the discrimination, not to give in to it. Having said that I would never judge an overweight friend for trying to fit in by losing weight. It takes a rare person to go against social norms. It is possible though.

  12. Luke Tunyich says:

    Does “Health at Every Size” (HAES) mean: “Health at Every Level of Obesity”, Health at Normal Weight and Health at Every Level of Underweight.

    It seems to me that the slogan “Health at every size” is misleading. I think that the real meaning of “HAES” can’t be: “Health at every level of obesity”, Health at normal weight and Health at every level of underweight.

    Obesity, particularly severe obesity, is a serious medical condition along with being underweight and severely underweight.

    I can’t imagine how people affected with severe obesity can be health, and I also can’t imagine how people that are severely underweight can be healthy while maintaining this weight.

  13. Deb Lemire says:

    The question that comes up often in our discussions at ASDAH (The Association for Size Diversity and Health) is where is the research being done to see why it is that some people become extremely large even given the same eating and physical activity level of those that do not? Of course we consider the genetic and SES factors etc, but that still leaves a gap in the research. Some very large people…500, 600,800 lbs etc. experience satiety issues, abnormally low metabolism, weight gain without overeating,etc. This is where we could use some unbiased, compassionate research to understand the larger body. If we do not understand it, how can we truly help a larger person seek or maintain health? We see a big push to catagorize obesity as a “disease,” but right now there is no substantial research to back that up. The primary motivation for the “disease” label seems to be to get insurance companies to cover expensive bariatric procedures. Is it a “disease” or a side effect of other conditions or behaviors? Until legitimate research is done we cannot know the answer to that question and will remain unable to truly provide the opportunity for health for larger people. ASDAH would welcome the opportunity to support research in this direction.

  14. Bill Fabrey says:

    The article and the comments are all very interesting. I believe in a HAES approach, and am extremely negative about weight loss surgery, as several friends have died from it, and the ones who didn’t, all regained their weight.

    None of this offsets the severe discrimination faced every day by larger people. Perceived health issues are often used as a bludgeon against the obese, when what most people object to is their personal dislike for the appearance of the larger figure, especially in women.

    The Council on Size & Weight Discrimination (www.cswd.org), of which I am a director, says that regardless of the health issues, nobody should be deprived a job, clothes, or the other necessities of life just because of the size of their body.

  15. Luke Tunyich says:

    It seems to me that Health at Every Size (HAES) is not actually “Health et Every Size” but it is “Health at Certain Size” (HACS).

    I think that “HAES – Health at Every Size” slogan is misleading for people affected with severe obesity.

    Another point about HAES is that they insist to call them larger people instead of calling them people affected with severe obesity and at the same time say that “Bariatric surgery is nothing more than a forced diet:” It is in this way that public opinion is strengthened that obese people can lose weight if they eat less. Furthermore, it strengthens public opinion that people get obese because they eat more then what they need.

    I believe that even many medical professionals involved in obesity treatment don’t think that obesity or sever obesity is caused by eating more food than the body needs and/or insufficient physical activity.

  16. Deb Lemire says:

    Understandingthe ‘health’ in HAES(SM) is the crux of ASDAH’s upcoming conference “No BODY Left Behind: The HAES(SM) Model: Ensuring an Inclusive Approach to Health & Wellness.”

    The ‘health’ in Health At Every Size(SM) does not come from some moral obligation to be healthy, but rather from the fact that it was originated by healthcare professionals in a grassroots effort to redefine health as not based on BMI.

    HAES(SM) does not mean any weight or body size is by default “healthy” for someone. That is as individual as we are. HAES(SM) is not against changes in weight, in either direction. HAES(SM) is weight neutral. We all change weight throughout our life as life happens to us. HAES(SM) Principles work to help us move toward a healthier body and whatever shape or size that may take. Of course if someone does not want to “move toward a healthier body” that is a choice they are free to make. That, however would not be considered a Health At Every Size(SM) choice.

  17. Sue Thompson says:

    I’m sorry, but something is very wrong when you have to tell people to stop using the words “overweight” and “obesity.” To me, this is tantamount to calling terrorism “man-made disasters.” Some words change with time, such as the fairly recent move to cease from calling developmentally challenged children “retarded,” only because it became a nasty epithet–but tellingly, people are now afraid to use the word for what it means, as in saying, “the growth of the tumor was retarded.” But “overweight” and “obesity” are not generally used in the same way “fat pig” might be.

    I have to agree with Dr. Berkeley that we are dealing here with a tremendous walk against a tide of deeply rooted cultural beliefs and messages. Buck the system by eating the way the body really needs food (reasonably sized portions, types of food, etc.) or by refusing to shoot for rail thin because that’s what one’s favorite celebrity looks like. But for many of us, being overweight is embedded in psychological baggage and a current belief that we should just stop trying to do things that don’t feel right. Like many who have lost significant amounts of weight, I can tell you first hand that losing is not as hard as maintaining, and it’s there I’ve battled with my mind, that last great frontier of all medical research. Show me all the studies you like, give me all the facts you want, but I believe that many times we search for the facts we want so we can give ourselves a reason to stop trying, working, seeking. It took me 40 years to find the weight loss solution that worked for me; 40 years to work through the psychological junk that kept me from succeeding; 40 years to fight the battle in my mind that had so many things attached to it.

    I am fairly addicted to all of the weight loss television shows (because they provide me with inspiration on many levels), and one thing I see over and over: when the diet begins and the exercise is implemented, the crying and boo-hooing and “I can’t do it!” come out full force. I realize now I must have been the same way. Even the most benign effort has people wailing like the babies they resemble that “It hurts!” and “I have to stop!” They resent being challenged, they hate being reminded–they said they wanted something but when the rubber hits the road, they didn’t really want it. They just wanted to SAY they wanted it. There’s a different diet/program/plan for every body, and searching for it until we find it is, to me, just as important as searching for that doctor who can diagnose some mystery illness that’s crippling us. I hold no belief that there is a simplistic (or even simple) answer to an individual’s struggle with obesity, but we hit that wall where we give up and say, “I can’t,” even when it’s clear others have and it is possible and WE CAN. That wall is scalable, but we’d rather stand beside it and say, “Let’s not call it a wall. Let’s call it your life setpoint.” “Let’s not call it work. Let’s call it reasonable extension of physical limits.” I don’t and can’t buy it.

  18. Mitzi says:

    I would really like to see this paradigm implemented, within reason. A woman trapped in her home unless she has a helper, disabled by severe arthritis compounded by weighing more than double what she should for her height, and on a walker indoors/wheelchair out in her 50s, is not “healthy” even if she does not have hypertension, diabetes, or cancer. She needed genuine help at a much younger age (which a HAES practitioner could have gently but firmly provided), to stop the damage before it was done, but doctors just told her to lose weight, not how to live the kind of lifestyle that would keep her truly healthy. Hopefully HAES will result in some real research into how to achieve what the acronym states. Waving our hands and preaching sunshine and self-acceptance will not make the crushing disability caused by obesity go away. It will not help the obese diabetic amputees I see in motorized chairs at the grocery store, unless it gets them to stop eating foods that are poisoning them. I have seen overweight, “healthy” people, and I have seen people destroyed by their own habits. I hope people will differentiate them as you do, and will not use HAES as an excuse not to give helpful direction to those who need it.

  19. RNegade says:

    Call it Paleo, call it Atkins, call it Primarian, whatever, the way I eat now has restored my health. Blood pressure normal (without medication). Fibromyalgia symptoms gone. Chronic hunger gone. Back pain gone. Foot pain gone. Chronic fatigue gone. Hyperglycemia gone. Hyperlipidemia gone. Brain fog (trouble with focus) gone. And so forth.

    If someone told you there is a way you can change your eating and possibly reverse all or some of the above ailments, would you do it? I would, regardless of whether or not it caused weight loss as a side effect.

    This way of eating is not a weight loss diet, to me; it is a way to restore and maintain my health. The fact that it also resulted in a weight loss of over 100 lbs is an added bonus.

    That being said. I could be a statistical freak. Maybe all of the above illnesses/symptoms/risk factors would have spontaneously gone away by themselves. Or by some other behavior change or medical “intervention”. Maybe this way of eating only benefits a small subgroup of people.

    In addition, I am lucky because I have access (for now) to nutritious foods. I have an income that supports the purchase of nutritious foods. (I do not, for instance, have to rely on a food bank or soup kitchen.) I have access to refrigeration and a clean place to prepare food.

    I am also fortunate because I have not suffered from very many social determinants of poor health. For instance, I haven’t had to cope with long term poverty, long term disability, long term lack of health insurance, long term discrimination (except for discrimination based on size, age, and gender), long term mental illness, unsafe housing, lack of transportation, lack of medical care, and so forth. These problems, and others, have existed in my life from time to time, but for the most part they have been transitory.

    However, for many people, these social determinants of poor health (along with many others) go on and on. No amount of personal/individual behavior change will fix these kinds of problems or improve resulting health outcomes. Many people can’t rely on any medical “intervention” –let alone one based on HAES–because they can’t afford medical care.

    Our social structures must change. Widespread social inequities (and the lack of social safety nets for people) result in many health problems and diseases. Often, short term assistance could help people avoid long term health problems. For instance, when people become unemployed they should not have to lose a safe place to live or lose access to medical care–and thus suffer deleterious health problems as a result.

    A Health at Every Size paradigm must acknowledge the need for improved social equality and better support systems to produce improved health outcomes. Without widespread social change, HAES will become just another so-called movement that pays lip service to the idea of improving health outcomes. It may become a way to help decrease discrimination based on size, and a way to help many people feel better about themselves. But, come on, that is hardly a paradigm shift! Reduced sizism and higher self esteem does nothing to improve all the other social determinants of poor health.

    I fear that HAES provides another distraction away from the greater social changes that must take place to reduce health risks and improve health outcomes for people of all sizes.

  20. Aggie says:

    Weight loss surgery is not the answer. It is far more dangerous and less effective than promised.

    Bariatric Surgery: The Most Life Altering Decision You Will Ever Make
    http://junkfoodscience.blogspot.com/2007/01/junkfood-science-weekend-special.html

    The posts on obesity and bariatric surgery on this site are food for thought. ;-)

  21. Luke Tunyich says:

    Bill Fabrey @ February 10th, 2011 at 5:54pm
    “…. and am extremely negative about weight loss surgery, as several friends have died from it, and the ones who didn’t, all regained their weight.”

    I am aware about the mortality and other consequences of weight loss surgery, and I am sorry to hear that this has happened to your friends.

    I am against any surgical intervention for weight loss but the reason for that is different from the reason of people that promote HEAS. I am against any existing weight loss program whether it is based on obesity drugs, dieting and/or increased physical activity for weight loss because it is based on a misunderstanding of the biological basis of fat mass formation, and on a misunderstanding of the mechanism of fat mass formation.

    Optimal level of physical activity and optimal nutrition is essential for health to everyone, independently if is he/she underweight, normal weight, overweight, obese or severely obese. On the other hand, any approach to treat obesity based on dieting or eating certain types of food alone, or combined with increased physical activity, is ineffective and counterproductive for health and for the body weight.

    I am against any size and weight discrimination because people don’t get overweight, obese or severely obese by eating more than what they need and /or insufficient physical activity.

    Obese people and parents of obese children don’t need sympathy borne out of pity, but they need a reliable science for obesity treatment, and all humans need reliable knowledge based on real science on how protect themselves and own children from obesity.

    Obesity in an individual level is misunderstood, and what are also misunderstood are the reasons for the epidemic of obesity in the last three decades. Obesity, particularly severe obesity in children and young people, is a new phenomenon, and apart from a few anecdotes it was unknown to any previous generation in recorded human history.

    We need an honest discussion about the basic science of obesity and an honest discussion about the causes for obesity epidemic.

    People from HAES point out that “post-surgical nutrition deficiencies are the norm” and that is right, but it is also right that obese people are affected with nutritional deficiencies. The fact is as they have more excessive fat mass and they have more nutritional deficiency. Nutritional intervention, whether it be based on food and/or dietary supplements, are ineffective. It is obvious that people affected with nutritional deficiency can’t be healthy, particularly nutritional deficiency on a prolonged time is harmful.

    In that case of obesity nutritional deficiency is not caused by inadequate nutrition. The only way to treat nutrition deficiency in obese people is to treat obesity.

  22. Christine says:

    What an interesting topic for debate! I admit I’m new to this term HAES, but I suppose I have been thinking about weight loss (and how it is perceived and achieved) versus weight acceptance (HAES) for quite some time.

    I guess my first thought is – really, isn’t HAES just a politically-correct term for “fat acceptance?” After all, HAES really doesn’t seem to apply to overly-thin people in any of the conversations I’ve read; it’s a term that’s used solely to describe overly-overweight people, is it not? For so many years I tried to lose weight. I tried the healthy and reasonable way (exercise more; eat less & more healthfully) and I also tried unhealthy ways (fad dieting; outright starvation) and no matter what I did, I continued to gain weight. At a certain point, my frustration over my weight gain got so bad that I just wanted say “screw it, I’m just going to try to love and accept myself no matter what size I am at.”

    It seems that the largest perceived problem with HAES is that for so many, accepting an overweight physique is harmful physically. It’s like Barbara and RNegade said…being overweight often leads to all kinds of physical problems, like diabetes, depression, sleep, anxiety, etc.

    On the flipside, though, half of those problems listed above are psychosomatic; if you embraced your size and loved yourself with an unconditional, zen-like vigor, regardless of how big you were, then your depression, sleep, anxiety, tiredness, and possibly some of the other side-effects would likely disappear. Depression, sleep, anxiety, tiredness, etc., are all linked to the fact that a person is unhappy with his or her body, not because the body is outright unhealthy. Half of the “unhealthy symptoms” would vanish with mere acceptance and self-love.

    But in order to eliminate the unhappiness, we’d have to change social standards and social pressures, and let’s be honest—that’s just not going to happen, no matter how many self-help guides and scientific research extolling the benefits of self-love get published. After finally losing 100+ pounds, I can honestly say that I am treated vastly different in my thinner body, and the change is incredibly positive. I could list a thousand examples here, but the biggest one is this: the number of people that smile at me has increased tenfold. People SMILE at me. It’s the most simple and easiest expression of acceptance there can be. I am more accepted by strangers, my peers, and even my loved ones as a thinner person than I was when I was overweight. It’s visible in nearly every face I encounter.

    Seeing the disparity first-hand, every day, just reminds me of why I was unhappy to begin with. I think I could have embraced my size, but I would never have been able to reconcile the fact that I got scowled at and doors slammed in my face while thinner people are smiled at and have doors opened for them. How can you embrace yourself when most others refuse to? I am in marketing, and I have so many more opportunities available to me as a thinner person than an overweight one; for instance, these days my clients go out of their way to call ME and talk to me, as opposed to two years ago when it was a challenge to track any of them down and took an act of god to get a call back.

    All that being said, I completely agree with RNegade’s point that it can all be boiled down to socioeconomic status. How did I finally lose the weight? I was finally able to get weight loss surgery (gastric banding), and it was paid for entirely by my health insurance. I thank goodness for the surgery every day, but I’m also acutely aware that not everyone has the ability to “purchase” their healthy body the way that I was able to. For so many, weight loss is an impossible struggle. I’ve been there; I remember how difficult it was. Until we are able to change society’s perceptions of overweight people (a change that I do not believe will ever occur) I think that it’s incredibly important to be compassionate to those who are going through the struggle. I wrote more about the topic of compassion here: http://www.phoenixrevolution.net/archives/365

  23. JMS says:

    Obesity, particularly severe obesity in children and young people, is a new phenomenon, and apart from a few anecdotes it was unknown to any previous generation in recorded human history.

    This is simply false. Look at photographs of very wealthy Americans and Europeans from the 19th century; at least a third of them will be obese. President Taft and his cabinet, for instance.

    If food had been cheaper and arduous physical labor less necessary in earlier generations, my guess is that there would have been similar proportions of obesity.

  24. Luke Tunyich says:

    I wrote “Obesity, particularly severe obesity in CHILDREN and YOUNG PEOPLE, is a new phenomenon, and apart from a few anecdotes it was unknown to any previous generation in recorded human history.”

    JMS says: February 14th, 2011 at 3:14pm
    “Look at photographs of very wealthy Americans and Europeans from the 19th century; at least a third of them will be obese.”

    Only among the MIDDLE AGED and ELDERLY very wealthy Americans and Europeans from the 19th century was obesity prevalent.

    The reason for the prevalence of overweight and obesity among MIDDLE AGED AND ELDERLY very wealthy Americans and Europeans from the 19 century can be discovered if you take a close look on the pictures that you have posted.

    To explain what I mean: Here is the link to the article posted on my web site that explains the reason for the prevalence of overweight and obesity among the wealthy population in the 19th century. http://www.biomechanicsandhealth.com/obesitytherealcause.htm

    In the same article, the reason why the prevalence of obesity in Japan is the lowest in the world is also explained.

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