Category: Blog

My Five Favorite Research Studies supporting HAES

This is a short list of a few of my favorite studies that support the Health At Every Size (HAES) movement. Of course, a whole host of studies exist supporting HAES, but I chose these five because they touch on a variety of key points and common misconceptions – and are interesting to read. Only one of these studies was actually written from a weight neutral perspective; the rest are from a weight focused approach but nonetheless have findings that support the HAES theory.  It is important to note that some of these authors use language that could be triggering, and/or discuss unhelpful judgments from a weight normative perspective in the introduction or discussion sections. Nonetheless, these studies have contributed to the body of evidence in support of HAES and are important ones to know about!

  1. A higher weight does not lead to decreased longevity

In our culture, a fear of fatness (fatphobia) leads to many false assumptions. One common one is that increased fatness causes a shorter lifespan. This meta-analysis looked at deaths associated with the full spectrum of weights, in older adults specifically. The lowest rates of death were associated with a BMI range from 25-35 (see graph below). Note that in our health care system, a BMI of over 25 is considered “overweight” and over 30 is deemed “obese.” Risk of mortality increased for those under a BMI of 23 (on the high end of the “normal” BMI range). Many large studies have come to similar conclusions – that higher body weight is associated with greater longevity. Another observation coming from these studies is that BMI is a very unhelpful and inaccurate tool that doesn’t take into account the actual data we have about body size and health.

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Winter, J. E., MacInnis, R. J., Wattanapenpaiboon, N., & Nowson, C. A. (2014). BMI and all-cause mortality in older adults: a meta-analysis. The American journal of clinical nutrition, 99(4), 875-890.

2. It’s habits that matter, not body size

This study looked at multiple health-related habits, including smoking and alcohol use, eating fruits and vegetables, and physical activity. They found that adopting healthy behavior changes improved health outcomes, regardless of one’s body size. The chart below shows that as the number of healthy habits increased, the hazard ratio for all-cause mortality decreased. Moreover, when one or more healthy habits were in place, the hazard ratio was pretty much the same, with no differences based on BMI. This study, along with others like it, backs the HAES approach of focusing on behavior changes rather than weight to improve health outcomes.

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Matheson, E. M., King, D. E., & Everett, C. J. (2012). Healthy lifestyle habits and mortality in overweight and obese individuals. The Journal of the American Board of Family Medicine, 25(1), 9-15.

3. Weight cycling compromises health, not body size

This prospective study came out back in 1991. It looked at the variability in body weight (weight cycling) of over 5000 men and women. The authors point out that body weight can fluctuate for a variety of reasons, but the most common is due to dieting. With dieting, a person might lose weight quickly, and then put the weight back on, plus a bit more (also called yo-yo dieting for this reason).  The authors found that persons with frequent weight cycling had a higher risk of heart disease and mortality than those who remained at a stable weight. This observation was independent of weight or BMI. Thus this study linked dieting with compromised health, rather than weight with compromised health, a result that has since been repeated by other studies. 

] L. Lissner, P. M. Odell, R. B. D’Agostino et al., “Variability of body weight and health outcomes in the Framingham population,” The New England Journal of Medicine, vol. 324, no. 26, pp. 1839–1844, 1991.

4. Stress related to weight stigma could explain health risks that are usually associated with body size

Could the stress caused by weight stigma be leading to the adverse health outcomes that often get associated with a higher body size? This study is one of several providing evidence for the hypothesis that weight stigma leads to increased stress – which increases one’s risk of various health concerns. The health conditions associated with a stress response include hypertension, heart disease, type two diabetes, and of course, mental health – conditions that are often associated with larger body size. To test this theory, Muennig et al cleverly looked at body image perceptions as a predictor for mental and physical health. Indeed, as the graph below shows, they found as the amount of weight loss a person desired increased, so did the number of unhealthy days they had. Moreover, they found that negative body image was a much higher predictor of unhealthy days than BMI.

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Muennig, P., Jia, H., Lee, R., & Lubetkin, E. (2008). I think therefore I am: perceived ideal weight as a determinant of health. American journal of public health, 98(3), 501-506.

5. The Health At Every Size approach has better health outcomes than a weight loss approach

Lastly, here’s a study that specifically looks at a HAES based group program compared to a traditional weight loss group program. This study identified two distinct differences in the groups: in the weight loss group, food restraint and a reduction in body size were encouraged. In the HAES group, food restraint was discouraged (in favor of intuitive eating) and body acceptance was encouraged. The study compared the health outcomes of the women in each group, looking at blood lipids, blood pressure, activity, eating behaviors, and mental health. Both groups showed initial improvements in all aspects; however, the weight loss group returned to baseline in almost all areas at the follow-up, with worsening self-esteem. The HAES group had sustained physical and mental health improvements at the follow-up. Moreover, 53% of the weight loss group participants reported feelings of failure, compared to 0% of the HAES group.

Bacon, L., Stern, J. S., Van Loan, M. D., & Keim, N. L. (2005). Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association, 105(6), 929-936

My approach part 1: HAES

“So what’s your approach?” This is a question I get asked frequently as a nutrition therapist. I always give a brief overview – I pull from many different frameworks and modalities to provide individualized care.  This blog series will serve as a much lengthier version of my answer to this question. I’ll take a look at each of the nutrition concepts and counseling modalities I subscribe to, starting with Health At Every Size (HAES). HAES is actually more of a movement, a paradigm shift, and a way of thinking about healthcare that has served as a foundation for my work, which is why I’m starting here.

My introduction to HAES (took way too long)

Like many other dietitians, when I graduated from my dietetic internship I had never heard of HAES. I was trained under traditional dietetic principles, which were grounded in a weight focused health care paradigm. The focus was on how to change people’s body size to make them healthier – a message that we are all familiar with thanks to the diet culture we live in.

Then, like many dietitians, I started seeing clients for nutrition counseling, and began to get a sense of how damaging weight loss messages can be. Many of my clients were eating very little and felt frustrated that they continued to gain weight. Some felt like they couldn’t have the foods they loved for fear they would eat too much. Many clients were switching from one diet to the next and experiencing weight cycling, usually ending up at a higher weight than when they started. The list went on. Two things most of my clients had in common were 1) they were trying to change their body size but couldn’t, and 2) they were experiencing some level of disordered eating.

No surprise that my training had done little to help me come alongside these clients. Fortunately, during this time, I came across HAES principles and immersed myself in it, eventually choosing to go back to school to study disordered eating. I wish it hadn’t taken over five years of studying nutrition for me to discover it! I know I speak for many dietitians when I say that the discovery of HAES has completely transformed my nutrition counseling practice and is the reason I am still a dietitian.

HAES Principles

HAES is a weight neutral approach that has come about due to considerable concerns and evidence that a traditional weight focused approach is not only ineffective, but harmful. If you’d like to take a look at the growing body of evidence supporting HAES, check out this paper as well this post on some of my favorite HAES studies.  I can also recommend Bacon and Aphramor’s book Body Respect for a deeper look into the science behind weight and the HAES approach – including great insights on the social determinants of health.

The main thrust of HAES is to support people of all shapes and sizes in having peace with their bodies and moving toward compassionate self-care. HAES is grounded in respect – for our own selves, others, and for body diversity. HAES also has a key emphasis on bringing critical awareness to people’s own body knowledge and lived experience, while challenging scientific and cultural assumptions. (Bacon & Aphramor, 2014).

HAES In Practice

HAES shifts the focus from weight onto behavior change.  In my practice, what that means is that instead of looking at weight loss as a measure of health, we focus directly on adopting positive behavior changes. Instead of diets, counting calories, or weight checks, we do the important work of body acceptance, rediscovering how to eat intuitively, and building the skills needed to move toward a healthy relationship with food and movement. As a nutrition counselor I come alongside my clients – the experts on their body – and support them in taking care of their nutrition and self-care needs in a compassionate way.

Approaching health from a HAES perspective can be a really big shift in thinking – it was for me too!  I find it necessary to discuss these concepts early on and to come back to them often, as it can take time to explore questions and grapple with the information. Feelings of anger and frustration may come up when considering the reality of weight stigma and the damage of diet culture. At the same time, talking about health from a HAES perspective can feel so obvious, and like such a relief. Having these important discussions about a weight neutral approach lays the groundwork for disordered eating treatment.

Telehealth Services

In response to Covid-19, like many others I have fully transitioned my practice over to telehealth. It was a bit bumpy in the beginning, but overall it seems to have gone well. I feel very grateful for the tools that have enabled me to be able to continue to stay connected with clients and other providers, and to provide nutrition counseling. While telehealth isn’t the same as in-person therapy, I will continue to offer telehealth even after stay-at-home orders are lifted. It is nice for clients to be able to receive the services they need in their own home, and for transportation to be a non-issue. And I sure don’t mind going to work in my slippers!

That said, I’ll still be eager to get back to seeing clients out of my Newberg office, once that becomes possible again. In the meantime, all my work and client sessions will be from my tiny home office.

We are living in a time of uncertainty and worry about the future. These feelings on their own can exacerbate disordered eating behaviors. However, I am concerned that this pandemic is creating the perfect storm for those struggling with an eating disorder. All of us are spending more time on social media, where diet culture, not missing a beat, runs rampant. Talk of weight gain fears, “good” foods and “bad” foods to keep in the house, and seeing a high BMI be listed as a risk factor for coronavirus are all examples of diet culture. Moreover, food scarcity and the disruption of our normal routines can also contribute to disordered eating behaviors. I’ve seen several good news articles highlighting the challenges of living with an eating disorder (and other mental health disorders) during this time – check out this TIME article.

This is an “unprecedented time” as they say, and many are struggling. It may be tempting to minimize disordered eating symptoms that may be popping up – but ignoring them will only lead to more disruption down the road. There are many online resources out there, and many providers who are stepping up to provide care during this time. Don’t hesitate to contact me, or call the National Eating Disorders Helpline at 1-800-931-2237 to find the services you need.