HAES : Part 3. Why a Dietitian Supports Health at Every Size

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HAES: Weight-inclusive care. Are we just giving up?

Hello, I am so glad you asked that question! 😊 I have always wanted to help people achieve their greatest possible health! HAES (an acronym for Health at Every Size) supports all people in adopting sustainable healthy habits that improve overall health and well-being. For an overview of Health at Every Size click on this link: HAES: Part One. A brief overview of Health at Every Size – Waistline Dietitian

HAES shifts the focus from weight to health. HAES works to remove the obstacles for making healthy choices that include food access and exercise opportunities. Improved health behaviors can improve health regardless of weight.

HAES promotes size acceptance and does not glorify or promote obesity. It encourages people to accept and respect their body. This is the key for keeping people motivated for self-care and improving sustainable health habits. So no, we are not giving up. We are digging deeper and getting to the root cause of health problems.

HAES supports sustainable behavior changes.

HAES proponents believe the best way to help people make behavior changes is by supporting them to foster self-acceptance to honor their body. People do not improve their health when they are shamed. They are more eager to make better health choices when they feel good about themselves. For more information on the weight-inclusive approach click on HAES: Part 2 Weight-Inclusive Health for Overall Well-Being and Doing No Harm – Waistline Dietitian

Health is multifaceted and encompasses overall mental health, wellbeing, physical health; and there are multiple causes of diseases (genetics, race, socio-economical, environmental, activity level, food access, physical and emotional stress, physical activity). But weight loss seems to be promoted as the answer to many health diagnoses today.

HAES is not against weight loss. HAES is against prescribing weight loss. Many times, weight loss is the first thing “prescribed” when someone goes to the doctor. I receive nutrition consults for patients with a BMI over 30 regardless of why they were admitted to the hospital. Many of these patients have complicated medical histories and are dealing with many chronic illnesses.

Why prescribing weight-loss is not the answer:

Sustainability:

There are many weight-loss diets, fads, cleanses, gimmicks that we are bombarded with daily. The weight loss industry makes billions of dollars and yet it does not deliver sustainable results. It is estimated that 80% of weight loss participants regain weight over a period of 3-4 years. ¹ And studies of long-term weight-loss outcomes show that at least one-third of the dieters regain even more weight than they lost! ²

Weight loss attempts do no fail simply because people are lazy. Many physiological and psychological mechanisms in our body can make weight maintenance difficult. Our metabolism slows down when we lose weight. That means we need less calories to maintain our new weight. Changes in brain processing and hormones make higher calorie foods more appealing. Dieting has been shown to impair cognitive function, especially executive function, which is the very thing needed to control behaviors.

Weight Cycling:

Weight cycling is also known as yo-yo dieting. Repeated attempts to lose weight can be more harmful than just remaining at a higher weight. One of the strongest predictors of weight gain is having a history of restrictive dieting. And normal weight people who have gone on restrictive diets tend to regain more body fat that what was lost.

Weight cycling results in increased inflammation which in turn is known to increase risk for many diseases. The association between weight and health risk may be better attributed to weight cycling than obesity itself. ^3,4 Studies have shown that with each diet and each cycle of weight loss by restrictive dieting, our body compensates by greater fat gain.²

Weight Cycling has been strongly linked to overall mortality, compromised physical health and psychological well-being. Increased loss of lean body mass often associated with weight cycling has decreased metabolic energy expenditure (you burn less calories). People with weight cycling have also shown increased weight gain over time, reduced physical activity, increased binge eating, and decreased self- esteem.

Weight stigma:

Weight stigma refers to negative weight-related attitudes and beliefs that manifest as stereotypes, rejection, prejudice, and discrimination towards individuals of higher weights. It is important to understand the association between weight stigma and diminished health and well-being. Weight stigma is related to increased health risks that are typically attributed to being obese.

Healthcare is a setting in which weight stigma is particularly pervasive. Telling someone to lose weight does not help them lose weight or improve their health. First, instilling that a “healthy weight” is the key to health may instill a sense of learned helplessness in people who are unable to attain these weight goals.  Secondly, this perpetuates negative judgements on higher weight individuals by promoting the view that (1) higher weight people are unhealthy and therefore a burden to society and (2) weight can be controlled, and thus if a person is fat that means they have poor will power or are lazy. 

Weight stigma is likely to drive weight gain and poor health. The latest science indicates that weight stigma can trigger physiological and behavioral changes linked to poor metabolic health and increased weight gain. Weight stigma is associated with increased food preoccupation and food intake, decreased self-regulation and increased levels of cortisol (which can increase risk for heart disease, depression, and anxiety). People with experiences of weight stigma correlate with avoidance of exercise. Self-reported experiences with weight-stigma predict future weight gain.

Weight stigma also has profound negative effects on mental health. Individuals who perceive that they have been discriminated against based on their weight are more likely to have mood or anxiety disorders, depression, binge eating behaviors and bulimic symptoms.^5,6,7,8.

Eating Disorders:

Eating disorders can develop from attempts to maintain weight loss. Anti-obesity efforts, especially those with restrictive diets, may inadvertently promote weight stigmatization, a disconnection with internal hunger cues, and food/weight preoccupation. Chronic restrictive diets can result in weight cycling, abuse of laxatives and diuretics, and binge eating, followed by compensatory purge behaviors.

Childhood obesity has been associated with a presence of eating disorders later in adolescence or adulthood and are associated with high morbidity and mortality. There are many factors that contribute to the development of eating disorders, including perceived pressure for thinness, thin-ideal internalization, body dissatisfaction; and research suggests that restrictive diets and weight stigma are included as well. During adolescence, when teenagers are most vulnerable and often unprepared to deal with the changes that accompany growth, attempts to lose weight may lead to increased risk for eating pathology that is further reinforced by social media. Most individuals with eating disorders acknowledge self-imposed diet attempts.^9,10,11.

Why HAES is against prescribing weight loss?

Would you agree to take a new medication if you knew it would only work 20% of the time? Would you take this medication if you knew it could make your symptoms worse?  Would you be willing to spend your hard-earned wages on something that could make you feel worse? This medication or prescription I am talking about is weight loss diets.

Weight loss diets are known to work when they are being followed. I am not saying weight loss is not possible. When you follow a restricted diet of any type you are likely to lose weight. The bigger issue is what these diets do to our bodies mentally and physically and their long-term negative health effects.

Most weight loss diets are not teaching you sustainable new lifelong healthy habits. They are difficult to follow long term. And they can cause you to regain more weight later.

With the potential harm caused by weight loss attempts it is unethical to prescribe weight loss to patients and communities as a pathway to health. Weight gain and weight cycling are connected to further stigmatization, poor health, and well-being. HAES is a weight-inclusive approach that supports the health of people across the weight continuum and challenges weight stigma. Interventions that emphasize self-compassion tend to improve patient’s compliance and willingness to address health issues.

HAES views on losing weight.

HAES approach is not anti-weight loss or glamorizing fat. The HAES approach is against prescribing weight loss for health. If weight loss occurs due to improved health behaviors and habits, then it is your body returning to its healthy set point and it should be easy to maintain and sustainable.

What does HAES support?

Body Acceptance

This is essential if you are going to take good care of yourself. Self-acceptance is a cornerstone of self-care. People with strong self-esteem are more likely to adopt positive health behaviors.

HAES supports the Intuitive Eating process for overall health

HAES teaches people to rely on internal regulation to increase awareness of your body’s response to food. Food is valued for nutritional, psychological, sensual, cultural, and other reasons.

Supporting Active Embodiment

HAES encourages people to build activity they enjoy into their daily routine. Physical activity tops the list of lifestyle habits that influence your health. Studies have found that it is easier to stick to activity in short bouts of physical movement throughout the day. Instead of carving out time for a “workout” you can find ways to incorporate more movement into your day.  For example, short walks on a lunch break and brief periods of activity before and after work all count, and the sum of their duration may have similar benefits to a single continuous interval of exercise of the same duration.⁴

Active living refers to moving more as part of your everyday life. There are many ways to be active without strenuous exercise. Sitting for long periods of time has been linked to increased risk for diabetes, cardiovascular disease, and cancer, and adverse effects on mental health and muscular strength. Even acting like a fidgeter (standing often, getting up from sitting, pacing, parking at the back of the parking lot, and taking the stairs) can help! ¹²

Conclusion:

When you shift the focus from weight to healthy behaviors and self-care you can make the biggest positive impact on your overall health. I have worked for almost 3 decades as a registered dietitian in acute care settings. My overall goal is to support my patient’s overall health and help guide them to sustainable lifestyle practices and daily routines that will support their overall well-being and will help them improve the quality of their lives.

Through education and acceptance, we can improve the health and overall well-being of our patients by promoting safe non-stigmatizing environments, respectful care for people of all shapes, sizes, colors, genders, socio-economic and religious backgrounds. The HAES movement digs deeper into the underlying cause of health disparity and works to provide safe and affordable access to healthcare. It also helps people find sustainable practices that support individual and community well-being.

NOTE: For more information on the benefits of a weight-inclusive approach for overall health and well-being see my blog: HAES. HAES: Part 2 Weight-Inclusive Health for Overall Well-Being and Doing No Harm – Waistline Dietitian

References:

1. Greaves, C., Poltawski, L., Garside, R., & Briscoe, S. (2017). Understanding the challenge of weight loss maintenance: a systematic review and synthesis of qualitative research on weight loss maintenance. Health Psychology Review, 11(2), 145-163.

2. Jacquet, P., Schutz, Y., Montani, J. P., & Dulloo, A. (2020). How dieting might make some fatter: modeling weight cycling toward obesity from a perspective of body composition autoregulation. International Journal of Obesity, 44(6), 1243-1253.

3. O’hara, L., & Taylor, J. (2018). What’s wrong with the ‘war on obesity?’A narrative review of the weight-centered health paradigm and development of the 3C framework to build critical competency for a paradigm shift. Sage Open, 8(2), 2158244018772888.

4. Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition journal, 10(1), 1-13.

5. Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being overweight loss. Journal of obesity, 2014.

6. Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’and harms health. BMC medicine, 16(1), 1-6.

7. Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An evidence‐based rationale for adopting weight‐inclusive health policy. Social Issues and Policy Review, 14(1), 73-107.

8. Vaillancourt, S. Strategies to decrease fat stigma in women’s health.

9. Samuels, K. L., Maine, M. M., & Tantillo, M. (2019). Disordered eating, eating disorders, and body image in midlife and older women. Current psychiatry reports, 21(8), 1-9.

10. Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk factors that predict future onset of each DSM–5 eating disorder: Predictive specificity in high-risk adolescent females. Journal of abnormal psychology, 126(1), 38

11. Cena, H., Stanford, F. C., Ochner, L., Fonte, M. L., Biino, G., De Giuseppe, R., … & Misra, M. (2017). Association of a history of childhood-onset obesity and dieting with eating disorders. Eating disorders, 25(3), 216-229.

12. Miller, K. R., McClave, S. A., Jampolis, M. B., Hurt, R. T., Krueger, K., Landes, S., & Collier, B. (2016). The health benefits of exercise and physical activity. Current Nutrition Reports, 5(3), 204-212.