Can We Be Healthy at Any Size?

It has been described as a compassionate and ethical model for thinking about health. However, it is rife with controversy which divides the dietetics and medical community at large. A recent google search on the topic yielded 2,920,000,000 results.

What I am talking about is Health at Every Size® as an approach to public health promotion.

The HAES® philosophy is relatively new, with most literature only starting in the early 2000s. Health at Every Size® is an approach to public health that seeks to de-emphasize weight loss as a health goal and reduce stigma towards people who are overweight or obese.  It was trademarked by the Association for Size Diversity and Health (ASDAH) in 2011.

Lindo (born Linda) Bacon PhD wrote the book Health at Every Size: The Surprising Truth About Your Weight. Published in 2008, it launched a national conversation and placed them into the spotlight as the expert on the topic.

Don’t confuse it with a diet. HAES® is not anti-weight loss, but it does not promote weight loss as a health strategy. Weight is not a behavior, and HAES® focuses on addressing behaviors. This philosophy supports improved health behaviors for people of all sizes without using weight as a benchmark. A focus on weight perpetuates weight stigma.

There are currently five principles which guide the Health At Every Size® approach, though they are under review and likely to be updated soon. The following is taken directly from the ASDAH website:

• Weight inclusivity: accept and respect the inherent diversity of body shapes and sizes
• Health enhancement: support health policies that improve and equalize access to information and services.
• Eating for well-being: promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure rather than weight control.
• Respectful care: acknowledge our biases, work to end weight discrimination, weight stigma and weight bias. Recognize the impact of socioeconomics, race, gender, sexual orientation, age, and other identities on weight stigma.
• Life-enhancing movement: support physical activity that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.

This behavior-focused approach is endorsed by The Academy for Eating Disorders; Binge Eating Disorders Association; Eating Disorders Coalition for Research, Policy & Action; International Association of Eating Disorder Professionals; and the National Eating Disorder Association.

Proponents cite 20 years of studies to demonstrate benefits including reduction of cholesterol, increased intake of fruits and vegetables, increased physical activity, improved self-esteem, and improved overall quality of life.

Critics point out that existing studies tend to comprise small sample sizes, limited evaluation of cardiometabolic outcomes, and exclusion of individuals with more significant obesity. The Academy of Nutrition and Dietetics in 2022 reviewed current evidence on Non-Diet Approaches/Health at Every Size and found that qualified studies were limited and showed little-to-no difference in metabolic markers of chronic disease.

It’s not that people can’t be healthy with an overweight or even obese BMI. They can, especially if they exercise and eat nutritious food. Current medical evidence suggests many obese people are not healthy and those who are may be at a much higher risk of progressing to an unhealthy state over time.

It’s a matter of risk. The controversy lies in whether this is due to actual weight or less than ideal health behaviors.

While being obese and staying obese can lead to joint problems and sleep apnea, it is also linked to stroke, gall bladder disease and 14 types of cancer. Body weight has been an easy target. Now that it is classified as a disease it has become a primary focus. Most doctors and scientists say that a weight loss as little as 5-10% of total body weight can improve health.

It is important to note that individuals of any size can also develop cancer or other cardiometabolic disease.

It remains to be seen whether the metabolic complications of obesity and associated disease risk can be managed for life through behavior change alone. But Patients need to feel seen and heard when they present for care; respectful care lays the groundwork for trust to develop. Healthcare providers need to be aware of individual biases. “Patient centered care“ is not just a buzz phrase. HAES® may or may not be the answer but it certainly provides food for thought and most importantly another option for promoting healthy behaviors and lifestyles without the added stress of a number on the scale.

One Small Thing: Other Weight-Neutral Approaches

While HAES® is trademarked, weight neutrality is not. Another well-known approach is Intuitive Eating. Registered dietitians Evelyn Tribole and Elyse Resch created their 10 principles in 1995. Click here to read more.

• Bacon & Aphramor. “Weight Science: Evaluating the Evidence for Paradigm Shift,” Nutrition Journal 2011:10(9).
• Bell JA, et. al. “The natural course of healthy obesity over 20 years,” J Am Coll Cardiol. 2015;65(1):101-102.
• Flegal et. al. “Association of All-Cause Mortality with Overweight and Obesity, Using Standard Body Mass Index Categories,” JAMA 2013. 309(1):71-82.
• Gaesser & Angadi. “Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks,” Cell Press iScience Review 2021.
• Mensider JL, et. al. “A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial,” Appetite. 2016 Oct 1(105):364-74.

Published: June 9, 2023; vol. 72