January 2016 Issue

Health at Every Size: A Dietary Approach that Focuses on Healthful Lifestyle Behaviors — Not Weight Loss
By Densie Webb, PhD, RD
Today's Dietitian
Vol. 18 No. 1 P. 26

As nutrition professionals, we all know that being overweight or obese poses an increased risk of type 2 diabetes, hypertension, cardiovascular disease, and some cancers, and that losing weight is important to reduce that risk. Or is it?

There's a movement afoot known as Health at Every Size (HAES), an approach to dietary behavior change that offers an alternative to traditional, restrictive diet programs and purports that health risks associated with overweight and obesity have been exaggerated in research and in the press. The philosophy of the approach is that it's better both physically and emotionally to be as healthy as you can at whatever weight you are. This view is based on the fact that the vast majority of people who lose weight eventually gain it back, resulting in yo-yo dieting, which carries its own health risks. "It's okay to be obese if you're taking care of yourself and your health," says Ellen Glovsky, PhD, RD, LDN, a nutrition therapist and author of Wellness, Not Weight: Health at Every Size and Motivational Interviewing. Statements like that have raised eyebrows and questions among many in the health care community. This opposing view has been described as both a "war" and a "revolution."

There's some research to back up the movement's claims, but experts say the approach requires extensive counseling—something few people are willing to endure or pay for. But without it, the HAES message easily can be misinterpreted simply as "eat whatever you want." Without professional guidance, it may result in even more weight gain.

The HAES Approach
Healthful behaviors, not weight loss, are the focus of the HAES approach. These behaviors include eating a healthful diet (but not restricting intake), physical activity, getting the proper amount of sleep, stress management, finding the joy in life, and intuitive eating—following hunger cues and eating mindfully. "Acceptance of where one's body lands in terms of shape and size is the goal," Glovsky says.

The HAES 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.1 In recent years, there have been a few short-term studies suggesting that the HAES approach positively affects eating behaviors and appetite, sometimes resulting in a decrease in energy intake,2-4 but there are no long-term studies that examine the effect of the approach on health.

Crux of the Weight Issue
The HAES philosophy is that unrealistic expectations and social stigma often are at the root of many individuals' weight issues. "As much as 70% of an individual's weight is dictated by genetics, 90% of people fail on diets, and 60% of them end up gaining more weight than they lost," says Marsha Hudnall, MS, RDN, CD, president and co-owner of Green Mountain at Fox Run in Ludlow, Vermont, a women's retreat for healthy weight and well-being. "The societal focus on weight loss is associated with an unrealistic ideal that dooms most people to failure," she says. "They're trying to force their bodies to be something that is not healthy for them, and they're often doing it through questionable means—fasting or cutting out major food groups, for example." The question she and other weight management experts pose is, "Are the health problems the result of their weight or the result of the behaviors that give rise to weight gain?"

Current approaches to weight management often include lifestyle changes along with diet modifications, but advocates of HAES believe "weight" should be removed from the RD's lexicon and eliminated as a goal. HAES is a weight-neutral approach. Rather, lifestyle management is the goal.

The only problem with HAES, Hudnall says, is that consumers and health professionals often misinterpret the message as to just "let go" and not take care of themselves. At Green Mountain, similar to HAES, the philosophy is to guide clients down a path that leads to a healthful weight naturally, rather than trying to chase after weight loss that isn't sustainable.

Health Risks Reevaluated
Any health risks associated with HAES that exist may depend on the degree of obesity. Researchers from the Centers for Disease Control and Prevention performed a systematic review of 97 studies with a total of 2.88 million individuals.5 They found that having a BMI greater than 35 was associated with a higher death rate, compared with normal-weight individuals. However, those with a BMI of 30 to <35 had no greater risk of death, and being overweight with a BMI of 25 to <30 was associated with a significantly lower death rate compared with those of a normal weight. In addition, any health risk posed by being obese also may depend on where the body fat is located. Abdominal fat poses a greater health risk than fat on the hips and thighs.

Researchers have estimated that about 35% of obese individuals are "metabolically healthy"; they have normal blood glucose levels, normal blood pressure, normal lipid profiles, and higher blood levels of anti-inflammatory proteins, such as C3 and C-reactive protein.6 That leaves an estimated 65% who don't fall in the "metabolically normal range," putting them at risk. However, it could be that chronic inflammation, rather than obesity, is the culprit.6 Following the HAES philosophy to eat healthfully and exercise regularly could help reduce inflammation and, therefore, reduce risk.

However, a recent study found that while some obese individuals may be metabolically healthy, most will, over the long term, naturally transition into the unhealthy obese category. The researchers found in a 20-year follow-up that one-half of healthy obese subjects transitioned to unhealthy obese status. Moreover, healthy obese adults were nearly eight times more likely to progress to an unhealthy state than healthy nonobese adults. They concluded that maintaining a healthy obese state over time is the exception, not the norm.7

To Lose Weight or Not to Lose Weight
Not everyone is ready to wholly embrace the HAES philosophy. Alexandra Caspero, MA, RD, CLT, nutrition coach and consultant in St. Louis, says, "I take HAES to mean that as long as you are healthy, it doesn't matter what size you are. But it doesn't mean you can be any size and always be healthy. No one is denying that you can be overweight and still be healthy, but transitioning from being overweight to obese/morbidly obese has even greater risk factors. Frankly, I find it a little unethical to tell people that weight doesn't matter."

Glovsky says, "For those people for whom their weight limits their movement, either because of their size or because joints are painful, losing some weight may help. But, we still have the problem that existing treatments for obesity and overweight are very poor."

Lauren Harris-Pincus, MS, RDN, owner of Nutrition Starring You in Green Brook, New Jersey, revealed that she was an obese child from the age of 7, eventually lost 50 lbs in high school, and has dedicated her life to keeping her weight down. "Of course we want people to be happy in their own skin, and a BMI of less than 25 is not going to be achievable for a lot of people." However, she says, "I've been in private practice for 20 years and it's rare that people have healthful eating habits and can't lose weight." She also says it's indisputable that obesity is a risk factor for disease. "There's a reason we see children with diabetes now that we didn't before." She also says intuitive eating, which is a cornerstone of the HAES approach, only works in conjunction with a significant amount of education. "HAES is admirable, but people need direction. My clients don't intuitively want kale. They can think, 'I'll eat Oreos or donuts mindfully.'" She believes in educating clients about calories and portion size, not because she wants them to count calories or weigh foods, but because they need a broad understanding of what foods contain in order to eat healthfully.

Caspero says, "While I never promise success, I also don't discourage my clients from trying. Some approaches work better than others." She incorporates intuitive eating into her practice as well. But, she says, it's not the only tool. "I think RDs should have a large toolbox of skills and techniques. There isn't any technique that's a one-size-fits-all. Some clients do really, really well with HAES and intuitive eating, and others don't. I'm concerned with their lab values, genetic predisposition to disease, and dietary intake. We need to focus more on reading the client and addressing their needs from where they are right now."

— Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.

1. Eating disorder organizations join forces to urge focus on health and lifestyle rather than weight. Medical News Today website. http://www.medicalnewstoday.com/releases/173723.php. Updated December 11, 2009.

2. Provencher V, Bégin C, Tremblay A, Mongeau L, Boivin S, Lemieux S. Short-term effects of a "health-at-every-size" approach on eating behaviors and appetite ratings. Obesity (Silver Spring). 2007;15(4):957-966.

3. 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.

4. Leblanc V, Provencher V, Bégin C, Corneau L, Tremblay A, Lemieux S. Impact of a Health-At-Every Size intervention on changes in dietary intakes and eating patterns in premenopausal overweight women: results of a randomized trial. Clin Nutr. 2012;31(4):481-488.

5. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309(1):71-82.

6. Phillips CM, Perry IJ. Does inflammation determine metabolic health status in obese and nonobese adults? J Cin Endocrinol Metab. 2013;98(10):E1610-E1619.

7. Bell JA, Hamer M, Sabia S, Singh-Manoux A, Batty GD, Kivimaki M. The natural course of healthy obesity over 20 years. J Am Coll Cardiol. 2015;65(1):101-102.