No, You Are Not Healthy at Every Size

After getting involved in the eating disorder community, and subsequently conducting an interview with an ED specialist that led to my inclusion in private “HAES” Facebook groups, I started to notice an ugly trend that we in the nutrition field are often apprehensive about addressing.

The “Healthy at Every Size” (HAES) movement is a relatively recent phenomenon, its roots starting probably about 20 years ago, though its current, markedly more radical form is much newer. It holds at the crux of its positions that health and body weight need to be separated in the medical field, lest we worsen weight bias and stigma. Of course, as with all new movements, this premise was not enough for them, and as the infighting over who was the most pro-“body diversity” (one of many of their odd euphemisms) intensified, the initially sound movement morphed into what many now see as a danger to public health.

A much needed preface

I ought to start off by shooting down the notion that I am at all sympathetic towards fat shaming or really anything that complicates the daily struggle overweight and obese individuals go through daily. Previously interning in the dietetic department of a residential eating disorder clinic and now working as a nutrition coach for the general population, I have at least gotten a taste of both extremes in this issue.

On one hand, young kids and teens (girls in particular) are inundated with ridiculous body expectations and even more ridiculous diet myths constantly. Especially for those with a predisposition for personality disorders, this can spiral down a pathological rabbit hole that leads to a debilitating relationship with food. These individuals push away family and loved ones, resort to extremely unhealthy and possibly fatal practices such as laxative abuse, and find the only coping mechanism they have is the entire reason they are in this predicament in the first place.

On the other hand, overweight and obese individuals (as I will go on to explain) suffer a myriad of crippling problems as well. Trouble breathing and sleeping, back issues, and general inconveniences (i.e. airplane seating and bending over to tie one’s shoes) are really just the tip of the iceberg. The array of metabolic disorders that excessive visceral fat opens you up to is alarming; we’re talking about insulin resistance and possible Type 2 diabetes, high blood pressure, dangerous blood lipid levels, heart problems, general organ stress, and edema, to name a few.

I find fat shaming just as reprehensible as the next compassionate individual, but I find it especially devastating given that I know how counterproductive it is. The bottom line is that making people feel bad (I should say worse; trust me, most of them already feel terrible) about their bodies does nothing but turn them away from finding help and a healthy outlet. I am an ardent preacher of the notion that we cannot begin to change ourselves until we learn to love ourselves. However, self acceptance and complacency are two vastly different concepts that I fear are becoming increasingly conflated, thanks largely to the efforts of the HAES movement.

HAES’ concerns

With that important preface out of the way, we can now get into what exactly this movement hopes to address. As I mentioned earlier, their core belief is basically that body weight and health are two separate issues, and that seeing them as a singular issue in the medical field has led to weight stigma and possibly even improper treatment. They hold that most diets don’t work, proudly boasting the figure of how many dieters fail to maintain their weight loss (importantly, this number is much lower than the made-up 95% statistic). Increasingly, they take pride in their “body diversity” and see fatness as a perfectly okay state that is just part of who we are.

To be sure, a lot of their beliefs, at their root, are logically sound and address real concerns the medical community could afford to begin acknowledging. To list them:

1. Giving the “just eat less and exercise more” advice as a doctor to your overweight/obese patient is anything but helpful.
2. Weight bias is a very real phenomenon, and it prevents large numbers of overweight/obese individuals from ever getting help or ever building up the confidence to step foot in a gym. As well, the way the media portrays these individuals (as lazy, gross slobs) is unhelpful at best and possibly harmful.
3. Most diets don’t work, at least not long term. They are mostly based off of food “rules” and place no importance on possibly the most important factor when considering long term lifestyle change — flexibility.
4. In many instances, body weight and health could afford to be separated, if for no other reason than that doing otherwise is lazy and misses the problem. If an overweight patient comes to you and is taking medicine that has the side effect of increasing blood cholesterol, yet you don’t take the time to explore their medical records in depth because you assume it must be the weight, that’s lazy and possibly dangerous.

Where they’re wrong

To simplify my qualms with their ideas, allow me to replicate the template of the 4-point list I just made.

1. The “just eat less and move more” advice from doctors is absent of any semblance of proper behavior psychology. This applies to more fields than just GPs dealing with overweight individuals — dentists, for example, go nowhere giving young children lists of foods they shouldn’t eat (which are basically just readouts of every food every child in America likes to eat). Where this goes too far: No, HAES advocates, doctors are not being “fat-phobic” or whatever you want to call it when they give this advice. It’s not because they hate fat people or are disgusted with their fat patients. And, more importantly, the solution is not for them to ignore the weight issue (surely, many HAES voices advocate for doctors to stop taking patients’ weight at appointments). It is for medical schools to update their curricula and prioritize human interactions — Jon Kabat-Zinn gives the great example of GPs unconsciously shaking their heads “no” when asking patients at the end of a session, “Do you have any other questions for me?”
2. Weight bias is a huge problem. Outside of the educated and well-trained circles I’m fortunate enough to be in (i.e. the Precision Nutrition coach certification grads Facebook group and the trainers where I work), I still hear others blabbing on about how easy it is to lose weight and — in the same breath — how it’s all about motivation and “not being lazy.” These are ridiculous ideas that show us most personal trainers and nutritionists are not keen to current behavior and habit psychology principles. I’m certainly not a master in that arena, but I’ve taken the time to read up and familiarize myself with the concepts because I realize how inextricably linked they are to weight management efforts. Where this goes too far: Advising that we remove entirely the classification of overweight or obesity is not productive; it is essentially robbing Peter to pay Paul. Now instead of dealing with weight bias, we’ll be dealing with weight ignorance and we’ll be no better for it. I applaud the efforts of UConn’s Rudd Center for Food Policy and Obesity, as well as the World Obesity Image Bank, for helping spread less weight-insensitive photos of overweight/obese individuals so that blogs and news articles can stop sharing the same old pictures of “fat slobs” while ostensibly hoping to help people with their weight issues.
3. Most diets fail because they are sensational and ignorant of actual science. The reality is that telling someone to put themselves in a caloric deficit and increase exercise while holding realistic goals for themselves is not going to sell any books. Where a vast amount of people are begging for an answer, there’s a market to be had, and so we see this wide array of nonsense diet fad propaganda filling up bookstore shelves and online news publications. This is not the answer to the obesity epidemic, but, again, neither is complete avoidance of the problem. Where this goes too far: The “non-diet” approach to dieting is becoming increasingly popular, but it’s not entirely helpful. Books like “Intuitive Eating” speak to some important points the diet industry avoids entirely (i.e. humans weren’t meant to follow strict food rules, labeling any food as indefinitely “bad” effectively places it on a pedestal and makes it that much more tempting), but in the grand scheme of things, they still present a side just as simplistic as articles that claim to help you “shed that belly fat in 2 weeks!!” People who have grown up around cheap, hyperpalatable foods, who were bribed with sweets when they stopped misbehaving, and didn’t live in an area where open space for physical activity was safe or available are not going to intuitively become healthy eaters by just “dropping the food rules.” Their weight is not going to be “normalized” (an ironically backwards euphemism of theirs) by eating to their heart’s content.
4. This is possibly the most contentious of the issues I’ve so far presented, but I do believe body weight ought to be seen as a separate issue from metabolic health in many instances. However, the link between the two can hardly be denied, and watching HAES advocates attempt to do so is like watching flat earthers debate actual Earth scientists. They are fully aware the vast majority of the scientific literature disagrees with them (waist to hip ratio is reliably one of the most effective measures of health), and yet they continue to salivate at studies conducted by Bobby Bobson’s College in Arkansas (sorry, Arkansas) that “prove” you can be morbidly obese and still healthy. The reality is that even if you choose to close your eyes at the heavily convincing evidence that excessive visceral fat deposition is totally correlated with every marker of metabolic syndrome, you cannot deny the other issues I pointed out earlier: obese individuals have strained breathing, increased risk for sleep apnea, trouble walking, back problems, heat regulation issues, organ stress, and many, many more I could spend all day listing off.

In closing…

The takeaway from this should not be simply that the HAES movement is ridiculous and unfounded (though, it is). Rather, it should be that we in the health and fitness community stay vigilant to these sensationalist movements and refuse to stray from evidence-based advice even when the other side seems so much more enticing (HAES has no shortage of emotional arguments in their arsenal). I encourage any health/fitness professionals reading this to treat their overweight/obese patients as humans just as deserving of help as anyone else. Telling them they were “good” or “bad” for eating healthy gets neither you nor them any closer to their goals. Treat one another with compassion but don’t throw out the baby with the bathwater.

Hope you enjoyed this!