My Thoughts on Health At Every Size (HAES)

We live at a time where there exists an immense amount of social pressure surrounding the maintenance of all aspects of our physical appearance, especially our body’s weight and shape.

This pressure has undoubtedly contributed to cultivating many of the damaging relationships that so many people around the world experience with both food and self.

The Health At Every Size (HAES) movement was started, in part,  as a means to quell this tide of negativity and swerve the trajectory away from the pervasive overemphasis of body weight as a sole indicator of health and wellness.

Although I will discuss my thoughts on HAES in great length shortly, let’s start by identifying some of the important beliefs are that generally associated with the movement:

1. The act of “dieting” does more harm than good.

2. Healthy eating, independent of weight loss, produces good health outcomes.

3. Weight loss is a challenging endeavour that, perhaps, not everyone is capable of.

4. The psychological stress associated with society’s favoritism of thin individuals can be just as damaging as the metabolic effects of obesity.

I don’t think anyone can really argue against the validity of the points above ( even if there are caveats/ limitations in some cases), which is why my goal today is not go through these points one by one to affirm or deny them.

That has already been done by others.

I’d much rather address my own perceptions and experiences surrounding the topic of HAES, which suggest to me that the ongoing debate that is taking place between those more fervent HAES supporters who may believe weight is a valueless metric, and individuals on the other side of that spectrum who may oppose that particular viewpoint, is what most people are interested in.

The goal of today’s article is to prove that one can respect BOTH the value of body weight as a health metric AND the absolute and utter need for it to never be the only thing that matters.

Let me start off by pointing out the elephant in the room, which is the fact that…..

I Work In Weight Loss

 The majority of the clients who walk through my doors have weight loss ambitions.

Six out of the seven days of the working week I offer guidance to AT LEAST one individual on how he or she can modify their diet to support the goal of improving their nutritional adequacy and , inevitably, changing the number on the scale.  I offer guidance to a significant number of individuals on how they can modify their diet to improve its quality and support the goal of changing their weight.

There is obviously a MASSIVE market of people out there who want to lose weight and clearly not every practitioner or company out there offers solutions to this problem in a healthy or sustainable way ( obviously I do though!…. more on this very important issue later in the article).

Some people may cringe when I say this but I personally cannot practically envision a time where, at any given moment, a significant portion of the population might have a desire to be at a different bodyweight ( whether lower or higher)than they are currently at.

That’s just me being honest.

I am NOT saying that I agree with a weight-centric, diet-centric approach to self-improvement.

Allow me to draw on my experience as weight loss practitioner to explain why.

Practice Insights: Unrealistic Weight Loss Expectations Are Harmful

I will be the first to say that one of the issues that I encounter in my practice that often saddens me is when clients who aspire to lose weight come in, and they’ve either been told by someone, or perhaps worked it out themselves, that they need to lose as much of 25% of their current weight to reach their “ideal weight” (which clients often consider in the 18.5-24.9 BMI range).

That right there is proof enough, to me, that the HAES movement has validity.

It’s Possible, If Not Rare, To Be Both Obese And “Metabolically Healthy”

I think that one of the messages that HAES tries to convey, which I agree with, is that health cannot be encapsulated by a BMI score in the 18.5-24.9 range.

The notion that someone could have a BMI significantly outside of this range, but still have good indicators of health, is gaining some traction in the medical community.

A 2013 paper discussing a niche group labelled the “metabolically healthy obese” described obesity as a condition that is experienced differently by differently people.

In other words, a sub group of obese people with certain characteristics may be fairly considered to be “metabolically healthy” and at lower risk of chronic disease than a certain “less healthy” sub-group of individuals in the “healthy” BMI range.

Some characteristics of a “metabolically healthy” obese individual may include:

  • a waist size of no more than 40 inches for a man or 35 inches for a woman
  • normal blood pressure, cholesterol, and blood sugar
  • normal sensitivity to insulin
  • good physical fitness

My honest wish is that every person, regardless of BMI, had good indicators of metabolic health and an impeccable dietary pattern but my inclination suggests that for those with high BMIs, the number who fall into this category is probably not substantial.

What I am trying to say is….

Weight Is Not Everything, But Context Matters

So what do I mean when I say context matters?

Well, the value of weight as an indicator of health is FAR less for an otherwise perky teenager than it is for an adult, especially one who is living with type 2 diabetes.

A 2017 study co-authored by the Harvard and Boston University Schools Of Public Health analyzed data from robust long-term monitoring of a significant number of  older men and women.

They found that people whose BMI never surpassed the normal range had the lowest risk of death from cancer or cardiovascular disease (which happens to be the two most likely things to kill a North American).

Weight also happens to matter quite a bit in type 2 diabetes.

Let’s take a closer look at some of the conclusions from an interventional weight loss study in type  2 diabetes which was published in the Canadian Journal Of Diabetes ( 2013):

1. Type 2 diabetes risk increases significantly as BMI exceeds 25

2. For every kg ( 2.2 lbs) lost through behaviour change practices, relative risk of diabetes drops 16%

3. The vast majority (almost 9 in 10) people living with diabetes have a BMI above 25. Excess bodily fat complicates the issues associated with type 2 diabetes, which is why weight loss is considered an essential part of management.

4. A modest weight loss of 5-10% is associated with significant improvement in markers of blood sugar control and metabolic health in people living with type 2 diabetes at 1 year.

In other words, I completely agree that we need to shield our young people from an overbearing weight stigma, but we also can’t pretend that weight is an utterly useless metric.

Let’s Re-Visit The HAES Approach

Before we go any further, let’s take a moment to sit back, relax and actually re-visit what HAES is all about.

1. Accepting that we all come in different shapes and sizes.

2. Acknowledging that extreme dieting behaviour does more harm than good.

3. Reminding us that the physical component of health is only one of a number of other components which should not be completely disregarded just for the physical components gain.

Nowhere in the HAES doctrine, that I am aware of, does it say that if weight loss is medically advisable (as in the example above) it is frowned upon.

I think this is a point that sometimes people are confused about.

The fact that health is determined by much more than weight, but also that, sometimes, losing weight is the healthy choice, need not be mutually exclusive acknowledgements.

Again, I don’t believe HAES is at all at odds with those realities.

With that being said, in the next and perhaps most important section, I will discuss what I perceive to be one of the potential unintended consequences that the HAES movement could bring forth if perpetuated in the wrong way.

Are There Potential Unintended Consequences Of HAES?

I believe that the pivotal component of the whole HAES movement, or any movement of any kind for that matter, is the manner in which it is perpetuated by the individuals who represent it.

Obviously some interpret the meaning of HAES differently and more fervently than others, and in this light it honestly reminds me a little bit (or a lot) of veganism.

There are two primary reasons for this:

1. I truly believe that both HAES and veganism are noble endeavours that obviously do more good than harm. I think it would be VERY hard for a rational, objective person to truly dismiss with the core values of either movement, even if they may not necessarily wholeheartedly abide by them.

2. But, the movements are defined by the people who represent them and everyone interprets them differently. Meaning that if I encounter a polarizing, judgemental vegan, I am far less likely to look kindly upon veganism. The same can be said regarding HAES, if someone is TOO opposed to anything that is not utterly HAES, they risk giving of a bad impression of the movement and leading people to misunderstand its objectives.

I hope you guys understand what I am trying to get at here.

However, we must also not forget the fact that although immense societal pressure to lose weight is fundamentally wrong, the desire for someone to want to lose weight is a personal choice and, for the sake of argument, not altogether that different than a person’s right to choose to eat or not to eat meat.

People Have A Right To Lose Weight… If They Want To

Look, I don’t ever want someone to feel they NEED to lose weight to be happy, but I also don’t ever want a client to feel stigmatized because they have a desire to lose weight.

Given that I work every single day with a population of people trying to lose weight, I think it’s important not to lose sight of the fact that people may enjoy living at a lighter weight because they believe it is obtainable to them and more importantly because they have felt better, moved better and lived better at a lighter weight in the past.

 How Do I Respect HAES Within My Weight Loss Practice ?

So how do I, as a practitioner who makes a living off of helping people lose weight, fend off the notion that weight defines health or self-worth, while still helping people with their objective of losing it?

That’s an excellent question!

I’m so glad I asked myself that.

Let me explain:

At the Initial Assessment

First and foremost when I ask a client what their goal in seeing me is (weight loss almost always comes up), I generally respond by acknowledging their objective but also letting them know that, in addition to helping them achieve it, I have a personal and professional responsibility to put their health first and ensure that the approach we take is both balanced and adequate from a nutritional perspective.

I also make it clear that, even if a significant weight loss is the long-term goal, the taking of weight at the initial appointment is 100% optional.

It is very often the case in my experience that someone who perceives they have a lot of weight to lose is not always comfortable being weighed, nor do they get any comfort in knowing their current weight.

At Follow Ups

 Just as with the initial appointment, I make it clear that weight taking is optional and I leave it for the end of the appointment because follow up success is not made or broken by changes on the scale.

I make it clear that I am obviously far more interested in how things went from a nutritional perspective, and even more importantly how the client is feeling with the changes that were made.

It’s important to also acknowledge that if someone has a desire to lose weight, they will obviously feel that little bit better if the scale shows a change.

It’s my job to frame the appointment in a positive light before any weight is taken, such that if the weight does change it is a bonus, rather than a defining factor.

I’ve heard some dietitians offer completely neutral responses whether a client gains or loses weight so as to diminish the power that weight holds over an individual.

I respect that approach but I will be first to say that I always share my clients emotions (whether positive or negative) with an eye towards continuous improvement and problem solving.

In other words, if a client is happy with their weight loss, so am I.

FINALLY….. I will often reference the fact that I’d ALWAYS rather have a client sitting a few pounds heavier with an impeccable diet, than a few lbs lighter with a very weak, restricted dietary pattern.

Where Do We Go From Here/What’s The REAL Problem?

So I hope that I have adequately articulated my stance on HAES thus far, but let me now take this opportunity to identify what I believe to be one of the biggest reasons why weight stigma is as prevalent as it is.

I promise that, regardless of where you stand on the issues discussed today, you will probably be on my side on this one.

I start with the simple question…

Why is providing weight loss /nutrition guidance not a more strictly controlled act?

Only certain health professionals can draw blood, provide a diagnosis, and prescribe medication…

So why is it that everyone and their dog can pretty much say whatever they want about nutrition while also legally providing nutrition advice and weight loss services?

I personally feel as though many of the problems we face with weight and diet stigma is owing, at least in partially, to how much voice and influence can potentially be given to people and companies who, quite simply, have NO clue what they are talking about nor do they have any business having other people’s health in their hands.

If dietitians were allowed to do our jobs in peace, employed more frequently and gainfully in positions of influence and public communication/education, and some more rigid rules were put in place around weight loss and nutrition guidance, I can’t help but feel as though some of these issues HAES aims to address would not be as nearly as bad as they are now.

Final Thoughts

HAES, at its most moderate and objective, is a valuable and even necessary movement.

We are all tired of immense social pressures leading so many down the road of a “lose weight or cry trying” approach to healthy eating.

Weight is a valuable metric in a number of contexts, but healthy eating is a valuable metric in EVERY context.

Weight loss can occur in the absence of healthy eating.

Healthy eating CANNOT occur in the absence of itself.

Don’t forget that.

Until next time,

Andy De Santis RD MPH