My Thoughts On Health At Every Size – Part Two

Many of you will have realized by now that my most recent Health At Every Size (HAES) article garnered some unexpected but ultimately deserved negative attention.

My understanding is that some HAES proponents and practitioners were concerned that I did not accurately portray the Health At Every Size philosophy in my previous piece.

Fair enough.

I took that feedback to heart and wanted to take a step toward addressing that shortcoming today by more accurately reflecting on the HAES approach.

I am opting to do so by reviewing and discussing a HAES intervention study conducted by leading advocate Dr Linda Bacon PhD.

This particular study from 2005 is often cited as interventional RCT evidence of the effectiveness of the HAES approach.

My rationale for this review is not only to learn more about the HAES methodology ( which is something I clearly need to do based on feedback I’ve received) but also to reflect on my own practice to see where I stand on the spectrum of “conventional weight loss” guidance and the HAES approach.

I am engaging in the later as an exercise in practice reflection and professional development, hopefully a few of you will also find it valuable as well.

DISCLAIMER: In order to get the most of this article you will need to read the WHOLE thing.

PREAMBLE: The study I am discussing today to is a randomized controlled trial looking at obese females in the 30-45 year old age group who were essentially provided either a HAES intervention or what was described as a “diet program ” intervention.  The interventions took place in weekly 90-minute group sessions for a period of 6 months, with a follow up at two years time.

Key Findings:

1. At the end of the 6 month intervention period the number of people who ultimately dropped out of the “diet” group was much higher than the number who dropped out of the “HAES” group. ( 41% vs 8%)

2. The HAES intervention group, despite maintaining weight, saw improvements in all outcome measures (including: blood pressure, blood lipids, psychological indicators of body-image, depression and characteristics of eating behaviours  ( ie: restrictive vs intuitive).). 

3. The “Diet” group lost weight and improved in some of the outcome variables at 1 year, but these changes were mostly lost at two years.

4. Conclusion: A HAES intervention is more sustainable and more effective than a standard “diet program” at improving a number of important health indicators, even in the absence of weight loss.

The results speak for themselves, no dispute there.

Now it’s time to dig deeper to understand what the HAES intervention ( & the “diet” intervention) actually entails, so I that may better understand the HAES approach, reflect that understanding here in print, and honestly reflect on where my own practices fall on the spectrum.

Let’s get started!

To minimize the risk of misrepresentation, let me be clear that the details of each intervention were extracted directly from the study itself.

Diet Group Intervention

Participants were instructed/encouraged/taught to:

1. Moderately restrict their calorie and fat intake

2. Maintain food diaries and regularly check their weight.

3. Exercise at an intensity as delineated by the CDC

4. Read food labels, learn how to count fat grams/exchanges, shop for food.

Self-Reflection: So am I A “Diet” Dietitian?

If you want to jump straight to the part where I admit that I did not properly represent HAES in my previous article, you can skip this section, which is really just me reflecting on how my practice compares to this “diet” intervention. 😉

I can only speak for myself and my practice approach when I say this so-called “diet” intervention bears little resemblance to my actual practice or professional training, which were both centered around dynamic (rather than static) patient-centered guidance aimed at offering 100% personalized nutrition care.

Although I may discuss some of the points above (if I determine the client’s trajectory dictates I should) these are not the guiding principles with which I steadfastly operate my weight management practice.

With that being said, it is also not particularly surprising to me that this control group did not enjoy great long-term success in the study based on what the intervention appeared to entail.

To be fair, however, the nutrition interventions offered in this study were carried out in a group setting, which obviously offers some  limitations in terms of providing effective patient-centered care.

As a weight loss/management dietitian:

1. I rarely ever explicitly discuss calories unless the client happens to be one of the rare few who enjoy/prefer to track their caloric intake.

2. I do not, by default, specifically discuss reducing fat intake unless it is blatantly clear that a practically modifiable choice is holding a client back from their goal (ie: excessive oil usage during food preparation).

3. I do not encourage clients to maintain food diaries unless they already do so and find peace of mind in-doing so.

4. I rarely discuss exercise (as it is not my area of expertise) beyond to say that it is something to be done to support good health and feel good.

5. I do not, by default, discuss food labels or how to count fat grams or do food exchanges. If the client’s particular case calls for it, I may discuss the value of label comparison ( usually for sodium in hypertension cases).

So based on my understanding of the “diet” intervention  used in this study and my intimate knowledge of my own practice techniques, I think it is safe to say that I do not fit the description of a “diet” approach to nutrition intervention, even if I may adopt some of the principles in a context dependent manner.

I know that’s not what you guys came to hear though.

HAES Group Intervention ( The Part Where I Admit I Was Wrong)

I will be perfectly honest in saying that, after reviewing this section of the paper, I must admit to incompletely and inaccurately characterizing the HAES approach in my first article ( not intentionally of course, but a glaring mistake nonetheless).

Those of you who claimed this about my first piece, minus the hyperbole, were absolutely correct and I fully acknowledge that.

Hopefully the characterization below, extracted directly from the study, is more apt.

The HAES Program Included Five Components:

1. Body Acceptance: Training aimed at improving self-acceptance independent of body weight and working towards separating self-worth from weight.

2.Eating Behaviour ( Modification): Education related to intuitive eating ( ie: internally regulated, following internal cues) as a means to replace restrictive eating.

3.Nutrition: Education related to what was described as “standard nutrition information” , the effect of food-choices on well-being and selecting foods that they enjoy, that are also good for them.

4. Physical Activity: Education related to breaking down barriers to physical activity and to coming to an agreement on the types of exercise that they enjoy and can engage in with pleasure.

5. Social Support: Facilitated by a PhD with a doctorate in physiology + focus on nutrition who conducted workshops to help women understand their common experiences in a “culture that devalues large women” (direct quote).

So , based on this, am I A “HAES” dietitian?

There is no question that I do not enact all or even most of the HAES principles in my practice, although I do now better understand what those principles are (which kind of was the point of this whole thing!) and appreciate them to a much greater extent.

For my own cathartic purposes, let’s go through the 5 HAES intervention pillars one by one to allow me to reflect on my own practice relative to those principles.

Body Acceptance: Admittedly, this is not something I regularly engage in as a default exercise because the majority of my clients come to me  with the primary expectation to return to a weight they have previously lived at (in most cases, not that long ago), and felt more comfortable at independent of health concerns.  It is  not my job to tell them to abandon that goal in place of accepting their current weight, especially if I feel weight loss can be realistically and healthfully attained with my support. Yes, I may use professional judgement to temper expectations and yes weight loss does not always occur as intended. As a result, I feel as though body acceptance is more of a reactive phenomenon in weight management practice that may arise when, despite our best efforts and dietary improvements, weight loss cannot be achieved. This is obviously not true body acceptance and definitely not the way HAES intends it to operate, but I am speaking honestly about how things tend to go in a weight-focused practice.

Eating Behaviour (Modification):  Although I may not always speak at length about intuitive eating by default,  I certainly discuss the importance of acknowledging hunger cues and, when my client and I feel that unaddressed hunger may be interfering with their goals, a discussion of foods that promote satiety and offer better hunger management will usually follow.

Nutrition: I certainly focus on helping individuals understand the benefits of healthy eating and how they can arrive at an improved dietary pattern on their own terms ( or better yet, how we can plan together for their success.)

Physical Activity: As I said above, I rarely discuss physical activity beyond to say it supports good health.

Social Support: I fully respect that weight stigma can make living as a heavier person a serious challenge. From my perspective, I’d like to think that I try my very best to empathize with my clients experiences, thoughts and feelings  to the utmost of my abilities even If am not in a position ( time/expertise/training wise)  to offer the level of social support outlined in this particular HAES intervention.

Perhaps this is an area for me to explore in terms of my own future professional development.

This is not my “I am now a HAES Expert” declaration.

This is me stating that I know slightly more about HAES than I did on Monday and that I am much more in tune with why my practice approach, partially by necessity, falls short of HAES standards.

Look, there is no denying that my weight management practice style, by its very essence, cannot truly embody the essence of the HAES style of nutrition intervention.

But it certainly does not embody the aforementioned cookie-cutter “diet” intervention either.

I think it’s realistic to say that it shares characteristics of both and exists on a spectrum between the two, and may realistically oscillate on this spectrum depending on the client am I working with and what I feel is most conducive to their success.

Re-Visiting The Value Of Weight & Weight Loss On Health Outcomes

Dr. Bacon provides a very thorough account as to why weight is essentially an overrated health metric and why weight loss should not be an area of focus in nutrition intervention because it is not necessary for good health.

The study I discussed today is a great example of how positive physiological and nutritional outcomes can occur in the absence of weight loss.

That’s why, for the most part, I do not dispute her claims and honestly believe her paper is an insightful and valuable read  with obvious merit and there is no doubt that her approach holds a lot of value for a lot of people.

With that being said,  I have seen a great number of people in my practice who want to lose weight because they simply feel better at a lighter weight.

Does that mean I go around promoting and advocating for widespread weight loss? No.

My job is not to promote weight loss, rather it is to help support those who have already made the decision to try to lose weight of their own accord.

I know I can only speak from personal experience and that, as per Dr Bacon’s paper there is evidence to the contrary, but I help people pair vastly improved dietary practices ( from a balance/adequacy perspective) with sustainable and modest weight loss on a regular basis.

Now, as a private practice dietitian primarily paid for by third-party insurance, I have the luxury of working with my clients in a very affordable, prolonged and intensive manner that is much different than what most people would have experienced.

I also appreciate that the value of my practice anecdotes have limits and that not every client is a glowing success story but even if a modest weight loss is not necessary to improve health outcomes, it still may hold great meaning to a given individual who just simply feels better at a lighter weight.

For those of you who read or took exception to my previous article, know I am not trying to say that HAES  actively or intentionally encourages stigmatizing those individuals, but it’s called a potential unintended consequence for a reason.

It’s just that – potential and unintended. 

Today’s blog post has turned into a literal dissertation  BUT… before proceeding to my final thoughts I must conclude by offering support to my former employers ( Diabetes Canada) whose  brand new 2018 Practice Guidelines (which are assembled by a team of  astute and diligent medical specialists in the field of diabetes) suggest that a weight loss of 5-10% is an important interventional goal in type 2 diabetes management that may help support improved blood glucose control.

The Diabetes Canada Practice Guidelines are a trusted resource utilized by diabetes practitioners across the country to help treat the nearly 3 million Canadians who are living with type 2 diabetes ( as well as those with type 1), so if someone reading today’s article is privy to robust and conclusive evidence to the contrary, you should call Diabetes Canada immediately to inform them.

They can be reached at 416-363-3373.

I am sure they will be eager to hear from you.

Final Thoughts

I can only hope that the proponents of HAES who were less than impressed with my previous piece (and rightfully so) will be able to acknowledge today’s article as my honest first step to learning more about the Health At Every Size Philosophy.

Although I’ve done it on my own terms and I fear that fundamental differences in our approach will always partially divide us, I believe we are both fighting the good fight in our own way by offering people personalized nutrition solutions, rather than jamming them into pre-existing one-size-fits-all non-sense.

I fully admit that it was unfortunate and irresponsible of me to fail to characterize HAES as accurately as I should have the first time.

I do feel I’ve done a better job this time around, but only Facebook comments can ultimately decide that ( haha!).

At the end of the day, I would much rather the seemingly large portion of the population seeking to lose weight ( whatever the reason) be in my attentive and affordable care than blowing thousands of dollars on destructive one-size fits all conglomerate weight loss programs that we can all agree will leave them without the skills, understanding or support necessary to achieve an improved state of health.

I also  respect and acknowledge the HAES message for both its scientific and social validity.

I genuinely appreciate that there are many out there, especially those who have had less than positive experiences with chronic dieting ( as did the subjects of today’s cited intervention study), whose health truly yearns for, and will benefit from, the wider adoption of a HAES-based philosophy.

Hopefully we can agree on that at least?

Until next time,

Andy De Santis RD MPH