New HAES Study

Science is not a sacred cow. Science is a horse. Don’t worship it. Feed it.
— Aubrey Eben

The new Health At Every Size paper, by Linda Bacon and Lucy Aphramor, is titled Weight Science: Evaluating the Evidence for a Paradigm Shift.   From the abstract:

Current guidelines recommend that “overweight” and “obese” individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. [...] A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. [...]  This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.

If it isn’t clear, this isn’t reporting new research: it’s reviewing and tying together existing research on HAES, and discussing why HAES is preferable than the traditional weight loss advice.   The introduction explains the basics of Health at Every Size and the research supporting it.

Several clinical trials comparing HAES to conventional obesity treatment have been conducted. Some investigations were conducted before the name “Health at Every Size” came into common usage; these earlier studies typically used the terms “non-diet” or “intuitive eating” and included an explicit focus on size acceptance (as opposed to weight loss or weight maintenance). [...] [Only randomized controlled trials (RTCs) and] studies with an explicit focus on size acceptance were included.

Evidence from these six RCTs indicates that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, eating disorder pathology) and psychosocial outcomes (e.g, mood, self-esteem, body image) [...] (See Table 1.) All studies indicate significant improvements in psychological and behavioral outcomes; improvements in self-esteem and eating behaviors were particularly noteworthy [...]. Four studies additionally measured metabolic risk factors and three of these studies indicated significant improvement in at least some of these parameters, including blood pressure and blood lipids [...]. No studies found adverse changes in any variables.

Clicking the “Table 1” link goes to a summary of studies from 1998 to 2009.   Many of us are familiar with “Bacon et al, 2005 and 2007“, which refers to the study Linda Bacon, Judith Stern, Nancy Keim and Marta Van Loan conducted to compare a standard diet program with a HAES program and its follow-up report.  It’s discussed in detail in Linda Bacon’s book Health At Every Size: The Surprising Truth About Your Weight and in a few articles.  The other studies primarily vary in what types of outcomes they measured.

The next major section details the assumptions people make about the weight-loss paradigm.  Each of these assumptions is discussed, with an eye to showing the actual evidence (or lack thereof). For example:

Assumption: The only way for overweight and obese people to improve health is to lose weight
Evidence: That weight loss will improve health over the long-term for obese people is, in fact, an untested hypothesis. One reason the hypothesis is untested is because no methods have proven to reduce weight long-term for a significant number of people. Also, while normal weight people have lower disease incidence than obese individuals, it is unknown if weight loss in individuals already obese reduces disease risk to the same level as that observed in those who were never obese [...].
As indicated by research conducted by one of the authors and many other investigators, most health indicators can be improved through changing health behaviors, regardless of whether weight is lost [...]. For example, lifestyle changes can reduce blood pressure, largely or completely independent of changes in body weight [...]. The same can be said for blood lipids [...]. Improvements in insulin sensitivity and blood lipids as a result of aerobic exercise training have been documented even in individuals who gained body fat during the intervention [...].

This is followed by a discussion of the support for using a HAES approach instead of a weigh-loss approach; the components of HAES (body acceptance, intuitive eating, and being active); and the ethics of using a HAES approach vs a weight-loss approach.  Naturally, being an academic paper, there’s an abstract, appendix, disclosures of conflicts of interest, etc.

Overall, the discussion I’ve seen of this paper seems to reflect people’s expectations.  The paper isn’t about HAES per se, it’s about how HAES is a better approach to improving health in fat people than prescribing weight loss (assuming, of course, that health improvements are desired).   The value of the paper for me is that it:

  • Summarizes the current state of HAES evidence, with bibliography. There isn’t just one study that supports HAES — multiple researchers have had similar results.
  • Argues the case for HAES in an organized fashion.
  • The full text of the paper is freely available on the web. You don’t have to get it from the library.
  • It helps show the current holes in the research.  There isn’t a randomized controlled trial comparing a diet approach vs a HAES approach in men, for example.  Most studies did not track physiological measures (e.g. blood pressure, blood lipids) in dieters vs the HAES participants.

The ethics discussion is also interesting.  Many doctors who are asked in the media about “If diets don’t work, what do you tell patients?” tend to come back with “Well, keep trying” or weight-loss surgery (as if that’s not a diet).   Linda Bacon and Lucy Aphramor argue outright that “the HAES paradigm shift may be required for professional ethical accountability.”

Further reading:

Also: NYTimes blog post on HAES and this paper.

12 thoughts on “New HAES Study

  1. At least one secondary analysis (not an intervention study) showed that “eating competence” (which is the HAES model of healthy eating and good nutrition status, based on attitudes toward food, ability to eat mindfully and intuitively, and not predicated on weight) was at least correlated with better blood lipids and blood pressure. http://www.ncbi.nlm.nih.gov/pubmed/17826698

    Anyway, I really like the breakdown given by the Halifax Courier article that explains what the paper means. I would like to see this sort of science writing in the mainstream media more often!

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  3. Have been giving this report much thought. The HAES paradigm presents a serious indictment against the current lack of understanding and knowledge (in addition to the biases and flawed ethical premises) widely accepted within our health care system as we know it, at least in the US.

    I have no argument against keeping weight a separate issue from behavioral-oriented interventions. However, I am struck by the trusting manner in which the authors of this HAES report base their assertions about the potential efficacy of health interventions (for patients with health problems that are often associated with particular forms of obesity), namely their arguments that behavioral interventions and other kinds of interventions have been shown to be more effective than weight loss.

    For example, there may be specific forms of exercise that help to lower blood pressure. Or specific dietary practices (such as reducing salt intake and increasing vegetable consumption) that improve hypertension outcomes. In fact there may be many such behavioral interventions that can be helpful for some people who are sick and also happen to be fat.

    My primary concern about advancing a HAES paradigm is more global (meta): it will be a paradigm advanced within the exact same system in which research is currently corrupted and dictated to by capitalist (corporate) interests, the beneficiaries of more costly interventions are usually those who are situated in privileged socio-economic positions (at least momentarily until their privileges expire), and the cheapest, yet still “effective” treatments (namely individual changes in behaviors) will still be recommended to those whose privilege does not extend to the health care system. It will remain, I fear, the demand for sick people to simply behave themselves into better health, since those behavioral interventions have been shown to be, at least, better than weight loss dieting. Meanwhile, studies that try to discover the conditions NECESSARY for behavioral changes (both implementation and long term practice) will not get funded–for where is the profit motive in revealing that our culture is failing to provide for the basic health needs of so many people?

    The blaming of individuals for their health problems will continue, sick people will continue to feel guilty for *causing* or *contributing to* their *own* illnesses, and the system that overlooks the plethora of pharmaceuticals in our drinking water, overlooks unsafe living and working environments, overlooks the devestating impact on health resulting from having low or no income, overlooks all the barriers to individual behavioral changes–yes, THAT system, well it will continue to get a pass by the HAES “paradigm” because the “paradigm” does not (sufficiently) challenge the social determinants of health but instead places responsibility for health outcomes right back onto individuals, including individual patients (and persons economically unable to be considered patients), and on the shoulders of doctors, nurses, and other providers who already suffer from moral distress while trying to cope with the day to day tragedies presented by daily inequities…inequities that largely remain invisible in the HAES “paradigm.”

    • I have no argument against keeping weight a separate issue from behavioral-oriented interventions. However, I am struck by the trusting manner in which the authors of this HAES report base their assertions about the potential efficacy of health interventions (for patients with health problems that are often associated with particular forms of obesity), namely their arguments that behavioral interventions and other kinds of interventions have been shown to be more effective than weight loss.

      I’m not sure that argument is supported in this paper either. If anything, its summary of the HAES research to date shows that there isn’t any research in using a HAES approach in treating people who have health conditions that are often associated with obesity.

      Sometimes there IS research showing that exercise or diet improvements without weight loss can help a condition, and that might support a HAES approach, but that’s different from a study of the HAES approach in the specific population. For example, there’s evidence exercise alone can improve insulin sensitivity, which may support a HAES approach, but that isn’t the same thing as a study of the HAES approach specifically among people with prediabetes. OTOH, it doesn’t lead me to believe that weight loss is a magic bullet either.

      It will remain, I fear, the demand for sick people to simply behave themselves into better health, since those behavioral interventions have been shown to be, at least, better than weight loss dieting. Meanwhile, studies that try to discover the conditions NECESSARY for behavioral changes (both implementation and long term practice) will not get funded–for where is the profit motive in revealing that our culture is failing to provide for the basic health needs of so many people?

      That is a concern of mine as well. HAES can be useful for improving overall health, but it isn’t a cure-all. For me it’s useful in that it helped me realize dieting was counterproductive and helped me focus on what health improvements I consider possible and useful for me. But there’s a reason I state that I exercise for “my own selfish reasons.” I don’t owe “healthy” as rent for taking up space.

      • What about HAES support groups (f2f or online) for people who want to change some behaviors, or for people who are struggling to gain access to assistance for specific health care needs? I mean, my lord, there are thousands of groups for people wanting to lose weight…sigh…but I’m not aware of any political activism by HAES advocates who want to support each other’s efforts (and hopes!) toward improved health.

        For instance, I went out and acquired an exercise ball to help strengthen my core muscles after I read about your *ball work* here. I felt empowered!

        It doesn’t have to be exercise, of course, but any area of action. Working up the courage to get a medical check-up could be something many people need support to accomplish. Or something simple like daily flossing, as small a thing as that seems, might be a task that people would want support/encouragement for.

        When I was much fatter it was really hard for me to consult doctors, perform self-caring efforts, and so forth, because I kept thinking how insignificant those things were in comparison to my size. I didn’t believe, for instance, that exercise would improve anything, for me, related to my health issues. I needed a walking buddy to motivate me to show up for our walks. Sadly, many people don’t have a buddy to support such efforts.

        Of course I realize FA in general provides a lot of support for many people, but it would sure be nice to also have some kind of *network* where fat folks could turn specifically for help/encouragement/support/resources with health issues. Some source of help where they know they won’t be told what they *should* do, or told to lose weight, but given assistance in whatever area(s) they may want to address. I dunno. I can even imagine a network of volunteers to help people in their regions to find/access to low cost or free clinics where they won’t feel judged or face discrimination.

        Sigh. I’m a hopeless idealist. Thanks for letting me have a little spot to dream outloud…

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  5. I am new to the concept of HAES, in fact your post was the first time I had come across it! Maybe it hasn’t reached the consciousness of us UK people ;)

    I would be interested though in any research that looks at the comparative risks of weight cycling (yo yo dieting) compared to just staying fat. I have read one or two papers that suggested that cycling your weight can lead to loss of lean muscle mass and of course leads to greater weight gain in the end. Be interested if there is a review article that summarises any other findings or the strength of the current research.

    My personal feeling is that actually maintaining my current weight for the last four years has been much better for me emotionally and health wise than the previous 20 years of my weight either going down quickly with crash diets and then creeping ever higher while I felt more and more as a failure. Maintaining a constant weight has given me the opportunity to learn to love the body I’m in and adopt a lifestyle that, while not making me thinner, at least has keep my weight stable and my health fine.

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