By Alex Raymond, RD,LD and Caroline Best, Student Intern
I am an eating disorder (ED), non-diet dietitian.
And I absolutely advocate for using the Weight Inclusive method of practice. What is this method? Why do align myself with it? Well, I became a dietitian to help people. I want to support individuals in feeling better about themselves. I want to support people’s food choices. And to improve quality of life. Food these days has become so complicated, through all the latest diet trends and fads. So, I wanted to be that voice to help people find peace. I want people to free from the false messages that are often portrayed in not only the media, but also through health messages from a wide range of people, including health care professionals.
Interestingly enough, there is a lack among the university nutrition programs of education surrounding Health at Every Size ® or HAES approach and weight inclusivity. Despite the research we have that discusses the consequences of weight stigma in our health care world, If you’re confused about all these terms, weight-inclusive, weight stigma, HAES…etc. I promise I will clear all this up for you in just a bit.
If you are reading this, and have never heard about HAES or weight inclusivity. I would encourage you to read this with an open mind. In this article, I am offering a different outlook on how to approach health. I find that some are skeptical at first. But bear with me! I encourage you to be curious, ask questions, and read the research.
I was inspired to write this blog after reading the article The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss by Tracy L Tylka, Rachel A Annunziato, Deb Burgard, Sigrun Danielsdottir, Ellen Shuman, Chad Davis and Rachel M. Calogero.
This article compares the evidence between practicing a weight-normative approach vs. a weight-inclusive approach and their health outcomes. The authors do support an evidence-based weight-inclusive approach. Much of what I will reference in this piece comes from this article and the research the authors compiled. I will also pull in information from the book Health at Every Size by Linda Bacon.
Please note: Linda Bacon recently wrote a new book, authored with Lucy Aphramor, called Body Respect: What Conventional Health Books Get Wrong, Leave Out, or Just Plain Fail to Understand about Weight. Bacon states that “As proud as I am of [Health at Every Size], I’m also aware of some of its shortcomings, including some of the ways in which it transmits my unexamined privilege and does damage.. To acknowledge the ways my view has changed, and to advance the field, I co-authored a second book.” You can click on the link to Body Respect to read more. The research in Health At Every Size, is relevant.
Firstly, let’s discuss the weight-normative approach. And what that means.
I can argue, and the majority would agree, that we live in a very weight and body focused world. Our healthcare system is especially weight focused. Think about it. When we go to the doctor, we are evaluated first by our weight. One example the Tylka et al. article provides us with is that patients who have a BMI higher than 30 are given advice on nutritional interventions for weight loss regardless of the primary reason they came into the see the doctor. On the other hand, patients who have a lower BMI, perhaps, “normal” or slightly “overweight,” may not be evaluated for Type 2 diabetes because “they do not fit the ‘high-risk profile’” of someone who may have higher blood sugar.
Why might this be an issue?
Well, this means that higher weight individuals are constantly being bombarded with messages from their healthcare providers (doctors, dietitians, therapists, physical therapists…etc.) that they need to lose and control their weight to be “healthier.” And, lower or normal weight individuals may not get screened for certain diseases. Despite research supporting weight is not a reliable indicator of health.
Because individuals in larger bodies are so fearful of being judged from health care providers, they are often discouraged from seeking medical help until it’s absolutely necessary, which allows time for the disease to progress instead of being diagnosed and treated at an early time.
Much of this is due to weight stigma which is defined as “negative weight related attitudes and beliefs that manifest as stereotypes, rejection, prejudice, and discrimination toward individuals of higher weights.” There has been research looking at the effects of stigma and discrimination from health care providers against higher weight individuals. There is a quote from the study Weight Science, Evaluating the Evidence for a Paradigm Shift by Linda Bacon and Aphramor that says “adults who face weight stigmatization and discrimination report consuming increased quantities of food, avoiding exercise, and postponing or avoiding medical care (for fear of experiencing stigmatization).” This focus on weight, and the stigma associated with it, marginalizes higher weight individuals and truly prevents them from getting the care they need.
But, maintaining a “normal BMI” is important for health and longevity, right? Let’s back up and talk about our society’s emphasis on weight loss for health and why that’s not true.
Like I said earlier, weight is not a reliable indicator of health. Despite what we often hear, weight loss/management is not necessary in order to be “healthy.” Firstly, there are mounds of data to show us that long term weight loss is non-sustainable. A well-known stat is that 95% of diets fail. “A diet” is defined as any change one may make in his or her eating to restrict or lose weight. When we look at the “long-term” results on weight loss studies, Talka et al. found through their analysis “no more than 20% of participants who complete weight based lifestyle interventions maintain weight loss one year later.” As the years go on, that 20% diminishes even more.
Additionally, Linda Bacon reviewed the research as well.
Many of the studies that have found connections between higher weight and increased disease risk did not control for weight cycling (yo-yo dieting), fitness/activity level, nutrient intake, or socioeconomic status when looking at this relationship. When studies control for these factors, the increased risk is no longer there. Sometimes the risk may even be reduced compared to “normal weight” individuals. So, isn’t is possible that these other factors increase disease risk?
So then, what is the other option? If weight loss/management isn’t the answer to living a long and healthy life, then what is?
Enter the “weight-inclusive” approach.
Many health care providers truly desire this to be the new standard of care. The weight-inclusive approach, defined by Talka et al. is “the assumption that everybody is capable of achieving a health and wellbeing independent of weight, given access to non-stigmatizing health care.” The weight-inclusive approach encourages positive behavior changes as opposed to focusing on a particular BMI or weight goal. It aims to reduce or eliminate weight stigma. The goal is patients feeling more comfortable discussing their health concerns. Providers can actually look at the whole person. As opposed to focusing on a specific weight number (which in our healthcare system today, creates bias).
I included a summary of the 7 principles of weight inclusivity from the Tylka et al article.
1. Do no harm.
2. Appreciate that bodies come in all different shapes and sizes and that optimal health and wellbeing is provided to everyone, no matter their weight.
3. Use a holistic approach to health and focus on behaviors rather than weight management
4. Encourage a process-focus (not end goals) for day to day quality of life.
5. Critically evaluate the empirical evidence for weight loss treatments and call for more research when evidence is weak or absent.
6. Create healthful, individualized practices and environments that are sustainable.
7. Work to increase health access, autonomy, and social justice for all individuals, regardless or weight, shape or size.
One of the more widely known approaches to practice weight inclusivity is called the Health at Every Size (HAES) Approach, which I mentioned earlier.
HAES is a trademarked term owned by the Association of Size Diversity and Heath (ASDAH). I encourage you to check out their website. Its a great resource to learn more about this nonprofit and its goals/values. The HAES approach is something that is not currently taught at most universities or internships. Some are making progress to have more information regarding this movement. However the education is lacking OR is provided along with information about the importance of weight loss. Like I said, in my education, I did not have any lectures on weight inclusivity or HAES. I learned through my own passions and research. I wanted to provide a brief introduction to the HAES approach by outlining its principles:
Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes. Reject the idealizing or pathologizing of specific weights.
Health Enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.
Respectful Care: Acknowledge our biases. Work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
Eating for Well-being: Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.
Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.
These principles were created by the “original steering committee” of ASDAH including: Claudia Clark, Miriam Berg, Roki Abakoui, Donna Pitman, Paul Ernsberger, Catherine Shufelt, Veronica Cook-Euell, Judy Miller, Lisa Breisch, Francie Astrom, Renee Schultz, Darshana Pandya, Judy Borcherdt, Joanne Ikeda, Ellen Shuman, Dana Schuster).
Many critics of this approach say that HAES supporters are disregarding health.
However, these critics do not fully understand the movement. Nor the importance of weight inclusivity nor the harmfulness of weight stigma. Health and longevity is truly at the core of the HAES approach (see principle #2). It can be so, so difficult for individuals in our society to give up the idea that one can be “healthy” in a larger body without striving for weight loss or management. I get it. “Weight loss” has been drilled in our heads. Especially if you’re in the healthcare field, for years and years. But again, I encourage you to have an open mind.
If you are a healthcare provider, please consider educating yourself more on HAES and weight inclusivity.
You may want to consider creating an environment that feels more comfortable for those in larger bodies. And less shaming when it comes to weight. For example, you can consider to have furniture that is comfortable, to respect a client when he/she does not want to be weight, and to have medical equipment (like blood pressure cuffs) that fits comfortably for all people.
Finally, I have found when my clients focus on behaviors (instead of weight loss) they feel SO much better about themselves and their health journey.
This includes those who have diseases like diabetes or high cholesterol. These clients have reduced their numbers without focusing on weight change. Empowering individuals to overall feel more confident in their relationship with food is one of my values. I feel way more aligned with that value when I take weight out of the equation and provide nutrition counseling that is non-stigmatizing, sustainable, and evidence-based.
If you have any questions about the weight inclusive approach or want to speak with one of our dietitians, email me at email@example.com or call our office at 240-670-4675