Traditional weight loss methods are based primarily on a medical model which treats obesity as a disease requiring diet, exercise, or pharmaceutical intervention. Conversely, the increasingly popular ‘Health At Every Size’ (HAES) movement believes that “individuals who are overweight and obese want to exercise and eat healthy foods, and they are capable of doing so when barriers are removed”.¹

The Health At Every Size® Principles are:

1. Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologising of specific weights.
2. 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.
3. Respectful Care: Acknowledge our biases, and 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.
4. 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.
5. 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.

While many academics, researchers, and practitioners applaud the overall aims of the HAES movement, in particular articles 1 and 4 have drawn criticism,² due to the a) demonstrable harm of adverse adiposity and b) the focus on inherent cues without external regulation that is at odds with our biology (i.e. the desire to seek and find pleasure in calorie-dense, sugar and fat-rich foods).

Are overweight and obesity a risk factor for early death and disease?

One of the key considerations in any debate about whether we can have health at every size is whether being overweight or obese are risk factors for poorer health outcomes, including earlier death and disease. In other words, can we, in actuality, be healthy irrespective of body size or adiposity?

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The research is clear that increased body mass index (a proxy measure for increased adiposity or ‘fatness’) is associated with disease and death.

• Higher waist circumference and waist-to-hip ratio increase the risk of all-cause mortality among men and women and are associated with increased risk of cardiovascular disease,  cancer and all-cause mortality.^{3, 4}
• Obesity is related to a higher risk of influenza infection and mortality.5
• Children with obesity have a higher risk of obesity and the length of hospital stays.6
• Obesity increases the risk of complications and mortality after liver transplants.7
• Obesity increases the risk of fatality from a motor vehicle accident (but might reduce the severity of head injuries).8
• Childhood obesity significantly increases the risk of later cardiometabolic mortality (diabetes, cardiovascular diseases).9
• Moderate increases in overweight, are mildly protective for the elderly due to problems associated with weight-loss (this is also reverse causation) but obesity is still a risk factor for older people.10
• Obesity is a significant risk factor for prostate cancer mortality.^{11, 12}
• There is an increased risk of mortality in western (but not Asian or Pacific) pancreatic cancer patients with obesity.¹³

The research is clear that increased body mass index (a proxy measure for increased adiposity or ‘fatness’) is associated with disease and death

Can being overweight protect against disease and early death?

In an oft-cited study, Flegal and colleagues found that being overweight resulted in a small yet significant lower mortality risk than being normal weight (0.94; 95% CI, 0.91-0.96). However, obesity was still associated with increased risk of mortality*.

However, analysis by Hu and colleagues of over 10.6 million participants has demonstrated that when reverse causation bias was corrected for (for example, when BMI was reduced as a result of smoking, or pre-existing illness) the participants with a ‘normal’ BMI (22-25) had the lowest risk of mortality, with risk increased significantly in the overweight and obese ranges, and every 5 BMI unit increase associated with a 31% greater risk of death overall.¹⁴

Can those with obesity be ‘metabolically healthy’?

It has also been suggested that those with obesity can still be metabolically healthy. While it is likely that there are some few people who can retain robust good health, despite a high BMI, increased adiposity of the body results in a milieu of biochemical, behavioural, and psychoneurophysiological factors that reduce optimal health.

While some people will be healthy in ranges outside what is considered ‘optimal’ body mass index (BMI), whether ‘under’ or ‘over’ weight, there is a greater risk, for most people, most of the time as adiposity increases. Those who are heavier due to increased muscle and have a higher BMI (i.e. athletes) should similarly not be included as metabolically healthy people with overweight or obesity, as they are not excessively adipose.

increased adiposity of the body results in a milieu of biochemical factors that reduce optimal health

The risks associated with obesity in those who are otherwise ‘metabolically healthy’, has been studied and those healthy individuals with obesity have a significantly greater risk of adverse health events (relative risk [RR], 1.24; 95% CI, 1.02 to 1.55) over the long-term (i.e. in studies with follow-ups > 10 years),¹⁵ and are at significantly greater risk of cardiovascular mortality.¹⁶ The combination of factors associated with excess adiposities such as increased inflammation, non-muscular load, and the predisposing factors to obesity such as more energy-dense, nutrient-sparse foods, reduced activity, poor sleep and other contributing factors to adiposity, result in damage that has significant health consequences.¹⁷

What does the evidence say about HAES?

The results from research on HAES is somewhat equivocal. Typically, people tend to feel better after being educated in a  HAES approach with an improved appreciation of cognitive dietary restraint, hunger cues, and increased self-worth and body image appreciation. There are few substantive benefits to physical health outcomes though.

• In a study of 25 sedentary, overweight women, physical activity was better adhered to in an exercise + HAES intervention versus exercise only (60% vs 36%).¹⁸
• In a 12-month quasi-experimental trial, women following a HAES approach lost an average of 3.5 Kg (from 96.9 +/- 16.4) (4.8% body fat loss) and participants reported being more physically active and having a better perception of their bodies, along with hunger and satiety cues. Participants also reported that they could identify feelings with eating choices and refrain from restrained behaviour. Interestingly, in this study dropout rates were over 50%,19 which is higher than most dietary interventions.
• In another study, no meaningful reductions in weight were noted for a HAES intervention, a social support intervention, and control over 16 months and no significant between-group effects for lipid profiles or other cardiometabolic indices. Both the social support and HAES groups noted improved susceptibility to hunger and cognitive dietary restraint.20
• In the previous intervention, it was also reported that energy intake and snack frequency decreased similarly overall groups (no benefit from HAES).21
• A three-year follow-up of participants of the previously mentioned trial showed continued improvements in perceptions of self-worth, health, and body image, for both the social support and HAES groups, however, despite some (trivial) weight-loss achieved early in the intervention, three years later, weight had increased significantly.22
• A trial comparing an ‘enhanced’ HAES program with a physical activity program and nutritional counseling to a standard HAES protocol resulted in no significant loss of weight, BMI, or waist or hip measure although the participants self-perception of health was improved.²³
• In a comparison of 49 non-diabetic adults, weight loss was over 3 times higher on a weight-loss diet intervention vs HAES, despite the weight loss group eating more…
• A trial comparing a usual diet control to 4-month HAES intervention (n=49 per group) found no difference in weight-loss, energy intake, or energy from snacking between groups.²⁴

What does all this mean?

The HAES movement is a positive one in that it has focused on empowerment.

Culturally we have been entrained to glorify the body beautiful and to vilify those that are larger. The typical ‘fix’ for obesity has been to focus solely on willpower and a person’s ability to restrict food intake and increase exercise to create a calorie deficit.

The typical ‘fix’ for obesity has been to focus solely on willpower and a person’s ability to restrict food intake and increase exercise to create a calorie deficit

While energy balance is critical to weight- and fat-loss, the approach has been counterproductive because it has not recognised the physiological drivers of hunger (metabolic dysfunction, lack of satiety from modern foods), the modern food environment, and the psychosocial aspects of food and life-food-social enjoyment.

There is a strong implicit bias against those who are overweight and there is also a naive assumption that those with obesity are lazy and that they should simply ‘exercise and eat better’. This thinking does not help us, nor further our understanding because the reality is that many people who are obese are no less proactive than those who aren’t, they simply drew the ‘metabolic short straw’.

HAES provides benefits to self-worth, body image, and might have some interesting benefits for shifting someone’s food relationship. However, the program has proven ultimately unsuccessful for improving quantifiable measures of health and appears to have similar attrition rates to ‘diets’ which have greater demonstrable benefits to health such as low-carbohydrate interventions which have better adherence with greater results for those with metabolic syndrome and obesity, than standard low-fat, high-carbohydrate regimens.²⁵

HAES provides benefits to self-worth, body image, and might have some interesting benefits for shifting someone’s food relationship.

The similarity in results between social support interventions and HAES shows that support, empathy, and consideration for the individual are the key. If this can be married to some degree of quantification in diet which also achieves substantive benefits to health, in an empowered way, appropriate to the individual, we can achieve the best of  both worlds, both for the psycho-emotional/psycho-social state of the individual, along with the greatest improvements in cardiometabolic markers of future health risk, of which adiposity is one.

One cannot be, according to the evidence, ‘Healthy at Every Size’ but a caring and empowered approach to nutrition practice can, and should, take into consideration more than the quantified markers of physical health. A holistic model of nutrition practice should strive to improve mental, psychoemotional, and physical health, through empowered and effective diet and lifestyle advice.

Additional notes:

• Possibly no association between obesity and oesophageal cancer 26 and sepsis mortality. 27
• There might be some protective effect of being overweight on mortality in chronic kidney disease. ²⁸

*1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured.

One cannot be, according to the evidence, ‘Healthy at Every Size’ but a caring and empowered approach to nutrition practice can, and should, take into consideration more than the quantified markers of physical health.

References

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5.            Zhou Y, 周裕洋. A systematic review of the association between obesity and influenza A related morbidity and mortality: The University of Hong Kong (Pokfulam, Hong Kong); 2014.

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7.            Barone M, Viggiani MT, Losurdo G, Principi M, Leandro G, Di Leo A. Systematic review with meta-analysis: post-operative complications and mortality risk in liver transplant candidates with obesity. Alimentary Pharmacology & Therapeutics. 2017;46(3):236-45.

8.            Desapriya E, Giulia S, Subzwari S, Peiris DC, Turcotte K, Pike I, et al. Does Obesity Increase the Risk of Injury or Mortality in Motor Vehicle Crashes? A Systematic Review and Meta-Analysis. Asia Pacific Journal of Public Health. 2011;26(5):447-60.

9.            Reilly JJ, Kelly J. Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. International Journal Of Obesity. 2010;35:891.

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11.         Golabek T, Bukowczan J, Chłosta P, Powroźnik J, Dobruch J, Borówka A. Obesity and Prostate Cancer Incidence and Mortality: A Systematic Review of Prospective Cohort Studies. Urologia Internationalis. 2014;92(1):7-14.

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13.         Majumder K, Gupta A, Arora N, Singh PP, Singh S. Premorbid Obesity and Mortality in Patients With Pancreatic Cancer: A Systematic Review and Meta-analysis. Clinical Gastroenterology and Hepatology. 2016;14(3):355-68.e2.

14.         Global BMIMC, Di Angelantonio E, Bhupathiraju Sh N, Wormser D, Gao P, Kaptoge S, et al. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet. 2016;388(10046):776-86.

15.         Kramer CK, Zinman B, Retnakaran R. Are Metabolically Healthy Overweight and Obesity Benign Conditions?: A Systematic Review and Meta-analysis. Annals of Internal Medicine. 2013;159(11):758-69.

16.         Zheng R, Zhou D, Zhu Y. The long-term prognosis of cardiovascular disease and all-cause mortality for metabolically healthy obesity: a systematic review and meta-analysis. Journal of Epidemiology and Community Health. 2016;70(10):1024.

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18.         Hsu Y-T, Buckworth J, Focht BC, O’Connell AA. Feasibility of a Self-Determination Theory-based exercise intervention promoting Healthy at Every Size with sedentary overweight women: Project CHANGE. Psychology of Sport and Exercise. 2013;14(2):283-92.

19.         Ulian MD, Benatti FB, de Campos-Ferraz PL, Roble OJ, Unsain RF, de Morais Sato P, et al. The Effects of a “Health at Every Size®”-Based Approach in Obese Women: A Pilot-Trial of the “Health and Wellness in Obesity” Study. Frontiers in Nutrition. 2015;2(34).

20.         Provencher V, Bégin C, Tremblay A, Mongeau L, Corneau L, Dodin S, et al. Health-At-Every-Size and Eating Behaviors: 1-Year Follow-Up Results of a Size Acceptance Intervention. Journal of the American Dietetic Association. 2009;109(11):1854-61.

21.         Leblanc V, Provencher V, Bégin C, Corneau L, Tremblay A, Lemieux S. Impact of a Health-At-Every-Size intervention on changes in dietary intakes and eating patterns in premenopausal overweight women: Results of a randomized trial. Clinical Nutrition. 2012;31(4):481-8.

22.         Côté M, Daoust M, Gagnon-Girouard MP, Bégin C, Provencher V, Tremblay A, et al. Three-year follow-up of a “Health-At-Every-Size” intervention among weight-preoccupied overweight/obese women. Canadian Journal of Diabetes. 2011;35(2):153.

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24.         Leblanc V, Provencher V, Bégin C, Corneau L, Tremblay A, Lemieux S. Long-term effects of a Health-at-every-size intervention on eating patterns in premenopausal overweight women. The FASEB Journal. 2011;25(1_supplement):588.3-.3.

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26.         Gupta A, Majumder K, Arora N, Singh PP, Singh S. Obesity and mortality in patients with esophageal cancer: A systematic review and meta-analysis. Journal of Clinical Oncology. 2016;34(4_suppl):20-.

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28.         Ladhani M, Craig JC, Irving M, Clayton PA, Wong G. Obesity and the risk of cardiovascular and all-cause mortality in chronic kidney disease: a systematic review and meta-analysis. Nephrology Dialysis Transplantation. 2016;32(3):439-49.