Health at Every Size

An Introduction to Health at Every Size, Set-Point Theory, and the Weight-Neutral Approach

Good evening! I hope everyone had a great weekend. As promised, today I’m doing a Q&A on Health at Every Size, body image, and the weight-neutral approach to health care….which turned out to not be entirely in a Q&A format, either. If you want to learn more about intuitive eating, check out last week’s post. Intuitive eating and Health at Every Size can go hand-in-hand to foment a holistic picture of health (physical, mental, spiritual, social…).

This post gave me a run for my money. Many links (and there are a lot of links) lead to primary literature in the sciences. Feel free to take a look if you want to learn about methodology, etc. I never want to tell you what to think, but I think what I present here at least merits that you reconsider the way we as a society think about weight. Keep an open mind and take a look.

Set-Point Theory

Set-Point Theory is the idea is that everyone has a distinct weight range at which their body will fight to stay. It is very difficult to go below your set point without heavy restriction and/or overexercise. Being below your set point, aside from the stress of food restriction and overexercise, can result in physical symptoms, such as low energy levels, hormonal imbalance, and amenorrhea (the absence of a menstrual period in a woman of reproductive age).

Your set point is not a specific weight, but rather a 10-20 pound range, and it can change over time- clearly, your set point won’t be the same when you’re 25 as when you’re 55. Some people have higher set points than others. While many people are aware that there is a genetic component to weight, we still tend to blame individuals for not pushing their weight down.

This makes no sense, because my neighbor and I could eat the exact same foods in identical amounts and move our bodies equally, and we would end up at different weights. Why? Because we are different people of different ages, living in different bodies. The weight would also be distributed in different ways.

Finding your set point

So how do you find your set point? Your set point is the weight at which your body naturally falls when you’re eating and moving intuitively.

It’s the weight at which you can go out for pastries with your best friend or cocktails with a blind date. It’s the weight at which you can teach your kids how to bake chocolate chip cookies and try all the different local foods when you’re on vacation. It’s the weight at which your social and family life don’t revolve around your exercise routine. (For these reasons, I’ve also heard it referred to as your “happy weight.”

It’s also the weight at which you can leave food on your plate when you’re full and the weight at which your eating is not chaotic. You’re not bingeing and you’re not restricting. You’re listening to your hunger and fullness cues most of the time. You’re getting enough rest.

The absence of the aforementioned symptoms (always cold, low sex drive, etc.) is a good sign, but just because you have a regular menstrual cycle (if applicable) does not mean you are at your set point. Your set point might be above or below your current weight, or it could be your current weight.

Your set point versus your “ideal” weight

The thing about your set point is that the set point for your body might not match up with the weight that you want your body to be. And to make peace with food and exercise, you’re going to have to make peace with your body, too. You don’t have to love it. But you do have to take care of it. I’ve heard many terms that may or may not resonate with you: body positivity, fat positivity, body respect, body love, body kindness, body acceptance, fat acceptance, body neutrality, being a caregiver for your body, tolerating your body…the important thing is finding something that resonates with you. Here’s a support resource on this.

As I have acknowledged in the past, this isn’t something to which I ever can fully relate. I am thin, and do not have to deal with the discrimination that can come with being fat. If you do live in a larger body, and suspect that your set point is higher than you want it to be, I suggest you check out some of the body positivity resources linked last week’s post.

For what it’s worth, body neutrality resonates with me. If you’ve never heard of body neutrality before, it’s the idea that you don’t really have to think about your body very much. You don’t need to love it, but you do need to treat it with respect and take care of its needs instead of hating it.

Health at Every Size (HAES)

Here are the five principles of Health at Every Size:

I know, more principles. You’ll have to forgive me.

Here is a succinct one-page info sheet that provides a good background on Health at Every Size, which is so misunderstood. This is what I used to make that graphic!

Health at Every Size was a book written by Linda Bacon, PhD. If you’re interested in learning more, she has a vast library of online resources on her website.

Some more key points are the idea that anyone can improve their health (if they choose to- this is a choice!) independently of weight loss and that you can’t tell whether someone is healthy based on their body size. I repeat: you cannot tell whether someone is healthy based on their body side (and for that matter, it’s none of your business whether a stranger is healthy. Health and healthy behaviors do not determine someone’s value.) Moreover, fat stigma (hello, “War on Obesity”!) actually worsens health.

HAES-informed health providers generally operate using a weight-neutral approach, meaning they neither seek nor try to prevent weight loss. They encourage healthy behaviors and provide all patients with evidenced-based care regardless of body size. (Some exceptions may apply, like weight restoration in eating disorder recover.)

Why do you support a Health at Every Size approach?

There are two reasons I think a Health at Every Size approach is so necessary:

1) It’s evidenced-based

The “lose weight for health” paradigm is not fully backed by evidence, whereas we know that including healthy behaviors (moving your body, getting enough sleep, including fruits and vegetables, taking care of your mental health…) improves health in the long term. The data at the very least demands that we question why our “ideal” medical weight lines up so neatly with our ideal body as seen in the media.

The first principle for medical professionals is “do no harm.” But…encouraging weight loss does do harm. It can push people to adopt disordered eating behaviors, it can negatively affect body image and mental health, and it can lead to weight cycling (losing weight and then gaining weight.) So if we’re going to encourage people to lose weight, we should have solid evidence that it is the right thing to do. And yet, the evidence on this is mixed, and we know that incorporating healthy behaviors improves health,

So why do we even encourage weight loss? Why does the focus have to be on weight? Why can’t we encourage moving our bodies and eating nutritious foods without talking about weight loss?

I’ll tell you why. Because we, as a society, want to be skinny, and we want everyone else to be skinny too. And we’ve confused that with health- thanks in part to sneaky diet marketing. (By the way, that’s culturally constructed. It’s a Western beauty ideal, and it hasn’t always been like that.)

2) More importantly, it’s ethical

Discrimination against people in larger bodies and weight stigma are real, and can hold so many wonderful and capable individuals back in their lives. Weight-based bullying causes serious psychological distress in kids that can stick with them for the rest of our lives, and is encouraged by posters encouraging “healthy” weights in schools and public BMI checks.

Often, from otherwise liberal individuals, I hear things like “it’s for their own good.” Do you hear yourself? Weight is extremely complex. It is controlled by a myriad of factors, including genetic and socioeconomic elements. Even if we had direct control over our weight, which we do not, it would not be okay to judge people for it. If you claim to care about social justice and equality, you cannot exclude people in larger bodies. It is not ethical to treat a person differently based on the body in which they live. 

Body shaming and encouraging weight loss can lead to mental health issues, isolation/loneliness, reduced physical activity, eating disorders (which often go undiagnosed in fat people: anorexia, bulimia, binge eating disorder, and others), all of which damage health.

Everyone deserves evidence-based, compassionate health care.  There are so many cases where people in larger bodies are refused care until they lose a significant amount of weight, which is almost impossible in the long term. This New York Times article on the topic uses some problematic language, but is well-researched and shows how the medical profession fails fat patients.

So when studies come out claiming higher weights hurt health outcomes, you should look at the methodology critically . Do they account for the differences in care between people in smaller and larger bodies? What about for socioeconomic factors? Is the goal really have improved health outcomes, or is it to make people skinny?

Why doesn’t intentional weight loss work in the long term? What is some evidence behind Health at Every Size?

  • Here is a review by scientists at UCLA of long-term studies on weight-loss programs. They conclude that “the potential benefits of dieting on long-term weight outcomes are minimal, the potential benefits of dieting on long-term health outcomes are not clearly or consistently demonstrated, and the potential harms of weight cycling…are a clear source of concern. The benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment for obesity.” (Yes, there are studies that show that intentional weight loss is possible in the short term. But that’s not really the goal. Most people will gain the weight back, and may even gain back more.)
  • Several studies (here is a report on a large and comprehensive one) have suggested that people who have BMIs classified as “overweight” actually have a lower mortality risk than people classified as normal, while people classified as obese class I had the same mortality risk as people classified as normal.
  • There is some evidence to show that weight cycling (when your weight bounces up and down, presumably because you go on and off diets) may be damaging to your health. Honestly, I personally am not yet convinced by the evidence on this point. More research is clearly needed. However, weight cycling does predict future weight gain. Even this paper that concludes that weight cycling in itself does not increase mortality risk in women found that weight cycling led to increased weight gain.
  • Linda Bacon also argues that as average weights have gone up, so has life expectancy. I’m a little skeptical about this argument too, because there are so many factors that have gone into that increase. I do think it’s worth thinking about, though, because the “obesity crisis” is framed as though we are sicker than we’ve ever been- when in fact, the opposite is true.
  • Here is a literature review of the effects of non-diet approaches improves on health outcomes. A great place to start if you do want to dive into the research on HAES is a paper by Linda Bacon titled “Weight Science: Evaluating the Evidence for a Paradigm Shift.

For a more readable article about all of this, I like this one from Everyday Feminism. I may not agree with everything, but one of the tenets of HAES is thinking critically about the information fed to us about weight.

 

But what about the obesity crisis?

Generally, in the Health at Every Size community, we don’t use the terms obesity or overweight, because they pathologize body shapes and sizes. A body size cannot be a disease. Calling people’s bodies an “epidemic” is unethical and wrong. I’ve even heard the so-called “crisis” referred to as a “plague.” “Obese” is a clinical term, but it brings so much stigma along with it. We know that labeling people as overweight can lead to weight gain over time.

Even worse, the so-called “War on Obesity” implies that we are actually waging war on people’s bodies. You can’t say you value all bodies and are body positive and then turn around and use this kind of rhetoric. I don’t understand why we’re fighting “obesity” (also known as fighting fatness, also known as fighting the bodies people live in every day) when we should be fighting to ensure that everyone has access to nutritious food and water. (How is it that we do have money to make giant posters on how fat = bad and then not to fix the water in Flint?)

If you’re someone who feels that “raising awareness” about the “obesity crisis” is going to end it, I encourage you to take a step back and think about it. We have spent at least the last two decades (my entire life!) “raising awareness” about the “obesity crisis.”  Would you say this has “helped”? Are we skinnier than we were 20 years ago?

No, but half of Ontario teenagers in public school feel unhappy about their bodies. This is government-endorsed fat-shaming. And it has real effects: one study found that one in four children had engaged in one or more dieting behaviors by the time they turn seven. Seven! (By the way, that full report has a ton of important information about body image, the media, and children.)

If we truly cared about health outcomes, rather than just eliminating fat because we don’t like it, priority #1 would be socioeconomic disparities.

Some alternative thoughts on the “crisis”

We have tremendous problems of access in this country. Fresh fruits and vegetables and other nutritious foods are extremely expensive and highly processed foods are abundant and cheap. Choosing less-nutritious foods is a survival strategy of families living in poverty, as I discussed above. Food banks are often short on fresh produce. School lunches are highly-processed, and the produce that is available tends to be kind of tasteless.

Plus, kids can be finicky eaters. I, for one, did not like more affordable fruits like bananas as a kid, but rather, expensive raspberries and blueberries. Moreover, my parents could afford the food waste that came with exposing me to foods like Brussels sprouts and pomegranates over and over again. These are two foods that I love now, but they definitely were not safe bets ten years ago.

Modern life and food

From the start, we are taught to disconnect from our bodies and ignore our internal cues. Eat our dinner when we aren’t hungry yet. Clean our plates regardless of our fullness.

We are taught that apples are better choices (nutritionally but also morally) than brownies, but then we glorify brownies as tastier than apples. We are taught that vegetables are icky but we have to eat them before we get dessert, even if that means we’re overly full. Cookies are the reward for forcing yourself to eat your yucky carrots. (Not to mention that highly-palatable foods are deceptively marketed towards kids, who don’t have the developmental capacity to understand food marketing.)

My sister, as a kid, holding a container of raspberries she picked.
A great way to get kids interested in trying new foods is to get them involved in picking and preparing them. To this day, the only fruits my sister likes are raspberries and wild blueberries…which she used to pick every summer as a kid. Coincidence? Maybe. But U-Pick berry farms can be very expensive and certainly are not easy to get to! This is definitely not what you’re worried about if you’re trying to get food on the table.

Our parents go to the gym while they’re on diets and then stop when they’re not. Moving your body is what you do when you want to lose weight, and on top of that it’s boring and unpleasant. The point is to burn calories. Exercise only counts if you hate it. As a reward for burning all those calories on the soccer field on Saturdays, you get to have Gatorade and giant cupcakes, just like Mommy and Daddy get to have dessert when they go to the gym. These are the myths that are fed to us from day one.

We eat in front of the TV or while scrolling through Instagram. We eat while on the run, rather than sitting down with our friends and families and talking about our days. There is little respect given towards meals.

I definitely don’t want to perpetuate the myth of the perfect Europe. But I will say that there tends to be somewhat more of a culture of enjoying homemade meals together on a regular basis, at least in Italy and Spain. (This is dessert, so that’s why we’re scattered.)

There’s also a classist and racist element to the discourse around the obesity crisis. All of these lazy, poor people who watch TV on the couch all day while eating bags of Cheetos. And then they have the chutzpah to use my hard-earned tax money to pay for their Medicaid.

I’m not the conspiracy type. But I think the “obesity crisis” is an easy out for the government/health care system/society when it comes time to explain poor health outcomes in comparison to other developed countries. It’s a way to say that it’s not our fault, it’s their fault, for being so fat (which again, we assume means unhealthy.) Instead of the prohibitive cost of health care, the inefficiency and inequality of the system (especially in delivering preventative care), and the limited access to nutritious foods, we blame patients for being fat.

Questions?

If you have any questions, feel free to leave them in the comments or contact me directly. As always, thank you for reading.

This was not an easy post to write. I know this is controversial, and you don’t have to agree with everything I said. I do, however, ask you to think why weight loss is touted as the end-all-be-all of good health. But again, if weight loss would occur through healthy behaviors anyway…then why do we focus on it? Why not encourage people of all sizes to adopt those behaviors, which would improve health in everyone? Why do we have to treat fat bodies differently?

Just food for thought.

As always, I’ll be back next Tuesday evening with a new post. Have a great week!