Health at Every Size Q&A
This year at FNCE (our national dietitian conference) several exciting things happened. First of all, it was the first FNCE where I was actually able to put RD on my badge! Second, the academy hosted a “debate” on Health at Every Size® (HAES) where Christy Harrison “debated” a weight management physician on the topic. If you’re interested in the actual content of the debate or learning more about what HAES is, Christy so generously made her slides available for download through her website. Until I have time to get on here and write a full blog post explaining background info on HAES, I highly recommend checking out the ASDAH website, this article from Linda Bacon, or this article from Vincci Tsui for the basics.
The other exciting thing about the conference this year, was the new feature on the FNCE app that allowed attendees to submit questions electronically to be answered by the speaker during the Q&A. Not surprisingly, there were literally hundreds of questions during this debate. Unfortunately, the moderator didn’t have a chance to ask more than a handful of them. However, I did snap screenshots of most of these questions and decided to spend my plane ride back to Austin answering them… and then finally publish my answers online a month later because, ya know, life!
Over the next few weeks, I’ll be publishing answers to a few of these questions at a time so be sure to stay tuned for more! And if you have more questions you would like answered, please don’t hesitate to let me know!
For now, here are the top 10 questions from the FNCE 2018 app:
1. “The latest research from the Framingham Heart Study is showing weight cycling as a primary risk factor for CVD. Given the poor outcomes and resulting rebound weight gain in all weight loss studies, how can we ethically still recommend weight loss programs?”
We can’t. Honestly, we really can’t ethically recommend weight loss and still claim to care about health. Weight loss is not sustainable and leads to weight cycling which has some pretty serious health effects including increased risk of CVD, insulin resistance, dyslipidemia, and hypertension. If we really care about improving our patients health, what we can do is take a look at the things we know are actual indicators of health, and the behavior modifications we know to improve health outcomes regardless of weight change.
2. “If an example of weight stigma includes not being able to fit into airplane seats, is the HAES suggestion that the world cater to a lifestyle that is scientifically proven as unhealthy?”
Wow let’s dig into this one:
First of all let’s rephrase that question please… an example of weight stigma is airlines not making airplane seats large enough to accommodate larger bodies. Not the other way around. Please, let’s stop victim shaming when we talk about these issues.
Second of all, not everyone with a larger body is a result lifestyle choices. Some people are born into larger bodies, some have health conditions that cause weight gain regardless of lifestyle, some gain weight as a result of finally taking care of themselves, some are actually trying hard to comply with your diet culture perception of a “healthy lifestyle” and all of those years of weight cycling has led to weight gain. There are hundreds of other facts that contribute to someones weight and it’s highly problematic to believe that you can tell anything about someone’s lifestyle, behaviors, or their health based on their size.
Of course there are absolutely health behaviors that are proven to be unhealthy. HAES does not deny that. The problem is the perception that body size as a behavior (it’s not) and assuming that the pursuit of weight loss is a health promoting behavior.
It also amazes me how similar the anti-fat rhetoric is to homophobic rhetoric. Let’s make a few quick adjustments to the wording of this question… if the question read “if an example of [homophobia] includes [gay people feeling uncomfortable on] airplanes, is the [LGBTQ] suggestion that the world cater to a lifestyle that is scientifically proven to be unhealthy?” would you be able to see how problematic that sounds?
3. “What are your thoughts on weight watchers being a contributing factor to eating disorders? WW does not take genetics into account and creates guilt and shame towards food and eating.”
Eating disorders exist on a spectrum, where “normal” eating is on one end, and eating disorders on the other. The middle space is a weird continuum of “disordered eating”. Diets fall along that disordered eating continuum, and weight watchers is without a doubt a diet, despite all of their new marketing and rebranding to hide behind the word “lifestyle”. If there are rules about what/how much to eat (or not) eat, guilt or shame around breaking those rules/listening to your body, or a goal of weight loss then it’s contributing to a disordered relationship with food that can easily shift along that spectrum into a full blown eating disorder.
I also feel the need to clarify that the HAES paradigm is not only relevant to the eating disorder community. This is relevant to everyone, and we need to be talking about it as such. I find it misleading and confusing when we keep the ED world and the HAES world so intertwined. Yes, the issues addressed by a HAES paradigm (like weight stigma and fat phobia) are often contributing factors to EDs, and have perpetuated a diet culture that encourages disordered eating, but limiting our discussion to EDs alone or assuming this paradigm belongs solely in the ED field misses the bigger picture of HAES as social justice for all bodies.
4. “Eating disorders are the most deadly mental illness. There is a significant overlap in eating disorder behaviors and dieting behaviors. What are the ethics of recommending for larger people what we would diagnose as an eating disorder in smaller people?”
It’s completely unethical.
Also note: eating disorders exist in all body sizes. Theres a common misconception that anyone in a larger body with an ED must have binge eating disorder (BED), and that BED only affects those in larger bodies. 100% false. We see anorexia nervosa in all body shapes/sizes, so prescribing restrictive behaviors to someone in a larger body that would be enough to diagnose them with anorexia nervosa in a smaller body is not ethical at all.
Also note: exercise is form of purging. We diagnose people with bulimia nervosa who purge solely via exercise (ie. no vomiting). So telling someone in a larger body to exercise an extreme amount is encouraging them to purge via exercise. You are prescribing bulimia.
5. “How do you reconcile the fact that bariatric surgery is essentially surgery induced malnutrition? Why do we treat some for malnutrition and cause malnutrition for others?”
Let’s be clear: when HAES professionals speak out against bariatric surgery, we are voicing anger and frustration with a medical system that normalizes amputation of a perfectly healthy organ in pursuit of something no one can prove is possible for a reason no one can prove is valid. We are absolutely not voicing anger or frustration with individuals who elect to have these procedures. Body autonomy is an important value of HAES, meaning everyone has the right to do whatever they want to their body. And when I look at how diet culture markets these procedures, it makes so much sense to me why so many people buy into it! The fact that our diet culture distorts our perception to the point where “surgery induced malnutrition” or “stomach amputation” is seen as the only option is what frustrates me, not the victims of this marketing.
6. “With all of the diseases associated with “obesity” listed, how many of those diseases are exclusive to people in larger bodies?”
None that I can think of! All diseases can happen in any size body.
7. “One example of weight stigma provided was “doctors making comments regarding one’s weight”—but isn’t it a physician’s job to make the patient aware of areas of current or potential health complications/risks?”
Yes, a physicians job is absolutely to make the patient aware of health complications and risks! However, weight tells us very little about someone’s actual health. Doctors should be talking to patients about true indicators of health. There are several diseases that require a doctor to legitimately know your weight and monitor your weight closely. For example, if you have some kind of disease that involves significant fluid shifts (CKD, heart failure, refeeding syndrome, etc…), if you are weight restoring from an ED, or if you are being prescribed a medication that is legitimately dosed based on weight (most aren’t).
Also, if we’re really going to talk about this, why aren’t physicians talking about potential health complications or risks associated with dieting when they try to prescribe diets and recommend weight loss? I don’t know about you, but if something had as high a failure rate as diets and could lead to weight cycling, which would do some serious damage to my body, that’s definitely a health complication or risk I would want to be aware of!
And of course a physicians job is always to first do no harm: by unnecessarily bringing up weight or focusing on weight instead of actual health indicators, the physician is doing harm by not addressing the patients actual health, and by contributing to stigma.
8. “How can we address weight bias/stigma and educate our society about the issue, while at the same time communicating the fact that obesity is a disease that involves an individualized treatment without judgement?”
Obesity isn’t a disease. Calling it one is judgment and contributing to stigma. If you’re interested in reading more on this topic, I highly recommend the book Fat Politics.
Instead, let’s educate others on how it’s problematic to call it a disease instead. That’s definitely one way we can address weight bias and educate our society on the issue. And hopefully provide better patient care with significantly less judgement and shame.
9. “Would HAES be supportive of supporting weight loss to improve comorbidities if HCPs were trained on the mental and emotional implications of the traditional approach to weight and the ever-important 5 tenants of HAES?”
Fist of all, we need to stop assuming that weight loss will improve comorbidities. Most improvements we see with changes in health behavior are independent of weight loss (meaning no matter what happens to someones weight, if they change behavior they will see improvements in actual markers of health). This is why it’s important to note that HAES is not anti weight loss. In the process of helping someone improve their health in a weight inclusive and non biased way, some people will lose wight, some will gain weight, and some will maintain their weight. If they lose weight, thats fine but we know that it’s not better for health than if their weight had stayed exactly the same.
Further, I don’t see a way that we can actively support/encourage someone in the pursuit of weight loss without inherently stigmatizing them or causing them harm: we know that weight loss outside of someones set point range is not sustainable, and it leads to weight cycling which causes negative health outcomes (see above). Also not commonly discussed is how focus on weight in healthcare leads to healthcare avoidance. When people feel stigmatized and shamed by their HCPs, they tend to stop going back. Unfortunately, this healthcare avoidance is part of why we see so many individuals in larger bodies with more “severe” health conditions—because they’re avoiding healthcare until it’s so unbearably bad that they can’t not avoid anymore. And in the process of avoiding their stigmatizing provider, they’re also avoiding important screenings, interventions, and early warning signs of disease.
Instead of focusing on weight, let’s focus on actual health please! Thanks!
10. “If measuring anthropometrics is the first step to evidence based practice (Guidelines for the Weight Management of Overweight and Obese) for addressing overweight and obesity why is it not an outcome collected as an outcome for HAES?”
Because HAES doesn’t believe that obesity is a disease, those guidelines are totally irrelevant to how we provide patient care. Yes, larger bodied individuals may have a health condition requiring interventions and treatment, however none of those diseases are exclusive to larger bodies (in other words, thin people get those diseases too). What interventions would you recommend and what outcomes would you measure in someone with a BMI of 22 with the same condition?
Look, at the end of the day we (dietitians) all have the same goal in mind: we want to help people improve their health and live for fulfilling lives. Instead of continuing to frame this as a “debate” as the academy has done, can we continue this as a discussion? Let’s ask questions, truly listen to each others answers, and keep growing together. I’m tired of “agreeing to disagree” because honestly, when you think about the big picture, we’re really all on the same side here!
Sources and additional resources: