Health At Every Size

[cariad]

It seems that over the past few months I have had quite a few conversations about the unwise fixation with weight in the dialysis and transplant world. This recent National Geographic article explains the basics of the Health At Every Size approach, based on an interview with one of the founders of the movement, Linda Bacon. It makes for a nice primer, and cites a few scientific studies that back her claims. I had no idea that they had studied the effect of food enjoyment on nutrient absorption, and this definitely adds a new layer to the proper way to construct a diet (including those not focused on weight loss). Health At Every Size (HAES) is an important component in understanding Fat Rights/Fat Activism. Having read hundreds of articles like these, I seethe when I hear of people on dialysis being denied access to transplant solely on the basis of BMI.

Enjoy!

Health At Every Size
Live Healthy Without Dieting

By Mary Schons

Tuesday, August 9, 2011

Health at Every Size (HAES) is a lifestyle that encourages healthy eating and enjoyable physical activity as a way to feel better and live longer. Unlike other programs, it does not believe weight loss through dieting is the way to become healthy.

Scientific evidence supports this idea. In a 2006 study by researchers at the U.S. Department of Agriculture, 78 obese women were placed into either the Health at Every Size program or a traditional weight-loss program. Women in the weight-loss program were instructed to eat less, count calories, and exercise more.

The Health at Every Size group was encouraged to eat when they were hungry and to appreciate the feeling of fullness, to make healthy food choices, and to find a style of physical activity that was most enjoyable for them. They were not given a list of "forbidden foods," nor were they told to exercise to lose weight. They were also given techniques to build their self-esteem and to increase the confidence they had in their bodies.

After two years, both groups weighed approximately the same. The women in the weight-loss group lost some weight after six months, but regained it after two years. The women in the Health at Every Size group had healthier blood pressure, lower cholesterol, and were more physically active than the dieting group.

The study's results came as no surprise to Linda Bacon, researcher and author of Health at Every Size: The Surprising Truth About Your Weight. Bacon holds a Ph.D. in physiology with a focus on nutrition and weight regulation.

"Health at Every Size is about taking care of your body without worrying about whether you're ‘too’ big or small," she says. "People might think they can tell who's fit and who's not by looking at them, but in fact, it's trickier than that. Lots of people are fat and fit—many avid dancers, runners, lifters, and sports team members are big to start with and stay that way. They tend to be far healthier than thin people who don't move around much or eat a nutritious mix of foods.

“Saying everybody needs to be the same weight is like saying all people should be the same height."

Diets Don’t Work

Your body's weight is determined by genetics. Like height or skin color, weight and body type vary from person to person. A person's ideal weight range is called their set-point weight.

Your set-point weight is controlled by a part of the brain called the hypothalamus. The hypothalamus regulates the body's feeling of hunger and satiety—the full feeling you get after you've eaten a meal. One of the jobs of the hypothalamus is to keep you as close to your set-point weight as possible.

When you go on a diet and lose weight, your hypothalamus interprets the sudden weight loss as a problem somewhere in the body. It will do whatever it can to get you back to your set-point weight. The hypothalamus will release hormones to increase your appetite. It will slow down your metabolism, so you don't lose weight quickly. It will even make you feel more lethargic, or sluggish, and less likely to exercise.

Dieting can backfire by resetting your set-point weight at a higher level, to protect your body against the sudden changes of future diets.

"No one who diets is fit,” Bacon says, “because dieting hurts your metabolism, and your metabolism determines how your body uses energy.

“But diets not only don't work—they're making us fat. Scientific studies show that if your weight 'yo-yos,' if it goes up and down a lot, that leads to long-term weight gain, especially when you're young. Teens' and preteens' metabolisms are trying to figure out what their adult pattern will be. Diets interfere with that. People with stable weights, even high ones, often enjoy better health than dieters and ex-dieters."

Fat Isn’t the Problem

In 2004, the Journal of the American Medical Association reported that 400,000 obese and overweight Americans die every year. That's the information it got from the Centers for Disease Control and Prevention (CDC).

However, the CDC later learned that the methods by which it got those numbers were faulty. When it re-did the report with better methods and new data, just 26,000 overweight or obese people a year died—fewer than the number who died due to guns, alcohol, or car accidents. The deaths were typically from people who had a body mass index (BMI)—a measure of body fat based on height and weight—greater than 35. Most overweight people are in the lower range, from 30 to 35.

In fact, life expectancy in the United States has risen—along with the obesity rate—from 70.8 years in 1970 to 78.2 in 2009. In its revised study, the CDC found that overweight people actually live longer, with 86,000 fewer deaths in the overweight category than in the normal weight category. And underweight people died more often than either overweight or obese people, suggesting that the thinnest people in the U.S. may be at a greater health risk.

In Health at Every Size, Bacon writes, "Many well-meaning scientists and medical practitioners are misled about the ill effects of being heavy. There is clearly a correlation between obesity and certain diseases and conditions, like diabetes or hypertension, but that doesn't mean being fat causes these conditions. It may be that whatever causes the diabetes also causes people to gain weight.

“To help explain this, one example I like deals with bald men and heart disease: Influential studies show that men with hair loss are more likely to have heart attacks. Does that mean going bald causes heart attacks? And can keeping your hair (or getting hair transplants) protect against cardiovascular disease? Well, of course not! After research and analysis, the baldness-heart risk association still isn't totally clear, but it appears that testosterone—which can cause both baldness and heart problems—is a likely culprit.

“In other words, fat isn’t the problem. When we see diseases that are more common in fatter people, it’s more about what they’re doing, than they’re fat. So the key is to make healthy changes in what you do and stop worrying so much about weight."

Health at Every Size

Health at Every Size focuses on health, not weight, as an indicator of your overall well-being. But if weight isn't a measurement of our overall health, how do we know we're healthy?

Bacon says, "Weight distracts us, and this focus results in poor medical care for everyone. 'Normal weight' people—who may have poor health habits and disease—don’t get good diagnoses or support for changing habits, which may catch up with them. People in the overweight and obese categories get stigmatized, encouraged in restrictive eating—even if they may actually have great health habits to begin with. Perhaps this could be a better focus for medical care—interviewing people about whether they have social support and manage stress well, whether they are regularly active, if they eat well.

"What's good for thin kids, fat kids and everyone in between, it turns out, is moving their bodies and a healthy mix of foods that taste good and nourish our bodies. Finding activity you enjoy might mean sports or workouts, but it could also be walking, jumping rope with friends, or dancing.

“With eating, Health at Every Size calls for intuitive eating. This means learning to listen to your body so you can recognize when you're hungry and when you're full, and what foods satisfy you. You don’t get as many nutrients from food when you don’t enjoy it, so do take care to choose foods you love. Sugar and candy can taste great, but they don’t give you other nutrients your body needs, and you’ll find that you can get grumpy, tired, and don’t do so well in school if that’s all you eat. And if you skip the fruit and veggies, you’ll probably find yourself struggling in the bathroom too long, so you don’t want to avoid those. So mix it up and get a range of nutrients in you to keep your body function best and to keep you most alert and in a good mood.  Experiment with food to see which ones make you feel best."

Bacon also recommends trying a range of foods to find ones that you enjoy. "What I find even more interesting is that research supports that people actually absorb more nutrients from meals that appeal to them than from meals they find less appetizing.

“In one interesting study, researchers fed a traditional Thai meal of rice and vegetables spiked with chili paste, fish sauce, and coconut cream to two groups of women, one Swedish and one Thai. The Thai women, who presumably liked the meal better than the Swedish women, absorbed 50 percent more iron from the same food than the Swedish women. And when the meal was blended together and turned to an unfamiliar and unpalatable paste, the Thai women’s absorption of iron from the meal decreased by 70 percent! So choking down the plate of steamed broccoli (if you hate steamed broccoli) is not likely to do you as much good as you think. Enjoying your food is an important nutritional practice."

The Health at Every Size plan doesn't put restrictions on the foods a person eats. Rather, it places more trust in the person to select foods that are right for them, and to stop eating when they feel full. Bacon says, "Have you ever noticed that, when you hear you can't have something—like ice cream, say, or chips—you want it all the more? Health at Every Size gets rid of 'in' and 'out' lists for food. If we trust our bodies and learn to listen to our appetites, they'll lead us to a healthy mix of foods and signal when we've had enough. When you can eat what you want and need, cravings and the munchies aren't such a problem, and you're no longer in danger of eating out of control."

Bacon writes, "What no one needs, at any size, is to feel bad about how they look or what they weigh. People who live by Health at Every Size ideas tend to feel better about themselves, and that can lead to better health, too, with less stress and disordered eating."

Link: http://education.nationalgeographic.com/education/news/health-every-size/#page=1

[MooseMom]

I agree with this article and with the point you are trying to make, cariad.  Using weight alone as a measurement of health (or, for that matter, illness) is extremely short-sighted.  While I think it is probably true that a 400 lb man who cannot control his food intake and who also never gets out of bed will be fundamentally less healthy than a man who eats a nutritious diet and exercises regularly, the obese man will almost certainly have a number of co-morbidities as a result.

Despite minding my diet and being probably the most compliant patient ever, no one can claim that I am healthy.  So the definitiion of health goes waaaay beyond someone's physical appearance.

There are probably plenty of thinner people out there who want to get on the transplant list but have not show the discipline to take their meds, watch their diet, collate their labs and generally take care of themselves as best they can.

Thanks for posting this. 

[jbeany]

Actually, just paying attention to when I felt full was a huge part of my weight loss, along with revoking my membership in the Clean Plate Club.

But there are a few problems with this kind of article - mostly that people tend to pull out only the information they want, and not get the whole picture from it.  The human capacity to latch onto one piece of information and deny all the rest of it is astounding.

Case in point - a friend of mine.  She's 5'2" and 200 pounds.  That gives her a BMI of 36.6, which puts her in the morbidly obese category.   But she refuses to work on her weight, her eating habits, or her exercise choices because "You can be fat and healthy."  just like this group says.
She's of the opinion that her yoga class, that she attends sporadically, maybe 3 times a month, counts as regular exercise.  She doesn't do it at home - only in the class, and she doesn't do much else active at all.  I was still anemic and recovering from massive abdominal surgery with complications the last time she visited - and I could make it up the steps faster than she could, and wasn't out of breath as bad as she was.  I've seen her eat, and no, it's not about food choices - it's portion sizes.  She frequently likes to eat things that any dietitian would consider a healthy meal, but I've watched her finish off a huge restaurant plateful, and then finish what I left on mine. She is vehement that her weight is not a health issue - but she's on cholesterol and blood pressure meds at 41. 

 When I say I need to lose more weight, even after my complication-induced 25 pound unplanned crash diet this summer, she's the first to loudly insist I shouldn't lose another ounce.  (I know, the sabotaging of my efforts are a whole 'nother issue, too.)  I told her I wanted to get to 150 pounds, which is still 5 pounds over the 20 pound stretch from 125 to 145 that is the correct weight for someone my height according to most BMI charts.  She insisted that BMI doesn't mean a thing.  Well, no, not as much as some docs think, I get that, - but really, I'm average build and average height - it's not an unreasonable estimate for me to think I should be close to it.  Heck, I don't need a doc or a chart to tell me that - that's what a mirror and the saddlebags on my hips and the jiggle in my thighs are for.  I look fine dressed - but I need to tone up after a year of not being allowed to exercise.  Since my diet is balanced nicely to keep me from gaining anything, the exercise will make me lose more.  I don't want to get skinny.  I think it's a bad idea for anyone with a chronic illness.  If I had starved myself down to the lower end of my BMI, I'd have been 125 when the complications hit - and a skeletal 100 now.  That's a 16 BMI when 18 and below is in the Underweight category. Not a good way to have a swift recovery, and not any healthier than being obese like my friend.


Ah, well, I worry about her, but I just change the subject to something non-weight related when she starts getting upset, because I can't change anyone's mind for them.

[MooseMom]

Let's face it, people are going to believe what they want to believe, and they will go to great lengths to justify their own actions.

I've seen people eat healthy food but in portions large enough to feed Seal Team Six.  When thinking about our own renal diet, we are constantly told that the key to the diet is portion size.  That's the key to just about any "diet".

[cariad]

Thanks for your comments, MM and jbeany. I'll warn you that I've just got out of my first PhD anthro course, so I am stuck in analytical mode right now. Please don't take offense at any disagreement, that's where the conversation lies.

jbeany, I don't see your friend as an indication of anything wrong with the article or Fat Activism/Acceptance/Advocacy, it is with her personal interpretation of it. FA might ironically refer to her as a "bad fattie" to illustrate the point that society divides people (especially women) into the "good fatties" who go on restrictive diets, hit the gym and force themselves to do exercise even if it is not enjoyable, and berate themselves for eating high calorie foods. OMG, I am so BAAAAAD, I just ate a plate of nachos! These are the people who, consciously or not, are joining society in assigning moral value to food. The bad fatties do not play along. They may be unhealthy which just encourages people to lay blame on them where we probably would not do this to a thin person except under extreme circumstances. Bad Fatties, at least how I've always understood the term, will eat what they want, exercise only if it's fun or makes them feel good, and not apologise for their appearance.

She may think of herself as healthy, but really that term is so broad as to have little meaning. Are you kicked out of the club for being on a few meds? I was on blood pressure meds from nearly day one - I was even in an early clinical trial for Minoxydil. No, I was not healthy, I was also not fat. It seems to me that the assumption is that if she ate less, she would be off those meds. I suppose that's possible, although in the case of cholesterol it is probably more to do with which food choices rather than portions, but I believe there is also a strong genetic component. Blood pressure is an ill-understood mechanism, but I do know that a professor of mine wanted to study stress in professors and had to call the project off because "you cannot find a white, male professor over 40 who is not on blood pressure meds". High blood pressure is also such an individual measure, I find those distinctions (high/low) to be more useless than anything. When I was tested for disability, I told the guy that if my systolic dropped below 100, I started to feel dizzy. He said that that was down to my renal history, and that someone my age (at that time) would normally have a blood pressure in that range.

I think it is possible that her weight has nothing to do with these conditions, that like the baldness/heart condition connection, there could be another answer, in fact I would almost bet that that will be the case. Correlation does not equal causation. There is a substance called Leptin that is produced by the body and helps to register the feeling of being full. I think it is probably obvious that Leptin levels vary between people. In rare cases, people cannot produce Leptin and never stop eating. Children have died from this, and parents have been scorned and even had charges brought against them. Paul Campos discusses a girl whose condition was caught in time, and they were able to give her medication that allows her to develop her own feeling of satiety, and she subsequently lost a load of weight and found her natural set point. A drug company even tried to create a diet pill from this information, but apparently it does not work on people who already produce Leptin.

Anyhow, I think it leads to issues of what the individual owes society. If there is no evidence that fat in and of itself is a danger to health, then why would we "owe" society, and more relevantly transplant eval committees, weight loss? Is the choice to NOT make all decisions based on optimal health a valid one? I'm sure you've all heard of CRON (calorie restriction, optimal nutrition) and how these people claim that existing on starvation levels of food, but with optimized nutrition, cures various ills and can also give you extra decades worth of life. It has been tested in mice and the results more or less back their claims. But the argument is "I don't want to live that way" and I think that needs to remain the individual's choice, and that public scorn for people who seem to have made these choices for themselves needs to be dialed back into non-existence. Your friend may have the exercise component all wrong - if she is calling sporadic yoga regular exercise, but other than that, she's eating healthy foods, just more than the average person. Obviously you know her and I don't, but from what you've written, it sounds like she's happy with herself and has decided to give up dieting rather than fight her body to reach some ideal weight.

OK, thanks for indulging me!

[jbeany]

 it sounds like she's happy with herself and has decided to give up dieting rather than fight her body to reach some ideal weight.

Ah, see, but that's what worries me - she's not happy.  If she was content and happy, I think she wouldn't be so hysterically upset whenever someone else mentions weight loss of their own. 

She hates the way she looks.  She wasn't happy about her looks even when I knew her back in college and she was a pretty normal weight.  When she started a desk job and started adding pounds, I think a lot of the meta message she was getting from her family was "At least you should be skinny if you can't be pretty."  I think some of the massive gain was a "F*** ***" response to that. 

I've got other friends who are big and just shrug and say "This is me - I don't care and I'm happy the way I am.  Take it or leave it."  If she had that attitude, I wouldn't worry about her at all.  But when the subject of weight loss does come up, she's practically screaming about it.  I could care less what size she is and she knows it - but when we were taking about the subject, she nearly yelled, "I'm sick and tired of people telling me that being fat means your life is over and you'll never be happy."  Ummm...whoa!  I was talking about wanting to lose weight and exercise more to keep down my bp and give myself the best chance of being one of those lucky transplant recipients who has one for 20 years.  Eating smaller portions and healthier food is just a natural part of that.  Liking the way I look thinner is just a nice bonus, not my incentive.  But yeah, hey, I'm a girl - of course it matters to me, too.  But I was talking diet and exercise plans to be healthier.  She's stuck on "I'm already healthy."  I just can't buy that being drastically out of breath after a single flight of stairs counts as healthy.  Add in the bad knees, and the other random health issues, and the meds, and there's just no way that adds up to healthy.

I would guess that her doc is on her to lose weight for her health, but I'm betting her family is after her so bad that the only thing she hears is the "Fat is ugly" message when her doc starts talking, too.  I think she's latched onto the headlines from articles like this one (without actually reading the details) to act as some kind of shield.  "I don't need to lose any weight - I'm healthy like this."  Insisting she's healthy isn't going to protect her from the "ugly" BS at all.  She wants to ignore all the societal messages that say thin is better - but the more she ignores that elephant in the room, the more she thinks about it.  Although maybe replacing the "Too bad you aren't pretty." message with "Too bad you aren't thin." is easier to deal with.  No one, especially her family, comments on her looks when all they see is her size, I suppose.

 (And for the record, there isn't a damn thing wrong with her looks.  She'll never be a super-model, but who will?  She's just always been totally uninterested in fussing with her hair or her clothes or bothering to put on make-up.  Which, of course, makes her "homely" in our looks-obsessed society.)

[jeannea]

Great article! I'm having weight issues myself. Part of the reason I was denied my disability claim was my neurologist wrote that I'm probably fatigued because I'm overweight and might have sleep apnea.

Never mind that he never tested me for sleep apnea. Never mind that I might be fatigued from ESRD and dialysis and anemia. Never mind that I have an abdomen full of PD fluid. I'm 5'0" and 140 lbs so to him I'm fat. And that's the main thing he reported when asked about my medical condition.

I hate the way some doctors treat weight. It's easier to keep a good weight when you're perfectly healthy like my doctor. Not so easy when you're sick.

[Gandalf]

Cariad, I am so glad you posted this article.  I have a similar frustration about the almost obsessive focus on matters of weight at Dialysis Centres, and especially with the direct link between weight and health and happiness.  I have spoken to women individually and in groups fairly frequently, and somehow, the topic of body size will inevitably emerge, along with diets/food/what to eat/what not to eat etc.  The one commonality in all these conversations seems to be an insecurity about body size and appearance - be it overweight/underweight or whatever, it seems that we as women are unable so often to find a sense of safety and security in how we look and how much we weigh.
So many women have described how a day can go from "wonderful" to "hideous" in the second it takes for the scale to reflect a number which is more than we had hoped.  How is is possible that we can allow ourselves to be victims of this culture of irrelevance!

This societal weight narrative thing does not really seem to be about reality, or about how much we weigh, or what our BMI is; I think it usually is about something totally different, defining what we as a society value and aspire to.  What is the most tragic, is that the big societal stick, perpetuated by the media and the medical fraternity of "how much you weigh" and the ominous presence of The Scale suggesting that "you are fat/unworthy/unwanted are matters that can reduce even highly mature, otherwise well orientated women, to quivering wrecks of unworthiness.
I really long for the time when we are no longer victims of this - I really long for a time when I am no longer a victim to this.......