Health at Every Size

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Health at Every Size (HAES) is an approach to public health that seeks to de-emphasise weight loss as a health goal, and reduce stigma towards people who are overweight or obese.^[1] Proponents argue that traditional interventions focused on weight loss, such as dieting, do not reliably produce positive health outcomes, and that health is a result of lifestyle behaviors that are independent of body weight.^[2]

History

Health at Every Size first appeared in the 1960s, advocating that the changing culture toward aesthetics and beauty standards had negative health and psychological repercussions to fat people. They believed that because the slim and fit body type had become the acceptable standard of attractiveness, fat people were going to great pains to lose weight, and that this was not, in fact, always healthy for the individual. They contend that some people are naturally a larger body type, and that in some cases losing a large amount of weight could in fact be extremely unhealthy for some. On November 4, 1967, Lew Louderback wrote an article called "More People Should Be Fat!" that appeared in a major national magazine, The Saturday Evening Post.^[3] In the opinion piece, Louderback argued that:

1. "Thin fat people" suffer physically and emotionally from having dieted to below their natural body weight.
2. Forced changes in weight are not only likely to be temporary, but also to cause physical and emotional damage.
3. Dieting seems to unleash destructive and emotional tendencies.
4. Eating without dieting allowed Louderback and his wife to relax and feel better while maintaining the same weight.

Bill Fabrey, a young engineer at the time, read the article and contacted Louderback a few months later in 1968. Fabrey helped Louderback research his subsequent book, Fat Power, and Louderback supported Fabrey in founding the National Association to Aid Fat Americans (NAAFA) in 1969, a nonprofit human rights organization. NAAFA would subsequently change its name by the mid-1980s to the National Association to Advance Fat Acceptance.

In the early 1980s, four books collectively put forward ideas related to Health At Every Size. In Diets Don't Work (1982), Bob Schwartz encouraged "intuitive eating",^[4] as did in Eating Awareness Training (1986). Those authors believed this would result in weight loss as a side effect. William Bennett and Joel Gurin's The Dieter's Dilemma (1982), and Janet Polivy and C. Peter Herman's Breaking The Diet Habit (1983) argued that everybody has a natural weight and set-point, and that dieting for weight loss does not work.^{[5][better source needed]}

According to Lindo Bacon, in Health at Every Size (2008), the basic premise of HAES is that "well-being and healthy habits are more important than any number on the scale."^[6] Emily Nagoski, in her book Come as You Are (2015), promoted the idea of Health at Every Size for improving women's self-confidence and sexual well-being.^{[7][page needed]}

Science

Diagram of the medical complications of obesity, from the US CDC

Proponents claim that evidence from certain scientific studies has provided some rationale for a shift in focus in health management from weight loss to a weight-neutral approach in individuals who have a high risk of type 2 diabetes and/or symptoms of cardiovascular disease, and that a weight-inclusive approach focusing on health biomarkers, instead of weight-normative approaches focusing on weight loss alone, provides greater health improvements.^[8][9]

There is high evidence that being overweight is associated with increased all-causes mortality, and that weight loss can improve several obesity-related health problems.^[10][11] A report from the American College of Cardiology found that with a variety of diets, weight loss is maximal at six months, after which slow weight regain is observed.^[10] Comparative reviews of different diets have largely found little evidence to recommend one diet over another and point to significant challenges in maintaining weight losses over the long-term.^[12][13]

Stephan Rössner, an obesity researcher, argues that efforts targeting weight loss may cause rapid swings in size that inflict worse physical and psychological damage than obesity itself.^[14] A 2007 review of existing research on dieting concluded that it "does not lead to sustained weight loss in the majority of individuals" and that because "the majority of individuals who engage in diets tend to regain most of their lost weight, no diet can be recommended without considering the potential harms of weight cycling", which it identified as an avenue for future research, along with the (more promising) potential of exercise as a means to treat obesity.^[15]

Overview of obesity

Obesity has been correlated with a wide variety of health problems.^[12][16] These problems range from congestive heart failure,^[17] high blood pressure,^[18] deep vein thrombosis and pulmonary embolism,^[19] type 2 diabetes,^[20] infertility,^[21] birth defects,^[22] stroke,^[23] dementia,^[24] cancer,^[25] asthma and chronic obstructive pulmonary disease^[26] and erectile dysfunction.^[27] A BMI greater than 30 is associated with twice the average risk of congestive heart failure.^[28][29] Obesity is associated with cardiovascular diseases including angina and myocardial infarction.^[30][31] A 2002 report concluded that 21% of ischemic heart disease is due to obesity,^[32] while a 2008 European consensus puts the number at 35%.^[33] Obesity has been cited as a contributing factor to approximately 100,000–400,000 deaths in the United States per year^[34] (including increased morbidity in car accidents).^[35]

There is no evidence to support the view that some obese people eat little yet gain weight due to a slow metabolism; on average, obese people have a greater energy expenditure than their healthy-weight counterparts due to the energy required to maintain an increased body mass.^[36][37][38]

Criticism

Amanda Sainsbury-Salis, an Australian medical researcher, calls for a rethink of the HAES concept,^[39] arguing it is not possible to be and remain truly healthy at every size, and suggests that a HAES focus may encourage people to ignore increasing weight, which her research states is easiest to lose soon after gaining. She does, however, note that it is possible to have healthy behaviours that provide health benefits at a wide variety of body sizes.

David L. Katz wrote an article in the Huffington Post entitled "Why I Can't Quite Be Okay With 'Okay at Any Size'".^[40] He does not explicitly name HAES as its topic, but discusses similar concepts. While he applauds the confrontation and combating of anti-obesity bias, his opinion is that a continued focus on being "okay at any size" may normalize ill-health and prevent people from taking steps to reduce obesity.

In May 2017, scientists at the European Congress on Obesity expressed scepticism about the possibility of being "fat but fit".^[41] A twenty-year observational study of 3.5 million participants showed that "fat but fit" people are still at higher risk of a number of diseases and adverse health effects than the general population.^[42]

Using data from 527,662 working adults in Spain, a January 2021 study in the European Journal of Preventive Cardiology found that an active lifestyle cannot cancel the negative effects on cardiovascular health caused by obesity.^[43][44] Study author Alejandro Lucia stated:^[45]

One cannot be "fat but healthy." This was the first nationwide analysis to show that being regularly active is not likely to eliminate the detrimental health effects of excess body fat. Our findings refute the notion that a physically active lifestyle can completely negate the deleterious effects of overweight and obesity.

References