HEALTH AT EVERY SIZE? MEETS THE CDC!

(Special thanks to my colleagues Jen Arnold for suggesting I write about this skeleton in my closet, and Ted Kyle for providing the idea for the graphic)

Skeleton in The Closet

When I was working concurrently on a masters degree in human nutrition and a PhD in health education in the late 1980's, I got involved in something that remains to this day, some 30 years later, one of the few real regrets in my life. But no, it wasn't drugs or gangs or even politics.

No, the regret is that I got involved with a physician friend of mine overseeing an OPTIFAST type weight loss program! For those who know me as a vocal champion for the Health At Every Size (HAES?) movement and a constant critic of ineffective and iatrogenic weight loss programs, contests and competitions, this is likely to come as somewhat of a shock. I have challenged our obsession with weight at many of the major health- and nutrition-related conferences in North America, written books and articles about it, and taught what I am pretty sure was the longest running HAES course at a Big Ten University for two decades.

And today I spend considerable time on LinkedIn challenging the endless litany of "weight loss breakthroughs" that seem to pop up almost daily. Although this is a relatively simple task, (all I have to do is ask for data to back up their claims of weight loss "success") responding to the sheer number of ongoing claims can be time consuming.

Semi-Starvation In The Name of Health

Back to the skeleton in the closet. For those unfamiliar with the term OPTIFAST, it was a type of intensive weight loss intervention, often referred to as a VLCD (very low calorie diet) which was all the rage at this time (think Oprah). Participants were taken off most or all real food and put instead on what was termed a "protein-sparing modified fast." Although the protocol varied, for most VLCD's, participants consumed only a number of what were basically flavored milkshakes, to the somewhat frightening tune of 700 or 800 calories a day for many months!

Of course, at that level of intake, the weight came off rather dramatically. In our defense, this was not a biggest loser competition where participants were yelled at, shamed and driven into submission. We hired a staff of exercise, nutrition and mental health professionals and held regular group meetings that combined health education, behavior modification and compassionate psychological counseling.

You can Google the details of these interventions. But, as anyone with any knowledge of them will tell you, the often impressive weight losses that sometimes amounted to 100 pounds or more, were followed by weight regain for the vast majority of participants, many gaining back more than they lost.

In fact, for years after we terminated the program (because of these results) I would see these folks walking down the street of our town - often trying to hide their faces in order not to meet my gaze. They were so ashamed - and yet in reality we were the ones who should have been apologizing. Though, at the time we didn't know better and were doing the best we could, we clearly violated our prime directive as health professionals - We did harm!

Health at Every Size

On the rebound from this really distressing experience, I decided to ignore much of what I had learned in college about weight and health, (and pay attention to the protestations against what we were were doing from my psychologist girlfriend who is now my wife) and embarked on a search for an alternative. It was at about that time I was introduced to what was later to become the Health at Every Size movement. I have written extensively about HAES and you can learn more about it here and here. I am honored to have been intimately involved now, as a national leader in the movement, for more than two decades.

In a nutshell, the HAES approach helps people to attain a more peaceful relationship with their bodies and their food by honoring and caring for the bodies that they have - right now. It is an evidence-based approach that helps people to improve the quality of their lives without the frustration, high dropout and iatrogenic consequences that routinely accompany traditional weight loss interventions. The basic conceptual framework of the HAES philosophy includes the following principles:

• Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
• 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.
• 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.
• 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.
• 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.

Contrary to the claims of some critics, the HAES approach does not suggest that health professionals ignore effective healthcare for larger people. When larger individuals present with medical problems, health professionals should consider and offer the same approaches that they would for a thin person presenting with similar problems.

In the case of a thin person with essential hypertension, for example, conventional medicine suggests dietary changes, increases in aerobic physical activity and stress management followed by medication, if necessary. Yet, a larger individual presenting with the same diagnosis is told to lose weight, despite all that is known about the likely unhealthy consequences of this prescription.

"Weighing In" On The Research

Over the past 3 or 4 decades, the research on weight loss programs, contests and competitions has been consistent and conclusive. Every such initiative that has been studied regardless of the population, the length and intensity of the program, the type of exercise and/or food intervention, the credentials of the people running the program, and every other variable imaginable has come up with the same set of results:

• Many people lose weight during the program.
• Most people regain their lost weight, many beginning to do so before the program is even over.
• Within a year or two after the program is over, most people have gained back most or all of the lost weight.
• Somewhere between 1/3 and 2/3 of participants end up weighing more than when they started the program.

It is hard to imagine that any other medical intervention with such a dismal set of results would continued to be prescribed, or perhaps even permitted, This is why a warning label should be included with every weight loss initiative, transparently detailing the most likely outcomes and potential negative consequences for participants.

The research on HAES interventions is growing. The first randomized controlled trial conducted in 2005 demonstrated the superiority of this novel approach compared to one of the most well respected behavioral weight loss programs in the country. Since that time more than a dozen such studies have been conducted. As a recent meta analysis of the literature concluded:

“Results from our review favor the promotion of programs that emphasize a nonrestrictive pattern of eating, body acceptance, and health rather than weight loss.”

Who'Da Thunk It?

Of course, even a dozen such studies have not yet made much of a dent in the obsession we have thinness and weight loss in this country. Acceptable body weight standards have been repeatedly lowered so that 2/3 of the American population is now considered to be "overweight" and in need of treatment.  Yet, there is no evidence that any of these treatments is effective and growing concern about negative consequences.

As a result children, women of all sizes and increasing numbers of men suffer from an intense fear of fat that plays havoc with their self-esteem and promotes disordered eating and exercise behavior. 

Despite some recent stagnation, the U.S. weight loss industry brings in some 65 billion dollars a year. Weight loss initiatives are still a mainstay of worksite wellness interventions. And the American Medical Association and most other health organizations now consider "obesity" (defined by the now scientifically discredited body mass index) to be a chronic disease with weight loss as the recommended solution.

That's why my interest was instantly piqued when I saw the title of a recent article in the Center's For Disease Control (CDC) own journal Preventing Chronic Disease:

"Do No Harm: Moving Beyond Weight Loss to Emphasize Physical Activity at Every Size"

And I was not disappointed (actually a bit shocked if the truth be told) on reading further, as the authors conclusions were as close as I have seen anything in the mainstream health establishment come to endorsing what we (HAES) have been promoting for more than 2 decades:

Let’s welcome patients who have avoided and feared going to the doctor because of feeling shame about their size. Let’s acknowledge the social determinants of health that affect a person’s body size. Let’s learn how to communicate with patients about these determinants and empower them to make healthy choices within the context of their own lives. Rather than harming patients with stigmatizing measurements that limit our ability to have a productive relationship, let’s focus our precious clinical time on helping patients to engage in active lifestyles. The result may be better outcomes in patient health and patient trust and improved patient–provider relationships.

Take Home

So it is with renewed optimism that I return to my work. I envision a time when people of all sizes will be treated with respect, a time when it will be their health and not their weight that will be the focus of any recommended treatments. Though we still have a long way to go - this article gives us hope that perhaps what Winston Churchill said when his generals turned back the Nazi forces at El Alamein might ring true with regard to the promotion of these ineffective and iatrogenic weight loss initiatives:

Now this is not the end. It is not even the beginning of the end. but it is, perhaps, the end of the beginning.

If this approach to helping people who are struggling with weight-related concerns intrigues you, we invite you to consider becoming a facilitator for our HAES work-site and community program - Heath for Every Body?. Details and registration for the upcoming facilitator training (in September) can be found here.

take care - Dr. Jon