my practice is grounded in the health at every size® approach

This means I promote:

  • Weight inclusivity: I offer the same respectful care to every person, celebrating the diversity of body sizes and shapes. I do not prescribe weight loss. I honor your body autonomy and your chosen priorities for health and wellbeing. I do not make any assumptions about you as a person, or about your habits or behaviors, based on your weight or body size.
  • Weight neutrality: I am not in favor or against of weight loss, but I reject the deliberate pursuit of weight loss, and trust that your body will take care of the question of weight when you are cultivating conscious and sustainable self-care and wellbeing in different realms: nutrition, movement, rest, stress management, emotions, relationships.

Additionally, I acknowledge that a lot of a person's health is not a consequence of personal choices, but rather of the interactions between genetic factors and social determinants of health. 

In alignment with a weight inclusive paradigm and the HAES approach, I deliberately avoid the terms "overweight" and "obesity" to refer to a person's size. When I use them, I do so with quotation marks to signal that I am challenging the construct and at the same time referring to a category according to Body Mass Index (BMI) as reported in research and/or a "diagnosis" made within the weight centric paradigm. Etymologically, the word "overweight" implies that all people should exist below an arbitrarily defined cutoff point (which by the way was established in alignment with financial interests of the pharmacology industry and the diet industry), or that all people who fall above said arbitrary cutoff point are ill or will live shorter lives (which is not backed by science). And the word "obesity" implies that a fat body is a consequence of eating in excess, which is not supported by evidence. In the words of Lucy Aphramor, creator of the Well Now approach the use of the 'o' words is obgobbing: "a phenomenon in which fat people's bodies are described using words that foster oppression. The words may be used thoughtlessly, inadvertently or intentionally. Obgobbing enacts power relations that strengthen existing hierarchies (...). It serves to repress marginalised voices and cultivates systems of thoughts and practice that deny people their agency and dignity". Like Lucy, "I reject the 'o' words because I am not working for a world without fat people. I am working for a world that is weight diverse, where nobody is starved of food, company or dignity - or equitable healthcare."

I include the 'o' words, in quotation marks, in the list of things I can help people with on my website because many people in the context in which I practice are not yet familiar with a weight inclusive or HAES approach, and although they are tired of the body shaming, they still believe they have the medical condition or diagnosis they have been given by someone who doesn't know better. If this is you, I want you to know that your body is not a problem to be fixed, and that there is a kind and compassionate way to cultivate self-care and wellbeing that is not contingent on your weight. This still applies if you have been diagnosed with prediabetes, diabetes and/or metabolic syndrome. Grounded in the HAES approach, together we can put in place behaviors that will allow you to care for yourself and achieve better metabolic and cardiovascular health independent of your weight, and free of the belief that your weight or body size is to blame. 

Below you can read more about the weight inclusive paradigm and the HAES approach, and at the bottom of the page you will find a list of references, in case you wish to learn more. 

 

weight-centered / weight-normative paradigm vs. weight-inclusive paradigm

The weight-centered health paradigm (WCHP) is currently the dominant paradigm in health care contexts. The majority of health providers - particularly physicians - are grounded in this paradigm, which defines "overweight" and "obesity" using mainly the Body Mass Index (BMI), and occasionally body fat percentages, and assumes that those categories represent pathological states (disease) in and of themselves. As a consequence, said paradigm typically prescribes weight loss in the interest of achieving what is commonly accepted as "healthy" or "normal" weight. Within this paradigm, interventions are based on energy intake reduction and increase in physical activity.

However, the dominant paradigm is not effective, and goes against the ethical principles of benevolence and non-malevolence (doing no harm) - it does not bring about sustainable weight loss for the majority of individuals, and paradoxically causes an increase in basal weight in the long term; and it doesn't necessarily result in better health outcomes. It also causes significant harms to health: development of disordered eating and eating disorders, weight cycling, increase in body dissatisfaction, low self-esteem, depression, anxiety, negative embodied experience, disconnection from the body, distraction from other meaningful goals in life, lower nutritional quality, less nutrient absorption, greater long term mortality risk and greater metabolic risk as a consequence of weight cycling. Additionally, when we use the terms "overweight" and "obesity", fat people are automatically diagnosed as unhealthy, and their bodies labeled as defective, which irrevocably links the physical shape and size of a person with disease. This creates a world in which no fat person can exist outside of a medical reference that labels them as defective. Inherently, the "overweight" diagnosis assumes that all people can and should be thin. These terms construct categories that confirm a health paradigm in which the BMI is assumed to be a reliable marker of individual health, and is considered to a large degree as something within a person's control (a bit of history about this index: the BMI was not created with the intention of diagnosing the health condition of a person, or of determining body composition, but to describe the distribution curve of weights in a population, that is for statistical purposes).

There is a different paradigm with solid evidence supporting its efficacy: the weight-inclusive paradigm, which avoids the use of weight as a health marker or outcome. Within this paradigm, the limitations and disadvantages of using BMI are acknowledged, and the idea that thin bodies are healthier is challenged. A broader lens is adopted to evaluate overall health and wellbeing, taking into account the physical, psychological, relational and spiritual needs of a person. A weight-inclusive paradigm seeks to eradicate weight-based iatrogenic practices in the health care arena, and to end the stigmatization of weight and size, as well as that of health problems (healthism). 

 

the tenets of a weight-inclusive paradigm

  • Do no harm.
  • Appreciate that bodies naturally come in a diversity of shapes and sizes, and ensure that all people, regardless of weight, have access to health care and wellbeing.
  • Because health is multidimensional, maintain a holistic focus, i.e. evaluate a variety of behavioral and modifiable health indices, instead of a focus on weight / weight loss. 
  • Encourage a focus on process (not outcomes) for quality of life, taking into account that wellbeing is dynamic and making continuous adjustments. 
  • Critically evaluate the empirical evidence around weight and weight-centered treatment methods.
  • Create individualized practices and sustainable environments.
  • Work to increase access to health, autonomy and social justice for people along the full weight spectrum, trusting that individuals will cultivate greater health when they have access to health care opportunities that are free of stigma. 

 

THE HEALTH AT EVERY SIZE APPROACH 

The Health at Every Size® (HAES®) approach (Health at Every Size and HAES are trademarks of the Association for Size Diversity and Health, ASDAH) is a growing trans-disciplinary movement that advocates for a weight-inclusive paradigm grounded in a social justice framework, and a shift in focus to weight-neutral outcomes.

The main intention of HAES in the clinical setting is to support health related behaviors and promote self-care in individuals of all sizes without using weight as a mediator; weight loss may or may not be a side effect.

HAES is emerging as a standard practice in the eating disorders field. The following associations explicitly support this approach: Academy of Eating Disorders, Binge Eating Disorder Association, Eating Disorder Coalition, International Association for Eating Disorder Professionals and National Eating Disorder Association.

HAES includes the following basic components (from Linda Bacon's HAES Community website):

  • Respect
    • Celebrates body diversity;
    • Honors differences in size, age, race, gender, dis/ability, sexual orientation, and other human attributes.
  • Critical awareness
    • Challenges scientific and cultural assumptions;
    • Values body knowledge and lived experiences.
  • Compassionate self-care
    • Finding the joy in moving one's body and being physically active;
    • Eating in a flexible and attuned manner that values pleasure and honors internal cues of hunger, satiety, and appetite, while respecting the social conditions that frame eating options. 

HAES principles (from the ASDAH website) are:

  1. Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights. 
  2. 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. 
  3. 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.
  4. 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.
  5. 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.

From a HAES approach:

  • We challenge the appearance ideals and promote liberation from experiences of guilt and shame around your body size and characteristics;
  • We counter diet mentality and body dissatisfaction;
  • We direct attention to what is happening within your body and your lived experience instead of criticizing your appearance;
  • We ground health practices in sustainable self-care from a place of body respect;
  • We explore whether there is a connection between disordered eating and emotional regulation;
  • We adopt a holistic focus to health that includes physical (among them metabolic and cardiovascular), emotional, nutritional, social and spiritual aspects;
  • We abandon dichotomous thinking about "good" and "bad" foods and morality surrounding food restriction;
  • We work on rediscovering and honoring your hunger and satiety cues;
  • We explore how different foods affect your body. 

 

WHAT THIS MEANS FOR YOU IN THE CLINICAL SETTING 

When you work with a health provider whose practice is grounded in a HAES approach, you as a patient will never be judged, nor asked to change the shape or size of your body, and you will  not be weighed during appointments unless it is medically necessary. You will find that you are treated by someone who is genuinely interested in understanding and addressing all of the aspects that may be affecting your health, including physical, emotional, financial, social, emotional and spiritual elements.

Weight is not a behavior, and all of the evidence in motivation science and behavioral change proves that a focus on weight is linked to poor motivation, high rates of attrition in any program or intervention, disordered eating and body shame, which have a negative impact on your quality of life, personal efficacy and self-care. This inevitably leads to worse outcomes and a lower probability of behavioral change.

On the other hand, we cannot infer anything about a person's health (cardiovascular, metabolic, mental, etc.) or about a person's behaviors simply by looking at their body size. There are people with health challenges and conditions and greater risk for certain illnesses all across the weight spectrum. I know the science well, and I don't deny the statistical correlation between BMI and certain health conditions; what I question based on a critical review of the evidence is that said correlation is equivalent to causality. 

When we put weight on the back burner, we can then redirect our energy and focus to cultivate sustainable and lasting change in habits and behaviors that will, in and of themselves, independent of weight, improve your health and wellbeing and reduce your metabolic and cardiovascular health (without negatively impacting your mental and overall health and wellbeing in the process). 

This behavioral change benefits ALL individuals of ALL shapes and sizes. It does not guarantee health for anyone (I know of no intervention or lifestyle that offers a signed guarantee of impeccable health for the rest of our lives), but it does increase self-efficacy, quality of life and the small percentage of our health that depends on self-care behaviors (as the rest is determined by genetics, environment and social determinants of health). 

 

References:

Aamodt, S. Why Diets Make Us Fat: The Unintended Consequences of Our Obsession with Weight Loss. New York, NY: Penguin Random House; 2016.

Aphramor L. Terms of belonging: Words, weight and ethical autonomy. NHDmag. 2018; 131: 41-45.

Bacon L, Aphramor L. Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight. Dallas, TX: Benbella; 2014.

Bacon L, Aphramor L: Weight science: evaluating the evidence for a paradigm shift. Nutrition J. 2011, 10.1: 9.

Be Nourished: Debunking the BMI myth. 2016. 

Brown H. Body of Truth: How Science, History and Culture Drive Our Obsession with Weight, and What We Can Do About It. Philadelphia, PA: Da Capo Press; 2015.

Brownell KD, Rodin J. Medical, metabolic, and psychological effects of weight cycling. Arch Internal Med. 1996, 154: 1325–1330.

Field AE, Manson JE, Taylor CB, Willett WC, Colditz GA: Association of weight change, weight control practices, and weight cycling among women in the Nurses’ Health Study II. Int J Obes. 2004, 28: 1134–1142.

Howard BV, Manson JE, Stefanick ML, Beresford SA, Frank G, Jones B, et al: Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial. JAMA. 2006, 295: 39-49. 10.1001/jama.295.1.39.

Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J: Medicare's Search for Effective Obesity Treatments: Diets Are Not the Answer. Am Psychol. 2007, 62: 220-233. 10.1037/0003-066X.62.3.220.

Miller WC: How effective are traditional dietary and exercise interventions for weight loss?. Med Sci Sports Exerc. 1999, 31: 1129-1134. DOI: 10.1097/00005768- 199908000-00008.

Moradi B, Dirks D, Matteson AV: Roles of sexual objectification experiences and internalization of standards of beauty in eating disorder symptomatology: a test and extension of objectification theory. J Counseling Psych. 2005, 52: 420–428.

National Institutes of Health (NIH): Methods for voluntary weight loss and control (Technology Assessment Conference Panel). Ann Intern Med. 1992, 116: 942-949.

O’Hara L, Taylor J: What’s wrong with the ‘war on obesity’? A narrative review of the weight-centered health paradigm and development of the 3C framework to build critical competency for a paradigm shift. SAGE Open 2018; April-June: 1-28.DOI: 10.1177/2158244018772888

Stice E, Agras WS: Predicting onset and cessation of bulimic behaviors during adolescence: a longitudinal grouping analysis. Behavior Therapy. 1998, 29: 257–276.

Stice E, Presnell K, Spangler D: Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psycho.l 2002, 21: 131–138.

Stice E: A prospective test of the dual-pathway model of bulimic pathology: mediating effects of dieting and negative affect. J Abnormal Psyc.h 2001, 110: 124–135.

Stice E: Interactive and Mediational Etiologic Models of Eating Disorder Onset: Evidence from Prospective Studies. Annu Rev Clin Psychol. 2016, 12: 359-81.

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Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C et al: The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity. 2014; 2014:1-18. doi:10.1155/2014/983495.

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