Thursday, February 10, 2011

Health at Every Size: The Article You MUST Read

In a recent post, I talked about the "what everyone knows": that good health is synonymous with a "normal" weight, usually as defined by the BMI.

But is this a fact or an assumption?

The history of science is littered with "scientific facts" that were subsequently proven to be utter bunk. Until relatively recently, for instance, bloodletting was considered a valid medical intervention. Well into the 19th century, bloodletting was one of the principal ways of curing many diseases. It was "medicine" and sacrosanct. No one questioned its validity.

I think that our scientific understanding of weight, weight management and health will also undergo a sea change in the coming years. The whole area is awash with assumptions that are considered to be facts. Furthermore, there is an enormous amount of controversy: high or low fat; no carbs; calories in-calories out; exercise is essential; exercise makes little difference, etc. etc. But something's got to give, because even the most die-hard diet supporter cannot shut her eyes to the fact that most people who go on a diet end up...fatter, often unhealthier and certainly unhappier.

Via the Fat Nutritionist, I recently read a long, scholarly article in Nutrition Journal entitled "Weight Science: Evaluating the Evidence for a Paradigm Shift", by Dr. Linda Bacon and Dr. Lucy Aphramor. If you have the time, I highly suggest you read the entire article here. It's much too long and detailed an article to properly summarize, but I'd like to give you a flavour what it says so that you will go and see for yourself. This article is certainly one of the most important articles on weight and health that I've seen in a very long time.

The article begins with the observation that despite major concern from the medical and public health authorities over the issue of overweight and obesity, and despite the fact that huge numbers of people are desperately trying to lose weight (and fueling a weight loss industry worth close to $59 billion per year), the majority of people cannot lose weight and keep it off, nor do they achieve the expected health benefits resulting from a lower weight. At the same time,

Concern has arisen that this weight focused paradigm is not only ineffective at producing thinner, healthier bodies, but also damaging, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination [6-8]. As evidence-based competencies are more firmly embedded in health practitioner standards, attention has been given to the ethical implications of recommending treatment that may be ineffective or damaging [5, 9].
In response to this sad state of affairs, a growing number of individuals and organizations are proposing a new paradigm, (or, if you will, a completely new way of seeing things) to replace the weight loss=success=health paradigm that has proved itself to be mostly unattainable and questionably correct. This new paradigm is "health at every size" (HAES).

The authors then deal with a list of assumptions about the conventional, weight-focused paradigm. Each assumption is accompanied by an evidence-based refutation.

Here are the assumptions, which I'm sure many, if not most of us, believe are "facts". (These assumptions are directly quoted from the article.):

  • Adiposity poses significant mortality risk.
  • Adiposity poses significant morbidity risk.
  • Weight loss will prolong life.
  • Anyone who is determined can lose weight and keep it off through appropriate diet and exercise.
  • The pursuit of weight loss is a practical and positive goal.
  • The only way for overweight and obese people to improve health is to lose weight.
  • Obesity-related costs place a large burden on the economy, and this can be corrected by focused attention to obesity treatment and prevention.

These assumptions are the basic "truths" of the weight-loss paradigm. Yet, Bacon and Aphramor have deftly refuted each one using almost 180 references from other serious studies to back up their statements.

Please take the time out of your busy day to read this article in full. Then tell me what you think. It's a real eye-opener and it's going to make a lot of people squirm. But that's often what happens when someone speaks truth to power.

It's time to stop wailing about the fattening of our society and looking at what we can do about our health. The two are not necessarily linked and constantly trying to establish a causal relationship between overweight and illness is robbing us of the time and energy we need to all be healthier in the body that we were born with. P.S. "The body that we were born with" is worth a post all on its own. Stay tuned.

Note: Dr. Arya Sharma has also published a post recently on this article. It's worth reading here.


  1. thanks for these links, especially to the main article. i actually hard-copied it to analyze. the arguments are interesting, from a preliminary glance.

    i will get back to you. :)

    this should be fun. (lurve me some rhet analysis!)


  2. after further reflection, i realized i could do a critical analysis of the article, but the analysis would be much longer than your blog post. i'm trying to break that habit. :)

    i guess where "health at every size" advocates and i would part ways would be at the point where lifestyle behaviors are suggested or implied to have a significant effect on overall health outcomes ("health promotion").

    in truth, we simply do not have adequate scientific research to know or begin to understand, yet, what behavior changes actually do for individuals in terms of health outcomes independently of other factors, such as commulative stress levels, an individual's options to choose change, socio-economic status, the role of discrimination, and so forth.

    it really bothers me when the haes paradigm or the (status quo) medical/science paradigm ASSUME that people have similar external resources and access to interventions. they don't. or assume that people have similar internal resources to interventions. they don't.

    as a nurse i have suffer every day from moral distress because our society shifts responsibility onto individuals for things that individuals do not have the ability to control. this happens all the time when it comes to the issue of weight. (because, as bacon says, "weight is not a behavior.") but somehow the foundation of that argument is lost when it comes to issues related to "behaviors" that individuals quite often have little or no control over, such as eating fresh fruits and vegetables or high quality protein, exercising, fully recovering from an accident before returning to work, avoiding polluted water and air, getting adequate rest, buying medications for their illnesses, and so forth.

    it's as if the "professionals" live on a different planet from most of us.

    and, indeed, many of them do live in a much different world, in a place that is far more protected and insulated from the harsh realities of what are common everyday struggles to survive, endured by those to whom professionals often enjoy giving (unhelpful) advice.


  3. i left a comment on Dr. Sharma's blog in reference to his article, to which you linked above, posted under my internet *nom*, RNegade. in case you are interested.

    hope you are doing well! looking forward to your next post. :)


  4. Hi Rebecca,

    Aha! I thought you were RNegade. Whatever your name, though, I always appreciate your wonderfully thoughtful comments.

    I can absolutely see where you're coming from with the above comment. Perhaps it's not right to do so, but I think one can, to a certain extent, separate out the socio-economic elements from the HAES/anti-HAES debate. You are absolutely correct in pointing out that many people do not have the economic means to put HAES into practice. But if we put this (albeit monumental) issue aside for a moment, I suppose my post was addressing the readers and writers of blogs I read quite regularly who have the means to eat fairly healthily (and I know that that term in itself is a mine field) but who are so enmeshed in the simplistic paradigm of good health equalling slimness that they will often actually sabotage their health in an effort to reach that elusive number on the scale.

    I'm having trouble trying to distill these thoughts into a coherent response to your comment. Feel free to contact me via my hotmail address to continue the discussion. I think it's really important.

  5. this is a great discussion! i continued it (ad nauseum?) in my email to you. :)

    i totally share your concern about people who hurt their bodies and minds by chasing after an elsusive number on the scale or measuring tape or calorie disagreement there.

    happy valentine's day!


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