Sunday, October 16, 2011

Book review: Trying to understand the Health at Every Size movement

As any regular reader of this blog can probably guess, I have a somewhat confused relationship with the whole concept of dieting. On the one hand, I love the idea of being proactive, making intelligent decisions about food, and getting into a smaller size of jeans. On the other hand, I feel like all of this diet mind-chatter is a waste of intellectual capacity, and that diets often take people further away from health and their goals instead of closer to them.  I have been spending a lot of time in this blog lately reflecting on self-love and its relation to health.

Because of these mixed feelings, the Health at Every Size (HAES) movement both attracts and repels me. I want to believe there is a healthier way to eat and live and to pursue balance of food and exercise.  On the other hand, I am terrified that the HAES approach just means learning to be happier in size 14 jeans (until those get too tight and I need a 16, and then an 18, and so on...)  A recent blog post on "Refuse to Regain" seems to echo the latter view, characterizing HAES as "eat without restrictions."

I read an interview in More Magazine with Linda Bacon that suggested there might be more to the HAES movement than what Frances has dismissively called "Fat Serenity." I asked for and received a free review copy of Health at Every Size: The Surprising Truth about Your Weight. (Though I never read the original version, the version I have says it is "revised & updated.")  This post will be an overview of some of the main ideas, but I'd like to start an online discussion about HAES, because there is just so much to talk about here.  Linda Bacon's book is thick and information-dense, and she's not the only writer in the HAES movement. I am sure there is plenty of disagreement even within the HAES movement about exactly what it means. However, this book seemed like a good place to start.

The overarching premise of the book is that our bodies are innately tuned to maintain a healthy weight range for us, but that our obsession with fat and weight, as well as environmental factors like highly engineered food products, have helped us to lose touch with our true hunger signals.  Our bodies' setpoints probably don't align with the current hyper-thin beauty ideal, but they may be lower than our current weights, especially if we have gotten caught up in the diet-regain cycle or are eating in response to emotions instead of hunger.  Our bodies are especially tuned, Bacon says, to avoid weight loss, which makes sense because human beings evolved in a harsh environment where food was difficult to obtain.  Our bodies are less sensitive to weight gain because storing a little extra fat was a good insurance plan against famine, especially for women, who needed extra protection from starvation because of the demands of carrying and nursing babies. 

The book echoes many criticisms we have already heard from the weight-loss gurus about food politics and processed foods and agrees that they have created a food environment where our "thrifty genes" make it hard to maintain our weight.  In our current food culture, food is always available, and the most available food is both high-calorie and low-nutrient.  We have also learned to ignore our hunger signals in favor of all kinds of conflicting messages and drives.  
External rules, such as belief systems about good foods, bad foods, or appropriate amounts or times to eat, drown out our innate ability to respond to setpoint cues. We eat not because we're hungry, but because we're sad, guilty, bored, frustrated, lonely, or angry. And because food can't take care of our emotions, we eat and eat and never feel satisfied.
Though the environment we live in encourages us to overeat and gain weight, we also are taught to judge ourselves harshly for even small amounts of extra weight. This sets up the diet-regain cycle.

To break out of this cycle, Bacon says not that we have to "eat without restrictions," but that we need to start paying more attention to our body's hunger signals and how different foods make us feel.  By decoupling healthy living from trying to attain an unattainable weight ideal, we can definitely become healthier and may even, like Bacon herself, lose some weight in the process. The tricky part, though, is that weight loss can't be the goal.  The goal is to increase physical activity and learn healthier eating habits.  Any weight loss would have to be a nice but unimportant side effect.  Bacon provides tools for those who want to become more in tune with their body's hunger signals, like a hunger scale and journal and a lot of information about food.  She also suggests that through using this approach, we can retrain our tastes so that we enjoy healthier, plant-based foods more and crave processed foods less.  She also says we need to learn to satisfy other hungers besides those for food, like the need for rest and emotional fulfillment.

The thing this makes this book truly unique is that it includes the results of a scientific study that tested its premise.  Women whose weights were in the "obese" range were recruited and randomly assigned to two groups, one that learned Bacon's HAES approach and another group, led by mainstream diet researchers and obesity experts, that followed current "best practices" for weight loss.  Both groups were tested for health markers at different points in the study, at the insistence of one of the diet researchers who thought that the HAES approach could endanger the health of the participants. The groups met weekly for six months.  The results after one year? Though the dieting group "showed some initial weight loss and health benefits," they ended up regaining the weight they had lost and reversing their improvements in health markers.  The HAES group improved health markers like cholesterol and blood pressure and increased their physical activity.  They said they were happier and enjoyed their food and activity more.  Neither group showed significant weight loss.  The message here is obvious: If weight loss is unlikely, wouldn't it be better to become happier and healthier than just more restrictive and negative?

I think that this approach has the potential to liberate women and improve their lives and health. It's a hard sell, though, even to me.  It's hard to think about giving up the hope of a smaller body that fits my own beauty ideal, even if I know from experience how difficult it is to achieve and maintain that ideal.  It's hard not to want what I want. I do see a lot of promise, here, though, of the kind of life I really want.  I want to love my body and treat it well. I want to stop making my happiness so dependent on what the scale says.  I want to free my mind from this weight obsession so I can pursue worthier goals.

I think this is going to be a book I will read and reread, and that the process of learning is going to be long-term.  Bacon herself admits to struggling with self-consciousness about her weight at times, but says that often those feelings help her tune in to other needs if she lets herself learn from them. She gives the  starting to crave richer food and noticing that she was gaining weight while writing the first edition of this book. When she looked her feelings more closely, she realized that she was responding to "fears of vulnerability" about the book, and that led her to make changes to make the book stronger.  It's interesting to think of "feeling fat" as a cue to something more important going on.  

I know that it's common for bloggers to ask questions at the end of posts as a way to encourage comments. In this case, I don't want the comments for their own sake, but am genuinely curious to hear what you think of this approach.  Do you have other HAES writers or books to suggest? Let's start a discussion, because I think there is something really important to learn from this approach.


  1. I feel deeply, deeply skeptical about HAES. I wouldn't go so far as to call it "Fat Serenity" though, because from reading the blogs of HAES proponents, I sense a lot of defensiveness, denial, and anger. That doesn't look like serenity to me.

    And while the concept of HAES does have a certain appeal, there has to be a size beyond which a person can't consider themselves to be truly healthy. Can someone call themselves "healthy" when they have sleep apnea? Or are so heavy they find it difficult to walk any distance? Or need to wear bike shorts under skirts and dresses to prevent "chub rub"? Or find it difficult to tie their shoe laces? Really?

    Now I'm starting to sound like Jillian Michaels, but I think you get my point...

  2. maybe ill get it, may provide some tips for my weight loss journey

  3. How does HAES differ from intuitive eating? About ten years ago I joined an intuitive eating group therapy program and it is very hard to properly embrace the intuitive eating rules, especially "eat what your body wants."

    Last year, I went to a cognitive therapist to examine and change my eating behaviour. The interesting discovery is that eating a certain food does not trigger overeating. What causes me to overeat is dieting or following dieting rules. If I feel like I'm on a diet, I will overeat.

    So I fully agree with the concept of eating without restriction. Not in amount or type of food. But, that does not mean that I will accept being overweight the remainder of my life. I just have to do it differently. Just because I can eat whatever I want doesn't mean that I will chose to do so.

    The psychological aspect of weight loss and dieting is routinely disregarded. It was no surprise when I read that dieting is the most common environmental trigger for eating disorders.

  4. Having met you in person fairly recently...and knowing that you know my story pretty well, here's my take:

    At almost 49 years old (as of November 10, 2011), I am the healthiest I've ever been in terms of cholesterol, BP, resting heart rate, sugar, hormones, thyroid, etc. My numbers are well within normal limits and I am not taking any prescriptions except for Armor thyroid and progesterone cream.

    That said, I have other issues like arthritis and a congenital birth defect that affects my lower back. These don't stop me fron working out however. A normal week has me kickboxing twice a week, doing a kettlebell/strength training workout two or three times a week, and walking three or four times a week. Other not-so-normal weeks, I might only walk a few times.

    But as you saw, I am not "skinny."

    Five years ago, I weighed less than I do now (not sure how much as I don't weigh myself any more), but I was on prescription meds for cholesterol and my BP and sugar numbers were borderline. I was unhappy and in fear of never reaching my goal weight or gaining it all back.

    So. I am healthy at a larger size. I am happy at a larger size. I am not defensive, per se. I am not perfect, either. But I am happy and healthy.

  5. Adding to my comment:

    In terms of eating, I have found that my body truly does know what it wants, and sometimes my mouth/brain wants something different. Usually when I am hungry and craving something, I know I need protein. That doesn't mean I go for protein every time, but that's usually what I need.

    I also find that when I eat a small amount of something of excellent quality (like chocolate), I am good to go versus when I eat some crappy, processed chocolate-ish thing...then I am left wanting more because there was no redeeming value in the crap.

    Eating good quality, minimally processed foods slowly and happily, whether it be a salad or a homemade cookie is much better on our bodies than scarfing down cheap, processed foods (salads included...) in a state of distress and desperation...

  6. Many swirling thoughts on this topic, but my first comment is a quick response to RedPanda - "chub rub" can be experienced by anyone of a healthy size and weight who has thighs that touch when walking and spend time in a warm climate, particularly a humid one. "Chub rub" is a normal phenomenon that results from skin friction. It's no different to the chafing experienced by runners, and the number of healthy size/weight people who don't have a complete gap between their thighs is quite small. So lets not use that as a marker of healthiness.

    As for the HAES movement, I think many of the principles and philosophies are sound, but I don't buy the idea of not working towards weight loss as a realistic one. Like it or not, society is not going to take away the importance of weight, and it's one of many useful ways of measuring our overall health. I think other markers should be used as well, weight measurement shouldn't be the sole focus. I absolutely believe that health and fitness are better overall goals, but weight and weight loss are convenient ways to measure progress in these domains.

    I think the mindfulness/intuitive eating aspects are very sound, and that type of approach can be very successful for weight loss and improving health overall. I don't have any HAES books or writers to recommend, but would STRONGLY suggest you have a look at The Happiness Trap by Dr Russ Harris. A lot of what he writes about (changing your life based on Acceptance and Commitment Therapy, which is an evidence based therapeutic approach) is applicable to weight loss, and will probably resonate with what you're interested in re: "I want to free my mind from this weight obsession so I can pursue worthier goals"

  7. I am a dietitian in private practice--over 25 years--and work extensively with clients who struggle with weight management, eating disorders and metabolic related diseases (diabetes, CVD, thyroid dysfunction, even cancer) I realize it is hard for many to reconcile a weight centric approach with the HAES philosophy.

    People mistakenly assume HAES is synonymous with abandoning oneself because it takes the focus off of their weight. Many dieters (and society at large)cultivate a fear of weight and used this fear as the prime motivator to try to starve themselves. Abandoning weight removes their rudder. Without a prime motivator (the fear of weight gain or preoccupation with losing weight) they often feel lost in the void.

    Adopting HAES is more than not being preoccupied weight. It is the grounded understanding that when you live your life listening (or learning to listen) to body cues, honoring your body, and allowing food it's rightful place, weight will take care of itself.
    Health at every size is the result and the process.

    Moving away from a diet mentality requires a great deal of learning. Dieting is often authoritarian and detracts from authentic self care. HAES honors food's rightful place in life. HAES promotes effective self regulation and adequate resilience. These are core components of living well at any size

  8. So the first commenter says HAES bloggers are defensive and then proceeds to be cruel.
    things that make you go hmmmmm...

    HAES is changing my life and if the message was given a fair shake would change the lives of many, many more.

  9. @ Janie - My comment wasn't intended to be "cruel".

    I was just stating my opinion that I don't think anyone who is dealing with the issues I mentioned can say they are in optimal health, or are doing everything they can to be truly healthy. I guess that's where the (perceived) defensiveness comes in.

    When I was obese and suffered from sweat rash and sleep apnea, and found it difficult to walk any distance, I didn't consider myself to be healthy.

  10. Just wanted to say I have been pondering this post since Sunday... mother visit keeps interrupting my internet time ;) Still scratching my head but wanted to say thanks for the brain fodder and for sharing your thoughts about such a difficult topic!

  11. RDStudent7:25 PM

    My experience with HAES has been very similar to Karen's. Bonnie is right when she says HAES is a process - it's not as easy as waking up one day and saying "I'm ok with my body and I'm never going to diet again and I'm going to eat everything I want!"

    When I finally did adopt HAES, I had been dieting for so long and forcing my body into unreasonable weights that I experienced a weight rebound and gained about 10 lbs. This was upsetting but I decided to commit to HAES because I could not take the extreme hunger and food preoccupation that I was living with. I quit the gym because I wasn't even sure if I liked exercise or just did it to be thinner. Fast-forward 18 months, and I am finally starting to get the intuitive eating thing, and I've started seriously exercising again because I realized that I actually love to exercise - it makes me feel great, it keeps me sane and it makes me strong. I'm not sure where my weight will go (I try never to step on the scale - that action in itself had become an almost twice daily addiction for me) but I do think it has stabilized now, and I don't binge on food anymore or fantasize about diving into a plate of cheese or pile of donuts. I turn down lousy chocolate because I know I will feed myself only the good stuff at home. I realized I don't even like a lot of the crap I would over-eat, which is really amazing to me. Overall, I am happier and healthier and I eat better than I did when I was trying to be thin. I have been craving roasted kale like crazy lately...not cupcakes. But I have the cupcake if I feel like it too. Which is really rare.

    I do understand your hesitance with HAES. Don't try it until you're ready, until you're tired of pursuing something that might never make you happy anyway, until you're really done with the crazies that dieting causes. Try some of the great books that are out there on Intuitive/mindful/normal eating:
    Intuitive Eating by Tribole and Resch
    The Diet Survivor's Handbook by Matz and Frankel
    Overcoming Overeating (an old one)by Hirschmann and Munter
    And for some soul searching on why we are so ready to hate our bodies, try Kim Chernin's wonderful The Obsession: Reflections on the Tyranny of Slenderness. It's old but you'd think it was written today.

    A word about the purported defensiveness of HAES proponents: embracing HAES is seen as going rogue. A weight-centered approach to living is unfortunately the norm. Accepting and loving a fat body is regarded as heresy. And for women, there is only ever one type of body (slender) ever depicted in the media, unless it's a headless fatty in a fat-shaming article. I'm mad that there is only one beauty ideal and that it doesn't depict the majority of women (60% of us overweight or obese, right?). Some days it's harder to love my body than to dive back into dieting, and that's just not fair. So I think some anger is definitely overdue.

  12. Well Red Panda that may have been the case for you but you still can't paint all fat people with a fat brush, I'm morbidly obese but perfectly healthy with the right clothes I avoid chafing and rashes. I exercise and eat well.
    ^^ I second what the previous poster said, there is justifiable anger when people throw out generalizations that support what society has fed us for years. You are wrong if you are fat. I disagree strongly - HAES is a beautiful movement that many would benefit from!


"Count your calories, work out when you can, and try to be good to yourself. All the rest is bulls**t." -- Jillian Michaels at BlogHer '07