# data[].attributes.headline
Weight Management for Children / Manejo del peso para los niños (English/Español)

# data[].attributes.subject
Weight Management for Children / Manejo del peso para los niños (English/Español)

# data[].attributes.body
Text: Quick read (translates to Spanish in browser)

Texto: Lectura rápida (se traduce al español en el navegador)

# data[].attributes.attachment_link.description
For overweight children 7 and older, the initial goal is to keep them from gaining more weight. Changes in eating habits and exercise are gradually introduced to trim pounds.

# data[].attributes.body
Audio & Text: 6:18 min.

# data[].attributes.attachment_link.title
Normative Does Not Mean Inclusive: A Diverse Approach to Size in Public Health Training​ – SOARS Virtual Conference

# data[].attributes.headline
AAP Guidelines on Childhood Obesity (English)

# data[].attributes.subject
AAP Guidelines on Childhood Obesity (English)

# data[].attributes.body
Text: Estimated 9 min. read

# data[].attributes.attachment_link.title
What Parents and Caregivers Need to Know About the New Pediatric Obesity Guidance

# data[].attributes.attachment_link.description
For the first time in 15 years, the American Academy of Pediatrics updated its pediatric obesity guidelines to recommend an active approach.

# data[].attributes.headline
Help Your Child Lose Weight Safely (English)

# data[].attributes.subject
Help Your Child Lose Weight Safely (English)

# data[].attributes.body
Audio: Review from 1:00-4:50 min.

# data[].attributes.attachment_link.title
How to help your child safely lose weight - CHOC - Children’s health hub

# data[].attributes.attachment_link.description
Dr. Katherine Williamson, a Pediatrician at CHOC, discusses how to manage your child’s eating habits while protecting a healthy body image.

# data[].attributes.headline
Weight-Neutral Approaches to Nutrition (English)

# data[].attributes.subject
Weight-Neutral Approaches to Nutrition (English)

# data[].attributes.body
Text &Tables

# data[].attributes.attachment_link.title
Debating Weight Loss vs. Weight Neutral Strategies for Improvements of Health

# data[].attributes.attachment_link.description
Despite decades of development and testing of weight-loss interventions, the adult populations worldwide have witnessed a continuous rise in body weight. There is an ongoing debate about how to move forward. Some argue that this rise calls for more…

# data[].attributes.headline
Nutrition Myth Busters / Mitos sobre nutrición  (English/Español)

# data[].attributes.subject
Nutrition Myth Busters / Mitos sobre nutrición  (English/Español)

# data[].attributes.body
Video: 4:31 min. - Stop at 3:30min. (Translates to Spanish in Closed Captions)

Vídeo: 4:31 min. - Deténgase en 3:30 min. (Se traduce al español en Closed Captions)

# data[].attributes.headline
Poodle Science / La ciencia del caniche (Poodle) (English/Español)

# data[].attributes.subject
Poodle Science / La ciencia del caniche (Poodle) (English/Español)

# data[].attributes.body
Video: 2:49 min. (Translates to Spanish in Closed Captions)

Vídeo: 2:49 min. (Se traduce al español en Closed Captions)

# data[].attributes.attachment_link.authors[].name
Association for Size Diversity and Health (ASDAH)

# data[].attributes.body
Video: 2:51 min.

# data[].attributes.attachment_link.title
Doctors use weight loss drugs to treat childhood obesity in kids as young as 12

# data[].attributes.attachment_link.description
NBC’s Vicky Nguyen sat down with a 16-year-old girl to discuss her weight-loss journey with Wegovy, an FDA approved weight loss drug for kids as young as 12 years old. The American Academy of Pediatrics now recommends weight loss drugs as an option to treat obesity in children, which is at 22% in ages 12 to 19.

# data[].attributes.body
Text: 6-pages

# data[].attributes.attachment_link.title
Weight-Inclusive Approaches to Nutrition and Dietetics_ A Needed Paradigm Shift.pdf

# data[].attributes.headline
Nutrition Guide for Toddlers / Guía de nutrición para niños pequeños (English/Español)

# data[].attributes.subject
Nutrition Guide for Toddlers / Guía de nutrición para niños pequeños (English/Español)

# data[].attributes.body
Audio and Text: 2:37 min. (translates to Spanish on website)

Audio y texto: 2:37 min. (se traduce al español en el sitio web)

# data[].attributes.attachment_link.description
While growth slows somewhat during the toddler years, it's a new era where kids will eat and drink more independently.

# data[].attributes.headline
Comparison of Nutrition Approaches / Comparación de los enfoques de la nutrición (English/Español)

# data[].attributes.subject
Comparison of Nutrition Approaches / Comparación de los enfoques de la nutrición (English/Español)

# data[].attributes.body
Audio: 2:41 min. (Translates to Spanish in Closed Captions)

Vídeo: 2:41 min. (Se traduce al español en subtítulos)

# data[].attributes.attachment_link.title
Weight Normative versus Weight Inclusive Approach at UNC

# data[].attributes.headline
BMI Associated with Head Start Participation (English)

# data[].attributes.subject
BMI Associated with Head Start Participation (English)

# data[].attributes.body
Text: 6-pages with Tables

Original Study:

Changes in Body Mass Index Associated With Head Start Participation | Pediatrics | American Academy of Pediatrics

# data[].attributes.body
Text

# data[].attributes.attachment_link.readable_text
Abstract

Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. Concern has arisen that this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, 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. This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. Randomized controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus. This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.

Peer Review reports

Introduction

Concern regarding "overweight" and "obesity" is reflected in a diverse range of policy measures aimed at helping individuals reduce their body mass index (BMI) ¹. Despite attention from the public health establishment, a private weight loss industry estimated at $58.6 billion annually in the United States [ 1], unprecedented levels of body dissatisfaction [ 2] and repeated attempts to lose weight [ 3, 4], the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality [ 5]. 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].

A growing trans-disciplinary movement called Health at Every Size SM (HAES) ² shifts the focus from weight management to health promotion. The primary intent of HAES is to support improved health behaviors for people of all sizes without using weight as a mediator; weight loss may or may not be a side effect.

HAES is emerging as standard practice in the eating disorders field: The Academy for Eating Disorders, Binge Eating Disorder Association, Eating Disorder Coalition, International Association for Eating Disorder Professionals, and National Eating Disorder Association explicitly support this approach [ 10]. Civil rights groups including the National Association to Advance Fat Acceptance and the Council on Size and Weight Discrimination also encourage HAES. An international professional organization, the Association for Size Diversity and Health, has developed, composed of individual members across a wide span of professions who are committed to HAES principles.

Health at Every Size: A Review of Randomized Controlled Trials

Several clinical trials comparing HAES to conventional obesity treatment have been conducted. Some investigations were conducted before the name "Health at Every Size" came into common usage; these earlier studies typically used the terms "non-diet" or "intuitive eating" and included an explicit focus on size acceptance (as opposed to weight loss or weight maintenance). A Pub Med search for "Health at Every Size" or "intuitive eating" or "non-diet" or "nondiet" revealed 57 publications. Randomized controlled trials (RCTs) were vetted from these publications, and additional RCTs were vetted from their references. Only studies with an explicit focus on size acceptance were included.

Table 1 Randomized controlled HAES studies reported in peer-reviewed journals

A seventh RCT reported at a conference also found significantly positive results [ 18], as did a non-randomized controlled study [ 21] and five studies conducted without a control [ 22- 26].

Assumptions underlying the conventional (weight-focused) paradigm

Assumption: Adiposity poses significant mortality risk

Assumption: Adiposity poses significant morbidity risk

Evidence: While it is well established that obesity is associated with increased risk for many diseases, causation is less well-established. Epidemiological studies rarely acknowledge factors like fitness, activity, nutrient intake, weight cycling or socioeconomic status when considering connections between weight and disease. Yet all play a role in determining health risk. When studies do control for these factors, increased risk of disease disappears or is significantly reduced [ 61]. (This is less true at statistical extremes.) It is likely that these other factors increase disease risk at the same time they increase the risk of weight gain.

As another example, consider type 2 diabetes, the disease most highly associated with weight and fat distribution. There is increasing evidence that poverty and marginalization are more strongly associated with type 2 diabetes than conventionally-accepted risk factors such as weight, diet or activity habits [ 30, 71- 73]. A large Canadian report produced in 2010, for example, found that low income was strongly associated with diabetes even when BMI (and physical activity) was accounted for [ 73]. Also, much evidence suggests that insulin resistance is a product of an underlying metabolic disturbance that predisposes the individual to increased fat storage due to compensatory insulin secretion [ 61, 74- 78]. In other words, obesity may be an early symptom of diabetes as opposed to its primary underlying cause.

It is also notable that the prevalence of hypertension dropped by half between 1960 and 2000, a time when average weight sharply increased, declining much more steeply among those deemed overweight and obese than among thinner individuals [ 90]. Incidence of cardiovascular disease also plummeted during this time period and many common diseases now emerge at older ages and are less severe [ 90]. (The notable exception is diabetes, which showed a small, non-significant increase during this time period [ 90].) While the decreased morbidity can at least in part be attributed to improvements in medical care, the point remains that we are simply not seeing the catastrophic disease consequences predicted to result from the "obesity epidemic."

Assumption: Weight loss will prolong life

Evidence: Most prospective observational studies suggest that weight loss increases the risk of premature death among obese individuals, even when the weight loss is intentional and the studies are well controlled with regard to known confounding factors, including hazardous behavior and underlying diseases [ 91- 96]. Recent review of NHANES, for example, a nationally representative sample of ethnically diverse people over the age of fifty, shows that mortality increased among those who lost weight [ 97].

While many short-term weight loss intervention studies do indicate improvements in health measures, because the weight loss is always accompanied by a change in behavior, it is not known whether or to what extent the improvements can be attributed to the weight loss itself. Liposuction studies that control for behavior change provide additional information about the effects of weight (fat) loss itself. One study which explicitly monitored that there were no changes in diet and activity for 10-12 weeks post abdominal liposuction is a case in point. Participants lost an average of 10.5 kgs but saw no improvements in obesity-associated metabolic abnormalities, including blood pressure, triglycerides, cholesterol, or insulin sensitivity [ 98]. (Note that liposuction removes subcutaneous fat, not the visceral fat that is more highly associated with disease, and these results should be interpreted carefully.)

In most studies on type 2 diabetes, the improvement in glycemic control is seen within days, before significant weight or fat is lost. Evidence also challenges the assumption that weight loss is associated with improvement in long-term glycemic control, as reflected in HbA1c values [ 99, 100]. One review of controlled weight-loss studies for people with type 2 diabetes showed that initial improvements were followed by a deterioration back to starting values six to eighteen months after treatment, even when the weight loss was maintained [ 101].

Furthermore, health benefits associated with weight loss rarely show a dose response (in other words, people who lose small amounts of weight generally get as much health benefit from the intervention as those who lose larger amounts).

These data suggest that the behavior change as opposed to the weight loss itself may play a greater role in health improvement.

Assumption: Anyone who is determined can lose weight and keep it off through appropriate diet and exercise

Evidence: Long-term follow-up studies document that the majority of individuals regain virtually all of the weight that was lost during treatment, regardless of whether they maintain their diet or exercise program [ 5, 27]. Consider the Women's Health Initiative, the largest and longest randomized, controlled dietary intervention clinical trial, designed to test the current recommendations. More than 20,000 women maintained a low-fat diet, reportedly reducing their calorie intake by an average of 360 calories per day [ 102] and significantly increasing their activity [ 103]. After almost eight years on this diet, there was almost no change in weight from starting point (a loss of 0.1 kg), and average waist circumference, which is a measure of abdominal fat, had increased (0.3 cm) [ 102].

A panel of experts convened by the National Institutes of Health determined that "one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years." [ 28] More recent review finds one-third to two-thirds of dieters regain more weight than was lost on their diets; "In sum," the authors report, "there is little support for the notion that diets lead to lasting weight loss or health benefits [ 5]." Other reviews demonstrate the unreliability of conventional claims of sustained weight loss [ 104, 105]. There is a paucity of long term data regarding surgical studies, but emerging data indicates gradual post-surgery weight regain as well [ 106, 107]. Weight loss peaks about one year postoperative, after which gradual weight regain is the norm.

Assumption: The pursuit of weight loss is a practical and positive goal

Evidence: As discussed earlier, weight cycling is the most common result of engaging in conventional dieting practices and is known to increase morbidity and mortality risk. Research identifies many other contraindications to the pursuit of weight loss. For example, dieting is known to reduce bone mass, increasing risk for osteoporosis [ 108- 111]; this is true even in an obese population, though obesity is typically associated with reduced risk for osteoporosis[ 108]. Research also suggests that dieting is associated with increased chronic psychological stress and cortisol production, two factors known to increase disease risk [ 112]. Also, there is emerging evidence that persistent organic pollutants (POPs), which bioaccumulate in adipose tissue and are released during its breakdown, can increase risk of various chronic diseases including type 2 diabetes [ 113, 114], cardiovascular disease [ 115] and rheumatoid arthritis [ 116]; two studies document that people who have lost weight have higher concentration of POPs in their blood [ 117, 118]. One review of the diabetes literature indicates "that obese persons that (sic) do not have elevated POPs are not at elevated risk of diabetes, suggesting that the POPs rather than the obesity per se is responsible for the association" [ 114].

Another unintended consequence of the weight loss imperative is an increase in stigmatization and discrimination against fat individuals. Discrimination based on weight now equals or exceeds that based on race or gender [ 129]. Extensive research indicates that stigmatizing fat demotivates, rather than encourages, health behavior change [ 130]. Adults who face weight stigmatization and discrimination report consuming increased quantities of food [ 131- 134], avoiding exercise [ 133, 135- 137], and postponing or avoiding medical care (for fear of experiencing stigmatization) [ 138]. Stigmatization and bias on the part of health care practitioners is well-documented, resulting in lower quality care [ 139, 140].

Assumption: The only way for overweight and obese people to improve health is to lose weight

Evidence: That weight loss will improve health over the long-term for obese people is, in fact, an untested hypothesis. One reason the hypothesis is untested is because no methods have proven to reduce weight long-term for a significant number of people. Also, while normal weight people have lower disease incidence than obese individuals, it is unknown if weight loss in individuals already obese reduces disease risk to the same level as that observed in those who were never obese [ 91, 93].

As indicated by research conducted by one of the authors and many other investigators, most health indicators can be improved through changing health behaviors, regardless of whether weight is lost [ 11]. For example, lifestyle changes can reduce blood pressure, largely or completely independent of changes in body weight [ 11, 141- 143]. The same can be said for blood lipids [ 11, 143- 145]. Improvements in insulin sensitivity and blood lipids as a result of aerobic exercise training have been documented even in individuals who gained body fat during the intervention [ 145, 146].

Assumption: Obesity-related costs place a large burden on the economy, and this can be corrected by focused attention to obesity treatment and prevention

Evidence: The health cost attributed to obesity in the United States is currently estimated to be $147 billion annually [ 147] and this cost estimate has been used to justify efforts at obesity treatment and prevention. Although this estimate has been granted credence by health experts, the word "estimate" is important to note: as the authors state, most of the cost changes are not "statistically different from zero." Also, the estimate fails to account for many potentially confounding variables, among them physical activity, nutrient intake, history of weight cycling, degree of discrimination, access to (quality) medical care, etc. All are independently correlated with both weight and health and could play a role in explaining the costs associated with having a BMI over 30. Nor does it account for costs associated with unintended consequences of positing the value of a weight focus, which may include eating disorders, diet attempts, weight cycling, reduced self-esteem, depression, and discrimination.

Because BMI is considered a risk factor for many diseases, obese persons are automatically relegated to greater testing and treatment, which means that positing BMI as a risk factor results in increased costs, regardless of whether BMI itself is problematic. Yet using BMI as a proxy for health may be more costly than addressing health directly. Consider, for example, the findings of a study which examined the "healthy obese" and the "unhealthy normal weight" populations [ 148]. The study identified six different risk factors for cardiometabolic health and included subjects in the "unhealthy" group if they had two or more risk factors, making it a more stringent threshold of health than that used in categorizing metabolic syndrome or diabetes. The study found a substantial proportion of the overweight and obese population, at every age, who were healthy and a substantial proportion of the "normal weight" group who were unhealthy. Psychologist Deb Burgard examined the costs of overlooking the normal weight people who need treatment and over-treating the obese people who do not (personal communication, March 2010). She found that BMI profiling overlooks 16.3 million "normal weight" individuals who are not healthy and identifies 55.4 million overweight and obese people who are not ill as being in need of treatment (see Table 2). When the total population is considered, this means that 31 percent of the population is mis-identified when BMI is used as a proxy for health.

The weight bias inherent in BMI profiling may actually result in higher costs and sicker people. As an example, consider a 2009 study published in the American Journal of Public Health (96). The authors compared people of similar age, gender, education level, and rates of diabetes and hypertension, and examined how often they reported feeling sick over a 30-day period. Results indicated that body image had a much bigger impact on health than body size. In other words, two equally fat women would have very different health outcomes, depending on how they felt about their bodies. Likewise, two women with similar body insecurities would have similar health outcomes, even if one were fat and the other thin. These results suggest that the stigma associated with being fat is a major contributor to obesity-associated disease. BMI and health are only weakly related in cultures where obesity is not stigmatized, such as in the South Pacific [ 48, 149].

Health at every size: shifting the paradigm from weight to health

This section explains the rationale supporting some of the significant ways in which the HAES paradigm differs from the conventional weight-focused paradigm. The following topics are addressed:

1. 1)
HAES encourages body acceptance as opposed to weight loss or weight maintenance;

2. 2)
HAES supports reliance on internal regulatory processes, such as hunger and satiety, as opposed to encouraging cognitively-imposed dietary restriction; and

3. 3)
HAES supports active embodiment as opposed to encouraging structured exercise.

Encouraging Body Acceptance

Conventional thought suggests that body discontent helps motivate beneficial lifestyle change [ 150, 151]. However, as discussed previously in the section on the pursuit of weight loss, evidence suggests the opposite: promoting body discontent instead induces harm [ 122, 133, 134, 152], resulting in less favorable lifestyle choices. A common aphorism expressed in the HAES community is that "if shame were effective motivation, there wouldn't be many fat people." Mounting evidence suggests this belief is unfounded and detrimental[ 8, 152]. Promoting one body size as more favorable than another also has ethical consequences [ 120], contributing to shaming and discrimination.

Compassion-focused behavior change theory emerging from the eating disorders field suggests that self-acceptance is a cornerstone of self-care, meaning that people with strong self-esteem are more likely to adopt positive health behaviors [ 153, 154]. The theory is borne out in practice: HAES research shows that by learning to value their bodies as they are right now, even when this differs from a desired weight or shape or generates ambivalent feelings, people strengthen their ability to take care of themselves and sustain improvements in health behaviors [ 8, 11].

Critics of HAES express concern that encouraging body acceptance will lead individuals to eat with abandon and disregard dietary considerations, resulting in weight gain. This has been disproven by the evidence; no randomized controlled HAES study has resulted in weight gain, and all studies that report on dietary quality or eating behavior indicate improvement or at least maintenance [ 11, 14- 23]. This is in direct contrast to dieting behavior, which is associated with weight gain over time [ 66, 123- 128].

Supporting Intuitive Eating

Conventional recommendations view conscious efforts to monitor and restrict food choices as a necessary aspect of eating for health or weight control [ 155]. The underlying belief is that cognitive monitoring is essential for keeping appetite under control and that without these injunctions people would make nutritionally inadvisable choices, including eating to excess. The evidence, however, disputes the value of encouraging external regulation and restraint as a means for weight control: several large scale studies demonstrate that eating restraint is actually associated with weight gain over time [ 66, 123- 126].

In contrast, HAES teaches people to rely on internal regulation, a process dubbed intuitive eating [ 156], which encourages them to increase awareness of their body's response to food and learn how to make food choices that reflect this "body knowledge." Food is valued for nutritional, psychological, sensual, cultural and other reasons. HAES teaches people to make connections between what they eat and how they feel in the short- and medium-term, paying attention to food and mood, concentration, energy levels, fullness, ease of bowel movements, comfort eating, appetite, satiety, hunger and pleasure as guiding principles.

The journey towards adopting intuitive eating is typically a process one engages in over time. Particularly for people with a long history of dieting, other self-imposed dietary restriction, or body image concerns, it can feel very precarious to let go of old habits and attitudes and risk trying new ways of relating to food and self. Coming to eat intuitively happens gradually as old beliefs about food, nutrition and eating are challenged, unlearned and replaced with new ones.

A large popular literature has accumulated that supports individuals in developing intuitive eating skills [ 8, 156- 160]. (Intuitive eating is also known in the literature as "attuned eating" or "mindful eating." Note that intuitive eating is sometimes promoted as a means to weight loss and in that context is inconsistent with a HAES approach.)

Supporting Active Embodiment

HAES encourages people to build activity into their day-to-day routines and focuses on helping people find enjoyable ways of being active. The goal is to promote well-being and self-care rather than advising individuals to meet set guidelines for frequency and intensity of exercise. Active living is promoted for a range of physical, psychological and other synergistic benefits which are independent of weight loss. Myths around weight control and exercise are explicitly challenged. Physical activity is also used in HAES as a way of healing a sense of body distrust and alienation from physicality that may be experienced when people are taught to over-ride embodied internal signals in pursuit of externally derived goals, such as commonly occurs in dieting. In addition, some HAES programs have used physical activity sessions, along with other activities such as art and relaxation, to further a community development agenda, creating volunteer, training and employment opportunities and addressing issues of isolation, poor self-esteem and depression among course participants.

Clinical Ethics

There are serious ethical concerns regarding the continued use of a weight-centered paradigm in current practice in relation to beneficence and nonmaleficence. Beneficence concerns the requirement to effect treatment benefit. There is a paucity of literature to substantiate that the pursuit of weight control is beneficial, and a similar lack of evidence to support that weight loss is maintained over the long term or that programs aimed at prevention of weight gain are successful. Nonmaleficence refers to the requirement to do no harm. Much research suggests damage results from a weight-centered focus, such as weight cycling and stigmatization. Consideration of several dimensions of ethical practice - veracity, fidelity, justice and a compassionate response - suggests that the HAES paradigm shift may be required for professional ethical accountability [ 168].

Public Health Ethics

The new public health ethics advocates scrutiny of the values and structure of medical care, recognizing that the remedy to poor health and health inequalities does not lie solely in individual choices.

This ethicality has been adopted by HAES in several ways. HAES academics have highlighted the inherent limitations of an individualistic approach to conceptualizing health. Individual self-care is taken as a starting point for HAES programs, but, unlike more conventional interventions, the HAES ethos recognizes the structural basis of health inequities and understands empowerment as a process that effects collective change in advancing social justice [ 169]. HAES advocates have also stressed the need for action to challenge the thinness privilege and to better enable fat people's voices to be heard in and beyond health care [ 8, 170].

The hallmark theme of the new public health agenda is that it emphasizes the complexity of health determinants and the need to address systemic health inequities in order to improve population-wide health outcomes and reduce health disparities, making use of the evidence on the strong relationship between a person's social positioning and their health. For example, research since the 1950s has documented huge differences in cardiac health between and across socioeconomic gradients which has come to be recognized as arising from disparities in social standing and is articulated as the status syndrome [ 171]. Since weight tracks closely with socioeconomic class, obesity is a particularly potent marker of social disparity [ 172].

Quite aside from the ethical arguments underscoring inclusive, non-discriminatory health care and civil rights, there are plausible metabolic pathways through which reducing weight stigma, by reducing inequitable social processes, can help alleviate the burden of poor health.

Conclusion

From the perspective of efficacy as well as ethics, body weight is a poor target for public health intervention. There is sufficient evidence to recommend a paradigm shift from conventional weight management to Health at Every Size. More research that considers the unintended consequences of a weight focus can help to clarify the associated costs and will better allow practitioners to challenge the current paradigm. Continued research that includes larger sample sizes and more diverse populations and examines how best to deliver a Health at Every Size intervention, customized to specific populations, is called for.

We propose the following guidelines, which are supported by the Association for Size Diversity and Health (ASDAH), to assist professionals in implementing HAES. Our proposed guidelines are modified, with permission, from guidelines developed by the Academy for Eating Disorders for working with children [ 7].

Interventions should meet ethical standards. They should focus on health, not weight, and should be referred to as "health promotion" and not marketed as "obesity prevention." Interventions should be careful to avoid weight-biased stigma, such as using language like "overweight" and "obesity."

Interventions should seek to change major determinants of health that reside in inequitable social, economic and environmental factors, including all forms of stigma and oppression.

Interventions should be constructed from a holistic perspective, where consideration is given to physical, emotional, social, occupational, intellectual, spiritual, and ecological aspects of health.

Interventions should promote self-esteem, body satisfaction, and respect for body size diversity.

Interventions should accurately convey the limited impact that lifestyle behaviors have on overall health outcomes.

Lifestyle-oriented elements of interventions that focus on physical activity and eating should be delivered from a compassion-centered approach that encourages self-care rather than as prescriptive injunctions to meet expert guidelines.

Interventions should focus only on modifiable behaviors where there is evidence that such modification will improve health. Weight is not a behavior and therefore not an appropriate target for behavior modification.

Lay experience should inform practice, and the political dimensions of health research and policy should be articulated.

These guidelines outline ways in which health practitioners can shift their practice towards a HAES approach and, in so doing, uphold the tenets of their profession in providing inclusive, effective, and ethical care consistent with the evidence base.

Appendix

¹ Critics challenge the value of using BMI terminology, suggesting that BMI is a poor determinant of health and the categories medicalize and pathologize having a certain body. We accept this argument; we have used "overweight" and "obese" throughout this paper when necessary to report research where these categories were used. We recognize, however, that "normal" does not reflect a normative or optimal value; that "overweight" falsely implies a weight over which one is unhealthy; and that the etymology of the word "obese" mistakenly implies that a large appetite is the cause.

² Health at Every Size/HAES is a pending trademark of the Association for Size Diversity and Health.

Conflict of interests Disclosure

Linda Bacon and Lucy Aphramor are HAES practitioners. Both also speak and write on the topic of Health at Every Size and sometimes receive financial remuneration for this work.

References

1. 112.
Tomiyama AJ, Mann T, Vinas D, Hunger JM, Dejager J, Taylor SE: Low calorie dieting increases cortisol. Psychosom Med. 2010, 72: 357-364. 10.1097/PSY.0b013e3181d9523c.

2. 115.
Ha MH, Lee DH, Jacobs DR: Association between serum concentrations of persistent organic pollutants and self-reported cardiovascular disease prevalence: results from the National Health and Nutrition Examination Survey, 1999-2002. Environ Health Perspect. 2007, 115: 1204-1209. 10.1289/ehp.10184.

3. 116.
Lee DH, Steffes M, Jacobs DR: Positive associations of serum concentration of polychlorinated biphenyls or organochlorine pesticides with self-reported arthritis, especially rheumatoid type, in women. Environ Health Perspect. 2007, 115: 883-888. 10.1289/ehp.9887.

4. 170.
Bacon L: Reflections on Fat Acceptance: Lessons Learned from Privilege. Keynote Speech, National Association to Advance Fat Acceptance conference; Washington, DC. 2009, [ http://www.lindabacon.org/Bacon_ThinPrivilege080109.pdf]

Google Scholar

Download references

Acknowledgements

Deb Burgard conceptualized the obesity cost analysis. The authors thank Deb Burgard, Sigrún Daníelsdóttir, Paul Ernsberger, Janell Mensinger, Elise Paradis, Jon Robison, Camerin Ross, Abigail Saguy, and Evelyn Tribole for their contributions and critical review. Lucy Aphramor thanks the WM NMAHP Research Training Awards for financial support.

Author information

Affiliations

1. Davis, and City College of San Francisco, University of California, Box S-80, City College of San Francisco, 50 Phelan Avenue, San Francisco, CA, 94112, USA

Linda Bacon

2. Applied Research Centre in Health and Lifestyle Interventions, Coventry University, Priory Street, Coventry, CV1 1FB, UK

Lucy Aphramor

3. Cardiac Rehab, University Hospitals Coventry and Warwickshire NHS Trust, Cardiology Suite, 1st Floor, East Wing, Walsgrave Hospital, Clifford Bridge Road, Coventry, CV2 2DX, UK

Lucy Aphramor

Corresponding author

Correspondence to Linda Bacon.

Additional information

Authors' contributions

LB initiated the collaboration. Both authors contributed to conceptualizing and drafting the review. LB was lead researcher and undertook the systematic review and designed and completed the tables. Both authors approved the final manuscript.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Reprints and Permissions

# data[].attributes.attachment_link.title
Weight Science: Evaluating the Evidence for a Paradigm Shift

# data[].attributes.attachment_link.description
Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality.

# data[].attributes.headline
Health at Every Size/ Salud a cualquier tamaño (English/Español)

# data[].attributes.subject
Health at Every Size/ Salud a cualquier tamaño (English/Español)

# data[].attributes.body
Video: 1:21 min. (Translates to Spanish in Closed Captions)

Vídeo: 1:21 min. (Se traduce al español en subtítulos)

# data[].attributes.headline
How Diet Culture Negatively Impacts Children's Health (English)

# data[].attributes.subject
How Diet Culture Negatively Impacts Children's Health (English)

# data[].attributes.body
Text: Quick Read

# data[].attributes.attachment_link.title
9 Tips Parents Can Use to Encourage Healthier Eating in Kids

# data[].attributes.attachment_link.description
Encourage healthier eating habits in your kids with these 9 practical tips, helping them develop a positive relationship with food from an early age.

# data[].attributes.headline
Should You Put Your Kid on a Diet? (English)

# data[].attributes.subject
Should You Put Your Kid on a Diet? (English)

# data[].attributes.body
Text Only

# data[].attributes.attachment_link.title
Should You Put Your Kid on a Diet? 10 Points to Think About - Jewish Action

# data[].attributes.attachment_link.description
Putting a healthy child on a diet may be culturally acceptable in the United States, but that does not make it right.

# data[].attributes.headline
Principles of Intuitive Eating (English)

# data[].attributes.subject
Principles of Intuitive Eating (English)

# data[].attributes.body
Text Only

# data[].attributes.attachment_link.readable_text
Principle 1: Reject Diet Culture

Throw out the diet books, food plans, and articles that offer you false hope that that food restriction or dieting by any name you call it will grant all of your wishes for a better life. Rather than getting angry at yourself, get angry at the lies from diet culture have led you to feel as if you were a failure every time a new diet or food plan stopped working. If you allow even one small hope to linger that a new and better diet might be lurking around the corner, it will prevent you from being free to rediscover Intuitive Eating.

Principle 2: Honor Your Hunger

Keep your body biologically fed with adequate energy and carbohydrates. Otherwise, you can trigger a primal drive to eat beyond comfortable fullness. Once you reach the moment of excessive hunger, all intentions of moderate, conscious eating are fleeting and irrelevant. Learning to honor the first biological signal of hunger sets the stage for rebuilding trust with yourself and food.

Principle 3: Make Peace with Food

Call a truce-stop the food fight! Give yourself unconditional permission to eat. If you tell yourself that you can't or shouldn't have a particular food, it can lead to intense feelings of deprivation that build into uncontrollable cravings and, often, bingeing. When you finally give in to your forbidden food, eating will be experienced with such intensity that it usually results in Last Supper overeating and overwhelming guilt.

Principle 4: Discover the Satisfaction Factor

The Japanese have the wisdom to promote pleasure as one of their goals of healthy living. In our fury to be thin and healthy, we often overlook one of the most basic gifts of existence-the pleasure and satisfaction that can be found in the eating experience. When you eat what you really want, in an environment that is inviting and conducive, the pleasure you derive will be a powerful force in helping you feel satisfied and content. By providing this experience for yourself, you will find that you'll eat the right amount of food to feel physically and emotionally satisfied.

Principle 5: Feel Your Fullness

Listen for the body signals that tell you that you are no longer hungry. Observe the signs that show that you're comfortably full. Pause in the middle of eating and ask yourself how the food tastes and what your current fullness level is.

Principle 6: Challenge the Food Police

The food police monitor the unreasonable rules that dieting has created. The police station is housed deep in your psyche, and its loudspeaker shouts negative barbs, hopeless phrases, and guilt-provoking indictments. Chasing the food police away is a critical step in returning to Intuitive Eating.

Principle 7: Cope with Your Emotions with Kindness

First, recognize that food restriction, both physically and mentally, can, in and of itself, trigger loss of control, which can feel like emotional eating. Find kind ways to comfort, nurture, distract, and resolve your issues. Anxiety, loneliness, boredom, and anger are emotions we all experience throughout life. Each has its owntrigger, and each has its own appeasement. Food won't fix any of these feelings. It may comfort for the short term, distract from the pain, or even numb you. But food won't solve the problem. If anything, eating for anemotional hunger may only make you feel worse in the long run. You'll ultimately have to deal with the source of the emotion, as well as the discomfort of eating beyond comfortable fullness.

Principle 8: Respect Your Body

Accept your genetic blueprint. Just as a person with a shoe size of eight would not expect to realistically squeeze into a size six, it is equally futile (and uncomfortable) to have a similar expectation about body size. But mostly, respect your body so you can feel better about who you are. It's hard to reject the diet mentality ifyou are unrealistic and overly critical of your body size or shape. All bodies deserve dignity.

Principle 9: Movement-Feel the Difference

Forget militant exercise. Just get active and feel the difference. Shift your focus to how it feels to move your body, rather than the calorie-burning effect of exercise. If you focus on how you feel from working out, suchas energized, it can make the difference between rolling out of bed for a brisk morning walk or hitting the snooze alarm.

Principle 10: Honor Your Health-Gentle Nutrition

Make food choices that honor your well-being, taste buds, and culture; while attuning to how your body feels. Remember that you don't have to eat perfectly to be healthy. You will not suddenly get a nutrient deficiency from one snack, one meal, or one day of eating. It's what you eat consistently over time that matters. It might be surprising for you to learn that what you eat and how you move your body only accounts for ten percent of your health. Progress, not perfection, is what counts.

# data[].attributes.attachment_link.title
10 Principles of Intuitive Eating - Intuitive Eating

# data[].attributes.headline
Weight Loss Drugs in Children / Medicamentos para adelgazar en niños (English/Español)

# data[].attributes.subject
Weight Loss Drugs in Children / Medicamentos para adelgazar en niños (English/Español)

# data[].attributes.body
Video: 8:07 min. (Translates to Spanish in Closed Captions)

Video: 8:07 min. (Se traduce al español en subtítulos)

# data[].attributes.attachment_link.title
Why more doctors are treating children and adolescents with weight loss drugs

# data[].attributes.body
Text: Estimated 7 min read

# data[].attributes.attachment_link.readable_text
National Eating Disorders Awareness Week runs February 27 through March 5, and I thought it an opportune time to discuss the newly evolving concept, Health at Every Size (HAES). HAES is a methodology developed by the Association for Size Diversity and Health to promote size acceptance and body positivity, and to end weight discrimination and weight-centric thinking.

Weight-centric thinking is the conventional-and arguably outdated-approach to health that suggests weight and weight management (primarily weight loss) are the primary determinants of health.

In a weight-centric society, weight and disease are directly correlated. This correlation places increased emphasis on personal responsibility for diet-, exercise-, and other health-related choices and outcomes. Emphasizing these things can contribute to the development of disordered eating.

There are many reasons why society should reassess the weight-centric approach such as:

It perpetuates the weight stigma and diet culture;

It can lead to faddish and unhealthy dieting practices;

It can lead to weight cycling, which is an independent risk factor for disease;

It can misalign the body's natural "set-point," which is the body's specific and natural weight that it wants to maintain based on genetics;

It poses a threat to psychological and physical health; and

It can increase the risk of disordered eating and eating disorders.

With an increasing cultural focus on weight loss, dieting, achieving and maintaining the 'perfect' figure, and the pace and ubiquity of social media trends, people tend to develop rigid rules and thinking around food. These rules foster negative connotations around food and can nudge people to identifying food as good versus bad. This rigidity, along with rules and restrictions, is linked to a high risk of disordered eating and the development of eating disorders.

Research shows that from 1999-2009, the number of men hospitalized for an eating disorder-related cause increased by 53%. 89% of teen girls have been on a diet by age 17, and 81% of 10-year-old girls are afraid of being fat. A survey from 2008 found that 65% of women aged 25-45 had some variation of disordered eating and of them, 10% met criteria for eating disorders.

This information means that 3 in 4 women eat, think, or behave abnormally around food by either skipping meals, restricting certain foods or food groups, binge eating, or feeling guilty or out of control around food. Such behaviors have become such a norm for our society; however, this state of things couldn't be further from reality or what is truly normal. Although not all diets and dieters progress to the point of disordered eating and eating disorders, majority of persons diagnosed with an eating disorder have a history of dieting stemming from weight-centric comments and beliefs.

Focusing on weight undoubtedly detracts from the real sources of health problems and chronic disease, most of which are genetically inherited, and can promote unhealthy behaviors related to food and exercise.

One approach to shifting the focus from weight and weight-centric modalities is the HAES framework.

When we think of health risks and nutrition counseling associated with improving them, lifestyle changes are recommended. Lifestyle changes are related to behavior change, which can be done readily. It is important to remember that weight is not a behavior and cannot be spontaneously changed or modified.

It is also important to remember that health and well-being are independent of weight status. Weight and body size are primarily determined by genetics. Eating nutritious foods, engaging in physical activity, mindfulness, and meditation, all make a difference in improving the heart rate, blood pressure, and blood sugar, independent of weight loss.

The challenge is that because of the widespread emphasis on weight loss above all else, when people make progressive and beneficial behavior changes and don't see weight loss, they become discouraged and quit what they're doing. Some lifestyle changes may lead to weight loss, but it needn't be the primary focus. The HAES methodology rejects the use of body mass index (BMI) and weight status as a proxy for health. Instead, this methodology works to support people of all sizes to find compassionate ways to take care of themselves, regardless of size. The focus is primarily on health and well-being opposed to weight, and promotes both physical and mental health behaviors through five principles:

1. Weight inclusivity

2. Health enhancement

3. Respectful care

4. Eating for well-being

5. Life-enhancement movement

As far as health improvement goes, the HAES model works. It has been tried and proven to improve cholesterol, lower blood pressure, and increase physical activity, while avoiding weight cycling and improving body image. HAES emphasizes having respect for and empowering persons in bodies of all sizes. It promotes health policies that give better access to care and reduces weight stigma. It encourages people to engage in intuitive eating and enjoyable movement practices while promoting body positivity.

A person described as having a positive body image can appreciate, accept, honor, and respect their body as it is. This is not quite the same as body satisfaction, which sometimes overlaps or is mistaken for body positivity. One can be dissatisfied with aspects of their body, yet still be able to accept and honor it for its limitations, without being self-destructive and demeaning. Body positivity is important because it can be protective against the development of disordered eating and an eating disorder.

Body positivity is associated with:

Self-acceptance. When you are body positive, you are more likely to feel comfortable and happy with the way you look and less likely to feel impacted or pressured by the unrealistic images on social media.

Increased self-esteem. This is what primarily impacts how you feel about and view yourself. When you are body positive, you promote and encourage yourself in your natural form, which in turn will impact every aspect of life and contribute to overall well-being and happiness.

Improved and healthier outlooks on lifestyle and behavior. When you're practicing body positivity, it is without a doubt easier to lead a well-rounded lifestyle with balanced and realistic expectations, healthier attitudes, and freedom. You are more likely to engage in healthier practices related to food and exercise when you are in sync with and respond to the all-encompassing needs of your body.

Although media and society want you to believe otherwise, there is no right or wrong when it comes to weight, shape, size, and appearance. One way to combat the pressure to fit a certain mold is by challenging beauty ideals and affirming yourself. We have the power to change the way we think, see, and feel about our bodies.

To help improve your body image, try the following strategies:

Focus on and emphasize your positive qualities, talents, skills, and attributes.

Say positive affirmations to yourself daily.

Focus on appreciating and respecting your body for what it can do.

Avoid comparing yourself to others.

Seek professional support if it is challenging for you to start these changes on your own. Professional support can help to steer you in a direction which helps you to change and challenge harmful beliefs and behaviors. (See Resources below for some places to get started.)

It is time for us to shift away from weight-centric thinking and to move forward in the HAES framework emphasizing body positivity, all-around health, and well-being.

Regardless of genetic makeup or size, everyone should be educated on the healthiest choices and recommendations for their body. After all, some people might be unaware of the ingredients in their 'healthy' diet that might be counterproductive to becoming the best version of themselves. This change can be achieved without placing emphasis on weight, appearance, and body size.

It is time to prioritize health in every form, respective to the person, as opposed to the standardized and outdated mold of "thin is better." Put the social constructs to rest and begin to realize how valuable you and your body are, just as you are.

RESOURCES
Hopkins-based Resources
Primary Care
Student Health and Wellness Center. Serves Homewood and Peabody students and trainees, as well as on-campus SOE students.

University Health Services. Serves students and trainees of BSPH, SOM, SON, and the Berman Institute of Ethics.

Students interested in working with a dietitian should reach out to their respective campus primary care clinics.

Mental Health
Behavioral Health Crisis Support Team (BHCST). Connecting behavioral health clinicians with specially trained public safety officers to respond appropriately and effectively to those in crisis, seven days a week, at 410-516-9355.

Counseling Center. Serves Homewood and Peabody students and trainees, as well as on-campus SOE students. To reach the on-call counselor, call 410-516-8278 and press "1" at any time 24/7.

Johns Hopkins Student Assistance Program (JHSAP). Serves grad students from AAP, BSPH, CBS, EP, SOM, SON, and SAIS. Getting help is free, convenient, confidential, and available 24/7 by calling 443-287-7000, option #1.

Mental Telehealth. Serves all Hopkins students.

University Mental Health Services. Serves students and trainees of BSPH, SOM, SON, and the Berman Institute of Ethics. For any urgent mental health concerns after hours or on the weekend, please call 410-955-1892 and follow the instructions to speak with a mental health professional.

# data[].attributes.attachment_link.title
Health at Every Size: A concept to reduce weight-centric thinking and to promote body positivity

# data[].attributes.attachment_link.description
National Eating Disorders Awareness Week runs February 27 through March 5, and I thought it an opportune time to discuss the newly evolving concept, Health at Every Size (HAES). HAES is a methodology developed by the Association for Size Diversity and Health to promote size acceptance and body positivity, and to end weight discrimination and weight-centric thinking.

# data[].attributes.headline
What BMI Doesn't Tell You About Your Health / Lo que el IMC no dice sobre su salud (English/Español)

# data[].attributes.subject
What BMI Doesn't Tell You About Your Health / Lo que el IMC no dice sobre su salud (English/Español)

# data[].attributes.body
Video: 4:59 min. (Translates to Spanish in Closed Captions)

Vídeo: 4:59 min. (Se traduce al español en subtítulos)

# data[].attributes.attachment_link.title
What BMI doesn't tell you about your health