Obesity. This word is associated with the words unhealthy, fat, and overweight. Obesity has become the sixth leading cause of death in the United States, with 300,000 adults dying of causes correlated to obesity each year, and the numbers are increasing. What Americans have done to address this problem, either as health professionals or as health enthusiasts, has been to advocate for a variety of intentional weight-loss strategies, through dieting and exercise, and even through surgery. But these approaches have little to show for their efforts at addressing obesity. Many have tried diet coaches like Jenny Craig. They have engaged in fad diets like the South Beach Diet or the Keto Diet. They have paid monthly dues to gyms to try to burn off their fat on treadmills and exercise bikes. Undergirding these traditional approaches is the diagnostic height-to-weight tables, which is based on a measurement of body fat called BMI (Body Mass Index), which is used to classify obesity and overweight individuals. Once identified with a BMI classification of obesity, individuals are encouraged to begin regimens of treatment to lose weight by dieting and/or exercising intentionally. The statistics on the success rates for this traditional approach to fighting obesity is alarmingly dismal. Weight regain of about 33% to 50% of the weight lost during weight-loss treatment is common within the first year and increases over time.1 Instead of continuing to engage in these often counterproductive approaches, we should consider the results of a movement called HAES (Health at Every Size). This movement encourages intuitive eating, joyful movement, and promotes the use of sustainable eating behaviors. Many health professionals, including certified dietitians like Aaron Flores, Danielle Bourgeois, and Sonia Rodriguez, have incorporated the HAES paradigm, with remarkable results.
The HAES approach has been applied as an eating disorder treatment. It is used as a methodology that dietitians and nutritionists use on clients of every body size, including those that meet the criteria for being overweight or obese. This paradigm considers more than just becoming physiologically healthier; it promotes mental health by spreading awareness and acceptance of our bodies, by forming healthy habits, and by creating a safer environment where every body shape and size is welcomed with open arms. This methodology throws out BMI standards, weight-loss diets, exercise regimens, and intentional weight loss. In other words, it throws out most of what health professionals have been taught to think about healthy bodies. What those health professionals then practiced was considered the only way to be considered healthy, successful, and even liked. The weight-loss approach has led to a diet-oriented society, inevitably increasing and normalizing fatphobia and distorting people’s perceptions of what a healthy body looks like. According to the HAES practitioners, healthy bodies come in all shapes and sizes, but if practitioners rely on BMI (Body Mass Index) to judge one’s health, they would solely be comparing our body weight to other groups of people using weight to height tables, further engaging in a weight stigmatic approach.2
To understand how health professionals classify obesity and overweight individuals, here’s the story on body mass index. BMI is made up of tables that provide a diagnostic tool for health professionals for assessing overweight, at weight, and underweight individuals. Height-to-weight tables were first introduced by insurance companies in the mid-1800s because of an increase in obesity and poor health; the weight tables were then linked to life expectancy. The reason that health insurance companies attributed life expectancy with BMI tables is that excess body fat and weight are correlated to cardiovascular diseases, diabetes, cancer, and musculoskeletal disorders, and therefore, a correlation with higher mortality rates. However, there is no evidence that obesity directly causes these diseases or higher mortality rates. Plenty of studies have been conducted that found a correlation/association with higher disease rates in obese individuals, but obesity is not the sole cause, and there is no evidence of obesity causing these diseases.3 The New England Journal of Medicine claimed to have found an association between body mass index and the risk of death. However, the risk of death is not directly caused by a large BMI (body mass index), but rather death results from other diseases previously mentioned. In an interview with a registered dietitian and certified diabetes educator, Sonia Rodriguez stated that people in larger bodies are at higher risk for certain diseases, but instead of further spreading the weight-loss approaches to achieve a healthier and more appealing body, we should screen for these diseases, and give these individuals the proper treatment.4
BMI should not be used as a screening tool for obesity and overweight individuals. There is a superficial degree of validity to BMI. The American Society for Nutrition said BMI is a “surrogate measure of body fatness,” which means that it correlates with clinical endpoints (the risk of developing the diseases associated with obesity and/or overweight individuals) but these risks cannot accurately be depicted through a BMI table. The inaccuracy of these BMI tables is attributed not only to the possibility of misclassifications of these obese and/or overweight individuals, but a variety of other factors that are not depicted in these height-to-weight tables. Those factors include an individual’s race or age, the individual’s health during his or her infancy and childhood, and whether he or she is engaging in an athletic sport or has special clinical circumstances. Therefore, BMI can be used to measure the amount of body fat and weight that an individual may have compared to that individual’s height, and even classify that individual as overweight and/or obese, but it should not be considered a method used by health professionals in treating obese and/or overweight individuals.5
Now that we have addressed the classification of obesity/overweight individuals and how it contains a superficial degree of validity when faced with various factors that have led to misclassifying obese and/or overweight individuals, let me explain further why BMI should not be used even as a screening tool for obesity. BMI as a screening tool has led to a traditional treatment approach for obesity and overweight individuals that includes reducing body fat and/or weight as a means of reducing the risk of disease and mortality rates. These approaches include dieting through restrictive food intake and exercising with the intention of weight loss. However, if weight loss is what health professionals are aiming for, there are several other ways to do it. Weight loss can be achieved by developing healthier eating habits and by including exercise patterns that are independent of intentional weight loss.
Exercise has been proven to be beneficial for every body shape, size, and type, but it doesn’t directly lead to weight loss. According to Linda Bacon, author of the book Health at Every Size, “the same people who exercise may also eat their leafy green vegetables, have better stress management skills, or maintain other habits that may explain some or all of the weight difference,”making it difficult to fully attribute weight loss to the activity of regularly exercising.6 This approach has been adapted by HAES not only to improve physiological health in obese/overweight individuals but also in anyone willing to live by this paradigm. A clinical study was conducted using thirty-one obese premenopausal women who exercised for ninety minutes four to five times a week for over six months. There were two group outcomes: the ones that lost body fat, and the ones that gained it. The results suggested that the difference in both groups was not outstanding.7 This data shows that exercise did, in fact, improve the health of all of these women, and although those who lost weight may have seen a larger increase in health, it was not necessary to start noticing a trending improvement. Therefore, regardless of weight loss or gain, exercise promotes healthy habits and increases health independently of weight loss measured by an improvement in carbohydrate and lipid metabolism.
As previously stated, weight loss is often targeted through dieting (restrictive eating), but a majority of individuals do not maintain the weight they lose long term, which in turn frustrates the weight-loss goal for health professionals. There is a problem with our weight loss industry. As a whole, we are spending about $59 billion per year on these programs and products, yet the United States is still increasing in obesity rates. This is because everyone has a natural set-point weight, which is every individual body’s preferred weight. When an individual loses weight, they fall under their natural set point. This decreases the production of the hypothalamus hormone called leptin, an appetite-suppressing hormone, as an individual diets’. Dieting leads to an appetite increase, and it decreases our metabolism, inevitably leading to weight gain.8 It is important to note that a hyperfocused view on achieving a certain body shape, size, or type can trigger psychological disorders, including a variety of eating disorders. There is evidence that dieting leads to fluctuation in weight, called weight cycling and yo-yo dieting. This has shown a link to depression, decreased self-esteem, and binge eating behaviors.9 Evidence begins with environmental factors. Eating disorders are more prevalent in upper and middle social classes, where dieting is common. Groups with a lower concern for weight loss, including that of lower socioeconomic classes, diet less and have fewer eating disorders. A study performed by Patton, Johnson-Sabine, Wood, Mann, and Wakeling examined the predictors of eating disorders in adolescent girls. The results showed that twenty-one percent of dieters developed eating disorders.10
We should be working with our bodies, instead of against them, but this is extremely difficult to achieve as we continue to engage in every-day fatphobia. Our society is obsessed with fatphobia, whether we would like to admit that or not. We are constantly being told by health professionals that a certain weight, body size, and type is wrong when compared to the mean BMI of other individuals. This constant comparison is the problem. We cannot compare our bodies with others because there are factors other than weight and percentage of body fat that makeup how an individual looks. Genetics falls into this category, along with sleep, stress, exercise, and eating habits independent from dieting. A prime example of fatphobia comes from a study of eight obese persons who had gastric restrictive surgery (a weight loss surgery). These individuals had success with keeping off one hundred pounds of their weight loss for more than three years, and were asked if they would prefer being obese again or rather have several other disabilities. “Ninety-two percent of these patients preferred leg amputation, and eighty-nine percent of them would rather be legally blind than obese.”11
People are afraid of gaining weight, afraid they will become fat, obese, and overweight. This stems from weight stigmatization and discrimination. Whether you grew up to believe that fat people are ugly, lazy, unintelligent, or unhealthy, these are all examples of weight stigmatization. Part of a study conducted by Linda Bacon and three collaborators Nancy Keim, Judith S. Stern, and Marta Van Loan recounts several stories about weight discrimination. They were looking for seventy Caucasian women between the ages of thirty and forty-five who were non-smokers to compare a traditional weight loss treatment with treatment using the HAES approach. The number of people she encountered lying about their age, due to a desperation for any chance at weight loss, was overwhelming. Linda Bacon recounted several of their confessions in her book. A woman was being threatened to get fired by her boss unless she lost weight, and another woman said that she would lose her job working at a fitness center if she didn’t lose weight, and one was even threatened with divorce.6 We often hold a stigma towards fat people. Many tend to believe that fat people have no self-control, or that they shouldn’t wear certain clothing in public. Some individuals are even criticized for stepping into a gym at a certain weight. According to a study made by Tatiana Andreyeva, Rebecca M. Puhl, Kelly D. Brownell, and data from the MIDUS (Midlife in the United States) study, weight/height discrimination in adults from the US increased by sixty-six percent from 1995 to 2006. Reports of weight discrimination were more prevalent in interpersonal relationships than in professional settings, but there is a rising trend in both.13
Getting rid of these stigmas and becoming educated over higher body weights, eating disorders, and disordered eating is the only way the HAES movement will be encouraged and continued to be supported by nutritionists, dietitians, and eating disorder associations. Society needs to change these judgmental perspectives about individuals. These individuals are suffering and it’s not just from obesity-related diseases. HAES promotes self-care and acceptance for every body type and continues to counteract the societal norm that is a “weight-loss at any cost” society. In a personal interview with a registered dietitian and HAES advocate, I asked Aaron Flores how we could, as a society, decrease the amount of fatphobia we see in the media and in our environment today. He stated that there have been fat people throughout history, and that it is inevitable. We are not going to live in a one size fits all world and the sooner we accept that we all come in different shapes and sizes, the safer people will feel and the more people will engage in self-care and healthy behaviors towards themselves and their bodies.14