Tuesday, March 20, 2012

Why HAES May Never go Mainstream

It's not the concept that's for sure.

For those of you who aren't familiar with the acronym HAES, it stands for "Health at Every Size", and it's a principle with which I strongly agree.

According to the official HAES community page HAES,
"acknowledges that good health can best be realized independent from considerations of size. It supports people—of all sizes—in addressing health directly by adopting healthy behaviors."
And truly, I could not agree more in that the words "healthy", and "weight", are not mutually inclusive or exclusive terms.

According to HAES' founder Linda Bacon, one of HAES' tenets is, "Show me the data", and in her recent Huffington Post piece, she says that we should all be demanding the data too and adopting HAES' "more skeptical" mantra.

Again, I could not agree more.

Yet despite readily agreeing that fat has been regularly and unfairly vilified by society and the medical community for decades if not centuries, and despite regularly telling my otherwise healthy overweight and moderately obese patients that their weights aren't likely contributing much if anything to them in the way of medical risk, I struggle with HAES as it would seem to me that they are fighting misinformation with misinformation, and in so doing, weakening and cheapening their incredibly important and valuable message.

Looking at Linda's debut Huffington Post piece here are the 3 things she wants readers to understand are, "known (even if everyone can't accept it yet)",
"-  Stable fat is blown out of proportion as a health risk (even dreaded "tummy fat"), but yo-yoing weights common to dieters do harm health.

-  The "ironclad" notion that obesity leads to early death is wrong: Mortality data show "overweight" people, on average, live longest, and moderately "obese" people have similar longevity to those at weights deemed "normal" and advisable.

-  Life spans have lengthened almost in lockstep with waistlines over the last few decades, which should make you wonder about the supposed deadliness of fat.
If we're talking, "show me the data", then lets talk data.  First, the data on yo-yo diets, otherwise known as weight cycling. Looking at the most recent and robust data, one set from than Cancer Prevention Study II Nutrition Cohort which followed 55,983 men and 66,655 women from 1992-2008, and the other set from the Nurses Health Study which followed 44,882 women from 1972-1994, neither demonstrated any relationship between weight cycling and mortality. Other studies have exonerated weight cycling from increasing the risk of hypertension, and type 2 diabetes, and there's a mixed bag of studies suggesting both protective and causal effects of weight cycling on various forms of cancer. But if we're really talking "show me the data", the only thing very conclusively linked to weight cycling are increased body fat percentages, and while I definitely agree weight cycling is symptomatic of a broken societal approach to weight management, and may well carry with it some harm, the data simply do not currently support a blanket, "harm health" statement.

Next the "ironclad" comment. While it's true that "overweight" has been shown to be protective in the over 65 population, and that "Class I", or "moderate", obesity carries the same risks as "normal" weight in that same population, what Linda omits here, other than the age qualifiers, is the ironclad fact that as weights rise more dramatically than simply "moderate" obesity, so too does risk. And it's not just as weights rise, but also as weight responsive conditions accumulate as is clearly shown by Dr. Sharma's Edmonton Obesity Staging System work which demonstrates that as EOSS stage rises, where EOSS evaluates weight in the context of having or not having weight related co-morbidities or quality of life impacts, so too does mortality.

Lastly we get to the lockstep comment about the last few decades. Here I'm nearly at a loss for words. Is Dr. Bacon honestly suggesting that the very simple fact that our life spans are continuing to lengthen, while at the same time as a society we're gaining weight, is in turn an argument that weight can't possibly be deadly? Isn't the whole point of HAES' existence to combat what HAES sees as correlations not being causal? Couldn't there be dozens, if not hundreds of other explanations for why our life spans are increasing despite our weight gains even if those gains did carry risk? Like for instance the very dramatic improvements in medicine that have occurred over the course of the past few decades?

Fighting misinformation with misinformation, relevant omissions with relevant omissions, and logical fallacies with logical fallacies, is not the way to accredit your movement, and if HAES has any hope of actually penetrating mainstream medicine, something I would dearly love to see happen, they're going to need to hold themselves up to at least the same, if not a higher level of scrutiny to which they hold others. If they don't do so, then their detractors will have an easy time dismissing them as champions of a self-serving, non-evidence based, over-hyped agenda, which ironically is the very same thing of which HAES is accusing mainstream medicine.

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  1. Amen. They completely discredit themselves by cherry picking data and unfounded conclusions. As an obesity researcher, I can tell you they have no mainstream traction or credibility.

  2. Anonymous7:44 am

    Thanks for the post! What you describe is fairly typical of fat acceptance sites, and while I certainly am against the attitudes and stereotypes that obese people face, these patently biased attempts to argue that there is nothing wrong with being obese seem perplexing and counterproductive to me.

  3. "Isn't the whole point of HAES' existence to combat what HAES sees as correlations not being causal?"

    No. The whole point of HAES' existence is to tell anecdotes about their "300-lb. great Aunt Martha who lived to be 90 and was never sick a day in her life! So Fat = Healthy!", to justify their poor choices, UNhealthy lifestyles, to blame the world for their problems and to lobby about why they should not have to pay for two airplane seats.

    1. Wow. What a clear example of why HAES is important.

      Someone needs to fight your brand of generalized hate.

    2. You beat me to it! I did recently attend a session by Jacqui Gingras on weight bias and HAES. I definitely agree with their work on weight stigma, but she didn't talk much about their "show me the data" side... will definitely have to look into it!

    3. Isn't that what you're doing? The point of the "organization," so to speak; its agenda -- is to make its adherents feel better about their decidedly UNHEALTHY lifestyle and to reinforce their telling themselves/each other that it's okay to be obese. You're an MD. You're far more knowledgeable about physiology, endocrinology and cardiovascular functions than I or the general public. Extra weight = diminished health, diminished quality of life and consequences. I used to be obese. I remember it well. If I were to strap on a 70-lb weighted vest to mimic the weight I've lost and kept off for four years, and wear it around all day for a month -- even for a week -- how would that work out for me? Would I begin to have knee pain and back pain again? Yes. Would my heart and lungs have to work twice as hard to do half as much? Yes. Would I sleep well, wake up rested and full of energy? No. Extra weight destroys health. Telling 200-lb. teenage girls that they're "fierce" and "curvy" isn't constructive. Are there any 65 year old HAES activists out there? Plenty of people can get away with an extra 50, 80, 100 lbs for a decade or two. Let's see how "healthy" they feel after middle age.

    4. Here I am, Norma. I'm a fat activist and I'll be 65 in June. Does that count? I have been fat all my life, went through dieting and weight cycling in my 20s and into my 30s when I decided to stop dieting and see what happened, simply because it just didn't make sense to me anymore. It was many years later that I found out about size acceptance and later, HAES. I am not on any medication. How many people of much younger age and smaller size do you know that can say that? I'm far healthier than many younger, thinner people I know. My health is not perfect, but whose is? My quality of life is what I have created. I have the time and energy to fight the discrimination against fat people and I love my life. I am happy for you and your sustained weight loss, but what worked for you, doesn't work for very many...and putting on a weighted vest is NOT the same as 70 pounds distributed over your body. We do not "spot" gain or lose, that's not the way the body works. Oh, and by the way, I don't have knee pain or back pain and have never had a join replaced or repaired. You can use yourself as an anecdotal example, so can I!

    5. Time for hard facts instead of anecdotes.

      What is your cholesterol like? What did your doctor say about your health last time you got a Physical?

      Obesity is a lot like smoking. Scientific studies consistently prove that both are unhealthy, debilitating, put extra strain on the healthcare system. And yet, some people have the genes to get away with it and live long anyway. Doesn't mean it is healthy.

    6. 215-lb. woman here.

      "Time for hard facts instead of anecdotes...What is your cholesterol like?"


      But anyway, my cholesterol is awesome. What did my doctor say about my health last time I got a physical? That my health is, quote, phenomenal.


    7. What you guys are missing, and what I think is the problem with HAES is not that there are varying "Body Compositions" and that people can be "healthy"(I put these terms in quotes because there are an N number of meanings to these words depending on who you ask) with more weight that the next person, but that in general, the average person(Not an anomoly healthyfat, or a food gouging skinny) should follow a standard of healthy living. It is not anecdotal that frequent, moderate exercise combined with a BALANCED DIET leads to a healthy happier life. Here in lies the problem, you are telling people who are average, genetically, or whatever term you want to put on it, that are overweight that it is OK, but the truth is it's not. The negative result of HAES is that it unconsciously promotes unhealthy lifestyles by justifying the few at the price of the many. Why are there no anorexic followers of HAES? Because that shit is terrible for you. Are pro-ana and HAES the same thing? No, and pro-ana aren't trying to convince the world that they deserve special treatment, or trying to recruit others to support them. Your lifestyle choice is YOUR CHOICE, that is the freedom you have. Let people decide for themselves, but don't tell them that your anomaly is OK for them. You want to be fat, or being fat makes you happy? So be it, but don't push your lifestyle choices onto others. I smoke, and it's probably going to kill me, but I exercise a lot and can still out perform most people cardiovascularly, but that doesn't mean its OK for me to tell others that smoking is OK because I run three miles in 18ish minutes.

    8. Anonymous4:58 pm

      What everyone is missing here is that the plural form of 'anecdote' is not 'data.' Yes, there are obese people who live to be 100. Yes there are obese people with okay cholesterol. But the cold, hard truth is that this is not the norm. Even just looking above the comments and reading the article, you'll see data about how people who are obese have much higher overall mortality rates, with those rates increasing with weight. And yet people seem to be so blase about it in these comments. I'm a terminal heart patient, and when my doctor told me I was going to die, I didn't just say "Oh well, guess we all have to die!" Although I've accepted that my days are more limited than most, I worked harder than I ever had before on becoming healthier and strengthening my heart. I realized just how precious each day was because I knew how few I had, and it made me want to have as many extra days as I could sneak in. I feel like a crazy person hearing about all these people who just accept their VERY reversible fate.

    9. I hate the fat acceptance HAES movement because it takes a problem and makes it worse by saying that the problem is not weight, but perception of weight. Yes, we have a crazy relationship with weight in our society but promoting a way of unhealthy living isn't the way to combat an epidemic that is changing lives for the worse...including our kids

  4. I also wonder about the use of "ANY" size...it apparently actually means only LARGER/obese size. Does HAES advocate that extremely thin people can be healthy? That anorexics, despite their mental illness, are "healthy"? Is a 5'10", 107 lb couture model healthy? I know, I know; the HAES crowd ALL eat clean whole foods and exercise, but their metabolisms are slow and this is the way nature intended them to be...none of them eat any Chinese food or pastries or watch much TV. They're all very conscious, portion-controlled, home cooking type eaters who walk the dog for miles a day and do Jillian Michaels shred. I've read their blogs. It must be true!

    1. Health at Every Size(R) is just that: accepting the diversity of ALL body sizes/shapes. Size acceptance includes thin and fat bodies, and all of those in between. HAES(SM) recognizes that we are all individuals, and that most everyone has room to improve their health (of course this includes those who suffer from any type of eating disorder). I believe that shaming and ridiculing body sizes/shapes will only increase weight cycling and eating disorders. There's no one path to health, we all can find our way.

    2. Norma - that is not how I interpret HAES at all. It does not say that 70 pounds, 170 and 700 are all equally healthy. It does not say that all is well, go watch American Idol every night with a vat of twinkies.

      What it does say to me is that I need to start where I am and focus on my health rather than a particular number on the scale. That whatever my size, I can take steps to improve my health -- and they may not result in a different body size. I've found that focusing on the scale has never had a beneficial effect for me. It leads to nothing for me but self-hate, and I usually don't take very good care of people I hate. If it has for you, I congratulate you on finding a path to better health. That does not mean it's the right path for everyone.

      No, I don't eat "clean" all the time, nor do I always exercise enough -- I work toward a better diet and more activity as I go, and I do not expect it to change my size. I try to find a balance that is healthy for me and that is manageable within the context of the rest of my life.

    3. I am naturally very thin. The highest I've ever seen my BMI go is ~21. I prefer to be at ~19 and that's an easy size for me to maintain. No starvation and I "cheat" twice a week. People in HAES have gone and grabbed photos of people my size and gone on expositions about how ugly and anorexic looking we are. At least that was the hashtag. When I first heard of it I was a bit excited thinking it would be a way for people to not hate their bodies on a fitness journey. I thought that would be great because my mom struggles to lose weight due to depression and she's high risk for a lot of problems because of her weight and genetics. I want my mom to be happy and be there for myself and my brother as long as she can. But it's turned into ridiculous claims of fat=healthy and thin shaming. Again. I have so much hope for these movements but they always let me down.

  5. Kerry9:19 am

    Wow bring out the fat hate, stereotypes and rhetoric Norma, your judgemental attitude is certainly going to change the world. It's revolutionary thinking! Or perhaps you could just round up all the fat people and shoot them - problem solved because clearly by your definition they're all lazy, fat liars and the world would be so much better without them.

    And Yoni I wonder what exactly you wish to achieve by writing this? Do you agree or not, do you wish to support people to be healthy or not? Do you wish to add to the body of knowledge or not? Or do you have a chip on your shoulder against Linda because yes, questioning and debating science is good and necessary, this was more like taking a chainsaw to weeding!

    1. A chainsaw to a weeding? Nope. Just a mirror.

      As to what I hope to accomplish?

      I'm hoping to bring some awareness to HAES that pots can't call kettles black and expect kettles to listen to them - which is a real shame as HAES' is such an important message for people to hear, and it resonates quite soundly without the need to stoop to the same statistical tricks and logical fallacies that HAES so vocally condemns.

  6. Anonymous10:19 am

    "Healthy At Every Size" is like
    ... being on a wheelchair basketball team -
    you're not like most people, but you're out there and active and trying your best to be as healthy as possible...

    True, it's better to not become obese. Like it would have been better to buckle that seat belt, for example, to avoid becoming paralyzed.

    HAES means not hiding at home alone.

  7. You know, I think that HAES really does have the potential to go mainstream, and I hope it does. Here's why.

    When it comes right down to it, most of the fat people who despise their bodies, limit their lives because of self consciousness, and feel that they deserve the abuse and contempt that's heaped on them... these people go to bariatric doctors, they lose weight and regain it over and over again, they get heavier over the years, and I think that they must be incredibly frustrated and unhappy.

    My own experience with HAES (which I've been practising for more than 20 years - since before it was called that), is that I stay healthy, my weight stays fairly stable, I can keep up with most average-sized people my age, and my size doesn't have much of an impact on any area of my life.

    HAES clears the weight-based garbage out of your life. People who don't focus on weight are free to manage their health in exactly the same way they would if they were thin. Food isn't a constant source of anxiety. Being active doesn't feel like a punishment. With or without supporting medical research, many people will find that HAES gives them better quality of life than a weight-based approach, and that's what will carry it.

  8. Anonymous11:31 am

    I think I see where Norma is coming from. Many of my clients often seek to find reasons for their obesity, and this often comes down to looking for excuses.
    I have clients who qualify as 'super morbidly obese', but thanks to HAES, fully believe that they are healthy. Even though they are unable to walk, work or maintain a personal relationship. And, dispute the myriad of major health problems.
    I think that the HAES point of view is valuable for those who have moderate body fat issues. But, when people begin to use their mantras as excuses, it becomes an impediment. I see it daily at my office.

    1. Alexie4:23 pm

      How are morbid obesity and being a singleton related? If your clients lost weight, would they magically get a relationship? And if so, why are so many skinny young women single?

      By the way, looking for excuses not to be in superb condition is something that affects a great many people, not only fat ones. A great many people know perfectly well they should exercise and eat better, and have the means to do so, but they choose not to, but are never vilified the same way that fat people are, because they're thin.

  9. Norma, the healthy anorexic is an oxymoron and I would HIGHLY doubt that any practitioner who is using HAES in their practice would categorize purging, over exercising, excessive weight loss, metabolic abnormalities and electrolyte imbalance which are often fatal, as ‘healthy’. HAES states that all size can be healthy and that making assumption that someone is healthy or unhealthy based completely on weight alone (re:skinny or fat) is a fallacy. Yes, the thinner individuals can be healthy but they can also be unhealthy-independently of a mental illness. HAES promotes a holistic model of health which looks beyond weight and asks patients: “how are you managing stress?, do you have social support?, do you have access to food? How are your sleeping patterns? etc.?.”

    As a nutrition practitioner, I’ve observed many patients and even colleagues experience food disconnection primarily because food is seen as calories and its these calories makes you fat and, fatness is ugly and unhealthy. And this food disconnection is not a “fat person” or “anorexic” issue, this is a societal issue. The assumption that fat=bad thereby automatically requirement a medical intervention. While Yoni states “despite regularly telling my otherwise healthy overweight and moderately obese patients that their weights aren't likely contributing much if anything to them in the way of medical risk” unfortunately this is not the norm in medicine. This is why, as a practitioner, I encourage and promote HAES within my practice. HAES advocates against is assumption that fat people are merely gluttonous requireing the conventional medical internvention of weight management/weight loss. This promise is not strongly supported by science; which is confirmed by Yoni: "healthy", and "weight", are not mutually inclusive or exclusive terms.

    HAES promotes empathy (not to be mistaken with “feeling sorry for someone”) between practitioner and patient (regardless of weight) with the purpose of rebuilding and reconnecting people with their body, minds and spirit; something foreign in conventional medical practices. This leads me to my concluding (but not last) point:

    As nutrition practitioner, I apply the HAES philosophy by using alternative, more sensitive health indicators other than weight such as such as blood pressure, blood lipids, blood sugars etc). The reason is because weight loss may or may not happen with the adoption of healthy lifestyle choices and without weight loss, people often continue to feel life failures regardless of their lifestyle successes (i.e. such as moving more, managing stress, engaging in social gatherings, included more veg and fruits. This overcasting shadow of shame and blame disrupts their healing process and may exacerbate underlying social and psychological issues.

    Yoni criticized the movement using 1 article while using several studies to defend the supposedly, misinformation used by HAES researchers. This approach is disheartening to me because as a proponent of HAES, the comments and posts have generalized this group of practitioners and individuals as ignorant, radical and untrustworthy.

    I would encourage Yoni, the blog commenters and readers to expand their knowledge of HAES. What i've provided here is one perspective and application of HAES in practice. While "showing the data" is an important piece to inform practice, not all successes can be captured with the medical measuring sticks and thus, this is likely why HAES is having difficulties “penetrating mainstream medicine”. HAES acknolwedges that disconnections between weight and the HEALTH FOCUS that HAES attempts to reintegrate into medicine i.e. intuitive eating, self-esteem, body satisfactions doesn;t fancy the measurable-calculated-quantifiable scientifc rigor medicine justify's iteself with.

    Not everything that counts can be measured. Not everything that can be measured counts.- Albert Einstein



  10. Anonymous, the vast majority of people who are classified as obese have a BMI under 40. Frankly, choosing yo-yo dieting rather than HAES is probably the most effective way get from a BMI of 35 to a BMI of 50. Some people hit that 50 BMI, decide that the yo-y dieting was a bad idea, and decide to give HAES a try. I say, more power to them. The reason it's called "Health at Every Size" is because working on eating habits and taking up regular exercise will improve anyone's health, regardless of their weight.

    However, saying you're a HAES practitioner does imply that you're doing things to advance your health. Why don't you try asking those patients that you're so dismissive of what they're doing as part of their HAES approach to health? The answers may surprise you. Maybe they have joint issues and have trouble walking, but are swimming laps several times a week. Maybe they used to be unable to climb more than a couple of steps but can now handle a flight of stairs. Maybe they're lowered their blood pressure, cholesterol and/or blood sugar, thanks to their efforts.

    I hope that you're not deciding that your patients are just using HAES as an excuse without asking these types of questions.

  11. Anon: You refer to your clients, I am assuming you are some kind of therapist, which if that is the case, it is your job to help them discriminate between a mantra and an excuse, if they had all of that figured out, they wouldn't be in therapy. Also, based on your statement you clearly need to read the literature more thoroughly as there is not a single HAES proponent who would say that any person of any weight who couldn't maintain any type of a personal relationship, or a job doesn't need to address those concerns. Blaming it all on the fat, however, is where we part ways. And even if it was the "fat's" fault and the person is in denial, when was the last time you met a client who was in the top five percent of those who maintain long term weight loss as a result of dieting? For the sake of your clients, please learn a bit more about the HAES philosophy. But re: whether HAES can become mainstream or not isn't as important to me as whether people find individual ways to living a healthy life, where self acceptance is the foundation and eating disorders are eradicated. Rather than argue about whether or not HAES can be mainstream, let's fight the forces that just made it possible for Qnexa to be approved. Let's fight the media oppression that has people learning to hate their bodies as early as three years of age. Let's fight the mainstream for what it already is promoting. Warmly, Dr. Deah Schwartz

  12. Dr. F, I appreciate your leadership in the Disney protest, and the opportunity to clarify.

    It is HEALTH, not HEALTHY, at Every Size, and we do not contend that people of all weights are always healthy, or that everyone is always at their healthiest weight. There are pathological processes which result in weight displacements, up or down. HAES focuses on preventing/treating those processes.

    We have experimental animal models of weight cycling causing hypertension and binge eating; we have abundant experimental and epidemiological evidence that almost everyone who pursues weight loss finds themselves having regained weight or more two years later; and until the NIH is willing to fund robust weight cycling studies, which need to be longitudinal, on a representative sample, and to have an appropriate operational definition of "weight cycling," we probably won't have a definitive answer.

    For now, as clinicians, we have to make our best guess about how to proceed with the evidence we have. It is a reasonable hypothesis that the health problems we see correlated with high BMI could be caused in part by weight cycling. It is also a reasonable hypothesis, given other lines of evidence, that they are in part caused by the stress of living with discrimination and stigma, and/or less access to medical care due to lower income or blatant insurance or provider discrimination.

    We are so accustomed to believing that pursuing weight loss is good, we fail to demand data for it, and instead demand data that it's "not good" - but you can't prove a negative. The burden of proof is on people who are proposing an intervention to change weight, to show that it is safe and effective - not at 6 months out, but at 2, 5, 10 years out. If this basic threshhold of empirically-supported treatment had been followed, we would now have a robust library of weight-cycling research.

    If we all agree that health problems increase at both statistical extremes of weight - which we can see in the data - then the processes that cause displacements in weight should be our focus for possible causal factors. And sure enough, we find that the pursuit of weight loss is itself a cause of those displacements - in both directions.

    The founders of the HAES model have tried to keep the focus on our practices and our environments, rather than weight per se, because even though there are higher rates of health problems at statistical extremes, it is too misleading to take particular weights as an inevitable sign of pathology when there are almost always people in good health who are also at those weights, and there are processes which are problematic at ANY weight, even "ideal" BMI.

    As clinicians, we wonder how to support our patients in doing the best they can to take care of their bodies. We have one kind of empirical support for the HAES model in Dr. Bacon's own RCT, which shows that taking the focus off weight led to the maintenance of both the health practices and the health benefits even two years out. Trying to keep the focus on the day-to-day things we have in our power to do to nurture ourselves is hard enough, without loading it up with a weight loss agenda that is doomed to fail for most people.

    It does not help people to feel that their lives are on hold until their bodies are "acceptable." It does not help people to engage in temporary and unsustainable efforts to become "acceptable." It does help people for all bodies to be deemed not just acceptable, but precious and worthy of care. That means sick bodies, fat bodies, starved bodies, "ugly" bodies, less functional or mobile bodies. The bodies that we pathologize are the homes of people we are making sicker and less able to participate in the world. That is a pathological practice that we can change.

    1. Dr. Burgard, I wish everyone who spoke for HAES did so as you did, where your points of action relied on evidence where available, were accepting of uncertainties, and didn't falsely attribute the status of fact to fallacies.

      I think if everyone did that, there'd be a great many more HAES supporters out there.

    2. Yup, Dr. Burgard, I can see why that would be terrifying to incorporate as a mainstream approach to health...there would be little money to be made if we didn't hate ourselves enough to be desperate on a daily basis.

    3. Dr. B & Dr. F - you are both beacons of light.

    4. Thank you Dr. Burgard. Very helpful indeed. That is just as informative for people who support HAES as it is for the public at large.

    5. Anonymous5:57 pm

      "We are so accustomed to believing that pursuing weight loss is good, we fail to demand data for it, and instead demand data that it's "not good" - but you can't prove a negative."

      You are misusing the phrase "You can't prove a negative". This phrase refers to phenomena that do not exist, because it is literally impossible to prove that they do not exist (no such proof can be conceived, even theoretically). It is perfectly possible to prove (or at least to provide reasonable evidence) that weight loss has a negative effect if it does indeed have such an effect, thus the phrase does not apply.

      I'm guessing that you meant to challenge the idea that "weight loss = good" should be the null hypothesis, i. e., the default position. However, it is not obvious why the opposite position should be chosen, given that both have clinical evidence to support them.

    6. Yes, using the negative in that sentence of mine made it confusing. What I saying is 1) people do not demand empirical evidence that pursuing weight loss is safe and effective, because they already believe it to be so. In fact, many weight cycling companies have said behind the scenes that it is not in their interests to conduct such research - why would they do so when it would only result in a loss of belief in their product? We now know that the weight cycling period is around two years - but US researchers tell me that it is almost impossible to obtain an NIH grant for a study with a follow-up period of two years. The result is that we have study after study, millions of dollars, spent on academic versions of "before" and "after" pictures, when the real interest should be, "what happens after "after"? Because almost everyone regaining weight makes the findings six months or a year out moot.

      Can you think of other examples in medicine where the default position is to give a drug before you test it? That is what we are doing with weight "loss" interventions. I wonder if there was a parallel with early versions of chemotherapy - before the standard was to see which drugs conferred a survival advantage at five years out. Apparently there were a lot of "Dr., the operation was a success (no more cancer) but your patient died" outcomes.

      2) I am also saying that you would have to know the entire universe of possible outcomes in order to prove that dieting did not work, which is a very different project than trying to show in a representative sample that dieting does work. The fact that people offering diets do not have to show that they "work" - which for me means, if you intend to change someone's weight, that your intervention changes it longer than very momentarily, is similar to saying, "hey, I have a way for people to breathe less! Look at my data" and only presenting data on 30 seconds or so of a breath-loss intervention.

      Can I prove that there is no way for people to reduce their breathing permanently? I can't prove that because I would have to know the entire universe of outcomes of people trying to reduce their breathing. So our scientific method works on the principle that if you are making a claim, you demonstrate it in the affirmative.

      The HAES model is not making a claim about pursuing weight loss - rather, we are saying, we are not seeing any data that support this as a project, and a lot of data that indicate it's not useful for most people. We are asking that people who make the claim that trying to lose weight is a worthwhile endeavor produce data justifying it, rather than relying on the magical thinking and fantasies of the public.

  13. Fabulous response. I too am a supporter of HAES and have had issue with distortion of the statistics and in how others hijack their message for their own need.
    By the way, in studies where the over 65ers had lower risk at moderate obesity (vs thinner individuals)--did they control for cigarette smoking?

    1. Thanks, and yes I believe they did.

    2. Paul Ernsberger7:55 pm

      This is always controlled for as smoking is the first thing people bring up. But no one seems to recall that obese people who smoke consumer more cigarettes. In other words, heavy smokers are heavy. It's light smokers who are lighter by a few pounds.

  14. Well, thank you, but let's notice that you apparently heard about HAES in the first place through Dr. Bacon, who has reached many more people with her work than some others of us, and she deserves credit for that, as well as providing us with one of the several RCT's testing HAES.

    One thing I have learned in doing this work over decades is that you can't have a neat and tidy paradigm shift. There will be people who are great at defining the center of the message, and people who are great at getting the message out, and even then, people who misinterpret the message. There are good reasons why the HAES message is distorted sometimes or hard for people to hear - it's flying in the face of some pretty entrenched financial interests and cultural beliefs. The public discussion of the HAES model is the result of the work of thousands of people over decades - all over the world - it is grassroots, messy, and I am eternally grateful.

    My plan has always been to keep showing up with the argument, construct the alternatives so people have a choice, and let people decide for themselves. Time will tell whether HAES is valuable to folks or not - so far, there is a growing band of people who seem to have found it sustainably helpful, and I don't think that depends on getting unanimous public approval, thank goodness. Thank you for the dialogue!

  15. I'm not really sure what Yoni's standards are. My understanding of the scientific method is that we are reliant on a process of falsification, and it seems clear that the 'mainstream' approach is based on very shaky foundations that mostly have cultural and social and, let's face it, pecuniary origins. The whole business is based on half-truths, at best, and profitable lies at worst.

    Placing the burden of proof on the HAES movement is not the same as validating mainstream beliefs. It's a sleight-of-hand that makes the notion of sticking it out with the old, familiar prejudices just that bit easier.

  16. Paul Ernsberger7:46 pm

    Weight cycling was first linked to increased mortality in the Framingham study in 1991 (NEJM 324:1839-44). In Framingham, all of the excess mortality from obesity could be explained by the fact that obese people are more likely to weight cycle. For weight stable obese people, there was no significant mortality risk. Since 1991, many epidemiological studies have examined weight cycling as a risk factor. Most have found an increase in mortality and only a few have not. The blogger picks two negative reports, both of which were analyzed by the same group at the Harvard department of public health. As discussed by CDC statistician Kathleen Flegal, this group is notorious for excluding or excising many or even most of their subjects. Reports on the relationship of BMI to disease in the Nurses’ Health Study exclude up to 70% of the original subjects. Subjects with various starting conditions or diseases, or certain patterns of weight gain or loss are excluded, and different criteria are used to weed out subjects in each report from the Harvard group. If we consider only complete cohorts, the vast majority of reports show increased mortality.
    Reports on risk factors such as blood pressure are not as consistent. But the problem where is that lab studies show that weight cycling does not result in a permanent spike in blood pressure. Blood pressure is high for a period during and after the weight regaining phase then slowly recovers to the starting level. But even a short term rise in blood pressure can be sufficient to trigger a cardiovascular event.

    1. Anonymous7:59 pm

      If that's the best response you've got to the author's criticisms of HAES' use of data, then I'm pretty sure the author's got a point.

    2. Deborah Kauffmann12:26 am

      Thank you very much for your comments Dr. Ernsberger. Regarding the recent weight cycling study Dr. Freedhoff first mentioned, my understanding is that the data actually showed significant health risks although the study concluded otherwise. Maybe you could comment on this. Also I believe Dr. Freedhoff mentioned NHANES III in his article. Data from this showed that after adjusting for age, race, smoking, health status and preexisting illness, overweight men with weight loss of 15% or more, overweight women with weight loss of 5 to <15%, and women in all BMI categories with weight loss of 15% or more were at increased risk of death from all causes.

  17. I’m glad you read my piece and always happy to hear a self-described “obesity medicine doc” agree that fat people can be healthy. Hard to believe even that simple truth was anathema in your field just a couple years ago.

    Still, there are errors here. One is naming me as “founder” of HAES. I’m actually a latecomer; the field was well established by the time I got involved.
    Let me next address the three points you criticized from my article. Twice you employed a common debate technique of misrepresenting my idea and then attacking that. The first time you grabbed this quote from me: The "ironclad" notion that obesity leads to early death is wrong: Mortality data show "overweight" people, on average, live longest, and moderately "obese" people have similar longevity to those at weights deemed "normal" and advisable.

    Because the data do support this fact (as we both agree), you jumped immediately to the example of extreme obesity – the thin, minority, end of the weight bell curve – as proof that I must be wrong. In fact, I had intentionally omitted this group, specifying “moderate” obesity, because the data are more complicated at the extremes and one blog post is inadequate to address the nuances. But even if we did add in the extremes where weight may be problematic (and that includes extreme thinness), the larger point remains that a focus on health, not weight, is much more valuable and scientifically supported.

    The second straw man argument can also be easily dispelled: “Is Dr. Bacon honestly suggesting that the very simple fact that our life spans are continuing to lengthen, while at the same time as a society we're gaining weight, is in turn an argument that weight can't possibly be deadly?” No, of course I’m not suggesting that this means “weight can’t possibly be deadly.” What I am suggesting is that we are not seeing evidence of the great weight-mortality/morbidity catastrophe that we’ve been predicting. For all the fear-mongering about weight, you would hardly know that we are living longer than ever before, are healthier than ever, and enjoying much delayed onsets, on average, of chronic disease. I am not attributing this to increasing weight, nor am I denying the importance of other influences you mention, like improvements in medicine.

    Your third criticism suggests that “the only thing very conclusively linked to weight cycling are increased body fat percentages” and demand I show you data suggesting otherwise. I did, actually, and they were referenced in the link I provided, but you either ignored or overlooked them. While I do understand that epidemiologic studies show association, and therefore can’t be considered “conclusive,” the substantial number of studies showing this association are nevertheless good evidence, particularly when combined with mechanistic research. As an example, check out this article entitled the “Influence of obesity, physical inactivity, and weight cycling on chronic inflammation. The abstract (http://www.ncbi.nlm.nih.gov/pubmed/20036858/) explains why “it is reasonable to speculate that weight cycling causes a more profound change in chronic inflammation than sustained weight gain.” Chronic inflammation, of course, plays a role in most of the diseases we blame on weight.

    Also, I believe the fact that so many studies do show an association is more important than the fact that some studies show no association. If you examine the latter group, you can come up with several reasons for this absence; for instance, the no-association studies may not have followed people for very long, meaning fewer deaths overall, meaning little significant data emerged in the results.
    I see that Dr. Paul Ernsberger, who has conducted original research in weight cycling, already commenting on this and provided more detail.
    More in a second comment below…

    1. Thanks for your response Dr. Bacon.

      I agree that there's not much point in spending time with a back and forth on data - happy to leave it to readers to decide whose arguments they feel are more filled with straw.

      HAES' position on non weight focused care is probably not too far from mine. In our unfortunately named office (we named it before our current philosophy evolved), we call it, "Best Weight" which is whatever weight a person reaches when they're living the healthiest lives that they enjoy. We don't use pounds, body mass indices, body fat percentages or waist to hip ratios to set goals of any sort.

      The point of my post, as I'm sure you're aware, is that I believe that HAES champions, including yourself, regularly promote and publicize data and statements that when examined, don't meet your "show me the evidence" mantra, and that so doing erodes HAES' credibility. In turn I believe that erodes the likelihood of HAES truly changing how the medical establishment approaches those patients who have obesity, an approach which I agree is broken and could certainly benefit from change.

    2. Yes, I get that you are accusing me and others of providing info that isn't supported by evidence. Yet absolutely none of the examples you provided supported that. You are the one that is putting up roadblocks by publishing unsubstantiated accusations.

    3. So, to review: You attack my integrity, making three points. Two of the points you raise are irrelevant, as they misstate what I wrote. (We’re in agreement that had someone written what you said I wrote I too would have found it problematic.) You accuse me of writing unsubstantiated statements, and in your third point, overlook the link I provided with evidence. When confronted, you sigh.

      The irony of this all is how perfectly it proves the point of the original Huff Post article that you were criticizing: You are so sure of what you “know” that you are unable to even hear perspective that challenges you. The difficulty for you was more intense than for many others: you couldn’t even read the article, let alone consider its contents.

    4. Anonymous12:38 pm

      I have over 300+ physicians as clients for over 15 years. When I visit them in their office, I always notice the patients waiting to see them. I rarely, if ever, see a n elderly morbidly obese patient waiting to see the practioner. I see many patients that are elderly and slightly over weight. So either the obese patients are staying home or they are dead. A large new study is the first to show a direct link between a high BMI and the risk of developing heart disease. For the study, researchers analyzed the data from more than 75,000 people in Copenhagen and found that people with a high BMI had a 26% increased risk of developing heart disease.

      Eat whole clean foods and keep a food journal. You'll see why you are too thin or too heavy.

    5. Anonymous3:26 pm

      "So either the obese patients are staying home or they are dead."

      You're right, but it's not because they're fat. It's more likely than not because their doctors diagnose their symptoms as "fat" instead of running tests or looking further, or outright refusing them treatment until they've gone away and lost some weight, forcing them to live with pain or other ailments that would have been treated immediately or taken serious if they were a thin patient.

      Check out http://fathealth.wordpress.com/ to see some of the stories, and then think about your assumptions here.

      Check out the other assumptions that doctors have about obese patients: http://www.washingtonpost.com/wp-dyn/content/story/2008/01/28/ST2008012801777.html

      These experiences are real, the dismissal of a fat person's pain or other ailments equally real. Your own reply shows the same dismissal with "clean" eating and food journaling being the solution to it all.

      Fat stigma is killing people more than fatness is.

  18. Part 2:
    But however we parse the data, Dr. Freedhoff, we still disagree on the fundamental question of how to address these medical issues: My HAES colleagues and I believe a weight focus is not only ineffective, it’s damaging, even in cases where an individual’s weight is contributing to poor health. (See http://www.nutritionj.com/content/10/1/9.)

    To a HAES way of thinking, it requires a kind of cognitive dissonance to be able to say on the one hand, “Sure, I accept that diets don’t work, that we don’t have guaranteed methods for sustained weight loss” but, then on the other hand say, “Of course, in some cases, you just have to try, because fat is doing damage here.” HAES can’t accept that dissonance.

    Even if you’re certain that size is posing a problem, there’s no point dwelling on it when we don’t have proven methods of changing it – and so much evidence that the pursuit of weight loss is damaging. HAES is about focusing on what you can change. Here’s a case in point. Joint disease has been on my mind a lot lately, as I just had knee surgery and my dad suffered from it, too. But because my father was fat, and I’m not, we were prescribed very different treatments.

    Suppose my father’s doctors had overlooked his size. They might have said, Mr. Bacon, surgery might be necessary for your knees, but first, try physical therapy. Sometimes strengthening the muscles around the joint can help. Or they could have explored surgery. But what did his doctors recommend? They put him on diets – over and over again. He never developed a regular exercise habit and struggled with weight cycling and disordered eating his whole adult life, and his joint disease never abated.

    Sure, the extra weight may have aggravated the problem. We all can think of myriad ways it’s hard to be in a fatter body. (I should add that it also confers health advantages, but lack space to elaborate on that here.)

    But focusing on my father’s weight was no kind of solution for his joints. There are plenty of ways to support people in improving their joints, and their overall, health much more directly than by dieting. HAES merely advocates for those: Make health/lifestyle changes directly, rather than trying to use weight as a mediator.

    1. Deborah Kauffmann12:43 am

      Thank you so much for your reply Dr. Bacon. And about the possible health benefits of a fatter body that you lacked space to mention, possibly you were referring to the studies associating a higher amount of genetically determined subcutaneous fat with a lower risk of heart disease in men and women, and a lower risk of type 2 diabetes and certain forms of cancer in women.

    2. It's my understanding that fat people also have a lower risk of osteoporosis as we age. But, I wonder, with all the dieting going on among fat people, if that correlation still exists.

    3. Kerry9:49 am

      Thanks for such an articulate response Dr Bacon. Your explanations continues to show that your level of understanding of this issue. Your continued efforts to explain and promote an alternative to the drone of sameness, judgements and blame laid at the feet of people who fail to meet a limited criteria, is inspiring.

  19. Dr. Freedhof,

    You bring up an interesting point, and though I do not necessarily agree with all of your assertions, you do touch on an important challenge to HAES - proof and validity.

    Though I do not necessarily agree with your typification of Dr. Bacon's (or other HAES advocates) presentation of HAES. I would like to set that aside in the hands of those better qualified than I to address the issue. Instead, I think it is interesting to approach the statement "Why HAES May never go Mainstream" and modify that statement with an "unless or until" at the end of it.

    What would be necessary, in your opinion, to make HAES mainstream? You state that HAES practitioners should be held to the same standard that they would hold mainstream practitioners in terms of their speech and representation of data. In response to another commenter you state,

    "I'm hoping to bring some awareness to HAES that pots can't call kettles black and expect kettles to listen to them - which is a real shame as HAES' is such an important message for people to hear, and it resonates quite soundly without the need to stoop to the same statistical tricks and logical fallacies that HAES so vocally condemns"

    You, as a Bariatric Physician, represent the mainstream. What does the proof required look like? Is your basis of proof one that privileges RCTs (Randomized Control Trials)? Is it a longitudinal study of health outcomes that compares weight cycling to stable weights? Is it meta-analysis?

    My disciplinary area is not medicine, it is Science Studies. When I present on HAES I am often asked if it ought to be classified as science denial - and I think the reason for that question is that debates like this one are taking place here, on the internet, instead of inside peer reviewed journals.

    This, I think is the "Unless and Until" that needs to be added to your criticism. Unless and until this sort of debate can take place within peer reviewed journals - within the disciplines that are trying to be changed HAES will be greatly challenged.

    I want to redirect your criticism from one of "HAES practitioners do x too!" to a questioning of why this debate is not happening where it should! Is it that peer reviewed journals will not print HAES based articles, the result of disciplinary differences or internal bias on the part of reviewers that prevent these sorts of studies from being published? Or, do the studies with the kind of proof that your dsicipline would want not exist? And if so why?

    Is it a lack of funding? Is the lack of funding because of the peripheral status of HAES or differing goals between HAES and funding institutions?

    I notice that many who support HAES are nutritionists. To what extent does professionalization and discipline play a role in all of this? Is there an element of the incommensurable (as Kuhn would put it) going on when nutritionists and Bariatric physicians try to have a conversation?

    In this post you have stylized yourself as a potential ally of HAES, while simou, and I think the desire of others posting a response to this blog, is not to silence you or your critique but to redirect it. As an "insider" of the mainstream that you claim HAES cannot penetrate you have an opportunity to create a dialogue between HAES and bariatrics that could help bridge this divide. I cannot help but feel a valuable opportunity is being missed - rather than saying "this is why HAES will fail" tell us what you think HAES needs to do and the mainstream discipline needs to hear to allow agitation and change to happen - to pull the debate inside of the discipline where it has a chance to be a paradigmatic revolution.


    1. Thanks for the thoughtful comment Julia.

      I used the word "may" purposefully. I think too that I made it clear that HAES principles resound with me, both experientially and philosophically.

      Where I struggle with HAES is that in my opinion, HAES supporters regularly (though I'm sure not uniformly) take liberties with evidence that is HAES friendly while at the same time demanding a much higher calibre/level of evidence for HAES unfriendly studies. That definitely makes it much easier for folks to just slough them off as extremists.

      From my understanding of the HAES literature, as far as longer term RCTs with follow up go, we've got Dr. Bacon's study with a 2 year follow up, and we've got Dr. Gagnon's with a 1 year follow up. Really exciting and promising results, but I'd argue 2 small RCTs don't yet mean everyone else is wrong, and yet that seems to me to be the way HAES and intuitive eating are often presented - and for many, that may be off putting.

      I have no knowledge of HAES' struggles to get papers published in peer reviewed journals - and admittedly to my ears that sounds conspiratorial and paranoid, but who knows, maybe there is this big, bad, old-school, network of folks trying to quash HAES' work?

      Regardless, best way to push HAES? Yup, studies of course, but also for folks who are promoting HAES to do so with the same degree of respect, both for the individuals they're chatting with and for the evidence for and against their positions, as they'd like shown to them.

    2. Lizbeth5:00 pm

      Dr Freedman - I appreciate that it is difficult to keep track of the threads and subthreads of this argument, so please let me specify that I am responding only to your paragraph above, the one that states: Where I struggle with HAES is that in my opinion, HAES supporters regularly (though I'm sure not uniformly) take liberties with evidence that is HAES friendly while at the same time demanding a much higher calibre/level of evidence for HAES unfriendly studies. That definitely makes it much easier for folks to just slough them off as extremists."

      I am a HAES supporter, and I don't agree with your statement that HAES supporters have different levels of evidence for themselves than non-HAES folks. I don't know who all is out there representing themselves as a HAES supporter. But what I get from the mainstream discussions I participate in, is that this is not true. Sadly, I can't "prove" that, but perhaps I can win some understanding from you if I write: Where I struggle with bariatricians is that IMO bariatric surgery advocates regularly....take liberties with evidence that is bariatric-surgery friendly while at the same time demanding a much higher calibre/level of evidence for bariatric surgery-unfriendly studies." When you think of all the people and groups that represent bariatrics, don't you find yourself agreeing with my modified statement, at least a little? Aren't there some "bariatricians" that you wish would shut up and stop twisting the debate to their own ends?

      And with respect to that last sentence, which (while you don't say it directly) casts HAES proponents with extremists - isn't that always the perogative of those in the mainstream, those in control - to cast the other guys as "extremists"? The next step of course is to generate fear of them (and there is plenty of that in medicine's "nocebo effect" prophesies of doom against fat people who are, however temporarily, healthy) and propose a way to lead the people out of the desert.

      This is very frustrating, especially for those of us who prefer reform to bloody revolution. So, a rhetorical question: Is it possible, then, to have paradigm shift without revolution?

    3. Thanks for the reply.

      Just to clarify - my thoughts on barriers to publication are purely speculative. However, from a sociological standpoint suggesting that non-normative standpoints may face challenges in being published does not have to be conspiratorial. Our peer-review process is designed to hold science to a high standard of internal validation - and this is a good thing. However, this process can sometimes present challenges for the introduction of new material. Reviewers may not be familiar with the internal logic or differential term use and this can hold up or bar publication - not out of some conspiratorial desire to prevent a view point but because of professional differences. We see this a lot in interdisciplinary interactions.

      Publication, like funding, often relies on the ability to reference other credible studies in the same discipline or viewpoint. If there are only a few, these articles could get held up in revise in resubmit simply because it is a new disciplinary perspective.

      This is the challenge of any new disciplinary viewpoint. Thus, barriers to both funding and publication can be the result of constraints relating to professionalization and disciplinary boundaries - no conspiracy required.

    4. I think so. I think it takes time for certain, evidence for certain, and momentum.

      I think too that HAES' revolution is actually underway, but that to take it to the next level, where it becomes the new paradigm, may require collaboration and not just confrontation.

      (BTW, I'm not a surgeon.)

  20. Lizbeth6:00 pm

    Dr. F - I find your comment encouraging - nothing to disagree with there. I understand that you are not a surgeon, and I realize I conflated bariatrician with bariatric surgeon to some extent in my re-cast of your statement. Part of that is because it was too awkward to get into the distinctions while staying faithful to your original statement. Another part is related to my basic point, i.e. of being mistaken for membership in a group that is close to (or even a subgroup of)your own group, but doesn't really speak for you.

  21. For me, I can picture HAES never going mainstream, but it has nothing to do with any of your reasoning Dr. Freedhoff (although I do say I have to agree with some of what you said.)

    This might sound cynical and like I don't have much faith in humanity, but for me a very obvious reason is that HAES probably won't go mainstream is that it simply isn't a very big moneymaker. It's telling you to avoid diet pills, fad diets, bariatric surgery, all of those awful things that add up to a $60 billion plus per year industry (in the US, anyway). So many of the products we see pushed for weight loss have nothing to do with weight loss (or health!) anyway, it's just about appealing to people's insecurities. Fear equals consumption, which means a big ol' CA-CHING for the diet industry and for many medical practices. I feel that these companies would do anything to quash a lifestyle that discourages these kinds of practices.

    I don't agree with it, of course, but we live in such a money-driven world that I think there would need to be a huge overhaul in order for HAES to be commercially successful.

    That's my two cents, anyway!

  22. For some reason the blogging platform isn't letting me enter this comment as an inline reply, so I'll add Dr. Bacon's comment here first before my reply,

    "So, to review: You attack my integrity, making three points. Two of the points you raise are irrelevant, as they misstate what I wrote. (We’re in agreement that had someone written what you said I wrote I too would have found it problematic.) You accuse me of writing unsubstantiated statements, and in your third point, overlook the link I provided with evidence. When confronted, you sigh.

    The irony of this all is how perfectly it proves the point of the original Huff Post article that you were criticizing: You are so sure of what you “know” that you are unable to even hear perspective that challenges you. The difficulty for you was more intense than for many others: you couldn’t even read the article, let alone consider its contents."

    Dr. Bacon - I do realize that you've convinced yourself of your absolute and irrefutable correctness but the fact that I don't agree with you isn't ironic, it's simply that I disagree with you. I do think you misrepresent data. I also think I provided a case for why I think that way, and your arguments haven't convinced me otherwise. And if you or other readers are interested you can click on the HAES tag below this piece, and you'll be provided with other examples where I believe you've misrepresented data.

    Believe it or not, I am as entitled to my opinions as you are to yours, as are all of the readers here entitled to theirs. Some may agree with you, and some me.

    What's truly ironic is how incredibly well your last angry paragraph typifies your reactions here.

    Sad too.

  23. It fine for you to disagree with her but it is not ok for you to misconstrue her words to then argue with.

    As a HAES newbie and I personally attest to my very much increased health and mental integrity. Something that no program or doctor has every helped with before and I applaud Dr. Bacon and her fellow HAES fighters for championing the truth even though it doesn't have an industry waiting to profit from fat people's shame.

    That is another point that I keep in the back of my mind. For every study that is volleyed back and forth - who was the money train behind it? Frequently when I follow the money I lose faith in the "data"...

  24. PS. Dr. Bacon has every right to be angry. She is just "showing" the data back to a world with their fingers stuck in their ears. Your misunderstanding of the movement a blatant example.

  25. Anonymous7:44 pm

    I would take issue with Bacon's statement: "For all the fear-mongering about weight, you would hardly know that we are living longer than ever before, are healthier than ever, and enjoying much delayed onsets, on average, of chronic disease". Type 2 Diabetes is increasing at an alarming rate and the vast majority of those diagnosed have been diagnosed in the last 10-20 years with ever increasing numbers that will be diagnosed in the future meaning that all the ill effects associated with diabetes will start to really show up 20-30 years in the future. People are being diagnosed at ever decreasing ages meaning that they will indeed have a life dominated by a chronic disease We are talking about 10 % of the population of the EARTH having diabetes in a very short time

  26. Dr. Freedhoff, I agree with you completely. I like the idea of HAES, but some of the so called obvious truths that I read about on their blogs just do not ring true to me. Plus, as an ex-obese woman, I know how I gained my weight, and I know how I lost it, and it wasn't been by starving myself, taking strange medications, courting anorexia, or any of these extreme measures that "less than 5% of people" supposedly are able to do to successfully lose weight. So if so many HAES advocates stereotype me, and ascribe wild untruths to me, that really hurts credibility with me. Regardless, if I don't see the evidence, emotional reasoning won't work with me.

  27. The bottom line is that most people don't want to give up certain myths:

    -that all fat people are lazy, lying slugs who sit around stuffing their faces with Twinkies all day while lying through their teeth, saying that despite all the exercise they do, they just can't lose weight;

    -that weight loss and, in particular, weight loss maintenance, are easy to do;

    -that once the weight is lost, a person can eat the same number of calories as someone who is exactly the same size and shape and of "normal" weight, but who has never dieted;

    -that HAES actual does not contain the word "health";

    -that every disease and condition can be improved through weight loss;

    -that, no matter how good your metabolic and other health markers are, you cannot be healthy with a BMI of 25 or over;

    -that you can accurately judge a person's level of health simply by looking at him or her;

    -that all thin people are healthy;

    -that people engaging in the same activity will all burn calories at the same rate;

    -etc. etc.

    Instead, we prefer to cling to the myths and stereotypes of weight loss that leave the vast majority of people mentally and physically less healthy than when they started out, in addition to being much fatter after having dieted themselves up the scale.

    There is no one single unified theory of HAES. Your definition is perhaps not the same as mine, but I'll bet you dollars to donuts (lol) that people living a HAES-based life are just as healthy, if not healthier than most dieters. They might also be fat by society's standards, but--unless, like most people you're fixated on the number of the scale--they'll actually be healthy.

  28. Anonymous7:52 pm

    My problem is less with the concept of HAES and more with some of its more vocal proponents, who claim that fat is completely health neutral (ignoring extensive research around fat and inflammation, fat and estrogen, fat and breast cancer risk etc), and even that there is no link between food, exercise and fat. Excess fat is always seen as either the outcome of dieting behavior, or as something genetic. Food choices cannot be discussed, as the HAES proponents of the Fat Acceptance movement claim that to do so is to fail to accept that there are individual variations in nutrition; this argument, which seems logical on the surface, is taken to the extreme, such that because ice cream might be a decent food for someone in hospital who has difficulty swallowing, there are therefore people for whom ice cream is life giving and ice cream can under no circumstances be criticized. Any attempts to modify food choices is seen as dieting or 'restriction', or bullying by 'food scolds'. Any research around obesity or food can always be dismissed as being the work of the $60 billion diet industry.

    Which is not to say that HAES is not a good proposal. The supporters are right to say that weight loss is a futile pursuit,for most people. But those insights, while worthwhile in themselves, are becoming linked to an ideology of obesity that Dr Sharma rightly terms 'obesity denial'.

  29. Thank you for writing about this Dr. Freedhoff - you have identified the point I always get stuck at with HAES. I have been reading up on it for a couple of years now, I completely agree with the philosophy behind it and it's helped me re-frame my own approach to my weight (BMI 37, EOSS stage 1 at the moment), but I keep bumping up against what I see as a knee-jerk hostility to medical doctors and any sort of medical intervention when it comes to body weight. I understand where this is coming from, as many many overweight and obese people are badly mistreated by doctors and HAES practitioners work very hard to help people overcome the psychological damage this does, but I have to say that I do often see a rigid refusal within HAES to acknowledge that medical intervention could have a role to play in managing obesity.

    I'm sorry Dr. Bacon, I appreciate your good work and your passionate advocacy on behalf of the overweight and obese, but I share the doubts that Dr. Freedhoff has expressed about misuse of data. Your angry reaction suggests to me that on some level you know that you are putting advocacy before scientific accuracy, and that maybe you have something of a chip on your shoulder about being criticized by a medical doctor.

  30. "Like for instance the very dramatic improvements in medicine that have occurred over the course of the past few decades? "

    I've always taken that to be the explanation and always thought that Linda Bacon meant the same thing. Perhaps I have been misinterpreting it, but I also think you may be a little big out for blood and reading too much into her statement because you're already worked up. I appreciate the rest of the article and, as always, will incorporate the new information (well, not really new to me since I've actually read it before) in my advocacy of HAES. Of course everything has to be taken with a grain of salt and I've seen a few great posts that have challenged some studies used in HAES and I'm grateful to see fat acceptance activists thinking critically about these things, but, as I said, the last bit of the article seems just like twisting what she said to make your argument sound better. Really the first two were fine.

  31. The response piece on Huffington Post by Jeff Halevy addresses the HAES fallacy as well:

  32. While I am intrigued by the debate above, I am even more preoccupied by the image chosen to initiate this post - the gun facing backwards. Dr. F can you elaborate on your process for choosing that particular image?

    1. Hi Jacqui,

      I chose the image because I think Dr. Bacon's article and style of argument is meant to pick off those who might not be supportive of HAES, and instead serve to challenge her own (and HAES') credibility.

      I was also considering a foot in mouth type photo, but feet in mouth tend to be accidental, and my perception of the track record is that it's anything but.

      Some may well disagree with me, and as is clearly evidenced by the comments here, they're certainly welcome to tell me so.


  33. Anonymous1:50 pm

    I am coming very late to this discussion, but to me the point of HAES is to dissociate size and health, but it does get a little carried away in arguing vigorously that there is no relationship at all. The Bacon article is cited as strong evidence, even though the sample size is tiny, differences between groups in health measures are not statistically significant, the HAES group (and the diet group) both showed significant declines in "good" cholesterol and the groups didn't seem to be unhealthy to begin with anyway (for instance their blood pressure is pretty low). Nonetheless this very limited study seems to be treated as incontrovertible evidence that HAES improves health.

  34. Anonymous4:40 am


    Saying HAES is scientific or has a place in the medical world is a joke.
    At best its a self esteem help mantra. If thats what helps you get through your day, to accept yourself, good on you.

    But if you are 300 pounds.. you are not healthy.
    If your truly satisfied, then stay that way.
    But don't try to justify it by saying you are healthy.

    You will never hear a doctor say that an obese person should not lose weight. It's not going to happen. Their job is essentially to find/fix the medical issues going on with your body not to try to boost your self esteem and give you false information.

    If you want to be overweight, thats your choice. If your happy that way then do what you want.
    Just like it's my choice to strive to keep my body in good physical condition.

    1. Anonymous5:11 pm

      You don't even know what HAES is, do you? It is HEALTH at every size, not "accept any behavior" for the sake of self-esteem. It promotes healthy eating and exercise, regardless of whether you lose weight doing it or not. You are just another fat bigot. Sorry for the crude language, but your mind is closed and I had to point that out. Read the book, then judge after you know what you are talking about.

  35. Anonymous12:31 pm

    HAES... yeah, right.

    If an HAES advocate runs into someone with a BMI of say, 13, said Health at EVERY Size advocate will be the first to concern troll the individual.
    HAES is a hate group, they view all non-obse people as "skinny bitches" or "shitlords" (their terms), accuse all those who are thinner of being anorexic and then request acceptance.
    Hypocrites, hypocrites.

  36. Anonymous4:38 pm

    The whole HAES movement, i feel is little more that feel-good nonsense to inflate egos, deflect criticism, and otherwise make people feel better about themselves at the expense of proper nutrition and knowledge, and giving people every excuse they need to be complacent with themselves instead of taking responsibility.

    Should people be eating right and doing exercise? Yes of course!
    However, there are right ways and wrong ways to do things, and if you WERE doing it right, you wouldn't be staying at an unhealthy weight in the first place.

    You don't get to, or stay at 300+lbs by moderate activity and proper healthy eating.

    The problems, I think are that
    1. People are generally ignorant on what proper nutrition is.
    2. People are generally ignorant as to what consitutes proper exercise/activity/ and how much energy it burns/how to avoid injury.

    I've seen way too many damn statements from the FA/HAES crowd going over everything from "liquid calories don't count," to "My diabetes demands more sugar intake right now," and blatant examples of not having a clue how to count calories. In addition to those considering walking across a room or standing upright to be "exercise."

    -signed, a shitlord who lost 40lbs and started getting in shape this year by actually doing proper research and due diligence, and feeling great as a result.

  37. Obesity is caused by a great many things. As a society are we essentially going to tell a person who is obese through no fault of their own that they may as well just lie down and order out because nothing is going to keep them from being sick? HAES basically tells people that at any size they can still effect their health in a positive way through common sense choices despite what they weigh. That obesity need not be a resounding death knell making the pursuit of health not worth the effort.

  38. Though I am unsure if you mean mainstream in the medical field or mainstream in the media? Because pseudoscience goes mainstream in the media- ALL THE TIME!