Size Acceptance: Should We Change How We Approach Obesity?

Occasionally my blog deviates from humor and I write about medicine instead. Today I’d like to dip into the public health well. It won’t be funny, but it will hopefully be enlightening.

Image credit: Microsoft Clip Art

Image credit: Microsoft Clip Art

Shifting Paradigms

Many of you know I have a professional interest in obesity. It’s no secret the issue is a worldwide problem, and it’s no secret weight loss is the best goal.

Or is it?

A session at the American Public Health Association’s national meeting in New Orleans last month forced me to think about the topic in a whole new paradigm. Or at least try to. We all view the world in a systematic fashion. Anything that challenges our established way of thinking chafes like a wet swimsuit. But closed minds get us nowhere. One look at the world shows us that. So for a few hours, I tried to open mine.

Healthy At Every Size®

The session was presented by the Association for Size Diversity and Health (ASDAH), and the discussion centered around an approach called HAES: Healthy At Every Size®.

The HAES® principles include:

  • Weight Inclusivity
  • Health Enhancement
  • Respectful Care
  • Eating for Well-being
  • Life-Enhancing Movement

The HAES® model “endorses size acceptance and health practices pursued for well-being rather than weight loss.” They believe putting the emphasis on numbers and scales only leads to stigmatization and fat-shaming.

Reactions like this lead to stigmatization. Weight loss is not the answer to every health problem.  (Image by Stephen )

Reactions like this lead to stigmatization. Weight loss is not the answer to every health problem. (Image by Stephen Taaffe. Shown in one of the HAES® session slides.)

Therefore, when tackling obesity and its numerous complications, our goal should be acceptance not weight loss.

But that seems counterintuitive, doesn’t it? High BMIs* put people at risk for diabetes, hypertension, stroke, heart disease, sleep apnea, and a host of other medical problems. Weight loss improves many of these issues. So while I abhor stigmatization—in fact, my latest novel explores the issues of bullying and fat-shaming, neither of which help my protagonist get healthy—isn’t weight loss the best way to treat these complications? Shouldn’t weight loss be our goal?

That’s always been the paradigm that guided my readings, research, and clinical practice. It’s also the paradigm that guides most clinicians, researchers, and public health professionals.

Which is exactly what ASDAH is trying to change.

Here is what I learned from their fascinating sessions:

1. Before we can shed the stigma of obesity, we need to remove the goal of weight loss. Only when people feel accepted can they truly alter their behaviors.

2. In a study of obese women, those whose treatment was guided by HAES® principles instead of conventional weight loss measures maintained improved eating behaviors better than the control group (for whom restraint and weight loss were the goals). In other words, the control group’s excessive dietary restraint resulted in a return to binge eating. They simply couldn’t maintain the deprivation.

3. Research has shown stigmatization leads to chronic stress and high cortisol levels, which in turn leads to chronic medical problems such as heart disease and high blood pressure. So it’s kind of like the chicken and the egg. Does obesity alone lead to chronic health problems or does the stress incurred from societal stigmatization contribute to them, too?

So what now?

Of course, the best way to manage obesity is to prevent it in the first place. This requires multi-level interventions, not just individual behavior changes. But for the two-thirds of American adults and the one-third of American children who are already overweight or obese, weight loss has always been the goal, and in my mind, it still is. After all, we can’t change our established paradigms in one sitting.

But that doesn’t mean I’m closed to new ways of thinking, and I agree, we absolutely must end stigmatization and fat-shaming. But should we also stop pursuing weight loss as the best way for millions of people to get healthy?

Hmm, I’ll need some time to chew on it.

Image credit: Microsoft Clip Art

Image credit: Microsoft Clip Art

*BMI is not the best indicator of overweight/obesity, but it’s often the easiest measured and the most often studied for research purposes. But that’s a whole other blog topic…

*   *   *

Rubin4Carrie Rubin is a physician and the author of The Seneca Scourgea medical thriller. For full bio, click here.

263 Responses to “Size Acceptance: Should We Change How We Approach Obesity?”

  1. Gail

    I think there is so much emphasis on being sensitive to people of all sizes, that even doctors are afraid to be honest with patients about their weight. I know someone whose daughter was an obese child and the pediatrician didn’t set off the alarms they should have. The little girl grew up obese and developed type 2 diabetes.

    In my opinion, denial is a primary reason for weight issues; denial about normalcy, the correlation between food and health, and the necessity for major lifestyle changes. Doctors who do not help their patients face reality for fear of shaming them are doing them an injustice, in my opinion.

    Like

    • Carrie Rubin

      Good point. It’s tricky, for sure. If a healthcare provider doesn’t bring it up, they’re not treating the whole patient or the potential root of some of the health problems. If they do bring it up, they risk offending, as you allude to. In pediatrics, I was sometimes faced with the parent who didn’t even recognize their child was overweight, and I’m sure my bringing it up probably annoyed them. But for the most part, I found people willing to discuss it when I approached it respectfully with them.

      Like

  2. J.B. Whitmore

    Fat-shaming is a side effect of a serious problem with our food supply. In the 60s and 70s we made a wrong turn, declaring war on all fats. We now know some fats are pretty good for us. But in the meantime we’ve stuffed the supermarket shelves with foods that substitute sugars of many kinds and flavor enhancing chemicals that make the most affordable foods almost irresistible. We set people up for obesity, diabetes and all the problems that come with those afflictions. The problem will not go away, nor will the stigmatization of overweight people, until we make healthy food available and affordable. Wonderful, thoughtful post about a difficult subject.

    Like

    • Carrie Rubin

      Thank you. The book ‘Salt, Sugar, Fat’ by Michael Moss discusses what you just mentioned: about food manufacturers lowering the fat content of food and boosting the sugar content to maintain the taste. It’s a great book with some eye-opening info about the food industry.

      Like

    • Carrie Rubin

      There seems to be plenty of that in the US now as well. People need to worry about their own bodies and not everyone else’s, me thinks. 🙂

      Like

  3. Katie

    So many thoughts swirling around…I see patients that would benefit from weight loss, but have so many medical, social, and economic issues that “eat less/move more” just does not seem like a winning proposal. One of the more enlightened statements I heard at a conference came from an orthopedic surgeon who said that he sends every person with arthritis to a nutritionist because of the likely decrease in activity.

    Like

    • Carrie Rubin

      I love that the orthopedic surgeon does that. Prevention is always best, and thinking ahead like that can help stave off problems.

      It’s not really quite so easy as “eat less/move more”, is it? So many other factors peck at that equation.

      Like

  4. gdkonstantine

    A very interesting and important topic. Thank you for writing about it. I find it fascinating that until just recently (when you consider how long human beings have been around) the main problem everywhere — and it still is in many parts of the world — was trying to get enough food to survive. I agree that focusing on healthy eating is a much better approach.

    Like

    • Carrie Rubin

      Thank you. In line with your comment, I bought a book at the public health conference’s expo called “The Evolution of Obesity.” It addresses how our evolutionary ancestors had to eat as much as possible when food was available in order to survive. This led to our ability to store fat efficiently. Of course, now we have food everywhere and this ability isn’t so great. I haven’t read it yet, but I look forward to doing so.

      Like

  5. barefootmedstudent

    Oh, I agree with so much of this post. I am so tired of seeing patients’ faces fall when I bring up the topic of weight and that is because they are so used to being belittled because of their size. I would love to encourage my patients to eat healthily and to get moving, and weight loss will just be a by-product. I’ll definitely be reading more about HEAS soon!

    Like

    • Carrie Rubin

      Yes, focusing on what can be done in the here and now and not on a specific weight target down the road could have the added benefit of dropping some weight. Baby steps, as we call them. 🙂

      Like

  6. Vanessa-Jane Chapman

    Really interesting post Carrie. If we start from a point of agreeing that it’s unhealthy to be obese (sure there can be some very overweight people who are fitter and healthier than some very slim people, but we’re talking generally here, there will always be exceptions), then the discussion is really around how best to tackle it. (And of course we all surely agree that stigmatisation and shaming of any kind is wrong).

    I’m drawn again to think about an article I mentioned on my blog a while back that you may remember (something I came across in my MA studies), it was to do with education, but time and again I see different ways it could be applied. It said that goal-setting is essentially a flawed system for many people, for many reasons, such as it involves a certain amount of future prediction, and it also repeatedly sets people up for failure. Anyone who has tried to lose weight at some time or other (which is most people right? Or certainly most women) will know that feeling of setting a goal to lose a certain amount by a certain date, and then failing to meet it and therefore feeling like a failure, and losing motivation etc.

    The article suggested a problem-solving approach to achieving things rather than a goal/target setting approach. So for instance, tackling someone’s obesity could be broken down into a series of problems that need to be solved, e.g. Problem: I can’t resist calling into one of the fast food joints I pass on my way home from work every day, Solution: Can I go a different way home that avoids them? Problem: I don’t eat enough vegetables, Solution: Take a new interest in vegetables by going to farmers’ markets, and by seeking out new recipes. Maybe those are silly examples, and they are things that people may look at anyway if they’re taking a goal-setting approach, but it’s really just about articulating what needs to be achieved as a series of problems to be solved rather than articulating it as goals to reach. I think it can motivate people in a different way that may work better for some,

    The other issue of course is the confusing and ever-changing messages about what is and what isn’t healthy to eat, perpetuated by the media and manipulated by the food manufacturers. I certainly don’t think that’s helpful!

    Like

    • Carrie Rubin

      Such a great comment, Vanessa. I think the idea of problem-solving rather than goal-setting could very much apply to this setting. It’s almost like a one day at a time approach, isn’t it? Focusing on a final number could be overwhelming, but focusing on a stop at the Farmer’s Market that day is much more doable. In fact, when we counsel people on weight loss (because that is still where a clinician’s focus is; as I said, it’s a difficult paradigm to change), we often recommend baby steps. Changing everything at once is too daunting.

      Great comment, and oh, don’t even get me started on the food industry… (But I have plenty to say about it in my book. 😉 )

      Liked by 1 person

      • Vanessa-Jane Chapman

        Yes, problem solving is like baby steps, not just because small steps are easier than big steps, but also because it brings it all closer to now rather than something in the future, I think that helps to take ownership of it more, and feel like its something that you’re part of, rather than something you’re trying to reach for?

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  7. Britt Skrabanek

    Interesting post, honey! We all have our opinions, of course, but I live by a simple motto and I try to encourage others to do the same.

    Don’t weight yourself, because they’re just numbers. Don’t eat processed foods, eat whole and organic whenever you can. Don’t compare yourself to others, especially those photoshopped celebrities and models who don’t look human.

    Do find the type of exercise that speaks to you so that you look forward to it instead of dreading it. Do what makes you and your body feel as awesome as possible and lose the rest.

    Like

    • Carrie Rubin

      Excellent advice. I don’t think people have to focus on the scale at first (unless their health is clearly at risk). Just changing their diet over to one you describe is a first start. Then, before they know it, the pounds will come off, and they weren’t even technically on a diet, since it involves a whole lifestyle change. Now, getting people to do that is the tricky part. Human behavior is complex.

      Thanks for the Twitter share!

      Liked by 1 person

  8. philosophermouseofthehedge

    Hey Carrie. Are you familiar with the national “Walk with a doc” initiative? (They have tshirts…and good ideas.)
    Here’s a local group that met today in one of our parks. All of them large to obese, but doing something about it. Not afraid to try.
    https://www.facebook.com/houstonbariatricandgeneralsurgery
    We need to get away from the Freak Show mentality and encourage everyone to get out and get moving.
    Thought you might find it interesting

    Like

  9. NancyTex

    Ooooheee, this is a juicy topic, isn’t it? I explored a similar vein in a post I wrote approx 18 months ago about whether Fat could every equal Fit, following a gym class I attended, led by an overweight instructor. She delivered a fantastic and challenging class, and exhibited excellent form, and it really caused me to rethink my preconceived notions that Fat automatically meant Unhealthy/Unfit.

    Like you, I’m not okay with fat-shaming, but I also worry about sending messages that obesity is okay. It’s definitely a grey area for me.

    Like

    • Carrie Rubin

      “Like you, I’m not okay with fat-shaming, but I also worry about sending messages that obesity is okay.”—Well said, Nancy. That’s exactly how I feel, so I’m not ready to let go of weight loss as the goal.

      I think I remember that post of yours, though I’m not sure I’ve followed your blog that long. Then again, maybe I have. Time flies in the blogging world. Can’t believe I’ve had mine for over three years now!

      Liked by 1 person

  10. Sandee

    Thanks for the discussion, Carrie! Please allow me to vent about the latest media trend that really “gets my goat!” Hahaha!

    The latest media ‘trend’ is the canned-phrase ‘fat-shaming’. Beauty transcends the physical, and no one should be teased about their appearance, but we shouldn’t accept that we’re severely over weight and morbidly obese. I observe celebrities who use the latest trend of celebrating obesity. Eventually they go on diets.

    Obesity is a health problem and shouldn’t be celebrated as a lifestyle choice. That idea gives the wrong impression to people who are in denial and keeps them sick. We shouldn’t parade around and dress it up.

    I think the song “All About That Bass” is a bunch of bull. It superficially celebrates the larger form. But there’s envy in the underlying tone. I saw a parody of the video that draws that out, so it’s obvious not only to me what’s really going on in that song.

    Like

    • Carrie Rubin

      I agree with you that we shouldn’t celebrate obesity and its complications as a lifestyle choice. That’s why I can’t completely get on board with getting rid of weight loss as a goal. If someone is diabetic and on high blood pressure meds, weight loss can reverse these conditions and allow them to get off meds (of course, not in all cases). So for me, it’s about getting healthy. But I think people need to have some sense of self-worth before they can make lasting positive changes. That idea I can get behind.

      Thanks so much for sharing your thoughts, Sandee. Hope all is well!

      Like

    • Nerija S.

      See, it kind of bugs me that whenever there’s an article that suggests we quit shaming people for their body size (for which there could be many reasons, and not simply laziness or McDonald’s addiction), and that every person deserves to feel worthy of respect, there are invariably comments concerned that we’re talking about completely ignoring health and “parading around” something bad. Why does not making people feel like sh*t if they’re struggling with weight have to be perceived as something immoral and unhealthy?

      The point is to focus on health rather than appearance – to encourage active lifestyles because they’re good for the heart, blood pressure, etc. instead of because it’ll make you thinner. Because a person may be very active and eat a balanced diet, and still be a size 12; it depends on their body type.

      Like

      • Carrie Rubin

        “The point is to focus on health rather than appearance – to encourage active lifestyles because they’re good for the heart, blood pressure, etc. instead of because it’ll make you thinner.”—Yes, well said. I think that’s an important point and one the presenters were trying to get across. Thin doesn’t always mean healthy just as overweight doesn’t always mean unhealthy.

        Like

        • Nerija S.

          Exactly! One can’t just assume, from a person’s size, whether they’re healthy, what they eat, how active they are, etc. Yes, there are many people who are overweight because of unhealthy food choices and lack of exercise. But I know someone who’s always biking, hiking, and doing her best to eat right, and still has a lot of weight. And she is an amazing, caring, strong-willed, beautiful person who deserves to love who she is right now.

          That’s why I believe in focusing on the less visible (and more important, in my opinion) signs of health, instead of believing that healthy has to = thin.

          Like

  11. Daniel Nest

    I also have a professional interest in obesity. To that end, I have sampled a wide assortment of fast foods, but so far I have only had modest weight gain. Alas!

    On a serious note, I always defer to professionals and data in these situations. If there’s a good indication that the HAES model actually helps more people than the traditional weight loss approach, statistically speaking, then why shouldn’t we give it more attention?

    Damn, could that answer be any more PC? But I mean it, though, so I guess that counts?

    Like

  12. talesfromthemotherland

    Carrie, you have covered a very tough subject with respect and thought. As someone who has never felt good inside her body, and who has also watched some very dear people in my life, be body shamed for years, I can’t help but think that weight inclusivity could only be good for both of us. Wonderful post!

    Like

    • Carrie Rubin

      Thanks, Dawn. Acceptance would go a long way to helping people get healthy, in every sense of the word. But with so much stigmatization out there, it’s tough for many to feel good about themselves.

      Like

  13. Sue Archer

    Love this post, Carrie. I think the problem with focusing on weight loss is it’s not a very positive goal for people. So you lost a pound – what exactly does that mean to you? My Fitbit, on the other hand, has motivated me to try to walk a certain number of steps each day, to be healthy. Whether it results in weight loss or not is not the point. It’s a positive goal for me – a concrete way to be more healthy that feels good, not stressful.

    Like

    • Carrie Rubin

      I don’t have a Fitbit, but I know many people love them. As you mention, it’s an objective way to track progress, and that can be very motivating for people. They have pretty fancy Fitbits now, too. Even some designers are getting into it!

      Liked by 1 person

  14. pegoleg

    This is a dilemma. Obesity IS a barrier to good health in the long run – there’s no way around the science of this. That doesn’t mean that shame has to go along with it, however.

    Very interesting, Carrie. Thanks for sharing.

    Like

  15. joannerambling

    Ok with over a 130 comments before me I would usually not bother with a comment but I just had to say this was bloody interesting I am a short fat middle aged woman who has finely stopped worrying about her weight and have to say I am so much happier. I do, however, want to punch the doctor when they tell me to lose weight

    Like

  16. La La

    I support the idea that the healthy choice that works is the best choice, so my mind is open.

    Certainly the education part of it is necessary. I know people are different and obesity happens for different reasons, but I am trying to imagine if being treated differently would have changed my bad feelings for myself and thus contributed to changed habits due to a growing respect for my own body. Then again, I also had 5 years of therapy. This week marks the week I reached 60 pounds lost and my weight goal. Yay! Thinking back, when I started liking other stuff about myself and enjoying my own company, the weight loss stuff kind of just fell into place.

    So it makes sense that acceptance is important!

    Like

    • Carrie Rubin

      60 pounds? Wow! That’s fantastic. Congrats to you. As you point out, when your self-worth improved, the weight came off more easily, which I guess supports what these presenters were saying. Until people accept who they are and like themselves, weight loss can be a challenge.

      Like

  17. Nicole Roder

    I have been to New Orleans! And it was for a public health conference too!

    I’m intrigued and very curious about this post. It sounds like the HAES principles are saying that instead of encouraging people to diet to lose weight, health professionals should encourage them to eat for well-being. That they should stop focusing on weight loss as the goal, but instead focus on eating healthier and reducing stress and stigmatization.

    But are they intending that that approach should naturally lead to weight loss? I get that the numbers on the scale aren’t necessarily as important as other health factors, but at some point, they are important. If you’re 5’2″ and weigh 300 pounds, you need to lose weight no matter how healthy your diet is. Right?

    Perhaps they mean that the stress of trying so hard to lose weight is making it difficult for some people to make healthy choices in their eating, and if they remove that stress, then it will make it easier for them to make the right choices, and the result, among other things, will be weight loss.

    I have a hard time believing that could work, though. Even if you convinced the entire medical and public health community to follow these principles (which is a big “if”), the rest of society would still be focussed on the “fat=bad, skinny=good” mentality. It seems nearly impossible to remove all that stigma. There’s even stigma around being too skinny!

    Also, I think for a lot of people (myself included), seeing the numbers go down on the scale is great motivation for continuing with healthy habits. When I track my calories and weigh myself regularly, I do much better than when I just think “I should just try to eat healthy.” I’ve never been obese, but I have been significantly overweight, and I’m not sure I could’ve lost it without all the tracking.

    Thanks for posting. Definitely an interesting discussion!

    Like

    • Carrie Rubin

      I think that’s their idea–that by getting a person to feel better about themselves and encouraging them to engage in a healthy lifestyle, weight loss may be a lucky side effect. But I agree with you–for those who are severely overweight with medical complications, the weight needs to come off to improve their overall health. That’s why I can’t completely get onboard. But as I said, I’m all for decreasing stigmatization and helping people improve their self-worth. It’s a very complex issue, and I think different approaches probably work for different people. As you point out here: “seeing the numbers go down on the scale is great motivation for continuing with healthy habits.” I think that’s a great point. Some people really need that.

      Thanks for your thoughts!

      Liked by 1 person

  18. Lori D

    Well, as you know, I like to delve into psychological reasons for behavior. I do believe we need to clear away psychological issues in order to move forward with any change, otherwise they’ll keep coming back to haunt us. I know that in many cases, I eat for comfort, which is an issue I should address before I look to lose weight.

    Here’s a little story that happened to me. About 20 years ago I walked into a weight loss place looking to lose 15 pounds. They looked at me and laughed. They said that people that come to them need to lose, at the very least, 40 pounds, but more like 50 or over. I felt like I needed help getting off that extra 15, but they weren’t willing to help. Why in the world would they expect people to wait until the pounds got out of hand and dangerous and not fix it beforehand? I would also get mocked by family and friends for wanting to get off an extra 10 or 15 because they thought it was such a small amount. Huh?

    I’ve seen obese people who diet drop 10 pounds in a week. I often wonder why I can’t drop 10 of an extra 15 that fast. It took me 4 months to lose 15. Sigh. Now it’s back on again. Anyway, this is a complex subject.

    Liked by 1 person

    • Carrie Rubin

      It is a complex subject and as such, it needs complex interventions. Expecting people to just eat less and exercise more isn’t getting us anywhere. There’s so much more to it than that, and as you point out, underlying psychological issues are often at the root of the problem.

      I agree–seems silly not to be willing to help someone just because their weight loss needs are less. Prevention is always the best route, so tackling the issue early on only makes sense.

      Liked by 1 person

  19. Perfecting Motherhood

    Quite a touchy subject for so many people… and something we don’t talk about honestly, in my opinion. Many doctors completely ignore their patients’ overweight issue and I don’t understand why. My best friend is quite overweight (technically obese) and not once her doctor has addressed her weight as a problem for her health issues. She had her gall bladder removed a few years ago without ever trying to make adjustments to her diet first. She now has to deal with the consequences of not having a gall bladder, which doctors don’t warn you about before the surgery.

    And sure, some people have to take their genetic predisposition into account, but let’s face it. Most Americans who are overweight are that way because they eat too much (junk) and don’t move around enough. And again, many doctors don’t do anything to encourage their patients’ healthy habits. Just look away and see if the problem goes away… That’s the problem with the health system today, which only benefits from sick patients. After all, doctors and specialists don’t make a lot of extra money with healthy patients. That’s a huge flaw that needs to be fixed. I have Kaiser for health insurance, with no middle insurance, and trust me, they do a lot to keep you healthy. Every time I go, they ask me how many times a week I exercise 30 minutes or more. Every time my kids go for a checkup, they ask the same question, along with the amount of daily screen time, and the types of foods they eat, and drinks they gulp down. It starts with educating the children (and the parents) to form lifelong healthy habits, and little of that is happening. At our house, we eat healthy but also don’t deprive ourselves of treats (chocolate, candy, ice cream, cakes, pies and cookies). My kids know that everything is in moderation and that moving around is what they can do best for their bodies. Overall I hope doctors become more aware of the elephant in the room (no pun intended).

    Like

    • Carrie Rubin

      There are many doctors who practice like that I’m sure, but there are also many who don’t. Most recognize weight as the source of many health problems. Unfortunately, when they bring it up, patients can become easily offended. This is especially tricky in peds, where oftentimes, parents don’t even recognize their child is overweight.

      But that never stopped me from broaching the subject (which is probably why I always ran behind–not enough time to deal with these complex issues in short office visits!) Luckily, the training med students and residents receive in obesity is better than it used to be, but there is still a long way to go.

      Also, in terms of pay-for-service, that too is a system that is in dire need of change. We’re getting there. Policies like pay-for-performance, meaning payments are linked to a patient’s improvement rather than the individual visits (that’s a simplistic view but I’m keeping it quick), are sprouting up. There’s no doubt the healthcare system needs to change. Too bad it’s such a slow process.

      Thanks, as always, for your thoughts. Hope you’re surviving the California weather (though perhaps the storms missed you in San Diego?)

      Like

      • Perfecting Motherhood

        I really hope doctors will show more and more concern about their patients’ healthy habits because it would help prevent a lot of diseases down the road. And I agree with you, many people are oblivious to their condition, or the condition of their children. Stuffing your head in the sand doesn’t make the problem go away, unfortunately.

        It’s been raining the whole morning here but no huge storm so far, so I’m keeping my fingers crossed. This steady flow of rain is very good for the earth (better than downpours), so I hope it continues until tonight, as is expected. I think it would have to rain every day for a whole year to make up for the last 4 years of drought, but I’ll take rain one day at a time. 🙂

        Like

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