The Intersection of Eating Disorders and the Philosophy of "Health at Every Size"
This paper was written in February, 2020 for a nutrition through the lifecycle course.
Recommending weight loss can have serious unintended consequences. Often, dieting behaviors result in cycles of weight loss and regain, which can negatively impact overall health and may, in some cases lead to disordered eating.1 Health at every size (HAES) is an evidence-based philosophy based on acceptance of natural body diversity.1 Body dissatisfaction has a strong negative impact an individual’s health. A focus on weight is not only ineffective at producing thinner, healthier bodies, but it also has unintended consequences including food and body preoccupation which lead to repeated cycles of weight loss and regain, negative body image, and increased risk for developing an eating disorder.2 In the HAES model, the intent is to support healthy behavior changes for people of all sizes.2 Weight is not a mediator or determinant of health. By removing the focus from weight, it is possible to make changes that improve one’s health independent of weight change.
The HAES model focuses on weight-inclusivity, which views health and well-being as multifaceted and directs efforts on improving overall health and health access, while reducing weight stigma.3 Weight stigma can be defined as stereotyping based on one’s body size.4 An example of weight stigma would be assuming that someone in a larger body has diabetes or hypertension based solely on weight status. While a higher weight is correlated with metabolic disorders, it is not a causal relationship. When using a weight-normative approach, weight is the focus, so regardless of health and disease status, someone in a larger body is prescribed weight loss.
In working with eating disorders, a HAES approach is the gold standard for care. Although eating disorders may have standard presentations, many people with life-threatening eating disorders do not fit perfectly into diagnostic criteria based on weight. Treating eating disorders with a weight-normative approach does these individuals a disservice. While some people with eating disorders do fit into the weight categories defined by DSM-V diagnostic criteria, a lot of people do not. Eating disorders do not have a “look”. Often, a client who is restricting caloric intake to levels of starvation may not be "underweight" and a client who frequently binge eats may not be "overweight". In the treatment of eating disorders, the healthcare professional should look at the individual as a whole and observe food behaviors, independent of weight status. A person who is "overweight" or "obese" based on BMI could be diagnosed with malnutrition, but in a weight-normative healthcare setting, this individual would be congratulated and praised for their “hard work and determination” in weight loss.
By taking a weight-neutral HAES approach, the healthcare professional is able to look at behaviors, independent of weight and prioritize behavior change, not necessarily weight change. For example, when someone with an eating disorder goes from restriction to eating a balanced and adequate diet, weight changes may occur (or they may not). If this person is in a larger body, recommending weight loss would be contraindicated because it would negatively impact their recovery and send them back to disordered behaviors. Sometimes, when behaviors change, weight changes as well, but weight is a side effect, not an outcome.
Robison J. Health at every size: toward a new paradigm of weight and health. MedGenMed. 2005;7(3):13.
Bacon L, Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal. 2011;10(1). doi:10.1186/1475-2891-10-9.
Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity, 2014, 1-18. doi:10.1155/2014/983495
Weight stigma. National Eating Disorders Association. https://www.nationaleatingdisorders.org/weight-stigma. Published February 18, 2018. Accessed February 28, 2020.
Brown JE. Nutrition through the Life Cycle.; 2017. http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=4770971. Accessed February 20, 2020.