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Health At Every Size

By Jennifer Van Pelt, MA

Society tells us that being overweight is unhealthy and unattractive. Now, that viewpoint is beginning to be challenged.

In 2002, a cardiac researcher first documented what is called the “obesity paradox”—that overweight and obesity is a major risk factor for many chronic diseases, yet larger individuals have a better survival rate than thinner individuals with the same diseases. Since then, the obesity paradox has been documented in heart failure, diabetes, coronary artery disease, renal disease, stroke, and hypertension (Brown, 2012). And recently, a large Canadian study found that individuals clinically classified as overweight had the lowest mortality risk from any cause (Orpana, Berthelot, Kaplan, Feeny, McFarland, & Ross, 2010). Healthcare and behavioral management strategies focused solely on losing weight to improve health are now being questioned.

The Health At Every Size (HAES) approach is an alternative to the weight-based paradigm that now informs much of medical and public health policy. Described as weight- and size-neutral, the initiative began decades ago, arising from the feminist and body acceptance movements. The Association for Size Diversity and Health, an international professional organization for those committed to HAES, was formed in 2003 to enhance health and wellness via education, research, and services that are free of weight-based assumptions and weight discrimination.

Wellness practice is in the midst of a paradigm shift regarding weight and health. Thousands in the clinical and lay communities worldwide now apply HAES principles in their health promotion work, according to Linda Bacon, PhD, a professor of nutrition at City College of San Francisco, a researcher, and the author of Health at Every Size: The Surprising Truth About Your Weight.

“We see HAES attitudes trickling into mainstream discourse. More and more journalists, doctors, and public health officials are adopting at least some aspects of our message—health first, not weight—in their lives, projects, and practices,” Bacon says.

HAES is a holistic approach to self-acceptance that focuses on treating our bodies well and practicing acceptance of our own and others’ bodies, according to Bacon. However, this approach does not have to be limited to larger individuals. Eating disorders, food anxiety, and body image issues can occur across a wide range of body sizes.

“For the few percent of people who are able to lose weight through dieting and keep it off long-term, they often maintain it at the expense of their mental health,” observes Judith Matz, LCSW, a psychotherapist, the director of The Chicago Center for Overcoming Overeating, Inc, and a coauthor of Beyond a Shadow of a Diet: The Therapist’s Guide to Treating Compulsive Eating and The Diet Survivor’s Handbook: 60 Lessons in Eating, Acceptance and Self-Care.

Matz, who specializes in eating and weight issues, became involved in promoting HAES because of the high failure rate of diets and the research that debunks myths about weight and health. She also realized that so-called yo-yo dieters had a greater risk of eating disorders, health problems, depression, lower self-esteem, weight gain, and shame. Matz concluded that actively participating in setting weight-loss goals for clients violated the principle of “first do no harm,” and HAES principles now inform her clinical practice.

Just as some larger patients may shun doctors because they fear judgmental messages about their weight, larger clients may mistrust social workers who say they want to help but then dole out damaging advice about clients changing the way they look, Bacon says. “Social workers’ counsel on nutrition and exercise is far more likely to take root when delivered with a body-positive, weight-neutral HAES approach,” she emphasizes.

Laura McKibbin, MSW, LICSW, agrees with Matz and Bacon: The HAES approach allows social workers to help without harming. With more than 20 years of experience specializing in eating disorder treatment and prevention, she codeveloped a hospital employee wellness program at Mercy Medical Center-North Iowa that incorporates HAES principles. McKibbin also is a HAES speaker and consultant, and she recently assisted in organizing the Size Diversity Coalition of Social Workers, an online group for social workers to collaborate about integrating HAES into professional social work discourse.

“Healthcare and mental health social workers are increasingly intersecting with adult and childhood obesity initiatives. But they are also faced with conflicting warnings from eating disorder specialists and advocacy groups warning that popular weight-loss interventions may harm clients,” she says.

Ongoing government efforts to combat obesity, especially in children, will continue to increase the number of social work clients concerned about weight and body size. Learning to send positive, weight-neutral messages to weight-conscious clients and patients can help social workers more effectively implement lifestyle changes. HAES supports the practice of intuitive eating, which eliminates the focus on food “rules” (eg, carbs are bad) and transforms what Bacon calls the “toxic, fearful” view of food that is common in many struggling with body weight issues. Intuitive eating fosters a healthy relationship with food, better body awareness, and trust in one’s inner cues in guiding eating.

“By removing the ‘lose weight’ imperative from medical, exercise, and other health-related interactions, the HAES approach enables greater trust between clients and practitioners, keeping them focused on real results rather than frustratingly unattainable goals,” Bacon explains.

Social worker should be familiar with the HAES framework, Matz advises. In addition to joining the Association for Size Diversity and Health (ASDH) and participating in online HAES groups, social workers can learn more at conferences and colleges. At the 2012 NASW symposiums in Iowa and Minnesota, McKibbin’s presentations on HAES were met with interest and gratitude from social workers who had not heard of this concept. As an undergraduate social work instructor at St Olaf College, she has incorporated information about HAES into the curriculum to ensure that new social workers are familiar with body size issues and the benefits of HAES principles.

Promoting Social Justice
Society’s “culture of thin” has fostered weightism—discrimination against those who are classified as overweight or obese by clinical definitions of body mass index—evidenced by weight discrimination in the workplace and bullying of heavier children and adults.

“Weightism is fueled by the incorrect assumption that people who are fat can simply choose to be thin,” Matz says.

By increasing awareness and the use of HAES principles in medical and social services, the ASDH hopes to combat weightism. “As members of a culture that idealizes thinness, even social workers are likely to have their own stereotypes about the character of a person who is fat,” she says.

Bacon, Matz, and McKibbin are working toward changing how social workers view larger people. “Many attendees at my lectures had never considered body size as an area of diversity and found it helpful to do so,” McKibbin adds.

Weightism is a social justice issue now, according to Matz. “Our profession has always been concerned with social justice issues, and we have an obligation to become aware of—and confront—weight-related attitudes and biases,” she says.

For social workers who are attuned to the needs of the disenfranchised and underserved, the HAES approach has a social justice aspect. Because obesity and related diseases are more prevalent among lower-income people, weightism targets them and exacerbates class consciousness, Bacon explains. Social workers are obligated to educate themselves about the intersections of race, social class, and body weight and the way these systems serve to oppress clients, McKibbin adds.

“By encouraging the letting go of weight stigma and judgment accompanying it, the HAES movement is committed to changing public health policy and the wider culture to support the message of body acceptance and HAES clinical approaches,” Bacon says.

Social workers who adopt the HAES paradigm have a tremendous potential to positively affect not only their clients but also the institutions where they work, Matz says.

“No matter the setting, promoting physical and emotional well-being for our clients is at the heart of our work,” Matz says, “and the holistic framework of HAES is consistent with the values of the social work profession.”

— Jennifer Van Pelt, MA, is a freelancer writer based in Reading, PA, and a frequent contributor to Social Work Today.

Brown H. (2012, September 17). In ‘obesity paradox,’ thinner may mean sicker. The New York Times, p. D2.

Orpana, H. M., Berthelot, J. M., Kaplan, M. S., Feeny, D. H., McFarland, B., & Ross, N. A. (2010). BMI and mortality: results from a national longitudinal study of Canadian adults. Obesity (Silver Spring), 18(1), 214-218.