Health at every size
| Not just a river in Egypt|
|♫ We're not listening ♫|
| Potentially edible!|
"Health at every size" (or HAES) is a pseudo-scientific concept peddled by certain fat activists which asserts — in complete opposition to current medical knowledge — that no kind of obesity is linked to poor health or unhealthiness. In most interpretations, HAES then goes on to claim that all kinds of obesity are completely natural and related to genetic causes (much in the same way all cancers and death from old age are), and in no way can be related to bad diet or (lack of) exercise; this leads to the assertion that if obesity is always a natural state of being then it's perfectly fine and not at all unhealthy. Other key canards are the assertion that the theory that obesity is caused by calories in exceeding calories out (and therefore the inverse, that weight loss is caused by calories out exceeding calories in) is not true, that diets do not work as a means of losing weight and/or often fail and therefore are not worth even trying, and that the medical profession are engaged in some sort of cover up of these facts to "fat shame" people for… some reason. HAES is a completely separate concept from the idea that obese people are of equal worth to, or do not deserve discrimination in favour of, people who are not obese.
Originally HAES was intended as a far less specious and far more medically sound idea — that diets, fad and crash diets in particular, in and of themselves are not a sensible way to lose weight and that one should instead focus on living a healthful lifestyle regardless of weight, which can, if the person so desires, lead to a healthy weight loss quest. The present, and most common, interpretation ignores the bit about a healthful lifestyle and disregards the idea of aiming for weight loss, and instead assumes that people who are not actually dead or filled with tumours are perfectly healthy, even if they are morbidly obese due to eating unhealthy food while maintaining a sedentary lifestyle. To reflect this dramatic shift in usage of the term, this article is about its present-day, pseudo-scientific interpretation.
Why is it bullshit?
HAES is pseudo-science that either outright denies established medical facts, or severely misrepresents them. Put simply, in all but a very small minority of cases, obesity is caused by calories in exceeding calories out, is a negative health condition in-and-of-itself, dramatically reduces the quality of life for people who have it and dramatically increases the risk of a large number of debilitating illnesses and chronic conditions. This is an accepted medical fact and there are few if any grounds for contradicting it; under the theory of extraordinary claims requiring extraordinary evidence, HAES simply cannot prove its case against the wealth of evidence for a calorie-based cause of obesity or for obesity being unhealthy. Virtually all governments and health authorities worldwide may not specifically deny the tenets of HAES, but they do fully endorse the opposite conclusions.
Aside from the concept of obesity being genetic and therefore natural and therefore good being the naturalistic fallacy writ large, the notion of obesity having a mainly or wholly genetic cause is easily evidenced as total bollocks by obesity rates doubling in the years between 1980 and 2015 according to the WHO, something which would be completely impossible if down to genetics (since it would require a dramatic change in the gene pool over the course of 35 years) but is easily explicable if one thinks about the massively increased prevalence, availability, consumption and lowered cost of high-carbohydrate and/or high-fat food, as well as its increased marketing to children and decreased levels of physical activity. It also does not explain why countries with much lower consumption and overeating of such foodstuffs, such as Japan, have lower obesity rates than other similarly advanced economies.
While some HAES advocates claim that they have tried to lose weight through increased exercise or lowered calorie intake and failed to lose weight, and that this therefore "proves" the conventional medical wisdom that obesity is caused by calories in being greater than calories out to be incorrect, actual studies have shown that where individuals claim to have attempted to restrict calorie intake below their basal metabolic rate and that this hasn't worked in causing them to lose weight, what was actually happening is that they were dramatically under-reporting the number of calories they were taking in, or over-reporting the amount of exercise they did. There are certainly medical conditions which will cause individuals to lay down excessive amounts of fat relative to their intake, such as Hashimoto's thyroiditis or other manifestations of hypothyroidism, and there are certainly means in which someone can eat a normal diet and still gain weight, such as disability or injury causing reduced activity levels, but these are relatively rare. There is also the issue that eating at or below their basal metabolic rate and gaining weight, or fasting and not losing weight would either be breaking the laws of thermodynamics or the product of digesting bodily organs in order to generate energy to lay down fat and run vital body processes.
The slogan "healthy at every size" itself is intended to respond to the accusation that obesity is, in and of itself, unhealthy, and state that physical size (or rather, presence or lack of fat deposits) has nothing to do with the health of an individual. Even leaving aside the dubious assertion that obesity is not in any way unhealthy in and of itself, despite the World Health Organisation calling it an epidemic that requires urgent action and it being something that in numerous ways can severely impair an individual's quality and length of life, body mass index (BMI) values above 30 (generally considered the threshold of obesity) are strongly associated with any number of elevated risk factors including type 2 diabetes, cancer and heart disease. A common response to this is to claim that BMI is invalid as a method of measurement, but this is a half truth; for most people (who are not incredibly tall or incredibly muscular) it is a valid means of at least indicating obesity that can then be confirmed using methods such as waist-hip ratio or body bad fat percentage. Certainly, if someone's BMI is over thirty and they obviously have large excess fat deposits, trying to claim that they are not obese because BMI doesn't work for outlying categories that they do not fall into is simply denial of reality.
Often HAES advocates concepts such as intuitive eating, which encourages people to pay attention to their own "hunger signals" rather than paying attention to the nutritional or calorific composition of food, by eating until one is satiated and no more. This concept is by no means scientifically supported, either as a means of healthy eating or one of weight loss, and can often be used as an excuse for binge eating — not to mention, some foods (especially starchy, high-carbohydrate ones such as potato chips and bread) are both high in calories and notoriously easy to eat large quantities of before one feels full, meaning that one's intuitive body signals might say things like "guzzle a whole tube of Pringles" — which is, suffice to say, not a particularly healthy attitude to take.
Some of the stranger HAES advocates consider that any attempt to restrict ones' calorie intake is a precursor to, or even a symptom of, anorexia, which aside from being obvious shite is insulting to people who genuinely do have anorexia, which distinguishes itself not by reduced calorie ingestion in order to achieve sensible goals but by a compulsive and overriding obsession with weight loss and food restriction. As well as being insulting, this is also actively harmful to people who have eating disorders by propagating the idea that anorexia is simply "being too thin", rather than an actual psychological disorder which requires medical attention.
Another assertion often coupled with HAES is that saying any of the above amounts to "fat shaming". But one does not have to think that a person is bad because they are obese to think that obesity is a bad condition; nor does believing or saying this necessarily "shame" people who are obese, except in the sense that it might make those people feel bad about being obese if they acknowledged it was not a good thing. There is a definite difference between insulting or even hating someone for being fat and not thinking that someone who is obese is healthy. This runs into the territory of the absurd when HAES advocates accuse actual doctors of "fat shaming" them for suggesting that their obesity may be a medical condition that requires attention, either implicitly or deliberately. One then has to consider whether HAES is actually a genuine belief that obesity is a healthy state of being, or a means of its advocates excusing responsibility for the consequences of their own life choices so as not to feel bad about them.
Kernels of truth
Studies have shown that actually shaming obese people really will do nothing to encourage them to lose weight, and will probably make matters worse by provoking comfort eating and other negative psychological effects. The problem comes when HAES advocates interpret genuine, well-intentioned offers of support from medical practitioners or family members as "shaming", refuse to recognise their obesity as a problem or refuse to even recognise their obesity exists or can (or should) be defined as existing.
There is also nothing intrinsically wrong with self-acceptance, but balanced self-reflection and self-criticism is also an important component of normal psychological well being — "I hate all of myself entirely and I am awful" and "I unconditionally love everything about myself and I am perfect" are almost as unhealthy as each other, while HAES would have one believe that either the latter or the former and that the latter is the right approach, ignoring the more sensible middle ground of reasonable self-critique. Similarly, an obsession with weight and calorie intake to the exclusion of all else is extremely unhealthy (indeed, that is more or less the definition of an eating disorder) but that isn't what anyone (least of all a doctor) would rationally advocate or is advocating, and it certainly doesn't mean that completely ignoring calorie intake or weight is a good idea. The real solution is to do what humans are meant to do: eat a sensible, balanced diet rich in vegetables and complex carbohydrates and low on (but not entirely without) sugars and simple/refined carbohydrates and processed foods.
The issue with HAES is that it takes the idea of "fat acceptance" to a deranged conclusion: not by wanting fat people to be welcomed into society as people to be judged on their merits, but by wanting the concept of morbid obesity or metabolically unhealthy-kind obesity itself to be considered good medically despite its numerous and documented health harms. The former is admirable; the latter is pseudo-scientific and dangerous.
There is also evidence that healthy behaviors significantly improve mortality rates even among obese people, so the obese can be more or less healthy with clear differences in mortality. In one study often cited by fat-acceptance people, Matheson et al in 2012 found significant benefits amongst all weight classes with people who followed four healthy behaviors (not smoking, drinking moderately, exercising regularly, eating 5 or more portions of fruit and veg), with overweight and obese people seeing particular reductions in mortality based on how many they practiced (although there are substantial benefits for all weight groups). In those with none of the healthy behaviors, the hazard ratio for the obese (BMI > 30) was about three times that for those classed with normal weight (BMI 18.5 to 24.9); but in those who did all four behaviors there was little difference in mortality between weight classes. The study notes the "lack of time spent counseling patients to adopt a healthy lifestyle" (although this may vary from area to area). There is a causal link between some unhealthy behaviors (such as not exercising and excessive drinking) and obesity, and like most studies it is a longitudinal study based on self-reporting, so it's not conclusive.
- World Health Organisation obesity factsheet: "The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended: Raised BMI is a major risk factor for noncommunicable diseases such as: cardiovascular diseases (mainly heart disease and stroke), which were the leading cause of death in 2012; diabetes; musculoskeletal disorders (especially osteoarthritis — a highly disabling degenerative disease of the joints); some cancers (endometrial, breast, and colon)."
- NHS Choices — Obesity: "Obesity is generally caused by consuming more calories – particularly those in fatty and sugary foods – than you burn off through physical activity… Taking steps to tackle obesity is important because, in addition to causing obvious physical changes, it can lead to a number of serious and potentially life-threatening conditions"
- National Institute of Health: "Being overweight or obese puts you at risk for many health problems. The more body fat that you have and the more you weigh, the more likely you are to develop: Coronary heart disease, High blood pressure, Type 2 diabetes, Gallstones, Breathing problems, Certain cancers… Your weight is the result of many factors. These factors include environment, family history and genetics, metabolism (the way your body changes food and oxygen into energy), behavior or habits, and more."
- Australian Department of Health: "Aside from genetic factors, overweight and obesity is caused by an energy imbalance, where energy intake exceeds energy expenditure over a considerable period of time… The health problems and consequences of obesity are many and varied, including musculoskeletal problems, cardiovascular disease, some cancers, sleep apnoea, type 2 diabetes, and hypertension to name a few."
- Public Health Agency of Canada: "Obesity is a complex phenomenon that involves a wide and interactive range of biological, behavioural and societal factors. While genetics play a role, genes do not operate in a vacuum; behaviours and social, cultural and physical environments also make important contributions… Obesity is associated with a number of health conditions or morbidities. A recent systematic review of the clinical literature found associations between obesity and the incidence of type 2 diabetes, asthma, gallbladder disease, osteoarthritis, chronic back pain, several types of cancers (colorectal, kidney, breast, endometrial, ovarian and pancreatic cancers) and major types of cardiovascular disease (hypertension, stroke, congestive heart failure and coronary artery disease)."
- Japan's obesity rate is 3.2% by the WHO standard of BMI above 30, versus upwards of 30% for the USA. However, Japan recently officially reclassified obesity as being over a BMI of 25, as opposed to the WHO standard of 30. This may at first glance seem to support the HAES proposition that health and BMI are not linked, however, the reasoning behind it actually torpedoes it; researchers ascertained that due to various factors, Japanese people actually suffer negative health effects such as diabetes at a lower BMI than do Westerners, and that the rate of obesity by this measure had actually quadrupled in men and tripled in women, which explained a commensurate rise in the rate of such health effects.
- Conclusion: "The failure of some obese subjects to lose weight while eating a diet they report as low in calories is due to an energy intake substantially higher than reported and an overestimation of physical activity, not to an abnormality in thermogenesis."
- A Diet Plan is a woo-free and exhaustive guide to making a diet plan which, in essence, basically boils down to what the text before this reference just said. For weight loss, that text plus a calorie-counting site like MyFitnessPal is pretty much all that is needed and fits virtually all medical advice about healthy eating.
- The science is clear: fad diets don't work Vox.com
- UK: Scotland Woman 'starved herself to death' BBC
- Healthy lifestyle habits and mortality in overweight and obese individuals. EM Matheson, DE King, CJ Everett, J Am Board Fam Med. 2012 Jan-Feb;25(1):9-15. doi: 10.3122/jabfm.2012.01.110164.