Health at Every Size™

Should we ditch our diets and take on a new approach to health and wellness? Registered dietician, Laura Harnish, MS, RDN, LDN, explains what the Health at Every Size™ movement is all about.

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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider. It’s a trending topic. Should we ditch diets for the Health at Every Size movement? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Laura Harnish. She is a registered dietician with UPMC. Thank you so much for joining us.

– Thank you so much for having me.

– This Health at Every Size movement has actually been around a while but is now starting to get lots of attention. Let’s explain to folks what it really is and means.

– The Health at Every Size movement really is just letting folks know that they can pursue health and well-being without having to focus on their weight. There are other ways. It’s also a social justice movement seeking to end weight-based discrimination and bias and our societal obsession with thinness, and just advocate for health care that supports folks in all sorts of body shapes and sizes.

– Is it safe to say, maybe, that this is a holistic approach to a patient’s health, and you’re looking at things way beyond weight?

– Absolutely. The Health at Every Size movement, it does consider things like how you’re moving your body, how you’re eating, but it also thinks about the individual as a whole person. You know, they have needs that are social, cultural, mental, emotional, and so on. And so it really is not wanting to harm someone on one of those fronts to pursue a physical health goal. It also really considers the barriers to care people might have, and also the social determinants of health and what all could go into creating a situation where someone can approach health. It considers the social determinants of health such as education, poverty, where someone lives, and really wants to increase access to quality care that doesn’t discriminate on the basis of weight or any other factor.

– How would someone approach this, and would you say it really begins with meeting someone where they are in terms of their body size? And what are the next steps after that?

– Yeah, I think, you know, there is an aspect of accepting that my body is my body. It’s, you know, maybe not the shape or size that you want because we are raised in a society where thinness is so valued and we have the body mass index charts that we feel like maybe we need to conform to. Maybe we’ve been told by health care providers that we should conform to that. It’s kind of pursuing, then, healthy habits if they feel right to you. So, figuring out how to eat in a way that provides you with nutrients and also pleasure and enjoyment and doesn’t leave you feeling really restricted. Figuring out how to move your body in a way that feels right and gives you benefits. And these are things that we can engage in these behaviors for just their inherent benefits to our physical and mental health, not because we have to create a calorie deficit to lose weight.

– Right, so we’re really not looking at the numbers of the scale but instead trying to institute healthy habits. What are some of the healthy habits that we can give folks as concrete examples of, you can incorporate this into this movement?

– Yeah, I think getting rid of the weight factor, but still thinking about, “What’s a healthy, nourishing diet look like for me? What makes me feel good?” Maybe thinking about the concept of intuitive eating and kind of reconnecting with your innate ability to pick foods that are nourishing and enjoyable. It might be figuring out a way that you can move your body that you actually enjoy that doesn’t seem like a chore and doesn’t remind you of all the diets that told you had to exercise for X amount of time, X amount of days per week. And Health at Every Size really thinks about the whole person, too. So, it’s not just physical health. That can certainly be part of it, but it’s also thinking about our mental health, emotional, spiritual, and so on. So, if nurturing your relationships with your family and friends, or maybe you establish with a therapist, or just doing work on your own to be more accepting of your body. Those types of things definitely fit in to kind of some of those lifestyle changes you could make with Health at Every Size.

– Right. You used the term “intuitive eating,” and can you explain to us a little bit more what that is?

– Yeah, absolutely, and that could be a podcast on it. So, but it is a process of figuring out, you know, what your body wants and what your mind wants, too. I think about a toddler, how they, if you give them the flexibility to eat what they want, they might kind of go on a jag and eat one food all day today, but in the course of a week or a month, they’re getting everything they need. Studies show that time and again. If we can reclaim some of that, we can still use some of the nutrition knowledge that we have, but getting back to eating in a more natural way that isn’t causing us a lot of emotional turmoil and we’re not having a moral dilemma about every morsel of food that we put in our mouth. So, it’s having that flexibility. I like to say all foods can fit, and I think with that intuitive eating with a larger conversation, there are 10 principles. If someone wants to know a little bit more about it, I would direct them to the book called “Intuitive Eating” by two dieticians, Elyse Resch and Evelyn Tribole. It’s an excellent resource.

– And is it safe to say that it’s maybe one of those things of eating when you’re hungry, knowing when to stop. Intermittent fasting is a big trend. So, it’s like, no, you don’t do that. You eat when you feel like your body is ready for you to eat.

– Yeah, that’s definitely a large part of it, is kind of honoring that we do have these hunger signals. I think, you know, a lot of times, because a lot of us have been conditioned to try to diet, or lose weight, and restrict our portions and intake, honoring that hunger can be the more challenging part because some days we’re just hungry more often and for more and different foods than maybe we feel like we should be consuming. But honoring the hunger and respecting your fullness, those are two of the 10 principles, and the first one is rejecting the diet mentality. And sometimes that’s the first step that is necessary but really difficult. And so, steps like maybe curating your social media feed so you’re not seeing a lot of accounts telling you to lose weight, that type of thing, or just being mindful, maybe, when friends and family bring up their diets that they’re on. You don’t have to engage in talking about things like that.

– So, we’re having this conversation, and I’m thinking, and I’m thinking, oh, people that are listening to this may say on the surface, this seems to fly in the face of everything we’ve ever been taught about diet, and exercise, and health, and our bodies. So, is there any kind of research that shows this is a good approach?

– Yeah, good question. So, yes, there are studies that do interventions with a Health at Every Size approach. The folks that do those studies, they tend to have both physical benefits. So, they see things like improvements in blood pressure and blood lipids. They also see a lot of psychological benefits. So, everything from their mood, to their self-image, their body image, they have fewer disordered eating habits. To highlight one study that I think really illustrates kind of this point, they’ve looked at the NHANES, or the National Health And Nutrition Examination Survey. It’s a really large-scale, nationally representative study, and if you look at the healthy habits and mortality, so if people are dying. By BMI category, there were some interesting results. First, the habits that they were looking at were, if you’re eating at least five servings of fruits and vegetables every day, if you’re doing at least 12 leisure-time physical activities per month, which, you know, going on a walk, or gardening. It was not intense exercise. And the other two were not smoking and then not drinking in excess. If people were engaging in all four of those habits, then even people in what is termed the obese category, they had the same life expectancy as people in the normal weight category. So, it really kind of backs up the idea that it’s more about the habits that people are undertaking than their body size.

– And so, how long would you say this movement has been around, and any thoughts on as to why, now, so many people are talking about it?

– You can trace its origins back to the 1960s. There were fat activists, actually, and that term is really used as a neutral descriptor: not saying fat is good or bad, just fat bodies exist. That’s where it kind of originated. And then, in 2010, the Association For Size Diversity And Health trademarked it. And I think the explosion recently, though, is really due to social media. There are, if you would search on Instagram, you could find a lot of Health at Every Size, intuitive eating, non-diet accounts. I think I only learned about the movement maybe one or two years ago, and I think I would be I’m pretty similar to a lot of dieticians. So, it’s become much more prevalent in both nutrition and eating disorder treatment. It’s on the rise.

– And when you heard about it, what was your first reaction? Were you like, this seems opposite of everything I studied in school, and what was sort of your journey to realize this is something that you wanted to incorporate?

– Yeah, no, you’re right. I thought it seemed crazy, but yeah, I definitely thought it was pretty a wild concept at that point. I was working in the hospital, inpatient. I now work outpatient, counseling patients, and it was really working with patients who I saw really struggle with just chronic dieting, and so much frustration, and so much feeling of just shame and like, “I’m doing what I can, and I’m fighting my body.” And I just saw people very torn up, and it made me give the Health at Every Size Movement another look. I was definitely on the fence for a while, but the more I work with patients and the more that I read and kind of see that there is evidence to support this, it definitely is something that I have adopted.

– We’ve talked about how there is a huge mental health component to this, and we talked about not only for the individual but really, as you called it, like a social justice movement of trying to end fat shaming, et cetera. So, how much of this, for this movement, do physicians and dieticians need to get on board, and how does that play into everything?

– There is definitely anti-fat kind of bias and discrimination for people in larger body sizes across all aspects of society. And so, health care is no different. We definitely need health care providers to at least consider and discuss this approach. Even if it’s not something everyone wants to pursue, it can definitely be helpful. I would at least like providers to kind of take a step back when they are recommending weight loss and think, “What are the risks and what are the benefits?” I think we all know what the possible benefits could be, but what about the risks? I think the most concerning risk would be the risk of developing an eating disorder. If we consider that a third of people that go on diets develop some kind of a disordered eating habit, and then 20 to 25% of those people will go on to develop an actual diagnosable eating disorder, you know, the statistics are concerning. So, it’s definitely something that I think would be would warrant consideration. Eating disorders are on the rise as well. And then, the other thing to think about would just be, what is the probability of weight loss actually really being a long-term solution? And unfortunately, for people that are trying, if we’re looking six to 12 months out, most people can lose weight. However, if we look long-term, and I’d consider two to five years to be long-term, that type of timeframe, pretty much 90 to 95% of people are back at their original weight, and a good chunk of those have gained additional weight. So, I’m not saying that higher weight is bad, I’m just saying it’s the opposite of what they wanted.

– And so, really, no matter what, if you are interested in this, you should be having a conversation with your doctor or with a dietician. As a dietician, how do you approach this with some of your clients and patients?

– I do try to just focus mostly on behaviors. I, you know, kind of like to think about a healthy weight being one that happens when you are leading a lifestyle that feels right to you, and is sustainable, and isn’t causing any emotional distress. So, I try to guide patients that way because I do see it as a more sustainable option. I might not call it the Health at Every Size movement. I think that might be a bit of a barrier to some people, but kind of let them know that there are other ways to approach health if they feel like they really do want to focus on weight loss.

– And so, as this has come about, have you found that there are misconceptions related to this movement, and what are some of the biggest misconceptions about this?

– There are a number of misconceptions. One of them would be that the movement is saying anyone can be healthy at any size. And it’s really not saying that. The big idea is that we can pursue health by means other than weight loss, that anyone at any size can definitely pursue health and well-being. Another misconception would be that it’s promoting an unhealthy body size. It’s really not promoting any body-changing at all. If that happens, it happens; your weight might go down, it might go up, it might stay the same. If we hate our bodies, we typically don’t treat them very well. So, usually if we have more self-acceptance, we do tend to have better self-care habits, and that really just promotes our health in general.

– Would you say that research is ongoing when it comes to this?

– Absolutely, yeah. It’s very easy to get funding for a weight-loss study in comparison to this type of research. So, there is research like I talked about, but we definitely need more, and that’ll help us to make, you know a better case and to just know more about exactly how this is helping people. I think there’s a need, I mentioned the increase in eating disorders, and I think even as a society we have a very tormented relationship with food and our bodies. I think that there is a lot of headway being made by, you know, I know of primary care physicians within the UPMC system that are HAES-aligned, or Health at Every Size-aligned. But, you know, the diet industry is really big business, so we’re up against that. So, I’m not really sure what the future holds, but I think that there’s definitely room for this because it is needed.

– Right, and so what do you say to people about the conversations they should be having with their doctors? Or, if they want to ask a dietician some questions, what would you say they should be keeping in mind?

– Your health care provider should be attentive to what your needs are. So if you bring up that, you know, “I’m interested in this other approach because I think I’ve had some harms done to me by my history of dieting or by being instructed to lose weight by a health care provider,” you know, hopefully, they are empathetic. You do have a right to have weight-neutral care if that’s what you want. There are providers out there of all stripes who are in line with the Health at Every Size Movement. They might not be necessarily the easiest to find, currently, but definitely out there.

– Laura Harnish, we thank you so much for coming in and spending time with us today. Some good information. I think we all learned something. Thank you for your time.

– Thank you so much for having me.

– I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

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