Abstract
Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. Concern has arisen that this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination. This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. Randomized controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus. This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.
Highlights
Concern regarding “overweight” and “obesity” is reflected in a diverse range of policy measures aimed at helping individuals reduce their body mass index (BMI)1
From the perspective of efficacy as well as ethics, body weight is a poor target for public health intervention
More research that considers the unintended consequences of a weight focus can help to clarify the associated costs and will better allow practitioners to challenge the current paradigm
Summary
Concern regarding “overweight” and “obesity” is reflected in a diverse range of policy measures aimed at helping individuals reduce their body mass index (BMI). This has been disproven by the evidence; no randomized controlled HAES study has resulted in weight gain, and all studies that report on dietary quality or eating behavior indicate improvement or at least maintenance [11,14,15,16,17,18,19,20,21,22,23] This is in direct contrast to dieting behavior, which is associated with weight gain over time [66,123,124,125,126,127,128]. There is extensive research documenting the role of chronic stress in conditions conventionally described as obesity-associated, such as hypertension, diabetes and coronary heart disease [173] These conditions are mediated through increased metabolic risk seen as raised cholesterol, raised blood pressure, raised triglycerides and insulin resistance. Quite aside from the ethical arguments underscoring inclusive, non-discriminatory health care and civil rights, there are plausible metabolic pathways through which reducing weight stigma, by reducing inequitable social processes, can help alleviate the burden of poor health
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