Sainsbury and Hay [1] did not cite a source for ‘Healthat Every Size’ in the original article. The following wassourced from the Association for Size Diversity andHealth (ASDH) website, accessed on 23rd March 2014:https://www.sizediversityandhealth.org/content.asp?id=152.“The Health At Every Size® Principles are:1. Weight Inclusivity: Accept and respect the inherentdiversity of body shapes and sizes and reject theidealizing or pathologizing of specific weights.2. Health Enhancement: Support health policies thatimprove and equalize access to information andservices, and personal practices that improve humanwell-being, including attention to individual physical,economic, social, spiritual, emotional, and otherneeds.3. Respectful Care: Acknowledge our biases, and workto end weight discrimination, weight stigma, andweight bias. Provide information and services froman understanding that socio-economic status, race,gender, sexual orientation, age, and other identitiesimpact weight stigma, and support environmentsthat address these inequities.4. Eating for Well-being: Promote flexible,individualized eating based on hunger, satiety,nutritional needs, and pleasure, rather than anyexternally regulated eating plan focused on weightcontrol.5. Life-Enhancing Movement: Support physicalactivities that allow people of all sizes, abilities, andinterests to engage in enjoyable movement, to thedegree that they choose.”While we subscribe to and support most of the above-mentioned principles, in particular the high importanceof ending weight stigma and weight bias, the article waswritten to address issues related to Principles 1 and 4.With regards to Principle 1, and for the reasons out-lined in our commentary, we respectfully disagree that itis possible to be - or to stay - truly healthy with body weightsoutside of certain thresholds.With respect to Principle 4, we believe that externallyregulated eating plans and/or an explicit focus on weightcontrol are necessary in some situations for people to at-tain or maintain a healthy body weight. While we our-selves frequently draw on principles such as eatingaccording to appetite and pleasure in our clinical prac-tice and research, there are situations where intuitiveeating plans per se do not result in loss of excess weight.For instance, such intuitive eating plans - while promotingpsychological health - have shown disappointing resultswith respect to weight loss in clinical trials [2]. We be-lieve it is most likely that intuitive eating plans need tobe combined with some elements of structured, exter-nally regulated dietary programs in order to produce re-liable weight loss. Such elements may include a specificfocus on choosing certain types of foods in preference toothers [3,4], keeping a written record of hunger and sati-ety levels and eating only within externally-prescribedhunger levels [5], or heeding biofeedback on markers ofphysical hunger, such as blood glucose levels [6]. Giventhe challenges of adhering to such requirements, par-ticularly in today’s obesogenic environment, many adults(but not children) may benefit from an explicit focus onweight loss in order to promote adherence.In addition to a lack of robust or reliable weight lossunless combined with aspects of externally regulated eating,ad libitum eating plans are not suitable for people whoprefer to follow more structured weight loss plans, orfor whom internal hunger regulation may be disrupted,perhaps due to the hypothesised hypothalamic changesoutlined in our commentary. Many people with a body massindex in the obese range may indeed benefit from severeand highly externally regulated weight loss strategies suchas very low energy diets [7,8] and bariatric surgery [9,10].
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