A focus on weight loss can affect many individuals negatively.
This article will describe a weight-neutral approach to health and fitness instruction. Problems with weight-focused paradigms are discussed, as are strategies for becoming a weight-neutral instructor.
Original Article by Souza, Brian J. M.S. in ACSM Journal
Health and fitness professionals often work with clients who have weight loss goals. Many of these seek help because they believe that physical activity is efficient for weight loss (16). Moreover, body weight often is used synonymously with health, so these clients might think losing weight is the equivalent to gaining health. The U.S. Centers for Disease Control and Prevention (18), for example, makes numerous references to and gives advice for maintaining a healthy body weight on its Web site. Physical activity is included as a key component of weight management (18) such as when references are made to moving more and sitting less to help achieve a healthy weight. Physical activity however generally is inefficient at producing meaningful weight loss (13). In addition, any clinically significant (e.g., 5% to 10% of body weight) weight loss, through diet, physical activity, or a combination, rarely is sustained longer than 5 years (3,17). Furthermore, the notion that weight loss directly causes improvements in health has been challenged (15). It is more likely that behaviors such as improved diet and increased physical activity benefit health and help some people, and not others, lose weight. It is important to note that those people who do not lose weight can still experience profound improvements in health and fitness.
The purpose of this article is to advocate that health and fitness professionals adopt a weight-neutral approach to their instructional practice and also help their clients adopt this approach. Situations and environments that focus on obesity reduction can create stigmatizing and discriminatory practices toward larger people (17). Adopting a weight-neutral approach potentially can reduce harms that are sometimes associated with a weight-focused approach to health (17). For example, a weight-neutral approach can help some individuals reduce fears that obesity is necessarily unhealthy, avoid perceptions of failure when weight loss is not achieved, and extinguish unhealthy relationships with food and physical activity. It is important to note that not all clients have weight loss goals and those who do have weight loss goals are not harmed automatically by a weight-focused health paradigm. However, helping clients of all sizes reframe their weight loss (e.g., outcome) goals into behavioral (e.g., process) goals can help increase motivation, enjoyment, and participation in sports and physical activities throughout the life span while still experiencing optimum health.
Weight, Fitness, and Health
Overweight and obesity (defined, respectively, as body mass indexes [BMIs] of 25 to 29.9 or greater than or equal to 30 kg m−2) often are associated with poorer health outcomes (e.g., hypertension, cardiovascular disease, type 2 diabetes) compared with normal weight (BMI, 18.5 to 24.9 kg m−2) (18). In fact, overweight and obesity often are viewed as the cause of these negative health outcomes. Overweight however has been associated consistently with the lowest risk for all-cause mortality in certain populations (6).
Moreover, obese and physically fit individuals have a significantly lower risk of mortality than normal-weight unfit individuals (10). In a meta-analysis of randomized controlled weight loss trials with a follow-up of at least 2 years, Tomiyama et al. (15) found no significant correlations between weight loss and blood pressure, blood glucose, cholesterol levels, or triglycerides. These data suggest that unmeasured factors might account for any health benefits or consequences that are associated with increased weight, that body weight is resistant to long-term change, and that weight-related risks can be ameliorated through increased physical activity/fitness.
Not only is physical fitness an important modifier of the weight-health relationship but so are factors such as weight cycling, perceived weight-based stigma and discrimination, disordered eating, and psychosocial (dis)stress (17). These factors rarely are considered in research involving weight and health and also can explain why higher weight is sometimes associated with negative health outcomes. Addressing these factors can improve physical and mental health independent of weight loss (2).
Excluding factors such as physical fitness, stigma, and discrimination influences individuals’ attitudes, beliefs, expectations, and experiences related to diet and physical activity. For example, some individuals who improve their health behaviors and lose weight might perceive that the weight loss improved their health. Weight loss cannot continue forever however and, when weight loss plateaus, these individuals could experience motivational difficulties. On the other hand, individuals who change their behavior positively and do not lose weight — but do become healthy — might feel like failures because they believe that they should be losing weight. Framing weight loss as a side effect of positive health behaviors — that some people experience and not others — is a more sustainable and positive message that health and fitness instructors can promote (2). This way, everyone is capable of success!
Anti-Fat Attitudes in the Fitness Center
Some fitness professionals possess implicit and explicit bias toward obese people in the form of believing that obese people are personally responsible for their fatness, lack willpower, are lazy, and are uneducated as to the benefits of a healthy lifestyle. Holding biased attitudes toward larger people can affect a fitness instructor’s practice. In a process known as the self-fulfilling prophecy (8), an instructor might expect lower motivation and success from an obese client hoping to lose weight. This can lead the instructor to provide poor quality and quantity of programming, feedback, and social support, resulting in a lack of results for the client. Naturally, the lack of results confirms the expectations of the instructor that the problem is the client and not the weight-focused paradigm of health that creates negative perceptions and expectations of obese people.
Negative attitudes can not only lead to ineffective fitness instruction and a lack of results for clients but also can affect clients’ health. Many obese people will attempt to avoid situations where they perceive obesity bias to be present. This includes health-promoting environments such as fitness centers and physicians offices (17). As a result, obese people might receive poorer interactions in health-promoting environments when they do seek help and, if they avoid these contexts, then they are less likely to be diagnosed and treated for various ailments, helping to explain weight-health relationships that do exist. As a fitness professional, it is important to acknowledge any negative attitudes one might have toward obese people. Taking a weight-neutral approach to one’s fitness practice can help improve one’s own attitudes and also help obese people feel more accepted and encouraged in health and fitness environments.
The Health at Every Size® Paradigm
The Table is a printable representation of the Health at Every Size (HAES) principles (1). Professionals who adopt the HAES approach to health and fitness will uphold the principles to every extent possible. The HAES approach is a weight-neutral approach to healthy living and can help fitness professionals enhance the physical and psychological wellness of clients of every size. A fundamental tenet of the HAES approach is that because body weight is (a) mostly uncontrollable, particularly in the long-term, and (b) not a behavior, it should not be a goal of personal or public health efforts. Indeed, short-term weight loss is possible through diet and physical activity, but long-term weight loss maintenance is not common (3). When weight is the barometer of success and the definition of health, weight regain can lead to frustration, perceptions of failure, and extreme diet and physical activity behaviors (17).
Instead, a HAES approach advocates that a focus be placed on equitable access and treatment in health care and health-promoting settings and on personally controllable behaviors such as improving one’s relationship with eating and physical activity. Improving factors such as those can increase health and reduce greatly the risk for mortality and morbidity even in the absence of weight loss. To be clear, both the weight-focused and weight-neutral approaches to health are focused on diet and exercise, which are two important components of weight management. However, the HAES approach is process focused and the end goal is sustaining realistic and enjoyable health practices, independent of weight loss, and creating safe and supportive environments for larger people to achieve health.
Three recent reviews (2,4,17) have detailed the results of up to six randomized controlled trials putting a HAES approach against a “traditional” diet-and-exercise approach on physiological, psychological, and behavioral indicators of health. Both HAES and traditional participants typically experience physiological benefits such as improved cholesterol, triglycerides, and blood pressure and group differences are generally not significant. This means that the HAES approach can produce as meaningful physiological benefits as existing approaches to health. In addition to physiological indicators of health, HAES groups often significantly outperform traditional approaches when it comes to restrained eating, disinhibited eating, drive for thinness, body dissatisfaction, depression, and self-esteem. All those factors are important for maintaining not just a healthy body, but a healthy mind. Furthermore, HAES groups also have shown significantly greater maintenance of physical activity and increases in motivational variables such as competence and autonomy (9). Importantly, most of these differences are maintained anywhere from 6 months to 2 years poststudy. Lastly, attrition rates typically are lower in HAES groups, indicating a potential preference and openness to the programs (2,17). Taken in context, it is clear that the HAES approach can benefit individuals looking to improve their physiological, psychological, and behavioral health. However, weight-neutral approaches such as HAES do have critics.
Criticism of the HAES Approach
The following recent arguments against weight-neutral approaches to health come from Sainsbury and Hay (although Hay offers a counter to Sainsbury’s criticism) (12). The first criticism is that research indicates that even a 5% to 10% weight loss improves health, even when a person remains in the overweight or obese BMI categories (12). This argument fails to acknowledge that it is more plausible that improved lifestyle habits improve health and help some people lose weight, not that the weight loss is a causal factor in improved health. Secondly, if a person remained overweight or obese even after losing 5% to 10% of her or his body weight, she or he would still be considered unhealthy according to weight-focused definitions of health. Evidence showing that maintaining more than a 10% loss in body weight is lacking, so even this level of weight loss should be unacceptable to weight-focused practitioners.
A second argument is that, across time, the effects of obesity will eventually “catch up” with an obese person (12). For example, obese people are at a significantly greater risk for joint-related problems such as osteoarthritis. The study for this argument did not include physical activity as a variable. It is unclear whether physical activity or inactivity had a role in the results, and the suggestion that obesity leads to joint problems goes beyond the data. The “eventually catch up” argument also is based on a meta-analysis indicating that metabolically healthy obese people have a significantly increased risk of mortality after 10 years. This is true, but the definition of metabolically healthy was indicated by the absence of metabolic syndrome factors. There was no control for physical activity, physical fitness, weight cycling, or other indicators of multidimensional health. Furthermore, the same meta-analysis showed that the risk of being normal weight and metabolically unhealthy was much greater than the risk of being obese and either metabolically healthy or unhealthy (12). This adds support for the importance of promoting health at all sizes because, if weight is the barometer of health, then thin people might feel that they are at no risk for health problems.
This leads to a third criticism of HAES approaches to health — that accepting that one can be healthy at any size is a license to engage in unhealthy behaviors or put off losing weight (12). This argument is based out of ignorance and not understanding the philosophical underpinnings of weight-neutral approaches to health. It also ignores the possibility that many thin people might engage in unhealthy eating and low levels of physical activity on account of their thinness (e.g., their “good” health). Approaches to health such as HAES advocate self-care and not giving up on oneself. This is a primary example of the negative attitudes obese people face in everyday life experiences.
Putting It Into Practice
Believe in Every Body
The first step in adopting a HAES approach is accepting and respecting the value and abilities of all body sizes and shapes. At the same time, practitioners should reject the idea that individuals with larger bodies are unhealthy and less capable than their thinner counterparts. Remember that the expectations fitness professionals have of their clients can affect the quantity and quality of service. Fitness instructors should have realistic and flexible expectations of clients (8). It is not realistic to expect that all obese clients will lose weight through diet and physical activity. It is realistic, however, to expect that all clients, regardless of their size, can participate and enjoy physical activity and improve their health. Body size is not an indicator of any personal characteristic nor a measure of one’s competence at athletic or fitness tasks. Expectations that are flexible should be able to change across time and be responsive to a client’s particular personal and life circumstances. Each individual client should be treated as such, an individual. Practitioners should take an accepting and empathetic attitude toward individuals of all sizes and treat all individuals as motivated optimally and equally capable of achieving their personal best.
Recognizing that health and weight are multidimensional is necessary to the HAES approach. Conventional wisdom asserts that excess energy consumption and low energy expenditure are responsible for overweight and obesity. This attributes the cause of and the cure to weight problems as individual responsibility, willpower, and personal agency (11). Health, however, is more than physiology and includes social, spiritual, emotional, environmental, and intellectual components. Practitioners should take a holistic approach to understand their and clients’ multidimensional wellness. Take, for example, the previous fact that many — not all — larger people will avoid fitness-related environments because of social stigma. By taking a holistic approach, one will see that negative societal attitudes should change and that, when all individuals are supported, their multidimensional wellness can be nurtured. Health and fitness instructors can help by asking questions about and supporting optimal health in each wellness dimension. Individuals of any size can be high or low in the dimensions of health. An individual with an overweight or obese BMI is not necessarily in poor health. In addition, leanness does not indicate good health or well-being. There is diversity in body size, and the HAES model supports holistic wellness across the spectrum of sizes. Health and fitness instructors can benefit from this by creating positive expectations and perceptions toward every client. Identifying where any improvements in holistic health can be made will help improve motivation and enjoyment in physical activities.
A focus on weight as an important indicator of health can lead to disordered eating and/or unhealthy eating practices (17). Practitioners adopting a HAES approach should learn about and promote intuitive eating. Intuitive eating involves becoming attuned to one’s internal hunger cues and signals rather than consciously counting (and restricting) calories in an effort to maintain or reduce one’s weight (2). Practitioners should encourage individuals to eat foods that are satiating and pleasurable. Importantly, intuitive eating is not a license to binge on “bad” (e.g., unhealthy) foods. To the contrary, once intuitive eating is learned, individuals usually report improved nutrient intake because they understand that healthier choices make them feel better (2). Intuitive eating promotes self-care, not uninhibited consumption. Practitioners can help improve individuals’ self-efficacy for intuitive eating by learning about and practicing intuitive eating themselves (e.g., being a role model) and providing encouragement to the individuals with whom they work. In addition, education about the benefits of and how to practice intuitive eating will help athletes and clients develop actual intuitive eating skills.
Acknowledge Privileges and Oppressions
Not only is health multidimensional but so is one’s identity (14). The historical, social, and political context that a fitness instructor was raised, educated, and lives in can influence her or his beliefs about other individuals. For example, a lean instructor who grew up and lives currently in a mostly white, middle class, well-educated community with the resources and access to sports, physical activity, and diverse natural foods might have a difficult time understanding why an overweight or obese person does not eat well or engage in physical activities. One’s own privileges (and oppressions) can affect implicit and explicit bias. Acknowledging that categories of difference (e.g., race, ethnicity, sexuality, body size, etc…) affect behavior and health is important to help provide a compassionate and understanding approach with all clients. This should impact how an individual experiences health positively and is an important step to reducing bias and creating a safe, caring, ethical, and effective fitness instruction.
Finally, practitioners who adopt a HAES approach should support individualized and personally meaningful physical activity. Typically, long endurance exercise is promoted as necessary for weight loss. Some larger people find this type of activity boring and experience distress about finding multiple hours multiple times per week to be active, especially if weight loss does not occur (7). Practitioners cannot expect that individuals will remain motivated to engage in activities that are boring and distressful. Individuals should be encouraged to find enjoyable activities and to focus on the experience of the body moving (e.g., active embodiment). It is important to articulate clearly that some movement is better than no movement. If an individual does not have time to be active for 10 to 20 or more consecutive minutes a day or 150 minutes per week, then simply standing more often or performing short bouts of movement that break up sitting are profoundly beneficial for health (13). Promoting activities that individuals are good at (or can become good at), find optimally challenging, and will choose freely should be promoted to enhance intrinsic motivation and align with a HAES approach to an active lifestyle (5).
In summary, weight loss often is perceived as important for personal and population health. Because weight loss is difficult to maintain (3), when individuals aspire to lose weight and do not, then perceptions of personal and moral failure can result. These perceptions of failure affect more than an individual. Societal messages make it clear that weight loss should be achievable for anyone who is willing and hardworking. Instead of validating these stereotypes, fitness instructors can help their clients autonomously adopt behavioral goals that are amenable to change, result in increased motivation for healthy behaviors, and promote physical and psychological health. Individuals should be encouraged that health can improve independent of weight and that weight might change but this should be considered a side effect of becoming healthier. The HAES approach involves respecting, supporting, and valuing individuals of all sizes, promotes intuitive eating, seeks to understand how various identities intersect to impact health and behavior, and encourages personally meaningful and enjoyable physical movement. Much of the criticism of this approach fails to fully understand or acknowledge that accepting one’s size is not about giving up on health. To the contrary, the philosophy of the HAES approach to health is empowerment. The HAES empowerment philosophy toward health can help fitness instructors inspire self-determined behavioral regulations, nurture perceptions of competence and relatedness, develop intrinsic motivation for health behaviors (5), and improve self-constructs such as body satisfaction and self-worth (17). The HAES approach will help fitness instructors support and promote the multidimensional health and wellness of individuals of all sizes and abilities and will help develop ethical, efficacious, and culturally competent professionals.
Bridging the Gap
Long-term weight loss is unlikely for many individuals. Negative societal attitudes however suggest that weight loss should be achievable through diet and physical activity. This leads some people to avoid health-promoting environments and behaviors. Positive health can be achieved independent of weight loss. Fitness instructors can help improve physiological, psychological, and behavioral health by adopting a weight-neutral approach to their practice.
I thank Dr. Vicki Ebbeck for her continued support and constructive feedback on multiple drafts of the manuscript. I also acknowledge the constructive feedback from the anonymous reviewers of the manuscript.
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Adrien Paczosa is a Registered and Licensed Dietitian practicing in Austin, Texas and the surrounding counties.
She is the owner and founder of I Live Well Nutrition her Dietitian practice which started in 2007 and serves clients in the Austin, Texas area in two locations. Fearless Practitioners, the division of her business that offers training to dietitians and wellness professionals.