the HAES® files: Blackboard Bungle−Rethinking Nutrition Education

by Health At Every Size® Blog

by Linda Bacon, PhD, and Lucy Aphramor, PhD, RD

How contemporary nutrition education does more harm than good, and how that can be changed

Nutrition science reaches us in large part through dietitians. If you have heard public health messages around nutrition, you have been influenced by dietitians. If you buy groceries, eat in schools, or patronize restaurants, hospitals or cafeterias – well, if you eat – you have been influenced by dietitians. That’s why the recruitment and training of dietitians matters so much.

And that is a problem. And an opportunity. Nutrition education today woefully misrepresents nutrition science. Its gospel reflects too well the interests of industry and too little the views of environmentalists, consumer, labor, and social justice advocates, and others with a personal (rather than financial) stake in the eating, making and selling of food. It rarely considers the emotional and social dynamics that underlie how food choices are made. It gives a misleading view of the science of health by frequently misrepresenting the role of food in health outcomes. And its teachings (and teach-ers) cling to outmoded biases that end up excluding whole classes of people from entering or succeeding in the field.

Dietetics isn’t working

Membership in the American dietetic organization, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), has soared to 74,000, and dietitians are now on the forefront of health education. Despite the increasing presence of nutrition in public health campaigns – and the increasing visibility of the Academy and dietitians – there is little evidence that nutrition education effectively motivates people to make better nutritional choices. Studies show that Americans have, however, become more anxious about healthy eating and that body image distress has reached epidemic proportions, exponentially outscaling the incidence of nutrition-sensitive diseases such as heart disease or diabetes. Eating disorders are also on the rise.

Rather than improving well being, current public health nutrition education backfires, leading to a heightened preoccupation with food and weight with no concomitant improvement in self-care, health outcomes, or healthy weight management.

If so little of what is taught in dietetics degree programs actually improves real-world nutrition or well being, it’s time to erase the blackboard and rethink what we’re teaching.  This rethink spans a number of inter-related issues, and in this blog post we’re going to get started by discussing industry influence.

Mm-mmm bad: Financial influence skews the field

The disconnect between evidence and belief doesn’t come from nowhere. It’s an unfortunate and inevitable product of the subtle and not-so-subtle influence of those with a financial stake in food science. More than we realize, private business interests shape and influence much of what we believe or think we “know” about nutrition and our bodies.

Nutrition science has financial, medical, social, legal, and cultural implications for the production and consumption of food. In fact, a key way to shape tastes and beliefs about food is through scientific research, leading to a blurring in recent decades of lines between private industry, science, government, and medicine. As Woodward and Bernstein had it explained to them during Watergate: “follow the money.” We might like to think of scientific inquiry as the pure product of curiosity, but researchers need to make a living, and most are funded by corporate grants – or government grants meted out by those with corporate interests. And in nutrition, these grants often align with (you guessed it) corporate interests.

Observe what happens when you follow the money behind published research. Industries with a stake in the outcome often fund nutrition studies. Statistics clearly show that when industry funds research, what gets published is more likely to show beneficial effects than research conducted without industry funding. The most comprehensive study of this topic examined commonly consumed beverages and found that those funded entirely by industry were approximately four to eight times more likely to be favorable to the financial interests of the sponsors than articles without industry-related funding. None of the interventional studies with all industry support had an unfavorable conclusion.

We’re not implying that companies overtly buy the results, although it does seem that way. More likely, scientists who accept corporate sponsorship are well-intended and have internalized the values of the sponsor, and the belief in science as a neutral enterprise, so thoroughly that they think themselves independent. But let’s be honest: Sponsored studies have only one purpose—to establish a basis to sell products, not to understand the science or promote public health.

The result? Many commonly accepted beliefs (promoted by dietitians and published in textbooks) are not supported by data. Consider milk. Would you believe there is no evidence to support the commonly held belief that milk builds stronger bones?  Prospective studies and randomized trials have consistently shown no relation between milk intake and risk of fractures. One of the largest studies, for example, the Nurses’ Health Study, investigated 78,000 women and found no evidence that higher intakes of milk reduced bone fracture incidence or osteoporosis. In fact, they found higher risk of hip fracture for women drinking two or more glasses per week compared to women who drank one or less per week! In contrast, research finds that those who eat the most fruits and vegetables have denser bones. The real reason milk – not fruits and vegetables – is believed to be the ultimate bone panacea is because the produce lobby doesn’t pump nearly as much money into research, publicity, and “education” as the powerful dairy industry.

Studies follow the available grant money, and textbooks, teachers, and dietary recommendations follow the published studies.

Scientific ideas are never the result of objective “knowing.” What any of us believes to be “true” or “tested” – or worthy of study in the first place – is unavoidably influenced by our surrounding culture: by faith, fashion, politics, business, and prevailing scientific trends. This is particularly tricky in the field of nutrition because we all have to eat and there are huge financial stakes in influencing our beliefs. The result is that those seemingly “objective” nutrition truths end up reflecting food industry values much more than scientific fact. Private industry has transformed not just our understanding of nutrition, but our attitudes toward food itself, even our taste preferences. There is nothing inevitable about what you like to eat.

Just because something is conventionally accepted doesn’t mean it’s true. Don’t let the dispassionate voice of a textbook or the authority of a credentialed nutrition “expert” fool you. When bias isn’t acknowledged, count on the source as being a (typically unwitting) conduit for industry values.

And know that there is hope. Bias doesn’t need to be a bad thing: it just is. Awareness can lessen its negative impact and help us uncover what we really need to know. Stay tuned for further blog posts that offer an alternative understanding of nutritional concepts, and the data and reasoning to counter confusing nutritional ideas and shaming cultural messages about the worth of our bodies. We’ll also be providing recommendations to help you nourish yourself well, and to reclaim the pleasure in eating.

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PhD-nutritionists Linda Bacon and Lucy Aphramor, experts in the Health at Every Sizeâ (HAES) approach, are co-authors of the cutting edge Weight Science: Evaluating the Evidence for a Paradigm Shift, a peer-reviewed study that up-ends conventional thinking in weight-loss research. Their forthcoming book, Eat Well: For Your Self, For the World, promises to reboot nutrition education around evidence-based dietetics and the HAES-inspired directive that “the best nutritionist you’ll ever know lives inside your skin.” Stay tuned to the Health At Every Size Blog for excerpts and for more information about other collaborative work.

Lucy AphramorLucy Aphramor, RD, PhD, is a dietitian who pioneered the use of a HAES approach in the UK National Health Service. She is now Director of the not-for-profit organization Well Founded Ltd working to encourage compassionate care and social justice through delivering HAES training, courses and services. Dr Aphramor has published widely in the field of critical weight science and is active in the new Critical Dietetics movement where her research spans issues of ethics, equity and embodied knowledge in the dietetics profession.

Linda BaconLinda Bacon, PhD, is a researcher on the inside track of weight regulation science – a scientist whose three graduate degrees, research, and clinical expertise uniquely prepare her to understand and translate the physiological, psychological, and socio-cultural underpinnings of weight control. An internationally recognized authority on weight and health, Dr. Bacon has published her work in top scientific journals as well as the highly acclaimed popular press book, Health at Every Size: The Surprising Truth About Your Weight.

16 Comments to “the HAES® files: Blackboard Bungle−Rethinking Nutrition Education”

  1. Yeah, all of us dietitians are sheeple that spout off what we’re told and don’t bother to think or reason for ourselves. While I understand the point uou are making and agree I am a little upset and the stereotyping. Dietitians were lumped into one big category and I am afraid the way the article was worded, may possibly undermining any info we may try to impart to our patients/clients. I try to review the evidence myself before I make recommendations and I always work with patients on an individual basis to help them. I know not all dietitians do, but some of us are trying.

  2. One unexpected benefit of adopting the Health At Every Size ® approach has been a much more nuanced understanding of how public policy, corporations, research organizations and politics actually “work”. It’s improved my understanding of not only my health and what impacts it, but of many other areas of my life living in the U.S.

    And I appreciate very much that two nutritionists are willing to look honestly and openly at what needs to get better in nutrition education! Another great post.

  3. I agree with Snicker’s Mom. I’m displeased with this description of “credentialed nutrition experts” followed by statement like, “More likely, scientists who accept corporate sponsorship are well-intended and have internalized the values of the sponsor, and the belief in science as a neutral enterprise, so thoroughly that they think themselves independent” will likely lead many who need the advice of the Registered Dietitian to throw up their hands and do nothing.
    I’m really disappointed that this is the attitude of an organization that I have supported for years.

    • It is great to see the spirited dialogue that is emerging in response to this blog post. Regarding whelanmphrd’s comment regarding “the attitude of an organization,” we wanted to remind our readers that as noted in our Disclaimer above, “The opinions and conclusions expressed in the blog posts herein are the opinions of the original authors and do not necessarily represent the views and policies of The Association for Size Diversity and Health.”

      Our intention is to publish a wide variety of opinions and perspectives on the HAES® model in this blog in order to encourage an honest and open dialogue. However, unless expressly so stated, the opinions of individual bloggers should not be attributed to ASDAH, and vice versa.

      Respectfully,
      The ASDAH Blog Committee

  4. I am very disappointed with this post. I really don’t appreciate being stereotyped. I an am RD who thinks independently and is not influenced by industry. More harm than good, my patients would disagree with you!

  5. I think it is important to distinguish between the authors’ opinions and facts based on scientific research. For example, the statement, “Rather than improving well being, current public health nutrition education backfires, leading to a heightened preoccupation with food and weight with no concomitant improvement in self-care, health outcomes, or healthy weight management.” The authors give no reference for this statement. On the other hand, the Journal of Nutrition Education and Behavior contains hundreds of articles documenting the positive impact of nutrition education. This Journal is published by the Society for Nutrition Education and Behavior (SNEB), established in 1970, whose members are professional nutrition educators. The Society estabished a Division of Weight Realities” (DWR) in 1999, with the mission of promoting HAES. It has produced and up-dated a slide presentation on HAES that has been shared with nutrition educators nationally and internationally. Members published an article in JNEB challenging data presented by the National Weight Loss Registry. They also maintain a list of HAES resources on the SNEB website. Negative generalizations made about nutrition educators, many of whom are our allies, is uncalled for. I do not deny the assertion that there are many dietitians and nutrition educators who are clinging to the traditional weight loss paradigm. On the other hand, there are also those who have abandoned this paradigm and moved on to promote HAES.

    Joanne P. Ikeda, Current Vice-President, Society for Nutrition Education and Behavior.

  6. I read this article and the following comments and believe that there are many dietitians who are and do actively work to analyse and interpret information, who are not puppets in a system and are dedicated and active in moving beyond the limiting and industry driven paradigms. I take this article to refer to the bulk who do not and have not and after reading the comments perhaps this blog was intended to reflect the thinking of all those who recognise these issues. As a student dietitian I have been very glad to meet so many insightful, critical thinking dietitians who I know share these insights and practice quite differently from the institutionalised thinking and rhetoric that this article refers. You are all my motivation that change can occur and is occurring and I would like to acknowledge that from where I sit. However I do see much of what is discussed occurring and it bothers me a lot and for bringing awareness to these issues I am also grateful.

  7. As a recent dietitian grad I have to agree that the education needs changing, but I want to remind you that change within a system takes time. And believe me, us dietitians see the flaws, and we’re working towards making those pilars (such as the social and emotional aspects of food) stronger.
    I believe it should also be noted as dietitians we work in the food system, and that industry/science/lobbyest etc. also promote and create a lot of that panic that exists around food today. We are doing the best we can to work in a system that is, let’s face it, not working well.

  8. From the authors:
    It is heartening to see the passion for the positive role of dietetics and nutrition educators that is reflected in the comments – the same passion that motivated us to post. We write as nutrition professionals committed to advancing ethical, integrative practice. Of course we are by no means alone in this. The new Critical Dietetics movement stands as witness to the drive for a spirit of critical inquiry in the profession, and the comments point to individual practitioners, and groups, committed to best practice. But when we take a panoramic view of western dietetics it becomes apparent that critical engagement is the exception rather than the norm: that those of us who journey to criticality do so despite, and not because of, conventional education by nutrition educators. This accounts for the real buzz when we find each other as HAES dietitians, or hear of each other’s work via Critical Dietetics, for instance, because the level of reflection we strive for individually is not something we’ve been able to take for granted among our professional colleagues nor provided in our education. Which is damaging for the profession, and dangerous for our clients, and needs to change. The fall out of harm from conventional attitudes to weight promulgated by dietetic professional organisations is well documented. The detrimental impact of existing paradigms on dietetic students is also starting to be researched along with issues of trust, some of which were highlighted in responses, and that warrants further exploration. What does it say of us as a profession when the recommended textbooks for dietetic students in the UK and US make no mention of HAES and instead promote unscientific and unethical approaches to weight management? When a nutrition professor teaching a core nutrition course required for entry into dietetics programs is asked to take HAES out of the curriculum (Linda’s experience)? The fact that we embrace ethical practice individually does not create grounds for complacency. It is important that we can stand by our own practice, but it is not enough. As long as the integrity of the profession is at stake we need an ongoing conversation towards transformation so that people do not just throw up their hands and walk away.

    We are grateful for ASDAH to providing another platform for this debate.

    Further reading:

    ASDAH member Jacqui Gingras has written extensively on dietetics education. See, for example, the following:
    Gingras, J. (2009). Longing for recognition: The joys, complexities, and contradictions of practicing dietetics. York, England: Raw Nerve Books

    Gingras and Brady, Relational consequences of dietitians’ feeding bodily difference, Radical Psychology, Volume 8, Issue 1: http://www.radicalpsychology.org/vol8-1/gingras.html

    Gingras. Evoking trust in the nutrition counselor: Why should we be Trusted?., Journal of Agricultural and Environmental Ethics 18 (1) (2005): http://philpapers.org/rec/GINETI

    For information on the ethics of teaching HAES vs. conventional weight mangement, see:
    Bacon, L., & Aphramor, L. Weight Science: Evaluating the Evidence for a Paradigm Shift, Nutrition Journal, 2011, 10(9). http://www.nutritionj.com/content/10/1/9

    Aphramor, L., Validity of claims made in weight management research: a narrative review of dietetic articles, Nutrition Journal 2010. http://www.nutritionj.com/content/9/1/30.

    The Critical Dietetics website is here: http://www.criticaldietetics.org/.
    For more connection: “HAES-RD is a listserv that is a community space for RDs and other nutrition-based professionals who endorse HAES to discuss what is important to us, share resources and strategies for implementing the HAES tenets in our work, empower individuals to dump the dieting paradigm, advocate for an end to size discrimination, and transform the profession. To subscribe, send a blank e-mail to: HAESRD-subscribe@yahoogroups.com
    HAES-sensitive dietitians may also want to consider entering the information into the HAES Community Registry (www.HAESCommunity.Org).

    Linda and Lucy

    • I find it interesting that in your original article you were discussing nutrition science unrelated to weight and weight management and now you are not. I do not think that just because the dietetics profession has generally failed to challenge the conventional thinking about weight and weight management, we can assume that the profession does not look critically at nutrition science in general.

  9. First, I am encouraged that a Critical Dietetics movement has begun! Brava for all involved!

    Second, thank you for adding the “further reading” resources in the comments section. The article by Gingras and Brady (“Relational Consequences…”) beautifully gestures towards some of the ethical imperatives that should compel health care professionals to focus far more critical attention (analysis) on: (a) forces of social domination (and social control) as threats to public health and as disease risk factors for individuals, and (b) the ethical implications of dominant discourses (in relation to public health threats and disease risk factors)—most especially, of course, the dominant discourses of health care professions (e.g., medical discourses, nursing discourses, etc.)

    Finally, I want to express my admiration and appreciation for the section on “Public Health Ethics” in the Bacon and Aphramor article (“Weight Science…”); reading that section filled me with hope—that social justice issues are being taken very seriously by HAES advocates.

  10. This article is very upsetting to me and I will explain why. Individual registered dietitians have the responsibility to explore the research supporting nutrition recommendations and education. And at times I have questioned the validity of nutrition recommendations supported by the Academy of Nutrition and Dietetics (in addition to the obviously inaccurate recommendations regarding weight and weight management). However, this article seems to me to be supporting nutrition counseling/education provided by uncredentialed (unlicensed) practitioners…..and this is very dangerous!!! In my community, these practitioners are doing great harm. A short while ago I attended a talk by a “nutritionist” near where I practice. Apparently, she had attended Andrew Weil’s program. She held up a package of Quaker oats and told the audience it was “nothing” and the body could not digest it. Later, someone from the audience asked what would be a good snack at work in the afternoon when she was hungry and tired. This “nutritionist” told her “anything fresh, like a green salad”…..as if this food, with almost no energy value, would help this woman at that point in time. Another “nutritionist” in my area, who had graduated from a different holistic program, spoke to a local eating disorders support group. One of my clients happened to attend this meeting. She had made great progress in resolving bingeing and had been able to incorporate desserts appropriately without bingeing. Utilizing mindful eating strategies, she was exploring which desserts she enjoyed and felt good in her body. The “nutritionist” told her she should only eat desserts that were sweetened with fruit juice. When I next saw the client, she was greatly distressed and had returned to frequent bingeing. If I discover these “nutritionists” are providing medical nutrition therapy, I will be reporting them to our Board of Dietetic Practice. In my view, it is dangerous for uncredentialed pracitioners with questionable education to be providing health coaching and education as well as medical nutrition therapy, but as far as I know there is no law against this….so buyer beware! I am a member of the Nutrition Entrepreneurs Dietetic Practice Group within the Academy. Although I am frustrated at this group’s usual approach to weight and weight management, I am generally very impressed at the level of knowledge and expertise in other areas. And often, nutrition recommendeations are questioned and debated on this list serv. These are the people with the knowledge and expertise to conduct this debate!!

  11. Thank you to Lucy and Linda for taking this brave leap and challenging the ‘status quo’ in nutrition and dietetics. This article will add to the growing number of people involved in the “Critical Dietetics” movement who are questioning and challenging the way we educate, research and practice in dietetics. As a dietitian, I am inspired that we are beginning to have these difficult conversations. Change comes with awareness and thank you Lucy and Linda for this awareness-raising piece. Also, just an FYI Critical Dietetics has a free access journal that can be accessed through this site http://www.criticaldietetics.org/. Join the conversation!

  12. The authors stated that nutrition education provided by dietitians has led to a preoccupation with food and weight. While I believe it is true that the majority of dietitians accept conventional beliefs about weight (just as the majority of all healthcare practitioners unfortunately do), I also believe that nutrition education provided by others has led to a much greater preoccupation with food and weight since this education not only promotes conventional beliefs about weight, but also a very rigid view of healthy eating. This rigid view of healthy eating is inconsistent with the process of intuitive eating, a critical principle of the HAES® paradigm. Nutrition science is constantly changing and there will always be controversy and debate. This is why I feel the process of intuitive eating is so important for individuals. Also, since I think the last sentence of my previous comment was misleading, when I wrote “these are the people with the knowledge and expertise to conduct this debate”, I was not just referring to registered dietitians who are members of the Academy or a specific DPG within the Academy, but all registered dietitians as well as other nutrition professionals with legitimate education and credentialing.

  13. Way cool! Some very valid points! I appreciate you penning this write-up and the way you have presented the specific matter on Nutrition Education is too effective and informative.
    I find comment also too useful as well.

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