the HAES® files: A Dietitian’s Road to HAES

by Health At Every Size® Blog

by Joanne P. Ikeda, MA, RD

In the early 1990’s, it became apparent to me that we had no successful treatment for obesity. I came to this conclusion because I was very conscientious about reading the scientific literature. One of my myriad job responsibilities as a Nutrition Education Specialist in the Department of Nutritional Sciences at UC Berkeley was to keep abreast of the research and to extend the findings to health professionals if the conclusions had practical application. “If we can’t help large people lose weight, is there anything we can do to help them?” I asked myself.

One of the things that bothered me about research on “obese” people was that it always focused on weight loss. It was as if that was the only thing obesity “experts” cared about. For sure, they didn’t give a damn about the people they were treating. They hardly knew them. These experts would design a program and then would write a grant to obtain money to fund their program. Once the funding arrived, the researchers would hire staff to do the recruiting, the screening, the intervention, and the collection of data. Oh, they might appear at the first meeting of the patients so they could inform the group as to how knowledgeable they were and how lucky the patients were to be treated by such an esteemed obesity scientist. After that, interactions between experts and patients were pretty minimal. In fact, in my interactions with these experts, I sensed that they really didn’t like fat people; thought they were lazy and out-of-control; and they often made prejudiced statements about the people they were supposed to be helping.

Another thing I noticed was, they were totally preoccupied with only the physical health indices of patients. They collected data on their BMIs, their blood pressure, cholesterol, HDLs, LDLs, hematocrit, etc., but not one of them administered an instrument that evaluated the patient’s psychosocial health. Most of them got very nervous when this discrepancy was pointed out, and they usually said that the patients felt so much better about themselves when they lost weight. Not a word was said about what happened when the patients didn’t lose weight or regained the weight. Most studies lasted a year. There were 6 months of treatment and 6 months of follow-up. The success rate was based on the number of patients who remained in the program for a year. Dropouts were not counted, which skewed the data in the researcher’s favor. Even today, it’s easy to get the results of a one year weight loss program published in a scientific journal even though the data is meaningless. The gold standard used to be following people for 5 years after they completed an intervention. Now researchers talk about 3 years being ideal, and even with this change, people start to regain weight by the 2nd and 3rd year.

Along with changing the gold standard for what constituted “effective” treatment, the experts changed the goal. In the beginning, people were supposed to lose incredible amounts of weight to get to a BMI under 27. Then it was reduced to a BMI under 25. When the experts realized their programs were failing, they changed the goal. It became losing 10% of body weight. When they couldn’t even achieve that, they reduced it to 5% of body weight. Can people lose 5% of their body weight and keep it off? The results of the Look AHEAD study that went on for over 10 years found that the average person, after years of treatment, managed to lose and maintain the loss of 2% to 3% body weight. Is anyone clapping? No, and in fact, these results have not been widely publicized and the obesity experts are calling for more money for more research on treatment!!! Talk about a waste of taxpayer’s money – this is a real example.

In the meanwhile, many of us who had been brainwashed into believing that weight loss was the only goal worth pursuing, began to wake up! Someone actually asked, “How can we tell if someone is healthy?” Doctors had been assessing their patients’ health for years…how did they do it? They did it by taking a patient’s blood pressure, getting lab values for cholesterol, HDLs, LDLs, blood glucose and insulin, hematocrit, etc, and by examining and interacting with the patient. “Perhaps we should evaluate the health of fat people this way rather than just determining their BMI,” suggested some of us. But the obesity experts were not keen on this. “Why bother?” they would say, “we already know those people aren’t healthy. Look at all the studies showing that obesity is a strong risk factor for chronic disease!”

From the mid-1990’s onward, there was more and more research published that hinted at the fact that many larger people were healthy. None of it was given much attention. I thought the results of the National Health And Nutrition Examination Survey (NHANES) published in 2008 by Wildman would put an end to the debate when the data showed that over half of people categorized as overweight and nearly a third of those deemed obese were actually healthy! Again, no one appeared to notice. “Am I the only dietitian in the world who read this research?” I asked myself. It certainly appeared to be the case since my own professional organization, the Academy of Nutrition and Dietetics, endorsed weight loss as an achievable goal.

And then came bariatric surgery. Dietitians had even more patients to treat since this surgery causes havoc with the digestive tract. I am convinced that someday it will be viewed in the same way we now view lobotomy.

Finally, the results of the Look Ahead study were published in 2012 with no fanfare because after all the years of treatment and support, the average weight loss was around 7 pounds. “Why? Why?” I ask myself, “Why does the scientific community refuse to admit this approach has failed?” There are a lot of reasons. The so-called obesity experts are still with us. Many of them are in their 80s and 90s, but they don’t dare retire and give up the influence they have on the public and the government. After all, if weight loss is not possible, then they have wasted their entire careers trying to achieve it. Then there is the aspect of “following the money.” What would happen to all of these obesity experts, diet programs, diet products, diet books, and diet gurus if we gave up trying to get people to lose weight?

The group I feel sorriest for are the public health professionals. For years, they were underfunded. No money went into the prevention of chronic disease while billions were spent on treatment. The “obesity epidemic” finally persuaded politicians to loosen the purse strings and spend money on environmental changes that are much more supportive of healthy lifestyles for people of all sizes and shapes. Now there is an excuse for schools having quality physical education, for selling nutrient dense foods at lunch, and for not signing contracts with soft drink companies. Is doing good for the wrong reasons still doing good? Would politicians spend money if they were told it was to improve the health of the populace? Well, they’ve always had that choice, and they didn’t choose it until there was an “epidemic” declared.

I retired from UC Berkeley in 2007. My husband and I travel, do volunteer work, and some occasional paid consulting. I still keep up with research. I am active in NAAFA, ASDAH, and the Society for Nutrition Education and Behavior. I keep promoting the HAES approach and fighting size discrimination. My hope is that we will get a bill passed at the national level that will ban discrimination based on body size. My worry is that someday scientists will be able to genetically engineer human fetuses to be a specific size and shape as adults. Fortunately, if it does happen, I probably won’t be around to witness it.

Ikeda_JoanneJoanne Ikeda, MA, RD is a HAES pioneer and also a nationally recognized expert on pediatric obesity and the dietary practices of ethnic and immigrant populations. She co-founded the UC Berkeley Center for Weight and Health, and though she retired from UC Berkeley in 2006 as a lecturer, Joanne remains very active in the field of nutrition education. Joanne is the current Vice President of the Society for Nutrition Education and Behavior (having formerly chaired their Weight Realities Division) and also serves as a nutrition consultant to the Cartoon Network.

13 Responses to “the HAES® files: A Dietitian’s Road to HAES”

  1. Thanks very much both for thinking this out and for the history. I didn’t know about the decline of standards in research.

    However, I think you have a typo here: “In the beginning, people were supposed to lose incredible amounts of weight to get to a BMI under 27. Then it was reduced to a BMI under 25.”

    Are the BMI numbers reversed?

    • Joanne seems to be referring to the 1998 “adjustment” in the BMI by the NIH. Up until 1998, 27 was considered the upper end of “normal” (already a dubious concept) but that was changed to 25. CNN broke the “news” with this memorable lead: “Millions of Americans became “fat” Wednesday” http://www.cnn.com/HEALTH/9806/17/weight.guidelines/

    • I don’t want to speak for Ms. Ikeda, but I’m pretty sure they’re not. In the late 1990s, the cut-off point between “normal” weight and “overweight” was lowered. People with a BMI of 25 or 26 went to bed one night “normal” and woke up “overweight”. That lowering plays a role in the “explosion” of people considered overweight. It’s shameful.

  2. As a college counselor, and someone recovered from binge-eating disorder, I’m very familiar with the myth that thinness equals health and happiness. I appreciate your important work and your promotion of the HAES movement. Thanks!

  3. I wish this could be presented in my medical school! A couple of students organized some lunchtime panels on nutritional science this past year; I went to two. At the second one, the prof had us begin by calling out 10 conditions associated with obesity. …yeah.

  4. Thank you for all the work you’ve done for years! We may be slowly dragging folks to see that health, rather than weight loss, is a worthy — and achievable! — goal. Very slowly, but it’s happening. Or at least I like to believe it is.

    And that what matters is not just physical health, but also all other aspects!

  5. This was so interesting to read. I have a lot of interest in food and nutrition and diet after spending some years dealing with my late husband’s food needs (he had muscular dystrophy and was chronically severely underweight) and occasionally I consider getting some kind of formal training in the area of diet and nutrition, but the party line emphasis on weight loss as the major key to everything under the sun would, to put it frankly, drive me nuts. I’d probably get flunked out of my first class for bringing up all the studies that don’t agree with the ‘normal BMI is best’ rubbish. So I haven’t done much of anything because it seems like having the qualification would be important, but the people giving the qualification are teaching things that I believe are actively harmful. (It’s not like I’d just be sitting in a class that was boring, you know? They’d be indirectly actually doing harm. I couldn’t just sit there with that.)

    At the moment I’ve ended up helping my mom out anyway (she has a form of bone marrow cancer) so I don’t really have the time to go back to school, but it does often depress me when I think about the possibility and how entrenched we are socially in the whole diet industry.

    The thing that gets to me about the whole mess other than the mental trauma people go through because of the diet industry is that we get so hung up on weight loss ridiculousness that often we completely ignore any diet/nutrition-based changes that might help people with health issues if it doesn’t first start with ‘omg, lose weight!’ (Like I just learned that the specific type of psoriatic arthritis I have, there are some indications that too much dietary sodium causes increased inflammation. If that holds out, I could be horribly overweight and have no interest at all in weight loss and still benefit enormously from that information and appropriate changes to my eating habits because inflammation HURTS. And we know that chronic pain is super hard on the body, physically and mentally. But if that does end up being the case – that I should be watching my sodium intake more than most people – and I was very overweight, would a doctor even bother to tell me? I kind of doubt it.)

  6. My concern is the nearly one-half of all overweight and two-thirds of obese people who are not healthy. Of weight loss is not the answer, then what do we do to get these people to be healthy and encourage them to practice the behaviors that will get and keep them healthy. Yes, over one half of overweight adults are healthy, but if two thirds if the adults in this nation are overweight, that means that over 30% of adults in this country are unhealthy, and that doesn’t include the number of unhealthy adults who are not overweight. That is unacceptable! I am sure that diet and exercise contribute to health, since our ability to eat ourselves into oblivion while leading a completely sedentary life is relatively new to mankind. But what do we do to change people into those who value their long-term health over a short-term desire to eat something junky or not exercise today? How do we get people to eat healthy and be active on a daily basis? To realize that being healthy is not about deprivation, but can be fun? That you do not have to live on salads and train for a marathon to be fit and healthy?

  7. This is a fascinating article Joanne, especially as it is written from the point of view of an industry ‘insider’. There are massive vested interests in the weight loss industry, as you point out, and those interests keep on moving the goal posts to suit themselves. I totally agree that ‘health’ requires assessment of a wide range of factors other than weight!

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