The Sower

Unreasonable Doubts About Obesity and Health

“’Obesity’ is not the health risk it has been reported to be,” says the HAES® Fact Sheet. But that assertion stands in stark contrast to the findings of a new study in Lancet Diabetes and Endocrinology this week. The study adds to a large body of evidence and begs a question. At what point does healthy skepticism become the promotion of unreasonable doubts? What’s the difference between critical thinking and propaganda?

Overwhelming Evidence About Obesity and Mortality

Krishnan Bhaskaran and colleagues studied a cohort of 3.6 million adults in the UK. They found that people with either obesity or excessively low body weights die approximately three to five years sooner than people at a healthy body weight. In particular, deaths due to cancer, heart, and lung disease were higher in both men and women with obesity. These are all diseases with a strong biological link to obesity.

In a companion editorial, Deirdre Tobias and Frank Hu sum it up:

This study adds to the overwhelming evidence about the public health importance of the obesity epidemic to overall and cause-specific mortality.

Unreasonable Doubt

Meanwhile, the HAES movement remains impervious to those facts. Not only do its advocates insist that obesity isn’t such an important health risk, they assert that obesity treatment inevitably does more harm than good. For example, the HAES Fact Sheet also says:

Weight-loss surgery (WLS) intentionally damages healthy organs in order to force adherence to a restrictive diet and incurs a host of short- and long-term risks including death and malnutrition.

Given the preponderance of evidence that metabolic and bariatric surgery extends life and improves health, that statement qualifies as propaganda. Not information. Nor a statement of fact.

Fatima Cody Stanford is an obesity medicine physician at Harvard and a strong advocate for respectful, science-based obesity care. She finds the mixed messages from the HAES movement to be frustrating:

While some positives come from the fat acceptance movement – such as an urgency to eliminate weight bias and stigma – other aspects are less helpful. Some believe that physicians and health care providers should not be treating obesity. They argue, falsely, that it’s not disease.

Respecting Both Opinions and Facts

Daniel Patrick Moynihan famously said that everyone is entitled to their own opinions. But not their own facts.

HAES advocates will tell you that social justice is a primary focus of the movement. Thus in fighting weight bias and stigma, they have much to offer. Furthermore, on the subject of weight and health, a personal decision to focus on health first and not weight deserves respect and support. Likewise, people who seek help with weight management deserve respect. The decision to seek bariatric surgery is an intensely personal one. Neither pressure nor propaganda is helpful.

In the end, sowing unreasonable doubts about medical aspects of obesity helps no one. Propaganda gets in the way of personal autonomy – and it’s a lousy way to pursue social justice.

Click here for the study by Bhaskaran et al and here for the companion editorial. You can find yet another new study, on the causal relationship between BMI and mortality, here. For some solid thinking about reasonable and unreasonable doubt, click here.

The Sower, painting by Vincent van Gogh / WikiArt

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November 2, 2018

14 Responses to “Unreasonable Doubts About Obesity and Health”

  1. November 02, 2018 at 9:03 am, Stephen Phillips said:

    Obesity is not a homogeneous condition. Obesities have very different causations and often not associated with disease.
    Obesity. risk factors are statistically determined . Statistics are central tendencies and not individuals. Some obesities have health risks and some do not.
    We have always advocated for a diagnosis of Obesity NED (no evidence of disease) A one-size-fits-all diagnosis is expedient but not in the best interests of bariatric science or patients

  2. November 02, 2018 at 9:17 am, Traci said:

    One of the major parts of the HAES approach is that weight stigma/bias/discrimination causes not just psychological harm, but also physiological harm (i.e. elevated blood pressure, endocrine system dysregulation). These physical health conditions are almost always connected to body weight/body adiposity/obesity as the primary cause, without adequately looking at how the weight stigma/bias/discrimination plays into the picture. This stigma results in increased likelihood of engaging in maladaptive/coping behaviors such as restriction/dieting, binge eating, decreased activity, all of which move people from their biologically appropriate weight. So, the cycle continues.

    And, beyond the impact of weight stigma/bias/discrimination on physical health are the socioecomomic stressors (poverty, food insecurity, racial/sexual/etc discrimination, etc) and how living amidst all those challenges impacts physical health. Dito above maladaptive behaviors and cycle…

    All of these factors are playing a role in a person’s health, however, way too often the solution/recommendation gets boiled down to weight, uses body weight as the indicator of success/failure/health, and advocates for dieting/weight loss attempts. Health At Every Size is advocating for a shift away from the body weight/weight loss/dieting as the primary focus to one of focusing on actual health behaviors (i.e eating habits, activity habits, sleep, stress mgt, etc) as the driver of the conversation, intervention, etc…..

    The challenge is that the human body has strong mechanisms at play that fight against weight loss, and make it very challenging to lose weight and maintain that weight loss. So, then, the weight cycling begins, along with years of stigma/bias/discrimination and poor physical and emotional health. HAES questions how this often overlooked aspect plays into the situation.

    I just met with probably my 500+ client over the past 16 years who began her dieting roller coaster ride when she was put on her first weight loss specific diet at age 10! A person’s body ends up well above what would have been their natural and biologically appropriate weight range and suffers from the physical health consequences (high blood pressure, elevated lipids, diabetes) and emotional health consequences that perpetuate the cycle.

    The cultural standard of body weight “should”, weight loss attempts, diet-culture, body shaming is not helping ANYONE improve their physical and emotional health!

    Another major part of HAES is that body size diversity has always been present and we (as a collective culture) need to do better to recognize this, and treat all shapes and sizes with the same level of respect, and not always assume a person in a larger body has ill health and needs to lose weight.

    I’ve spent a decent part of my RD career working with kids/adolescents and I am very concerned about the body shame/self-hatred and disordered eating behaviors I am seeing in youth. This is what has led me to think/say “this just isn’t working” and explore other possibilities

    I’ve decided to focus the rest of my career on reshaping the conversation and pushing back against our fat-phobic/diet/weight loss driven culture. I am not anti-weight loss. I am pro advocating for health and well-being and body size diversity/acceptance as the primary focus.

    • November 02, 2018 at 9:45 am, Ted said:

      Traci, I agree with you. We need to reshape the conversation about obesity. And push back from an excessive focus on weight loss. In the short term, stigma, bias, and fat phobia do more harm than obesity. We need to do this with honesty and respect for facts, along with respect for human diversity. Thank you for working to make things better.

  3. November 02, 2018 at 10:21 am, Katherine Flegal said:

    According to the editorial, ” the authors estimated that, assuming causality, overweight and obesity (BMI ≥25 kg/m2) contributed to 5·5% of total deaths” This is almost identical to the estimate from our 2005 article in JAMA on ‘deaths due to obesity’ which came up with an estimate of 5%. ( see Flegal et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005). Factual observations are important but how to interpret them in context is not always that clear-cut and should be considered a judgment call. One person’s 5% might be overwhelming evidence and another person’s 5% might be considered relatively minor.

    Although the estimates are almost identical, there is a difference worth noting. The Lancet article followed the practice of limiting analysis to never-smokers and eliminating the first 5 years of deaths. This methodological approach is supported by strong beliefs and little data. We applied these methods in a large (12 million participants) cohort that used measured, rather than self-reported data and found little impact of these restrictions (Flegal et al. Comparative effects of the restriction method in two large observational studies of body mass index and mortality among adults. Eur J Clin Invest. 2017).

    For readers interested in the topic of obesity and attributable fractions, a more complete discussion of this topic is in our recent paper (Flegal et al Estimating population attributable fractions to quantify the health burden of obesity. Ann Epidemiol. 2015.).

    • November 02, 2018 at 10:52 am, Ted said:

      Excellent perspective. Thanks, Katherine.

  4. November 07, 2018 at 11:22 pm, Joanne Ikeda, MA, RD said:

    Those critical of HAES appear to believe that we have effective treatments that will make large bodies smaller. The “Look Ahead” study, which was designed to result in weight loss for over 5,000 participants, had an 85% drop out rate. After restricting their calories for over 9 years, the women in the study lost an average of 9 pounds and the men lost an average of 1 pound. (N. Engl. J. Med. 2013 June 24 ) Continuing to advise people to lose weight when we know that if it is achieved, it will be temporary, is unethical. As a retired member of the Nutritional Sciences Department at the University of California, Berkeley, I helped develop HAES , an approach that focuses on improving physical, psychological and social components of health. Those who continue to focus on weight loss, know little about components of health other than physical. Their ignorance of the impact they are having on psychological and social health is extremely distressing.

    • November 08, 2018 at 9:46 am, Ted said:

      Hi, Joanne, and thanks for taking the time to comment.

      I completely agree with your focus on improving the physical, psychological, and social aspects of health. And as I stated above, I genuinely believe that HAES has much to offer that is good.

      I don’t really understand why you are so focused on the idea of “making large bodies smaller.” I certainly agree that an excessive focus on weight loss is counter-productive. In the clinical care for obesity, good providers focus on maintaining good health and a stable, healthy weight for the long term. Many individuals also have personal goals for losing weight and they deserve respect, too.

      Finally, your comments about the Look AHEAD study are false and misleading. You claim the 85% of patients dropped out of the study. But that is simply false. 5,145 patients enrolled in the study. Only 188 dropped out. That’s less than a 4% dropout rate. The analysis of weight outcomes is published here, where you will see that the study offered eight, not nine, years of the intervention to all participants. Women lost an average of 10.6 pounds – 5.1% of their starting weight. Men lost an average of 10.1 pounds – 4.2% of their starting weight.

      Considering the emphasis of HAES on health, not weight, your misleading omission of health outcomes from the study is puzzling to me. It’s true that intervention did not prevent strokes, heart attacks, and death. But it did improve quite a number of health measures. Diabetes control was improved and patients needed less insulin. Blood pressure improved, too. Furthermore, urinary incontinence, sleep apnea, depression, quality of life, mobility, and physical functioning all improved.

      I agree with you that many people promote many ignorant ideas about weight and health. You are correct in saying that they cause great harm by doing so. Likewise, using misinformation to promote HAES does not help your cause.

  5. November 08, 2018 at 8:44 am, Rebecca Scritchfield said:

    “Likewise, people who seek help with weight management deserve respect. The decision to seek bariatric surgery is an intensely personal one. Neither pressure nor propaganda is helpful. In the end, sowing unreasonable doubts about medical aspects of obesity helps no one. Propaganda gets in the way of personal autonomy – and it’s a lousy way to pursue social justice.”

    WOW! How many HAES practitioners do you speak to about their practices? What work have you done to examine social justice and intersectionality? I have MUCH more work to do in this area, but I have at least done some work — enough to know that advocating for fat people’s rights and illuminating the systems and structures that uphold weight stigma to keep people oppressed is helpful social justice. It is FAR harder for someone to choose to resist the social pressures to pursue weight loss as the primary, desired outcome and those who do are treated with MUCH disrespect.

    I think you’ll find if you examine, HAES practitioners support body autonomy — all bodies. And though they don’t center weight loss in their practices, they fully expect to have clients with weight concerns. I bet that there are even HAES informed practitioners working in weight normative models of care because they need jobs — even bariatric surgery.

    Finally, I’m sure it’s not harmful to help clients make an INFORMED CONSENT on choosing surgery, including this recent meta analysis showing increased risk for suicide and self harm ( A link to this paper may have been helpful to include under your fact sheet blurb.

    As HAES clinicians, we don’t tell people what to do. We don’t judge them. It’s outrageous to say we do.

    I have not recommended bariatric surgery, but I have had clients who have had it done. I stand behind all my HAES work. Even with the dramatic weight loss, the culture is STILL a harmful place for them. In the end, that is what HAES is working toward fixing — our oppressive culture.

    • November 08, 2018 at 10:23 am, Ted said:

      Hi Rebecca, and thanks for taking the time to comment.

      I agree with you about the great harm that bias and stigma cause. And as I said above, I think the HAES movement has much to offer for fighting bias and stigma.

      Regarding your comments about HAES practitioners, I assume you are talking about healthcare professionals such as yourself. And if you read what I wrote, you will find that I made no generalizations about health professionals who use HAES principles in their practice. I have no doubt that you and your colleagues deliver a high standard of care. I’m quite confident that you do not use misinformation such as I quoted from the HAES Fact Sheet in your clinical work.

      My concern is very specifically with the use of pressure and propaganda as by illustrated by misleading statements in the HAES Fact Sheet. I hope you’ll agree that it has no place in clinical care.

      Regarding the risk of self-harm, I certainly agree it’s relevant. The fact 2.7 patients per thousand might have that risk is a relevant part of a balanced risk benefit discussion. As I’m sure you’d agree, sensationalizing it would be inappropriate.

      Again, thanks for your comments.

  6. November 08, 2018 at 12:18 pm, Maria Ricupero said:

    How much of the improvements in metabolic parameters and other outcomes can be attributed to changes in lifestyle (e.g. increased fitness) people adopted vs the effect of weight loss? Weight loss here is not a causal effect nor perhaps can we say the same for lifestyle, so it’s important to be transparent and honest with how results are communicated.
    There is plenty of research showing how the same benefits can be achieved even in the absence of weight loss. We really need to send the message to people that living arrangements, housing, etc are what really matter in achieving better health and stop the weight loss discourse. Dennis Raphael, PhD has done a lot of work in this area and he states, “The so-called lifestyle factors of diet, activity and tobacco use stand for little compared to the living and working conditions Canadians experience.” Improve the living arrangements etc of people and that is likely to improve their health. A lot more complicated. This is really where efforts need to be focused so that once and for all we STOP blaming people.

    • November 08, 2018 at 5:22 pm, Ted said:

      Thanks, Maria. You’re right. It’s time to stop blaming people for obesity. I could not possibly agree more.

      And you’re right, that the health benefits seen in the Look AHEAD study were due to lifestyle changes. So was the weight loss. It was a randomized, controlled trial of an intensive lifestyle intervention.

  7. November 08, 2018 at 6:30 pm, Kerry Beake said:

    I’m not really sure if you are genuinely interested in dialogue to improve understanding or if you are being deliberately provocative to increase traffic to your site and your opinions?

    If you were interested in HAES® and the science, social justice foundations on which it is and has been built and those who work from this perspective, then why not engage in discussion with us?

    If you are in support of addressing weight stigma and it’s relationship to health outcomes then why murky the waters with BUTS?

    There is no defined purpose for this piece from what I can see but more of the same lazy fat = bad argument with cherry picked data to attempt to undermine HAES theory laced in bias and privilege.

    • November 09, 2018 at 4:20 am, Ted said:

      Kerry, thanks for taking time to share your opinions about what I think. Yes, I am interested in genuine dialogue – which doesn’t include telling someone else that you know their thoughts.

      As a matter of fact, you are wrong in your speculation about my purpose. Health at every size is an important concept with great value. It is so important and sound that it can be promoted with facts and reason. When advocates resort to misinformation and propaganda, they undermine HAES. That’s counterproductive and it hurts your cause.

      My whole message here is simple. Stick with the facts to promote HAES. They’re on your side.

  8. November 09, 2018 at 11:47 am, Katherine Flegal said:

    Before the Look AHEAD trial, there were already ample data to show that weight loss improved factors like blood pressure and blood glucose levels. However there were no data clearly showing that weight loss was associated with improved mortality or clinical outcomes of “hard’ clinical endpoints (like a myocardial infraction or a stroke). In fact, there were even some data suggesting higher mortality associated with weight loss, but such data could not clearly distinguish intentional form unintentional weight loss.The purpose of the Look AHEAD study was to asses whether intentional weight loss would reduce the incidence of hard clinical endpoints. People with diabetes were selected as the sample for the trial because people with diabetes have a relatively high probability of such endpoints. Thus Look AHEAD was a trial of intentional weight loss vs specified outcomes and it failed. The trial did not find that intentional weight loss reduced the incidence of such outcomes. A trial should be judged primarily on its pre-specified primary outcomes, not on secondary outcomes like improved blood glucose control. From the point of view of primary outcomes, Look AHEAD was not a success, even though it demonstrated secondary outcomes that were already well-known.