Recently I appeared on SBS’ Insight, talking about emotional eating. During the show, that old chestnut “… but can you really be healthy at any size?” was posed, and infuriatingly, my response was edited out. Instead, they asked Phillipa Hay, a psychiatrist whose anti-HAES®* sentiment is so intense that she wrote a paper calling for an “Urgent Rethink of the Health At Every Size Concept”. On the show, Hay used examples of people at very low weights with restrictive eating disorders, and people at very high weights, to allege that people can’t possibly be ‘healthy at any size’, thus putting this ‘crazy fringe movement’ in its place.
This BS gets right up my nose, because it’s frequently used to dismiss the HAES approach. But here’s the thing: HAES doesn’t claim that people are healthy at any size.
It’s HEALTH at every size, not HEALTHY. HAES calls for weight inclusive health care, for people of all sizes. HAES also recognises the social determinants of health, refusing to dumb down the complex issue of ‘health’ to a BMI score. At no point does it claim that ‘perfect health’ is possible for all sizes.
I’ve been meaning to rage-blog on this topic, and the offensive anti-HAES article, for a long time, so strap yourselves in!
The Anti-HAES paper by Sainsbury-Salis & Hay (2014)
I’ve read a lot of research in my time, but this is one of the weirdest. It’s less like a scientific paper and more like one of those weird arguments you get into with your grandparents when they start ranting about ‘the gays taking over’.
The feelpinion commentary, written by Amanda Sainsbury-Salis and Philippa Hay, was published in the Journal of Eating Disorders (where Hay is editor-in-chief) in 2014. The first section, “The argument for an urgent rethink”, was written by Sainsbury-Salis, an academic and (conflict alert!) author of 2 weight loss books, The “Don’t Go Hungry Diet” (2007), and “Don’t Go Hungry for Life” (2011).
In academia, critical evaluations generally start with defining the issue they’re discussing. But not Sainsbury-Salis, who chose to lead with what she considered to be a witty metaphor, but in fact is an incredibly awkward fatphobic clanger:
“When I was a child my grandmother used to say “Don’t pull an ugly face, because if the wind changes, your face will become stuck like that”….I say “Don’t eat an ugly diet or let yourself stay fat, because if the wind changes you may become stuck with permanent o**sity” (1).
She then blasts the fat acceptance movement for ‘overlooking the long term effects of ‘excess calories and adiposity on body weight regulation’ (p.1). Because how dare fat activists focus on human rights, instead of studying fat cells!
The ‘re-think’ quickly deteriorates into abject confusion, reflecting Sainsbury-Salis’ biased feel-pinions. She agrees that ‘it is possible to have healthy behaviours that provide health benefits at a wide variety of body sizes’. But, she declares, “I disagree that it is possible to be – or to stay – truly healthy at every size”.
Her first statement is actually pro-HAES. But this aggrieved protest against being ‘truly healthy at every size’ is a misunderstanding of HAES. We’re in this surreal land of ‘urgently rethinking’ something that is factually incorrect.
Stating that HAES means “healthy at every size” is a false premise – an incorrect proposition upon which Sainsbury-Salis bases her anti-HAES argument. When the first premise is false, the entire argument is wrong. It’s like saying that you disagree with feminism because the world will be taken over by lesbians: the protest has nothing to do with the original subject, but it’s an extreme enough red herring that it can totally derail sensible discussions. In this case, ‘healthy at every size’ effectively ‘smears’ efforts to examine the HAES paradigm shift more deeply.
During her urgent re-think, Sainsbury-Salis repeatedly makes statements which are aligned with HAES, such as:
– BMI is not an accurate marker for health
– People can demonstrate health at a variety of sizes (even the “O” BMI categories)
Even without weight loss, health supportive behaviours can result in health gains.
She then brings out the “buts” – for example, the correlation between higher BMI and metabolic health issues. She talks about knees, and people who have problems with mobility. The fact that some people with higher BMIs experience health challenges is not news. The “but what about health” question is a common ‘niggle’ for people new to the HAES world. The relationship between BMI and health is exquisitely complex. Most health disparities typically attributed to BMI alone are much better explained by social determinants of health (race, class, gender, oppression, health care access), and their intersections. Consider factors such as aging, fatphobia and the impact of weight cycling (the sum impact of dieting), and you’re beginning to see the bigger picture.
None of these are reasons to ‘urgently rethink’ HAES. In fact, the terrible standard of health care for larger people, and health disparities due to systemic inequity, particularly for those with marginalised identities, is a major driver for the HAES paradigm shift. The assumption that ‘health’ is the consequence of an individual choice, without recognising the powerful forces of social inequity, is reductionist, naive and fanciful.
In a rare moment of lucidity, Sainsbury-Salis writes “The health at every size concept implies putting off doing anything about excess weight indefinitely, instead accepting a higher BMI and focusing on healthy behaviours (2).” This is accurate, because HAES recognises not only the ineffectiveness of intentional weight loss efforts (which lead to metabolic damage, inflammation, and weight gain, not loss, over time), but also the harms – physical, psychological, and social – inflicted by weight-centrism. The simplistic assumption that ‘health’ can be achieved via intentional weight loss is simply not supported by science. For every health condition where weight loss is recommended, there is a weight-neutral alternative – because thin people experience health issues too!
Not spending our whole lives focused on weight loss is for Sansbury-Salis ‘deeply worrying’. Because according to rat research (all of her assertions about weight regulation are from rat studies), there’s only a small ‘window’ in which we can act in order to ‘prevent’ becoming larger bodied.
Sainsbury-Salis’ drive to urgently re-think HAES is based on her own (unsupported) hypothesis is that the longer people stay large, the more ‘stuck’ they become in ‘permanent o**sity’. In her world view, body diversity does not exist: higher weight people are always the result of a brain malfunction caused by overconsumption of food.
Sainsbury-Salis notes the existence of the set point and genetic and epigenetic contributions to BMI, but leaves out the role of intentional weight loss in driving higher weight over the long term. There’s also no discussion regarding how best to look after the people whose rat-window of effortless thinness has closed. Even though her own hypothesis recognises that body size, once established, is pretty much fixed, she misses a golden opportunity to recognise HAES approaches as relevant, non stigmatising, and health-supportive.
Instead of building coherent arguments against HAES, the bulk of the paper champions her own rat-weight regulation theory. She then admits there’s no scientific evidence to support her claims for humans.
But ”by the time we have robust human evidence for this hypothesis there could be great numbers of people – and possibly also their offspring – who have become hard wired for a permanent state of o**sity”** (3).
Oh the horror! LET’S NOT WAIT FOR SCIENTIFIC EVIDENCE, WE MUST ACT NOW!
The prospect of living in a world in which there are more larger bodied people is so offensive to Sainsbury-Salis that she proclaims: “It is for this reason that I vehemently reject the fat acceptance movement and notions that people can have ‘health at every size’.
The second half of this article is titled “In response”, written by Phillipa Hay, who inexplicably commends her buddy Sainsbury-Salis for ‘presenting a persuasive argument for the rethinking’ of HAES. Raising serious doubts about her ability to peer review this topic, Hay claims that HAES ‘largely’ arose from the eating disorder community, because people with eating disorders are over-concerned with weight. This is not true: the HAES movement grew from many sources: it has its roots in the fat activism movement of the 1960’s, and the radical feminists of the 1970’s. Reducing the problem of entrenched fatphobia to an individual issue of ‘over-concern about body weight’ is fantastically ill informed.
Like Sainsbury-Salis, Hay (accidentally) makes several pro-HAES points:
– Health concerns regarding the BMI range 25-30 are often overstated
– Shaming people into pursuing weight loss, when the most likely impact long term is weight gain, will only add to poor self-esteem and worsen physical health
But internalised fatphobia overrides any opportunity for Hay to see the big picture: she basically says we need to keep doing ‘weight management’, as long as it doesn’t worsen eating disorders. Which is an incredibly blinkered comment, given that dieting is recognised as the most important risk factor for developing an eating disorder.
Hay’s section doesn’t even pretend to re-think HAES. Instead, she focuses on Sainsbury-Salis’ weight regulation theory, leaping from rats to humans and then making the incredible claim that the ‘metabolic impact’ of being larger is the reason diets don’t work. This is clearly incorrect: diets also don’t work for thin people, resulting in weight regain and producing long lasting metabolic changes. It’s like she’s never read any weight science.
Hay calls for ‘early intervention’ (aka diets) using tips drawn from Salis’ diet books, which involve paying attention to internal fullness cues, but only for those in the magic rat-window of still being thin. Her section isn’t an urgent re-think of HAES, it’s an argument to bring ‘weight management’ into eating disorder treatment, which is a complete mind fuck.
The “Correction” – May 2014 (AKA The Unravelling)
Two months after their first urgent re-think, Sainsbury-Salis & Hay published a ‘correction’ in the same journal, which feels a lot like getting a “and another thing…!” text from grandad in the middle of the night .
They (finally) list the 5 HAES principles, from the ASDAH website. Hilariously, they accessed this website 5 days after the urgent re-think was published.
This goes some way to explain how they got HAES concepts so wrong in paper #1 – they hadn’t bothered to read a simple definition of the fundamental principles. Do we dare to dream that we’ll finally get a decent corrected-re-think?
The HAES principles from the ASDAH website
Intriguingly, Hay & Sainsbury-Salis now claim that they AGREE with most of the HAES principles, “in particular the high importance of ending weight stigma and weight bias”. Given the extreme level of fatphobia which saturated their re-think, I’m not convinced.
But they do have “issues” with Principle 1. “..For the reasons addressed outlined in our commentary, we respectfully disagree that it is possible to be – or stay- truly healthy with body weights outside of certain thresholds”.
It’s now astounding, because we know that they’ve read what HAES actually is, and they STILL don’t get it. Accepting body diversity and not pathologizing body size is not the same as claiming ‘true health’ for all sizes. Why is this so hard to understand?
They also ‘disagree’ with Principle 4, claiming that externally regulated eating plans and an explicit focus on weight control are ‘sometimes necessary’, so that people can “attain or maintain a healthy body weight”. They’ve literally missed the entire point of eating for well-being. They’re also wilfully ignoring the plethora of scientific research which unequivocally demonstrates that diets do not work, and lead to weight gain, not loss, over time, thus dooming their optimism about ‘explicit focus on weight control’.
Sainsbury-Salis & Hay actually claim to use ‘intuitive eating’ in their clinical practice and research, but report ‘disappointing results’ for weight loss. The level of not-getting-it is NEXT LEVEL. It’s like they’re protesting against accepting homosexuality because it doesn’t lead to heterosexuality. They can’t see the forest for the fatphobic trees.
‘Disagreeing’ with 2 HAES principles is not a coherent basis for re-thinking the entire paradigm. Especially when you’ve misunderstood one of them.
By the end of their ‘correction’, Sainsbury-Salis & Hay totally abandon weight science and any pretence of discussing HAES, and reveal their fatphobic, thin-at-all-costs roots. They push for extreme weight loss, endorsing ‘severe and highly externally regulated weight loss strategies such as very low energy diets and bariatric surgery’ (in spite of recommending against the use of very low calorie diets in their first paper).
I honestly feel sorry for people still stuck in the weight-centric paradigm. It feels like they know their time is up, much like Big Tobacco when the cancer articles became impossible to suppress, but they keep trying to make their old approach relevant in a desperate effort to preserve their careers. Like it or not, the winds of change are blowing. The re-think we need is the weight-centric paradigm, not HAES. As I like to say:
“Don’t let yourself stay fatphobic, because if the wind changes you may become stuck with permanent irrelevance”.
* In 2011, The Association for Size Diversity & Health (ASDAH) trademarked HAES in order to stop the term being stolen by the weight loss industries & used for bait & switch purposes, or used in a way not in keeping with the original intent of the phrase.
** Fun fact about ‘offspring’ – The well-known Barker hypothesis demonstrates that babies of mothers who have been restricted during pregnancy (ie, dieting mums!) have a hugely increased risk of coronary heart disease, hypertension, type 2 diabetes, and stroke.
