Overweight AND Healthy - a New Target?

Summarized by Robert W. Griffith, MD
August 17, 2005

Introduction

The pressure on obese people to try to get thin is considerable. And, unfortunately, many of their efforts to lose weight fail. As many as 57% of US women are now dieting, according to a recent telephone survey. A large part of their motivation is the emphasis placed today on the ill-health associated with overweight and obesity. However, some voices are being raised, pointing out that it may be possible to be both overweight and healthy.

A study published in the Journal of the American Dietetic Association has reported a 6-month study that compares a "health at every size" program (HAES) with a standard diet program, from the health viewpoint. Here's a summary of the findings.

What was done

White women living in Davis, California, were recruited for the study. To enroll in the study they had to be: obese, i.e. a body mass index (BMI) of 30 or above; a non-smoker; have a history of chronic dieting; non-diabetic; and generally healthy.

There were two treatment groups. Both groups received 24 weekly sessions lasting 90 minutes, followed by monthly aftercare sessions for a further 6 months, if the participant wished.

The Diet Group sessions provided education and advice on eating behaviors and attitudes, nutrition, social support and exercise. Energy and fat intake were to be restricted, and exercise within the targeted heart rate was encouraged. Food and weight diaries were kept. These sessions were taught by an experienced registered dietician.

The HAES Group sessions focused initially on improving body acceptance and self-acceptance, with encouragement to live as full a life as possible, regardless of individual BMIs. Then eating behavior was to be changed, as far a possible, to abandon restrictive measures and replace them with 'internally regulated' eating; participants were to become sensitized to internal cues (appetite and taste) and not external cues. However, there was supportive education about the health benefits of certain foods and the effects of food choices on well-being. The sessions were run by a counselor with a doctorate in psychology and nutrition.

Evaluations were made at baseline, 12 weeks, 26 weeks (the end of treatment), 52 weeks, and 104 weeks (follow-up). They included weight, height, blood pressure, full lipid tests, energy expenditure estimation, eating behavior measures, and psychological assessments that included a measure of 'cognitive restraint', which expresses the degree of adherence to dietary (or other) restrictions on behavior.

What was found

Thirty-nine subjects were randomly assigned to each treatment group; there were no significant differences between the characteristics of the members of the two groups. Their average age was 41, average weight 223 lbs, and average BMI 36.

Cognitive restraint was decreased in the HAES group and increased in the diet group, indicating that both groups followed their program directions. At 6 months almost half the diet group had dropped out, whereas less than 10% of the HAES group had left the study.

Body weight and BMI values were, on average, unchanged in the HAES group, while the diet group members showed a weight loss (an average of 11 lbs) during the treatment period, which had lessened to a 3 lb loss at the 104-week follow-up.

Blood pressure changes were similar in both groups; there was a significant lowering - about 6 mmHg - at the end of treatment, which was sustained during follow-up.

With respect to lipid levels, the HAES group had an initial increase in total cholesterol, which was followed by a significant decrease at follow-up. The diet group had no significant change in total cholesterol levels at any time. Low density lipoprotein cholesterol (LDL-C) levels were decreased in both groups at the 52-week and 104-week examinations.

Finally, a questionnaire the subjects completed showed that 100% of the HAES group respondents reported that their participation helped them feel better about themselves, compared with 47% of the diet group.

What this study means

The findings in the diet group participants in the study were similar to those usually reported for dietary restriction regimes - initial weight loss followed by gradual relapse, and a high proportion of drop-outs from the study. In contrast, the HAES group showed little change in body weight throughout. However, the improvements in systolic blood pressure and blood lipid levels that occurred in both groups were sustained for 2 years in the HAES group.

Health At Every Size is an approach to obesity and overweight that is catching on. It involves the following concepts:

• Accepting and respecting natural diversity in body shapes and sizes.
• Ineffectiveness of dieting for weight loss.
• Importance of relaxed eating in response to internal body cues, thereby balancing nutritional needs, hunger, satiety, appetite, and eating pleasure.
• Promoting individually appropriate, enjoyable, life-enhancing physical activity.

These basic principles have been elaborated in a paper by the Association for Size Diversity and Health (see first link below).

There's no doubt that dieting to reduce weight is not very successful, for most people. Any new approach needs to be explored, and the HAES program appears to be worth following up. However, before you throw your scale away, consider that there may be room for a half-way approach that embraces some degree of dietary restriction with a more relaxed eating attitude, along the lines outlined by HAES.

Remember that overweight and obesity are not just a matter of pounds and BMIs, but also involve blood pressure, blood lipids, blood sugar, joint health, and cardiovascular function, all of which should be evaluated in addition to judging how you feel about yourself.

Source

• Size acceptance and intuitive eating improve health for obese, female chronic dieters. L. Bacon, JS. Stern, MD. van Loan, NL. Keim, J Am Diet Assoc, 2005, vol. 105, pp. 929--936

Related Links
The Association for Size Diversity and Health (ASDAH)
U. Berkeley: The Center for Weight and Health
Eat as Much as You Like and Lose Weight?

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