Browse ‘health at every size’ on social media and you will soon see why this weight-inclusive movement attracts such frenzied debate. There is certainly much to admire about an approach which rejects weight-loss goals; invites a broader view of health; promotes enjoyable physical movement for people of all sizes; fights weight stigma; champions inclusive access to health services; and encourages eating for wellbeing, satiety, nutrition and pleasure, not weight control. There are pictures of people with obesity exercising for “joyful movement,” not for shame-driven weight-loss. Doctors reminding us that health depends on good relationships and sleep, not just waist size. Ads for plus size gym kit and inclusive yoga classes. Lots of beautiful peer support: “Let’s approach fitness with curiosity, not expectation.” And nutritionists sharing sound advice: “Eating as little as possible is not a virtue.”
But there’s more. A lot more. And here comes the controversy. There are fitness professionals with obesity declaring, “Your waist size doesn’t matter.” Nutritionists insisting, “You can eat pancakes every day, if that’s what your body is telling you.” And some truly eyebrow-raising health messages. “The narrative that there are ‘healthy’ foods and ‘unhealthy’ foods is not based on nutrition science,” says one nutritionist. “All of the health consequences that the medical community associates with fat can actually be attributed to anti-fat bias,” declares another. Heart surgeons would disagree. One psychologist offers advice for anyone craving ice cream for breakfast: eat it.
Nobody expects balance and common sense from social media. In reality, many health professionals align with the movement’s values and approaches, but still encourage honest conversations about weight. However, it’s a useful warm-up to the debate. To its supporters, it is a welcome attempt to reject toxic diet culture and to promote health and body positivity to people of all sizes. To its critics, it is a delusion, fashioned out of flimsy research and wishful thinking, which ignores a mountain of evidence that obesity has grave consequences for human health.
Obesity: a growing problem
This debate matters for one big reason: according to the World Health Organisation (WHO), obesity has nearly tripled since 1975, with 2016 data confirming 1.9 billion adults are overweight (with a Body Mass Index, or BMI, of 25 or over) and 650 million adults are obese (BMI of 30 or over). In the UK, 63.8% of people are overweight or obese, rising to 73.6% in America. And by 2035, 51% of the world’s population is forecast to be overweight or obese. Half the planet. Wow.
And science – uncompassionate but undeniable – confirms that obesity is bad news. The Centres for Disease Control and Prevention (CDC) and the WHO link obesity to all leading causes of death, from heart disease and diabetes to some types of cancer, including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney and colon, as well as high blood pressure, high cholesterol and musculoskeletal disorders. To pluck out just two of a zillion studies, a huge meta-analysis of 239 papers, covering 10.6 million people in Asia, Australia, New Zealand, Europe and North America, found that a person’s mortality risk rises with their level of obesity. And a meta-analysis of 228 studies involving 30.3 million individuals found that “overweight and obesity is associated with increased risk of all-cause mortality.”
The problem is that nearly all attempts to tackle obesity are failing. Diets typically fail: research suggests one third to two thirds of dieters regain more weight than they lose, with most participants regaining 30-40% of their lost weight within a year. We live in an obesogenic environment, with fatty food and sugary snacks everywhere. And human willpower is fickle.
It is in this bleak context that the ‘health at every size’ movement claims to offer a powerful new approach. As Dr Jon Robison, a long-term supporter, has written: expecting different results from failed dietary restrictions and behaviour modification strategies is “the definition of insanity.” That does not mean ignoring the risks of obesity. But by focusing on a broader, weight-neutral view of health, advocates aim to build a person’s self-esteem, and therefore encourage more daily movement and healthier food choices, without worrying about weight-loss.
But some say the phrase ‘health at every size’ is an oxymoron, which promotes the idea that being overweight is not a health issue. In an article for the Journal of Eating Disorders, Professor Amanda Salis, of the School of Human Sciences at the University of Western Australia, called for an “urgent” rethink: “While I certainly agree that it is possible to have healthy behaviours that provide health benefits at a wide variety of body sizes, I disagree that it is possible to be – or to stay – truly healthy at every size.”
Social media support
The movement – which shares some goals with the body positivity, fat acceptance, anti-diet and intuitive eating movements – has been growing since the 1960s, through formal groups, the work of academics, activists and medical professionals, media articles, books such as Health at Every Size by Dr Lindo Bacon and, more recently, through Instagram, Facebook, TikTok and Twitter. The ‘Health At Every Size’ registered trademark is owned by the Association for Size Diversity and Health (ASDAH), a non-profit organisation launched in 2003 which shares educational resources, lists supportive healthcare providers and champions change.
The movement’s goals are praised by some health experts, who have integrated its values into their clinics, clubs, gyms or educational settings. But some of ASDAH’s statements set alarm bells ringing. For example, it affirms “a holistic definition of health, which cannot be characterised as the absence of physical or mental illness, limitation or disease.” Most doctors would insist good health is precisely the degree to which we are free from illness, limitation or disease. Supporters point out that ‘health at every size’ is not the same as ‘healthy at any size.’ Even ASDAH says it’s a “myth” that it believes all fat people are healthy. But some of the research it shares appears to reject the health benefits of weight-loss. And the messaging is clouded, especially when spread among supporters online. As a few disillusioned nutritionists have noted, extreme supporters believe even discussing weight-loss is “fatphobic”.
Amid so much ferocious debate, it is easy to lose track of what matters. But for most people, there are two questions which need to be answered. Is ‘health at every size’ a positive or regressive movement? And can we really achieve health at every size?
Weight does not equal worth
Looking at wider societal progress in recent years, the movement, in conjunction with parallel body-positivity trends, has played its part in reducing stigma, rejecting unattainable body image, promoting health access for all and rejecting the idea that a person’s weight is a proxy for their worth. A huge consensus statement – led by 36 international academics – has called for an end to weight-based stigma, which causes distress and low self-esteem and leads to decreased health motivation, avoidance of healthcare, social isolation, reduced physical activity and disordered eating. One enormous review led by Yale University found that weight-stigma translates into inequities in employment, healthcare and education. Even children’s cartoons are more likely to show characters with obesity as unattractive, unintelligent or evil.
But today we’re seeing more diverse body shapes on TV, more inclusive sports kit, and a proliferation of inclusive trainers, fitness classes and yoga classes. For example, some yoga classes now offer more chair-based stretches, and inclusive gym classes offer standing weight-lifting exercises that are easier for people with obesity. We are also seeing a positive shift in language, from framing exercise as a punitive quest to torch calories to celebrating it as a joyful pastime.
This is not just about “being kind.” Extensive research indicates that stigmatising people with obesity demotivates healthy behaviour, leading people to consume increased quantities of food and avoid exercise. People afflicted by weight stigma have a 60% higher chance of being inactive. In contrast, a review found that improving the positive psychological wellbeing of overweight women facilitated their weight loss and lifestyle changes. In short: stigma doesn’t help; body positivity does. Scornful gym coaches, fitness trolls and dismissive doctors, take note.
In one supportive paper, Lily O’Hara, Associate Professor of Public Health at Qatar University, insisted that ‘health at every size’ offers a compassionate, humane and evidence-based approach to weight concerns, free of moral judgements or the profit-making antics of pharmaceutical, fitness and weight-loss companies.
Many academics welcome this broader approach to obesity. In that robust consensus statement, the international team of experts emphasised “current scientific evidence demonstrating that body-weight regulation is not entirely under volitional control.” No, people are not just lazy. Obesity is multifactorial, with biology, genes, environment, gut hormones, neural signals, metabolism, sleep, stress and housing all playing their part. For example, research has shown that unhealthy foods are cheaper than healthy foods, and low-income areas have fewer green spaces for exercise.
Data cannot be denied
But fighting weight-based stigma does not mean accepting that obesity has no health consequences. Acknowledging that a person’s weight is not entirely under their control does not mean that they have no control. And any desire to lose weight is not always about societal pressure; it may be motivated by a rational pursuit of better health. But Dr Salis has stressed that it is only after many years of obesity that signs of serious disease appear, yet “the health at every size concept implies putting off doing anything about excess weight indefinitely.” If someone waits until serious illness strikes, it may be too late. Even the mechanical impact of obesity is a problem, with overweight adults more than twice as likely to develop knee osteoarthritis.
Most controversial, however, is how some ‘health at every size’ supporters challenge the idea that adiposity poses significant mortality and morbidity risks at all. But a huge study, including data from 68.5 million people followed over 25 years, confirmed that a high BMI is linked to 4 million deaths globally. That kind of data cannot be dismissed.
Other experts question whether the link between high BMI and ill health is actually “causal”. Maybe it’s the lack of exercise or poor nutrition that’s killing people, not weight per se? But a major study in the International Journal of Epidemiology concluded that “elevated mortality rates at high BMI appear causal.” Doctors point out that it is not weight that is the problem anyway, but visceral adipose tissue – the belly fat wrapped around your vital organs. This adipose tissue is not inert; it is metabolically and hormonally active and triggers a cascade of negative effects, including the release of pro-inflammatory molecules, the accumulation of fatty deposits in blood vessels, the disruption of fat metabolism, the build-up of cholesterol and hormonal disruption. That’s what causes the health problems.
There is certainly reasonable evidence that dieting can be harmful, with restrictive dieting and weight cycling linked to slowed metabolism, eating disorders, reduced bone and muscle mass, stress, suppressed immune function and increased mortality. And it’s hard, too: research suggests the probability of a morbidly obese person achieving a 5% weight reduction in a year is just 1 in 8 for men and 1 in 7 for women.
But harmful diets are not the same as positive, sustainable lifestyle change. For example, research found that people who adopted a Mediterranean diet lost 4kg in 18 months, and, crucially, adherence remained at an impressive 54% after 18 months. Another study found that the Mediterranean diet has good adherence even after five years. And a paper found that exercising for one hour a day, following a low-calorie diet, self-monitoring weight and keeping consistent eating patterns all show successful results. The experts concluded that “long-term weight loss maintenance is possible.”
This is a hugely important message because losing even a small amount of weight can help. In a well-known research paper, people with pre-diabetes who lost 5-7% of their bodyweight reduced their risk of diabetes by a huge 54%. And weight-loss of 5-10% has been shown to offer big improvements in cardiovascular risk factors. In fact, weight loss can lower blood pressure, improve lipoprotein particles and increase insulin sensitivity. So if anyone with obesity is hearing the message that weight-loss isn’t possible or beneficial, that’s not true.
Exercise and healthspan
So without encouraging weight-loss, what health benefits does the ‘health at every size’ approach offer? Quite a few, it seems. One study found that this approach can improve metabolic fitness, blood pressure, blood lipids, cholesterol, activity levels, self-esteem and body image. And another study showed that the method has good adherence too, with just 8% of subjects giving up after 6 months compared to 41% on a traditional diet. And research suggests intuitive eating – a key strategy in the ‘health at every size’ approach, which involves focusing on internal cues such as hunger, satiety and mood, rather than external weight-loss goals – can improve body image, wellbeing, glycaemic control, cholesterol and fruit and veg consumption. But what is almost always missing in these studies is weight-loss. That is why people with obesity may need more structured meals, healthy food swaps or food diaries too.
It is certainly true that all positive lifestyle changes help, even without weight loss. An important study showed that adopting health-promoting habits, such as eating more fruit and veg or doing more exercise, led to a reduction in all-cause mortality risk, regardless of BMI. And research shows that improved fitness can aid a person’s mortality risk, whatever your BMI. In fact, research suggests the benefits of fitness on metabolic health may be augmented in those with higher levels of obesity.
And this is the big win for the ‘health at every size’ approach. If you get people with obesity exercising more or choosing healthier foods, without worrying about weight-loss, then this approach triumphs where extreme diets, impatient doctors and fat-shaming personal trainers have failed.
But the reality is that achieving some weight-loss would be even better. A study in Diabetes Care found that, compared with lifestyle changes alone, weight loss in conjunction with lifestyle changes resulted in a greater reduction in Type-2 diabetes. And a study concluded that even unfit normal-weight individuals have a 30% lower risk of death from any cause than fit obese individuals. So, again, this is where the ‘health at every size’ approach falls short.
Clearly there is much to learn from ‘health at every size,’ from the provision of more compassionate medical care and inclusive gym classes, to the importance of body positivity and the benefits of lifestyle changes. But the danger is when people believe weight-loss is not possible or beneficial, and drift into a learned helplessness. The movement does not seek to help people with obesity lose weight. And that brings us onto the second crucial question: is it actually possible to have health at every size? Can we be – to use the crass colloquial term – ‘fat but fit’?
Fat and fit?
Many ‘health at every size’ supporters point to studies which suggest overweight people can still be “metabolically healthy,” characterised by good insulin sensitivity, normal lipid and inflammation profiles and few signs of hypertension. For example, a 2008 study showed that some overweight people are “metabolically healthy.” And a 2013 study suggested that while the extremely obese have a higher mortality risk, those with Grade 1 obesity (a BMI of 30-35) do not. Indeed, HAES claims there is evidence that “obesity is not the health risk it has been reported to be.”
But in the largest study of its kind, involving 520,000 subjects in 10 countries, researchers found that being overweight increases the risk of heart disease by 26-28%, even if you have normal blood pressure, blood sugar and cholesterol. Lead researcher Dr Camille Lassalle concluded “there is no such thing as being healthy obese.”
One major 20-year study by University College London revealed that among the number of supposedly “healthy obese” with low cardiometabolic risk factors, 31.8-35.8% were unhealthy obese after 5 years, and 34-48.1% were unhealthy obese after 20 years. In other words, at first checks, the negative health effects just hadn’t kicked in yet. But they did soon enough. Indeed, an 11-year study of 380,000 people found that those with ‘metabolically healthy obesity’ had a higher risk of heart failure, respiratory disease, diabetes and all-cause mortality. The researchers concluded that the term ‘metabolically healthy obese” is “misleading.”
But there’s another strand to this debate. Oddly, some studies have suggested that increased mortality is linked only to very low and very high BMI but that being slightly heavier is better than being slightly underweight. One paper suggests that although a BMI of 35 or above increases mortality risk by 40-62%, a BMI of 22-31 does not. This quirk has been dubbed the “obesity paradox,” with some data even suggesting obese people with Type 2 diabetes, hypertension, cardiovascular disease or chronic kidney disease may enjoy greater longevity than thinner people with these conditions. It’s as though being overweight somehow offers a “protective” effect.
But experts such as Professor Ryan Masters, a social demographer at the University of Colorado, Boulder, Dr Hailey Banack, of the Department of Epidemiology and Environmental Health at Buffalo University, and Dr Andrew Stokes, a demographer and sociologist at Boston University, have pulled this argument apart. It seems many studies which suggested this paradox included people who lost weight due to an existing illness, older patients who lost weight in later life, smokers or subjects with eating disorders. Having those people in the “normal weight” pool makes this group seem more ill, and the overweight people seem healthier, skewing the results.
The BMI data may also be flawed. Many subjects recorded as having a “healthy” BMI had been overweight or obese in the decade prior. Obesity can lead to illnesses which, paradoxically, leads to rapid weight-loss, artificially inflating the mortality risk in the low-BMI category. And as BMI data is based on weight and height only, it fails to take into account where fat is distributed. This is crucial. As discussed earlier, it is the excess adipose tissue that causes harm. When studies combine BMI data with waist measurements or skin folds to clarify the presence of abdominal fat, the link between obesity and mortality is clear.
When Professor Masters re-crunched the numbers, without all these biases, his research revealed that excess weight increases mortality risk by 22-91%. With similar findings in their own study, Dr Banack and Dr Stokes concluded: “The only ‘paradox’ we can see here is why researchers continue to claim to have evidence of a paradox without careful consideration of potential methodological explanations.”
In fact, a huge meta-analysis of 72 studies, covering 2.5 million participants, concluded that however you measure central fatness – waist circumference, waist-to-hip ratio, waist-to-height ratio – the link to mortality is clear. In fact, one eye-catching study concluded that most studies probably “underestimate” the adverse effects of being overweight.
And this is the Everest-sized mountain of evidence that the ‘health at every size’ movement keeps butting up against. Yes, it is nobly fighting stigma. Yes, it helps people of all sizes to get moving. Yes, obesity is complex. But any approach which downplays the harms of obesity will always be limited in what health gains it can offer its followers.
Drawing wrong conclusions
The problem is that some ‘health at every size’ supporters sometimes draw wrong conclusions from real problems. That is why many health experts distance themselves from it. Dr Yoni Freedhoff, a respected obesity doctor, wrote in a blog that although he supports many of its principles, misinformation is “weakening and cheapening their incredibly important and valuable message.”
We face the same old conundrums. The fact that losing weight is hard does not mean it is impossible. The fact that obesity is multifactorial does not mean an individual has no influence over their weight. The fact that BMI is a crude analytical tool is not an argument against ignoring the medical dangers of excess body fat. And the fact that we have serious societal issues with unrealistic body ideals and a toxic diet culture does not mean every attempt to lose weight is a submission to social norms or body negativity: it can be – and usually is – a genuine quest for better health.
At its best, ‘the health at every size’ movement offers a wonderful support network, an accessible motivational launchpad for people with obesity, a powerful voice in the war against stigma and extreme diet culture, and a catalyst for positive change. To those harnessing this approach in a responsible way, most medical experts nod and say: keep up the good work. But at its worst, or most extreme, it can resemble an echo chamber for its own followers, which fails to acknowledge the known harms of obesity, and which is unlikely ever to facilitate life-enhancing weight-loss.
Compassionate compromise
So where might the approach fit into the ongoing conversation around obesity? It is helpful to imagine the two huge pillars of scientific evidence between which health practitioners and individuals with obesity must navigate. The first pillar of evidence confirms that weight-based stigma is toxic, and weight-loss is not entirely within a person’s control. Unless health professionals, personal trainers and nutritionists wake up to this fact, people with obesity will be let down. Intolerant gym coaches or doctors who regard people with obesity as lazy just aren’t reading the science. But the second pillar of evidence confirms that obesity is incredibly harmful for human health – and people can lose weight. While everyone can be healthier at every size, it is not possible for most people to be medically healthy at every size. Yes, we’re all different shapes and sizes, but abdominal fat harms our health in myriad ways.
If we accept these two pillars of scientific evidence, maybe we can navigate an intelligent path forward. Healthcare experts may require a ‘pick ‘n’ mix’ approach, harnessing the ‘health at every size’ approach as a powerful tool but retaining the science-backed confidence to discuss the health benefits of weight-loss. And individuals with obesity may confidently enjoy ‘health at every size’ classes and clubs, but also engage with their doctor about weight loss. In an article in the American Journal of Public Health, population health scientist Dr Tarra Penney and professor of health promotion Dr Sara Kirk recommend we “move beyond an ideological debate.” They welcome how ‘health at every size’ improves body image and inspires positive societal change but worry that it ignores the proven benefits of weight loss and warn about “its desire to remove weight entirely from the discussion.” They suggest “the likely way forward may well be through extracting the most relevant and salient aspects of traditional and HAES approaches.”
If we can embrace the inclusivity, compassion and social progress of ‘health at every size’ but accept the scientific reality that weight-loss is medically beneficial for people with obesity, progress can be made. But it will require honesty from all parties – including ourselves. We know that 63.8% of people in the UK are either overweight or obese. But self-reported census data has revealed that 82% of us think we’re in good or very good health, with just 5.2% believing our health is bad or very bad. Science shows us the path to better health. The question is, do we want to listen?
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