The “health at every size” movement promotes a revolutionary approach to health which has many admirers and critics. The movement downplays weightloss as a health goal, instead promoting a more holistic view of health, from encouraging enjoyable life-enhancing activity for people of all body sizes to eating for wellbeing, satiety, nutrition and pleasure, not weight control. It also fights weight stigma and campaigns for more inclusive access to health services.

Registered dietitian Kate Hilton of Diets Debunked praises many aspects of the movement but is concerned about the consequences of failing to confront the known health risks of obesity. She has worked with clients with obesity and diabetes in NHS hospitals and in private consultations, and her nuanced, balanced discussions of dietary matters have attracted 33,000 followers on TikTok. Here are some of the highlights from our exclusive Unfiltered conversation.

Are there plenty of positives about the “health at every size” movement?

Definitely. I think particularly the way that HAES – Health At Every Size – started, I think it was a very positive movement. It rejected the idea that people commonly had that people who are overweight are only very slovenly and don’t ever do anything to improve their health. And it brought it to the forefront that you can’t judge what someone’s activity levels are like, what someone’s diet is like and things along those lines, based off of only looking at their appearance.

And it also empowered people to make those positive changes, irrespective of what their size or their shape was, or their fitness levels were. And I think that was a massively powerful message really, particularly coming from the 90s and 2000s where skinny was in, and it was the only thing that we would want people to see. And it was just assumed that you were lazy if you weren’t in that ideal.

I also appreciate that HAES has also brought to the forefront the disparities in things like healthcare for people who are obese. Many medical professionals, even now, will still only use things like BMI as a way to assess someone’s health. Equally, there is the idea that just because an obese person has a certain medical condition, that it is only going to be caused by their weight. And for those people where they do not get further investigations because it’s simply blamed on their weight, it can then cause massive repercussions to their health in the future, and overall their life expectancy and outcome.

I think they’ve also done a fantastic job in making it so that the general population is a bit more accepting of people who are overweight and obese, making sure that there are accessibility measures made for those people who require them – and that can be a really positive thing too. And I think overall that the biggest positive is the idea that you are empowered. That it doesn’t matter what size or shape your body is, you should love yourself regardless and you should have positivity towards yourself rather than feeling like you have to hate yourself or demean yourself in order to have any kind of self-worth or make yourself feel valid.

I have an issue with the idea that weight is not associated with health in any way, shape or form, and that losing weight will have no benefit to your health”

Kate Hilton, Diets Debunked

Research suggests low self-esteem and negative body image lead to harmful health behaviours such as inactivity and binge-eating. Have you seen this with clients?

Absolutely, yes. And I think that it comes from a fact that most people who are overweight or obese, particularly in healthcare settings, they often feel very judged, and they feel very misunderstood and underrepresented. And that can almost cause some tension and cause them to not want to adopt those healthy behaviours.

So I think it is so important that you are understanding and empathetic towards someone firstly, and that you are encouraging people to massively address, firstly their mental health and their own self-image, above and beyond most other things, in order to help them make those positive changes for themselves. And I think encouraging them, as healthcare professionals, to see themselves in a positive light and look at themselves [positively], rather than this subjective “I don’t like the way I look” [and] to look at it more objectively in that scenario. And it can make a huge difference to someone’s compliance and someone’s actual willingness to change.

What are the problems with the HAES approach?

I think that there are definitely quite a few things about the movement that, as it has progressed, have become more and more concerning to me as a healthcare professional, and something that I am seeing when it comes to the health of my patients overall. I think it’s gone from a very empowering movement to a movement that is so really wanting to prove their point that you can be happy at any size, you can be healthy at any size, that it’s now gone to more of the extreme fringes and, in some cases, science-denying.

I think the primary thing that I have an issue with is the idea that weight is not associated with health in any way, shape or form, and that losing weight will have no benefit to your health. Oftentimes they will use certain studies to back this up. But when you actually look at the research behind it, the studies that they use are often small. They often have a huge amount of confounding variables which can influence the results. And overall, they simply do not agree with the scientific consensus.

The reality is we’re shown time and time and time again with meta-analyses, systematic reviews with various different, very controlled studies, that with an increase in weight and body weight, particularly body fat above a certain BMI, the probability of developing a weight-related condition such as hypertension, high cholesterol, non-alcoholic fatty liver disease, Type-2 diabetes, etc, etc, increases significantly and will increase further with [any] more amount of weight that you gain above that level…

Some more extreme HAES supporters insist any attempts at weight-loss are driven by societal body image ideals or lack of body acceptance, but for people with obesity weight-loss can be a very reasonable search for better health. Are those mixed messages a concern?

Yeah, absolutely. And I’ll be completely honest, I see the fringes of HAES doing this, and I do feel that they want to ignore the science, because if they ignore the science, it makes their argument stronger, if that makes sense. You know, you can say to someone: well, you shouldn’t be losing weight because [that means] you don’t want to look like me – that’s offensive to me, and that’s upsetting to me. And if they say that they want to do it for health, if you can just ignore all of that science, it makes your argument stronger and it makes you seem more valid within that argument.

Ultimately, I think that this is a massive problem. Firstly, even if it was about vanity and things like that, why is that a problem for people? If someone wants to look and feel better, feel more confident, that should not be an issue. But the reality is that scientific evidence absolutely does show that an increased body fat percentage, which is associated with a higher BMI, is absolutely associated with an increased risk of these conditions. And, you know, whether that person who was trying to lose weight has had a health scare, such as high cholesterol or pre-diabetes, they may have even been diagnosed with one of these weight-related conditions, or a family member may have been diagnosed with it, ultimately it should be empowering for that person to take the choice and take back control over what they can control within that situation and scenario. And it should ultimately be something that is encouraged.

There is a time and a place for intuitive eating, particularly with people who have poor relationships with foods or previous eating disorders”

Kate Hilton, Diets Debunked

One aspect of the HAES approach is “intuitive eating”, which involves following internal cues of hunger, fullness and mood, not external cues like weight-loss or dietary rules. Is there a place for this approach?

Absolutely. I mean, I myself am an intuitive eater and I have various different clients who we go down the intuitive eating route with, because it is appropriate for them. I think that there are, like in HAES, there are extremes of people who believe in intuitive eating. I would consider myself very moderate in that. I don’t think it is the cure-all for everything, like many intuitive eating dieticians do. But I do recognise that there is a time and a place for it, particularly with people who have poor relationships with foods or previous eating disorders that they are semi-recovered from. People who wish to find food freedom and get to a point where they feel more comfortable within themselves.

I don’t necessarily think that it is a fantastic tool when it comes to people wanting to lose weight because ultimately people’s internal cues are massively, massively altered. And we need to work on re-altering those cues and making them more aware of those cues before we then go into the intuitive eating realm, because that might make the situation worse.

The science says both weight stigma and weight gain have negative health consequences. How do you navigate a path between those realities?

I think it’s very much dependent on the individual. You know, with every client that I have, I would always listen to the concerns, wishes and desires of the client, whilst also taking into account their medical history, social history, cultural history, their history with their relationship with food, as well as their relationship with their body. And ultimately, that would forge my clinical path.

You know, there are some people who are overweight where body image issues are not necessarily a problem. And so we don’t have to take those into account as much, and we can be a lot more direct, a lot more objective and a lot more scientific about it. I can explain all of the science, I can explain the direct study. For example, if a client came to me and they had Type-2 diabetes, I could say to them, look, the direct study has shown that if you lose like 10 kilos of your body weight, over half of people go into diabetes remission. And the remainder will have a massive improvement in their glycaemic control. So if we can lose that weight, that would be fantastic. And of course, do that in a way that works for them, their social, cultural, financial, etc, history.

When it comes to people with poorer self-esteem, it tends to be a lot more of a subjective approach. We tend to go down the route of perhaps intuitive eating combined with another approach, for example, intuitive eating and some of the principles of intuitive eating, but maybe not doing it solely. We can do a combination of that as well as other approaches to aid with weight loss.

You don’t have to be starving in order to lose weight. You can increase the volume of your food. You can still enjoy the foods that you want”

Kate Hilton, Diets Debunked

Based on your clinical experience, what are the most successful strategies for weight-loss?

So I typically – if you couldn’t tell from the name of my business! – I typically do not particularly like traditional diets. I’m thinking things like Atkins, Paleo, Keto, those kinds of things. Ultimately, what you are doing with those diets is, yes, they will work short-term because of course you’re completely overhauling your diet. You’re reducing down the calories that you’re consuming. But therein lies the problem. You’re completely overhauling your diet.

There is a reason that everybody eats the way that they eat, whether it be for taste, whether it be for pleasure, whether it be for financial, social, cultural reasons. And when you are completely changing that to something completely different, yes, you may be able to stick to it for a few weeks, but ultimately you’re not actually adapting that diet to fit your life, your lifestyle, your likes, your wants, your desires.

So what I typically tend to champion is looking at your diet as it is now and making small steady changes every single week to improve that diet, that isn’t going to be too overwhelming.

As an example, I would typically recommend to people: change two to three things per week. These small things could be something as small as trying to add an extra portion of fruit or vegetables into your diet each day, or adding a protein source to your lunch, or reducing down the portion size of your carbohydrates at dinner by 20% or eating out one less time a week and instead learning to cook something. They can be small or they can be large changes, but ultimately if you can make those small and steady changes, it tends to fare a lot better. It’s a lot more sustainable and you can stick to it a lot longer than if you went for one of these complete diet overhauls.

In the same realm, I also recommend for people to avoid the race to weight-loss. At the end of the day, it is going to be far more sustainable if you lose that weight slowly and steadily than if you drop eight pounds in a week. Because ultimately, the reason you dropped eight pounds in a week is because that calorie deficit was far too large, and it’s just not going to be something you’re going to sustain. You’re going to feel tired, you’re going to feel lethargic, you’re going to feel weak, you’re probably going to end up fainting if you’re not careful, and people can’t stick to that for a long time.

Ultimately, as I say, don’t cause yourself to go into such a severe calorie deficit and let yourself starve essentially. You don’t have to be starving in order to lose weight. You can increase the volume of your food. You can still enjoy the foods that you want to enjoy in moderation. You just need to have bigger portions of food that are lower in calorie, higher in volume, to prevent yourself from getting hungry so that you don’t end up reaching for the higher fat, higher sugar, higher salt foods, higher calorie foods, because you’re so starving.