1. In a haze about HAES? Health At Every Size, Non-Dieting, & Weight-Inclusive Approaches.
Glenn Mackintosh
Principal Psychologist
Weight Management Psychology
BA(Psyc.), Hons (Psych. & HMS), Mpsych (Sp. & Ex.)
MAPS, FOPATS, PEWBIG
Thanks to person who invited me.
Introduce Weight Management Psychology.

2. Overview
Health at Every Size, Weight-Inclusive and Non-Dieting Approaches.
Definitions
Research
Limitations
Case studies and conversation
Psychology and weight management – I think it’s the key! It is effective in and of itself, and makes more traditional interventiions more effective, in the short- and long- term.
Team coming – for panel discussion at end  

3. Definitions Weight Management Approaches Weight Inclusive Approaches
HAES ®
Non- Dieting
Psychology and weight management – I think it’s the key! It is effective in and of itself, and makes more traditional interventiions more effective, in the short- and long- term.
Team coming – for panel discussion at end  

4. Definitions Where do YOU stand? Fad dieting Bariatric surgery
Weight reduction (med/beh/psych)
HAES
Weight - Inclusive
Fat acceptance
Dieting
Non-dieting
Where do YOU stand?
Weight normative Weight Inclusive

5. Definitions Non-dieting
“Non-dieting involves promoting healthy lifestyles and avoiding restrictive diets”
- Marchessault, et. al. (2007)
Opinions varied on
Teaching portion sizes and meal plans
Whether weight loss could be a goal

6. Definitions Non-dieting Principles (Health, Not Diets Website 2015)
Dieting Paradigm - Inflexible, quantitative, prescriptive, rigid, perfection-seeking, good or bad foods, rules, deprivation, time-based, fear-driven, guilt-inducing, shaming, body hatred, hunger, struggle, rationalising, temptation, thought-consuming, punishing.
Non-dieting Paradigm - Flexible, accepting, welcomes all foods, intuitive, qualitative, supporting, enjoyable, life balance, appreciating, comfort, confidence, variety, freedom, natural, calm, pleasurable, kindness, nurturing, grateful, nourishing, forgiving, satisfaction, trust-building.  
Non-diet group.
There were five aspects to the treatment program: body- acceptance, eating behavior, activity, nutrition, and social support. Initial treatment focused on enhancing body-accep- tance and self-acceptance, and subjects were supported in leading as full a life as possible, regardless of their body weight or whether they succeed at weight control. The goal was to first help participants disentangle feelings of self- worth from their weight. The secondary phase of treatment
focused on eating behavior. Standard nutritional instruction regarding diet quality was given; however, the emphasis was on regulating the quality and quantity of food intake accord- ing to internal cues of hunger, appetite and satiety. The activity component of the intervention focused on helping participants to identify and transform the barriers to becom- ing active, such as attitudes towards their bodies, and to find activity habits that were fun and appealing. The support group element was designed to help the women see their common experiences in a culture that devalues large women, and to gain support and learn strategies for asserting themselves and effecting change. The program was facili- tated by a counselor who has conducted educational and psychotherapeutic workshops and groups using this non- diet approach, and reinforced with a written manual.
From Bacon et. Al. (2002)
Purple in maybes 

7. – Linda Bacon, Health At Every Size
Definitions
Health at Every Size
“Let's face facts. We've lost the war on obesity. Fighting fat hasn't made the fat go away. And being thinner, even if we knew how to successfully accomplish it, will not necessarily make us healthier or happier. The war on obesity has taken its toll. Extensive "collateral damage" has resulted: Food and body preoccupation, self-hatred, eating disorders, discrimination, poor health... Few of us are at peace with our bodies, whether because we're fat or because we fear becoming fat. Health at Every Size is the new peace movement. Very simply, it acknowledges that good health can best be realized independent from considerations of size. It supports people of all sizes in addressing health directly by adopting healthy behaviors.”
– Linda Bacon, Health At Every Size

8. Definitions HAES Principles
A healthy relationship with food and physical activity
Body and self acceptance
Holistic self-care
Community and social justice
Bacon et. al

9. Definitions Weight-Inclusive Approach
“Emphasis on viewing health and wellbeing as multifaceted while directing efforts towards improving health access and reducing weight stigma”
- Tylka et. al. (2014)
Psychology and weight management – I think it’s the key! It is effective in and of itself, and makes more traditional interventiions more effective, in the short- and long- term.
Team coming – for panel discussion at end  

10. Definitions Weight-Inclusive Principles (Tylka, et. al, 2014)
Do no harm
Include all bodies - a norm of diversity
Given health is multidimensional maintain a holistic focus
Keep a process focus rather than end goals (daily QOL)
Evaluate and incorporate evidence (where it exists)
Create practices and environments that are sustainable
Increase health access and social justice for people across the weight spectrum
From Tylka article.
(1) Do no harm.
(2) Appreciate that bodies naturally come in a variety of shapes and sizes, and ensure optimal health and well-being is provided to everyone, regardless of their weight.
(3) Given that health is multidimensional, maintain a holistic focus (i.e., examine a number of behavioral and modi)able health indices rather than a predomi- nant focus on weight/weight loss).
(4) Encourage a process-focus (rather than end-goals) for day-to-day quality of life. For example, people can notice what makes their bodies rested and energetic today and incorporate that into future behavior, but also notice if it changes; they realize that well-being is dynamic rather than )xed. (ey keep adjusting what they know about their changing bodies.
(5) Critically evaluate the empirical evidence for weight loss treatments and incorporate sustainable, empiri- cally supported practices into prevention and treat- ment eorts, calling for more research where the evidence is weak or absent.
(6) Create healthful, individualized practices and envi- ronments that are sustainable (e.g., regular pleasur- able exercise, regular intake of foods high in nutrients, adequate sleep and rest, adequate hydration). Where possible, work with families, schools, and commu- nities to provide safe physical activity resources and ways to improve access to nutrient-dense foods.
(7) Where possible, work to increase health access, autonomy, and social justice for all individuals along the entire weight spectrum. Trust that people move toward greater health when given access to stigma- free health care and opportunities (e.g., gyms with equipment for people of all sizes; trainers who focus on increments in strength, 0exibility, Và! Max, and pleasure rather than weight and weight loss).

11. Health At Every Size
Assumption – weight-health relationship is exaggerated.

12. Health At Every Size
Assumption – weight-health relationship is exaggerated.
“The Worldwide Obesity Epidemic”
A lowering of BMI cut offs to current ranges (James, 2001)
Recommended to
IOTF majority funding (approximately 2/3) from Roche (Xenical) and Abbott (Reductil).

13. Health At Every Size
Assumption – weight is not a good indicator of health.
Flegal et. al. (2013)
Mortality risk associated with Body Mass Index Normal (20-25) 1, Overweight (25-30) .94, Grade 1 Obese (30-35), .95, Grades 2 and 3 obese (>35) 1.29, Obesity (general) 1.18

14. Health At Every Size
Assumption – there are better indicators of health
Metabolic Health
Kramer et. al. (2013)
(Source - Kramer) Relative risk in metabolically healthy and unhealthy people in normal weight, overweight, and obese BMI categories Normal weight 1, Overweight 1.1, Obese 1.19 Metabolically healthy. Metabolically unhealthy
Very interesting discussion point

15. Health At Every Size
Assumption – there are better indicators of health
Cardiovascular fitness
Stevens et. al. (2002)
Average
Normal weight
Fat
Fit 1
1.29
Unfit
1.37
1.53
Men
1.25
1.44
1.49
Women
1.32
1.30
1.57
GM’s note: Fitness is a more impprtant indicator for men, but just the same for women.

16. Health At Every Size Assumption – weight reduction is ineffective
Saris (2001)
Percentage weight regained after following a very low calorie diet Year , Year 2 – 52, Year 3 – 68, Year 5 – 115.

17. HAES Research Assumption - Health can be realised at any weight
Bacon et. al. (2005)
Not exaclty ANY weight Average BMI 35.9 (SD 4.6).

18. HAES Limitations
Based on the assumption that weight is not a good indicator of health.
It is an indicator.
And it may be a good indicator of specific health conditions
Severe joint pain
Obstructive Sleep Apnea
Other health conditions
GM’s idea – treat the WHOLE person,
being mindful of the tendency for weight bias.
BMI of above 35 – relative risk of 1.19 (19% more likely to die than a person in the normal weight category).
Certain conditions ARE linked with weight.
My recommendation – I believe this give a more person-centred approach. And critically asking if weight is relevant for this person.

19. HAES Limitations
Based on the assumption that weight ALL weight reduction methods are ineffective or harmful.
Bariatric surgery (e.g., O’Brien, Brennan, & Laurie et. al (2013))
Alternative psychological interventions
CBT + Hypnosis (e.g., Kirsch et. al., 1996)
Emotional Freedom Technique (e.g., Stapleton et. al., 2012)
Weight reduction + psychological intervention
Weight reduction + ACT (e.g., Lillis et. al. 2009)
Psychological intervention for food cravings
CBT/EFT (e.g., Stapleton et. al. 2015)
Paul O’Brien and Leah Brennan showed approximately 50% of excess weight reduced after 15 years. Also found lasting reduction in metabolic syndrome.
Hypnosis and EFT both show medium term improvements, and potentially continued improvements (more research required). EFT REDUCED
Lillis and colleagues showed (at 3 month follow up) – compared to weight list controls, improvements in obesity related stigma, psychological distress, body mass, distress tolerance, general and weight-specific acceptance and psychological flexibility. Effects on distress, stigma, and qol were above and beyond the effects due to weight control (more research required too) – THIS REDUCED WEIGHT STIGMA.
CBT and EFT for food cravings reduced weight at a year and also reduced restraint! 
GM’s idea – this offers the person a more complete investigation of their treatment options. If weight reduction becomes an aim, aim for modest weight reduction, non-dieting/mindful/intuitive eating style etc.

20. follow weight-inclusive and/or non-dieting principles.
HAES Limitations
Based on the assumption that weight ALL weight reduction methods are ineffective or harmful.
GM’s idea – with people who stand to gain important health benefits from weight reduction, explore SURGICAL and PSYCHOLOGICAL interventions AS WELL as HAES. If weight reduction becomes an aim,
follow weight-inclusive and/or non-dieting principles.
Paul O’Brien and Leah Brennan showed approximately 50% of excess weight reduced after 15 years. Also found lasting reduction in metabolic syndrome.
Hypnosis and EFT both show medium term improvements, and potentially continued improvements (more research required). EFT REDUCED
Lillis and colleagues showed (at 3 month follow up) – compared to weight list controls, improvements in obesity related stigma, psychological distress, body mass, distress tolerance, general and weight-specific acceptance and psychological flexibility. Effects on distress, stigma, and qol were above and beyond the effects due to weight control (more research required too) – THIS REDUCED WEIGHT STIGMA.
CBT and EFT for food cravings reduced weight at a year and also reduced restraint! 
GM’s idea – this offers the person a more complete investigation of their treatment options. If weight reduction becomes an aim, aim for modest weight reduction, non-dieting/mindful/intuitive eating style etc.

21. HAES Limitations
Based on the assumption that ALL people can become healthy at every size.
People of BMI
People of BMI 40 + (research not done)
People who are not receptive to HAES ideas
Non-responders
Differing individual preferences
GM’s idea – Further research into HAES for people with a BMI of Specifically, a long-term randomised controlled trial of HAES vs. Bariatric Surgery.
Also HAES Vs. Weight inclusive interdisciplinary approach.

22. HAES Limitations Research limitations Little replication
Especially from “independent” researchers
Long term follow up
5 year
10 year
Methodological issues
Attrition
Lack of gold-standard control group (diet vs. CBT).
GM’s idea – Further, independent, long-term replication of research required to support HAES approach.
HAES research is not without methodological research issues (like all research).
For example, Bacon et. Al, 2005 began with 78 randomised participants, at 12 months had 52 participants (.66), At 24 months had 38 participants (48.7) – rough extrapolation at 30% attrition per year leaves with approximately 2.5%.
Appropriate control group – maybe could have chosen CBT (known to work better than dieting, and in Peta Stapleton’s study, reduced restraint in 1 year).

23. Complete Paradigm Shift
HAES Limitations
Calls for a
Complete Paradigm Shift To
Health At Every Size
GM’s idea: A paradigm shift to a weight-inclusive approach, acknowledging the efficacy of surgical and psychological interventions, and limitations of HAES. More research on weight inclusive, psychological, and surgical interventions, and the interplay between them.
Weight Reduction + ACT (Lillis et. al., 2009)
Lillis and colleagues showed (at 3 month follow up) – compared to weight list controls, improvements in obesity related stigma, psychological distress, body mass, distress tolerance, general and weight-specific acceptance and psychological flexibility. Effects on distress, stigma, and qol were above and beyond the effects due to weight control.
GM worries replacing dogma with another dogma.
Also worries people will be less receptiv to some wonderful, evidence-based, and much needed ideas due to HAES “dogmatic” approach

24. Where do YOU sit on this continuum?
Definitions
Fad dieting
Bariatric surgery
Weight reduction (med/beh/psych)
Weight Management Psychology
HAES
Weight - Inclusive
Fat acceptance
Dieting
Non-dieting
Weight normative Weight Inclusive
Where do YOU sit on this continuum?

25. Connecting with Community
Psychology of Eating, Weight, and Body Image Interest Group
HAES Community
These pages will also be available to everyone – come and ask me and join up today (otherwise it will be like the many things we write down at these things but forget to follow up on!) 
We want to make links and help each other out!
© 2014

26. Summary & Questions
HAES, Non-Dieting, and Weight Inclusive approaches are related but have significant distinctions.
HAES is a preferable approach to weight reduction dieting in people of BMI 30 – 40, resulting in holistic health benefits and avoiding harmful effects of dieting in the short to medium term.
HAES advocates acknowledging the limitations of the HAES approach, efficacy of other approaches, and calling for more research may result in greater receptiveness to HAES principles and more integrated and efficacious paradigm shift.

27. Selected References.
Psychological intervention for weight management.
Shaw, K., O’Rourke, P., Del Mar, C., & Kenardy, J (2006) Psychological interventions for overweight or obesity (Review). The Cochrane Library, 4.
Bacon, L. et. al. (2002) Evaluating a “non-diet” wellness intervention for improvement of metabolic fitness, psychological wellbeing, and eating and activity behaviours. International Journal of Obesity, 26 (6)
Kirsch, I., Montgomery, G., & Sapirstein, G. (1995). Hypnosis as an adjunct to cognitive-behavioural psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 63(2):
Stapleton, P., Sheldon, T., & Porter, B (2012) Clinical benefits of emotional freedom techniques on food cravings at 12-months follow up:
A randomised controlled trial. Energy Psychology, 4(1), 1-12.
Miller, C.., Kristeller, J.L., Headings, A., Nagaraja, H., & Miser, F (2012) Comparative effecctiveness of a mindful eating intervention to a diabetes self-management intervention among adults with Type 2 Diabetes: A pilot study. Journal of the Academy of Nutrition and Dietetics, 112 (11), pp
Dalen, J. Smith, B.W., Shelley, B.M. et. al. (2010). Mindful Eating and Living (MEAL): Weight, eating behavior, and psychological outcomes associated with a mindfulness-based intervention for people with obesity. Complementary Therapies in Medicine 18 (6) pp
Weight-inclusive approaches and research.
Tylka, T., Annunziato, R. A., & Burgard, D, et. al. (2014). The weight inclusive versus weight normative approach to health: Evaluating the evidence for a paradigm shift. Journal of Obesity, pp
Flegal, K. M., Kit, B. K., & Orpana, H., et. al. (2013) Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. Journal of the American Medical Association, 309 (1), pp
Bacon, L., Stern, J. S., & Van Loan et. al. (2005) Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association, 105, pp
Saris, H. M. (2001) Very low calorie diets and sustained weight loss. Obesity Research, 9, pp
Kramer, KC. K., Zimnman, B., & Retnakaran, R. (2013) Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis. Annals of Internal Medicine, 159 (11), pp
Stevens, J., Cai, J., & Everson, K.R., et. al. (2002) Fitness and fatness as predictors of mortality from all causes and from cardiovascular disease in men and women in the lipid research clinics study. American Journal of Epidemiology, 156, pp
Marchessault, G., Theile, K., & Armit, E. et. al (2007). Canadian dietitians’ understanding of non-dieting approaches in weight management. Canadian Journal of Dietetic Practise and Research, 68 (2), pp
Limitations of HAES assumptions.
O’Brien, P.E., Brennan, L, & Laurie, C., et. al. (2013) Intensive medical weight loss of laporoscopic adjustable gastric banding in the treatment of mild to moderate obesity: Long-term follow up of a prospective randomised trial. Obesity Surgery.
Lillis, J., Hayes, S. C., & Bunting, et. al. (2009) Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioural Medicine, 37, pp
Kirsch, I. (1996). Hypnotic enhancement of cognitive-behavioural weight loss treatments – another meta-reanalysis. Journal of Consulting and Clinical Psychology, 64(3):
Stapleton, P. B., Sheldon, T., & Porter., B. (2012). Clinical benefits of emotional freedom techniques on food cravings at 12-months follow up: A randomized controlled trial. Energy Psychology, 4 (1), pp. 1 – 12.
Stapleton et. al. (2015 – currently unpublished)