Health at every size

{{cquote|Fat activism isn’t about making people feel better about themselves. It’s about not being denied your civil rights and not dying because a doctor misdiagnoses you.|||Cat Pausé<ref name="highline">[https://highline.huffingtonpost.com/articles/en/everything-you-know-about-obesity-is-wrong/ Everything You Know About Obesity Is Wrong]</ref>}}
[[File:Weight vs Habits 1.png|thumb|right|165px|HAES advocates to focus less (or at least not only) on weight but also on other healthy habits.]]
{{SJ}}
'''"Health at every size"''' (or HAES) is a multi-faceted movement with scientific, social, and a few anti-scientific components. Scientists with a HAES approach look for more effective ways to encourage weight loss and healthy habits. Activists with a HAES approach fight weight [[discrimination]], stigma, and toxic diet culture. Denialists with a HAES approach cherry-pick data to 'prove' that obesity isn't unhealthy.

There's a variety of views in HAES.  Good: promoting healthy eating and exercise no matter the weight, encouraging positive thinking, debunking [[Fad diet|fad diets]], not being a jerk to people because of their weight. Bad: denying obesity's health risks, forgetting to try at the "health" part of "health at every size," and denying that obesity is a disease.<ref>https://icd.who.int/browse10/2019/en</ref>

HAES can have a positive focus: encouraging heavier people to love and take good care of their bodies, and to not be afraid to do things like swimming or working out. Research shows that exposure to the HAES movement leads to better health outcomes and even weight loss.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/19857626 Health-At-Every-Size and eating behaviors: 1-year follow-up results of a size acceptance intervention.]</ref><ref>[https://theconversation.com/study-finds-fat-acceptance-blogs-can-improve-health-outcomes-2890 Study finds fat acceptance blogs can improve health outcomes]</ref><ref>[https://www.sciencedirect.com/science/article/pii/S0378512215300591 Effect of a non-dieting lifestyle randomised control trial on psychological well-being and weight management in morbidly obese pre-menopausal women]</ref> People who don't hate their bodies may put more effort into taking care of them.

But some proponents of the HAES may ignore their own doctors' advice to lose weight because ''there can't possibly be any link between obesity and disease.''<ref>[https://thisisthinprivilege.tumblr.com/post/41542890848/i-really-want-to-believe-in-your-blog-as-i-am-a Ask about sleep apnea] ''This is Thin privilege''</ref> However, doctors can miss other diseases if they only focus on the patient's weight.<ref>[https://www.healthline.com/health-news/my-doctor-fat-shamed-me My Doctor Fat-Shamed Me — And I’m Not the Only One] by Marie Southard Ospina at ''healthline''</ref> If you are concerned, ask your doctor to consider other possible reasons, make sure any refusals to conduct certain diagnostic checks are well-documented, and don't be afraid to get a second opinion if your doctor won't take treatment seriously.

==Causes of obesity==
The traditional understanding of obesity has centered diet and exercise as key determinants of weight. This has led to the common perception of obesity as being solely a product of poor self-control. However, recent scientific research, especially in the last decade, has pointed to a range of genetic, environmental, and socioeconomic factors that influence weight. These collectively suggest that obesity may be more complex than previously thought.

HAES seeks to advance the scientific understanding of obesity and in doing so improve the lives of fat people. The movement has several good points, but not all its claims are backed by scientific evidence. Some of this is due to lack of research.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386524/ The Health at Every Size Paradigm and Obesity: Missing Empirical Evidence May Help Push the Reframing Obesity Debate Forward]</ref> Researchers have found that a HAES (or "weight-inclusive") approach is linked with better physical health, better mental health, and healthier habits overall.<ref name="tylka">[https://www.hindawi.com/journals/jobe/2014/983495/ The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss]</ref>

=== Genes and environment play a notable role===
Research has shown there are many genetic, epigenetic, and environmental factors that shape our bodies. It has been estimated that obesity is 40-70% heritable.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2787002/ Genetic contributors to obesity]</ref> One study found that 80% of the children of two obese parents were obese, while only 14% of the children of average-weight parents were obese.<ref name="nytimes1">[https://www.nytimes.com/2007/05/08/health/08fat.html Genes Take Charge, and Diets Fall by the Wayside]</ref>

The {{wpl|thrifty gene hypothesis|thrifty gene hypothesis}} posits that the human propensity for obesity may be a byproduct of our [[evolution]]. For early humans, the ability to store energy as fat during periods of plenty would have been advantageous, allowing them to better endure times of reduced food availability, and increasing their chances of surviving famine. However, in the modern societies with more stable food supplies, this fat-storing tendency has seemingly become detrimental.<ref name="thrifty1">[https://www.physiology.org/doi/full/10.1152/japplphysiol.00757.2003 Eating, exercise, and "thrifty" genotypes: connecting the dots toward an evolutionary understanding of modern chronic diseases]</ref> This could explain why obesity rates rose alongside the wider availability of refined grains and sugars that followed the [[Industrial Revolution]].<ref>[http://web.colby.edu/st297-global18/2018/10/30/has-technology-caused-an-obesity-epidemic/ Has Technology Caused an Obesity Epidemic?]</ref> It might also explain why certain traditionally non-agrarian human populations, such as the {{wpl|Pima people|Pima people}} of [[Arizona]] and the {{wpl|Cook Islanders|Cook Islanders}} of the [[Pacific Ocean|Pacific]], developed some of the highest rates of obesity after being introduced to a Western lifestyle.<ref>[https://academic.oup.com/ije/article/38/1/63/694434 Ethnic variability in adiposity and cardiovascular risk: the variable disease selection hypothesis]</ref> 

Increased obesity rates can also arise from epigenetic factors. Famine can significantly alter how [[gene expression|genes are expressed]], and these changes may be passed on to successive generations. People in utero during the {{wpl|Dutch famine of 1944–45|Dutch Hunger Winter}} of 1944-45 tended to have higher-than-average birth weights, and were also more susceptible to obesity, diabetes, and high cholesterol in later life than people born before or after the famine.<ref name="dutchfamine1">[https://www.nytimes.com/2018/01/31/science/dutch-famine-genes.html The Famine Ended 70 Years Ago, but Dutch Genes Still Bear Scars]</ref><ref name="dutchfamine2">[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801462/ Uncertain Inheritance: Transgenerational Effects of Environmental Exposures]</ref> They also had a higher mortality rate sixty-eight years later.<ref name="dutchfamine1" /> At least one study also found that the grandchildren of Dutch famine victims had higher birth weights.<ref name="dutchfamine3">[https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.12136 Transgenerational effects of prenatal exposure to the 1944-1945 Dutch famine]</ref> 

Other environmental factors play a role. A meta-analysis of 240 studies found a link between certain plastics ([[PCB]]s, phthalates, and BPA) and increased rates of obesity and diabetes.<ref name="plastics1">[https://www.independent.co.uk/news/science/chemicals-in-plastic-linked-to-rise-in-obesity-and-diabetes-7578153.html Chemicals in plastic linked to rise in obesity and diabetes]</ref> Another meta-analysis of 100 studies found a link between dietary exposure to [[antibiotics]] used in meat production and an increased risk of obesity, suggesting changes in the [[microbiome]], i.e. the [[bacteria]]l ecosystem of the human digestive tract, as a cause.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867737/ Obesity in the United States – Dysbiosis from Exposure to Low-Dose Antibiotics?]</ref>

===Healthy eating isn't simple for everyone===
Maintaining a healthy diet is generally sound advice. However, it presumes that everyone has equal access to good, nutritious food. This isn't always true for marginalized and low-income people. Poverty is associated with an increased risk of obesity.<ref name="poverty1">[https://scholars.org/contribution/why-poverty-leads-obesity-and-life-long-problems Why Poverty Leads to Obesity and Life-Long Problems]</ref> Fresh vegetables and meat can be prohibitively expensive for the poor, leading them to opt for cheaper, unhealthier food choices.<ref name="poverty1" /> These typically include energy-dense foods like potatoes and processed meat products, which are more palatable, have a longer shelf life, and allow poor families to maintain energy intakes at a lower cost than more expensive, less-energy-dense foods.<ref name="poverty1" /><ref name="aus1">[https://www.vichealth.vic.gov.au/~/media/ResourceCentre/PublicationsandResources/healthy%20eating/Literature%20Review%20Poverty_Obesity_Food%20Insecurity.ashx A review of the literature describing the link between poverty, food insecurity and obesity with specific reference to Australia]</ref> However, energy-dense foods tend to have higher fat and sugar content, and are thus more unhealthy.<ref name="aus1" /> Nonetheless, agricultural advancements have made energy-dense foods widely available, and they now comprise 30-50% of the Western diet.<ref name="aus1" />

Some people live in "{{wpl|food desert|food deserts}}" with less access to affordable and nutritious food.<ref name="poverty1" /><ref name="fooddeserts1">[https://www.ajpmonline.org/article/S0749-3797(08)00838-6/abstract Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S.]</ref> These areas are typically poor, minority, or rural communities.<ref name="fooddeserts1" /> They often lack supermarkets, leaving residents with less food options and leading them to rely on convenience stores and fast-food restaurants, which offer cheap, energy-dense foods.<ref name="fooddeserts1" /> 

Special dietary needs can also limit one's food options in a way that makes healthy eating more difficult. [[Irritable bowel syndrome]] sufferers may find healthy-diet staples like leafy greens aggravate their symptoms, and may thus favour starchy and low-fiber foods in an attempt to alleviate them.<ref>[https://gastrocenternj.com/can-ibs-cause-weight-gain/ Can IBS Cause Weight Gain and What Can You Do About It]</ref> IBS has been linked to an increased risk of obesity by a number of studies.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302488/ Obesity and Irritable Bowel Syndrome: A Comprehensive Review]</ref> [[Autism]], with its attendant sensory sensitivities and need for routine, can also cause dietary restrictions that pose challenges for healthy eating.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601920/ Food selectivity and sensory sensitivity in children with autism spectrum disorders]</ref><ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310968/ Changes in food selectivity in children with autism spectrum disorder]</ref> Studies have found a link between autism and an increased risk of obesity.<ref>[https://www.spectrumnews.org/news/research-adds-heft-link-autism-obesity/ Research adds heft to link between autism and obesity]</ref>

==Diet and weight loss==
=== Diets often don't work and can be harmful ===
[[File:HCG Diet Products Are Illegal (6419420559).jpg|thumb|right|165px|Putting [[pseudoscience|non-FDA-approved chemicals]] into your body is probably a bad idea.]]
Traditional dieting is often ineffective<ref>[https://www.sciencedirect.com/science/article/abs/pii/S1499404606602479 The National Weight Control Registry: A Critique]</ref> and can be harmful in the long term.<ref>[https://www.sizediversityandhealth.org/content.asp?id=161 Health At Every Size Fact Sheet]</ref>{{dead link}} Recent scientific research has shown that dieting, especially using unhealthy means, is correlated with eating disorders, weight fluctuations, extreme dieting measures (such as laxatives), reduced self-esteem, increased susceptibility to weight gain, and other long-term health issues.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/21829159 Does dieting make you fat? A twin study.]</ref><ref>[https://www.sciencedirect.com/science/article/pii/S0002822306000046 Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later?]</ref><ref>[https://www.ncbi.nlm.nih.gov/pubmed/1580453 Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel. "Several epidemiologic studies have found that weight loss is associated with increased mortality..."]</ref><ref>[https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-10-9 Weight Science: Evaluating the Evidence for a Paradigm Shift]</ref>

Willpower alone doesn't explain dieting failure.<ref name="time1">[https://time.com/magazine/us/4793878/june-5th-2017-vol-189-no-21-u-s/ The Weight Loss Trap: Why Your Diet Isn’t Working] - TIME</ref> A meta-analysis found that diets generally do not work, and that many dieters regain more weight than they started with initially.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/17469900 Medicare's search for effective obesity treatments: diets are not the answer.]</ref> Up to 80% of dieters regain some or all of the weight within a year.<ref name="cnn1">[https://www.cnn.com/2011/10/26/health/post-diet-weight-regain/index.html After dieting, hormone changes may fuel weight regain]</ref> Diets can alter [[metabolism]] and hormone balance in ways that contribute to weight gain and retention.<ref name="nytimes2">[https://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html The Fat Trap]</ref> The human body has seemingly been hardwired by [[evolution]] to respond this way to apparent food scarcity (see the discussion of the thrifty gene hypothesis in the [[Health at every size#Genes and environment play a notable role|previous section]]).<ref name="nytimes2" /> This "famine reaction" leads to a reduced resting metabolism, meaning the body burns less calories and stores more fat, and this lowered metabolic rate may persist even as weight is regained.<ref name="time1" /> Major weight loss can be metabolically identical to starvation.<ref name="nytimes1" /> It can also trigger increased production of ghrelin, a gastric hormone tied to hunger, and decrease peptide YY and leptin, hormones associated with hunger suppression.<ref name="cnn1" /><ref name="nytimes2" /> These hormonal changes may also persist long after the initial weight loss.<ref name="nytimes2" /> All this means that not only are lost pounds regained, but subsequent weight loss attempts are more difficult. People who want to stay in shape must also adhere to stricter diets and exercise more than just three decades ago due to an apparent shift in biological and environmental factors.<ref name="1980s">[https://www.theatlantic.com/health/archive/2015/09/why-it-was-easier-to-be-skinny-in-the-1980s/407974/ Why It Was Easier to Be Skinny in the 1980s]</ref> A study found that people in 2006 had higher [[body mass index|BMIs]] than people of the same age who followed an identical diet and exercise regimen in 1988.<ref name="1980s" />

Reduced caloric intake can increase cortisol production and psychological stress.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/20368473 Low calorie dieting increases cortisol]</ref> Excessive cortisol, often known as the "stress hormone," can have several health consequences.<ref name="mayoclinic1" /> Not only does it cause weight gain, but it is associated with depression, anxiety, and sleep problems.<ref name="mayoclinic1">[https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037 Chronic stress puts your health at risk]</ref> It can also negatively impact the cardiovascular system, and has been linked to an increased risk of heart disease.<ref name="mayoclinic1" /> 

[[Fad diet|Fad diets]] are especially awful for losing weight.<ref>[http://www.vox.com/2015/10/29/9639982/low-fat-high-protein-diet The science is clear: fad diets don't work]</ref> More dangerous fad diets may even result in death. A woman in the UK died as a result of following a [[breatharianism|breatharian]] diet.<ref>[http://news.bbc.co.uk/2/hi/uk_news/scotland/453661.stm UK: Scotland Woman 'starved herself to death]</ref> Weight cycling, or "yo-yo dieting," increases heart disease and mortality.<ref>[https://www.thecardiologyadvisor.com/home/topics/prevention/cardiovascular-disease-risk-increases-with-body-weight-fluctuations/ Cardiovascular Disease Risk Increases With Body Weight Fluctuations]</ref> Some studies have found that the weight fluctuations associated with "yo-yo dieting" may have worse health outcomes than a stable (even overweight) weight.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/17283263 Consistently stable or decreased body mass index in young adulthood and longitudinal changes in metabolic syndrome components]</ref><ref>[https://newsroom.heart.org/news/yo-yoing-weight-blood-pressure-cholesterol-and-blood-sugar-readings-may-raise-heart-attack-and-stroke-risk?preview=6b93 Yo-yoing weight, blood pressure, cholesterol and blood sugar readings may raise heart attack and stroke risk]</ref>

It can be difficult to measure how strictly someone follows a diet. Dieters may under-report the number of calories that they eat and/or over-report the exercise they do.<ref>[http://www.nejm.org/doi/full/10.1056/NEJM199212313272701 Conclusion: "The failure of some obese subjects to lose weight while eating a diet they report as low in calories is due to an energy intake substantially higher than reported and an overestimation of physical activity, not to an abnormality in thermogenesis."]</ref> This means that they may not be following a diet as well as they think they do.

=== New approaches to healthy living ===
[[File:Preventing Childhood Obesity with Nutrition Basics.jpg|thumb|right|165px|Less focus on shame, more focus on healthy habits.]]
Due to the lack of positive results associated with diets, experts are now calling for a new paradigm, favoring smaller and sustainable gradual lifestyle changes over strict diets.<ref>[https://www.buzzfeed.com/sallytamarkin/weight-neutral-dietitians?utm_term=.wmYy4Ym3w#.yaBGRBLmZ 13 Experts Explain Why Diets Don't Work And What To Do Instead]</ref> A meta-analysis found that several practices improve body image and lead to better health: intuitive eating, Cognitive Behavioral Therapy, self-compassion, and exercise.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/31077956 The effectiveness of interventions aiming to promote positive body image in adults: A systematic review.]</ref>

Weight-neutral interventions that advocate a shift away from traditional dieting show improvements in mental health and disordered eating habits, as well as positive or neutral effects on biological markers of health.<ref>[https://www.sciencedirect.com/science/article/abs/pii/S1499404614007969 Impact of Non-Diet Approaches on Attitudes, Behaviors, and Health Outcomes: A Systematic Review]</ref> Weight-neutral approaches such as Health at Every Size are a scientifically valid way to improve health, especially with regards to psychological well-being and healthy habits.<ref>[https://www.sciencedirect.com/science/article/pii/S0195666316302343 A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial]</ref><ref>[https://www.sciencedirect.com/science/article/pii/S0261561416301406 A Health at Every Size intervention improves intuitive eating and diet quality in Canadian women]</ref><ref>[https://www.sciencedirect.com/science/article/abs/pii/S1499404615000111 Health at Every Size College Course Reduces Dieting Behaviors and Improves Intuitive Eating, Body Esteem, and Anti-Fat Attitudes]</ref>

====Intuitive eating====
HAES advocates promote intuitive eating, which encourages people to pay attention to their appetite rather than relying on self-imposed rules. One must eat until satisfied, and then stop.<ref>https://web.archive.org/web/20161221063021/https://healthateverysize.org.uk/12-2/#intuitive</ref> While intuitive eating sounds like regular behavior, it is something that chronic dieters and eating disorder survivors may need to re-learn.

Multiple literature reviews have found that intuitive eating is associated with lower BMI, healthier eating habits, and better psychological well-being, while noting that it is still an emerging topic.<ref>[https://www.researchgate.net/publication/256073762_Review_Article_Relationships_between_intuitive_eating_and_health_indicators_Literature_review Review Article Relationships between intuitive eating and health indicators: Literature review]</ref><ref>[https://www.sciencedirect.com/science/article/abs/pii/S0195666315300635 A systematic review of the psychosocial correlates of intuitive eating among adult women]</ref><ref>[https://www.cambridge.org/core/services/aop-cambridge-core/content/view/351A3D01E43F49CC9794756BC950EFFC/S0954422417000154a.pdf/structured_literature_review_on_the_role_of_mindfulness_mindful_eating_and_intuitive_eating_in_changing_eating_behaviours_effectiveness_and_associated_potential_mechanisms.pdf A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: effectiveness and associated potential mechanisms]</ref>

The practice has a few limitations: it focuses on when to eat (not what to eat), and it may not work well for people who have health conditions that impair their interoception, meaning that they cannot recognize hunger and fullness properly. Interoception issues can occur in a number of conditions, such as eating disorders, depression, autism, anxiety, and more.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6054486/ Interoception and Mental Health: A Roadmap]</ref> Someone who cannot recognize hunger properly may need to implement common-sense habits to make sure that they are eating enough.<ref>[https://misslunarose.home.blog/2020/05/21/counterintuitive-eating/ Counterintuitive Eating] - Autistic Dreams</ref>

===Weight loss programs===
"Failed" child obesity reduction programs have improved other measures of health, including athletic skills, time spent exercising, and time spent watching television.<ref>[https://www.cornwallhealthyschools.org/documents/Cochrane_Review_June_2013.pdf School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18 (Review)]</ref> Health programs for kids may not significantly change obesity, but they can improve test scores.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836343/ Effect of a Two-Year Obesity Prevention Intervention on Percentile Changes in Body Mass Index and Academic Performance in Low-Income Elementary School Children]</ref> Seeing weight loss as the end goal of such initiatives can result in overlooking positive changes.

==Social issues==
=== Negativity won't cause positive outcomes ===
[[File:Fat Yoga Class.jpg|thumb|right|185px|A [[yoga]] class designed for heavier individuals. Body-shaming may discourage exercise in communal settings.]]
Research suggests that negative and stigmatizing approaches to obesity don't lead to better health.<ref>[https://www.healthline.com/nutrition/fat-shaming-makes-things-worse The Harmful Effects of Fat Shaming]</ref> A 2014 study found that [[Shaming|fat shaming]] doesn't just fail to motivate weight loss, but, paradoxically, may actually prompt weight gain.<ref>[https://onlinelibrary.wiley.com/doi/full/10.1002/oby.20891 Perceived weight discrimination and changes in weight, waist circumference, and weight status]</ref> This may be because stigma creates a vicious cycle, causing increased stress that triggers binge or comfort eating, thereby leading to more weight gain.<ref>[https://pubmed.ncbi.nlm.nih.gov/24997407/ Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model]</ref><ref name="brewis">[https://www.sciencedirect.com/science/article/abs/pii/S0277953614005206?via%3Dihub Stigma and the perpetuation of obesity]</ref> In two studies, Schvey et al. found that, in obese women, exposure to weight-stigmatizing content increased caloric consumption and production of cortisol.<ref>[https://pubmed.ncbi.nlm.nih.gov/21760636/ The impact of weight stigma on caloric consumption]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/24434951/ The stress of stigma: exploring the effect of weight stigma on cortisol reactivity]</ref> Major et al. (2014) found similar results, concluding that exposure to "weight-stigmatizing news messages" causes obese (but not non-obese) individuals to "consume more calorie-rich snack foods" and "feel less able to control their diet."<ref>[https://www.sciencedirect.com/science/article/abs/pii/S0022103113002047 The ironic effects of weight stigma]</ref> Obesity and internalized shame have been linked to a greater incidence of depression and anxiety.<ref>[https://pubmed.ncbi.nlm.nih.gov/23836723/ Weight bias internalization, core self-evaluation, and health in overweight and obese persons]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/17712309/ Obesity and mental disorders in the general population: results from the world mental health surveys]</ref> Heavy people who feel discriminated against have shorter lifespans.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636946/ Weight Discrimination and Risk of Mortality]</ref> Around half of girls between ages 3 and 6 are worried about their weight,<ref>[https://pubmed.ncbi.nlm.nih.gov/20481395/ Am I Too Fat To Be A Princess? Examining The Effects Of Popular Children's Media On Preschoolers' Body Image]</ref> and preschoolers are less kind to their chubbier peers.<ref>[https://www.sciencedirect.com/science/article/pii/S0193397399800495 Thin is good, fat is bad: How early does it begin?]</ref>

Weight stigma can also strongly discourage physical activity among obese people.<ref name="brewis" /> Harassment, body-shaming, and judgment faced in public facilities like gyms and swimming pools can lead people to avoid them.<ref name="brewis" /> In a 2011 study, experience of fat shaming, internalization of "anti-fat attitudes," and internalization of societal beauty standards were all found to be associated with exercise avoidance (particularly at gyms).<ref>[https://onlinelibrary.wiley.com/doi/full/10.1038/oby.2010.234 Internalized societal attitudes moderate the impact of weight stigma on avoidance of exercise]</ref> 

Additionally, fat people often face [[discrimination|discrimination]] in hiring and salaries, further leading to marginalization.<ref>[http://www.jeffreyhunger.com/uploads/3/4/4/8/34481134/27._major_tomiyama___hunger.pdf The Negative and Bidirectional Effects of Weight Stigma on Health]</ref><ref>[https://www.marketwatch.com/story/only-15-of-hiring-managers-would-consider-hiring-an-overweight-woman-2017-12-11 Only 15% of hiring managers would consider hiring an overweight woman]</ref>

=== Weight stigma leads to worse healthcare===
{{cquote|Doctors repeatedly advise weight loss for fat patients while recommending CAT scans, blood work or physical therapy for other, average weight patients.|||Joan Chrisler, PhD<ref>[https://www.apa.org/news/press/releases/2017/08/fat-shaming Fat Shaming in the Doctor's Office Can Be Mentally and Physically Harmful]</ref>}}

Stigmatization and shame often follow fat people into the doctor's office. Researchers have found that negative bias can lower the quality of healthcare provided to obese patients.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381543/ Impact of weight bias and stigma on quality of care and outcomes for patients with obesity]</ref> Physicians in one study reported they prefer to spend signficantly less time with obese patients.<ref name="hebl-nature">[https://www.nature.com/articles/0801681 Weighing the care: physicians' reactions to the size of a patient]</ref> They were also more likely to rate them poorly in 12 out of 13 categories, including perceptions of self-discipline and health consciousness.<ref name="hebl-nature" /> Another study found that physicians tend to build less rapport with obese patients and are less likely to offer them empathy or reassurance.<ref>[https://onlinelibrary.wiley.com/doi/full/10.1002/oby.20384 Physicians build less rapport with obese patients]</ref> Nurses can also hold negative attitudes towards heavier patients.<ref>[http://sciencenordic.com/nurses-biased-against-obese-patients Nurses biased against obese patients] - Science Nordic</ref> 

The issues arising from weight stigma in medicine are two-pronged. Patients may delay or avoid seeking care if they fear being judged, shamed, or dismissed, and doctors may misdiagnose or overlook symptoms if they focus inordinately on weight.<ref name="brewis" /><ref>[https://www.tandfonline.com/doi/abs/10.1080/21604851.2016.1213066?journalCode=ufts20 Sizeism is a health hazard]</ref><ref name="purcell">[https://longreads.com/2017/10/26/no-fatties-when-healthcare-hurts/ "No Fatties": When Health Care Hurts]</ref><ref>[https://www.cbc.ca/radio/thecurrent/the-current-for-august-1-2018-1.4769487/how-fat-shaming-from-doctors-is-leading-to-misdiagnoses-for-obese-patients-1.4769569 How 'fat shaming' from doctors is leading to misdiagnoses for obese patients]</ref><ref>[https://www.today.com/health/medical-weight-bias-causes-misdiagnosis-pain-depression-t153840 'It wasn't about my weight': How weight bias in medicine can lead to missed diagnosis and physical and mental pain]</ref> Beyond eroding the doctor-patient relationship, this can lead to serious medical conditions going undiagnosed, or not being caught until they are more severe and possibly untreatable.<ref name="purcell" /> A review of 300 autopsy reports found that obese patients were 1.65 times more likely to have previously undiagnosed serious medical conditions.<ref>[https://www.sciencedaily.com/releases/2017/08/170803092015.htm Fat shaming in the doctor's office can be mentally and physically harmful]</ref> Studies have consistently shown that obese women are less likely to be offered or seek screening for several cancers (breast, cervical, colorectal, and ovarian) and more likely to be diagnosed at a more advanced stage.<ref>[https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.23408 Obesity and screening for breast, cervical, and colorectal cancer in women]</ref><ref>[https://www.nature.com/articles/0803105?foxtrotcallback=true Barriers to routine gynecological cancer screening for White and African-American obese women]</ref><ref name="mullins">[https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.32451 Perceived discrimination, trust in physicians, and prolonged symptom duration before ovarian cancer diagnosis in the African American Cancer Epidemiology Study]</ref><ref name="erondu">[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900212/ The Association Between Body Mass Index and Presenting Symptoms in African American Women with Ovarian Cancer]</ref> This problem is compounded for women of color.<ref name="mullins" /><ref name="erondu" />

Poor-quality healthcare are particularly concerning in light of the US Preventative Services Task Force's recommendation that regular check-ups and extra support are ideal for patients seeking to lose weight.<ref>[https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/obesity-in-adults-interventions1 Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions] - US Preventive Services Task Force</ref>

==Issues==
===HAES doesn't address all health concerns===
[[File:Medical complications of obesity.png|thumb|right|165px|Diagram of obesity-related medical complications.]]
Research has shown that obesity is linked to a number of health issues.<ref>[https://www.niddk.nih.gov/health-information/weight-management/adult-overweight-obesity/health-risks Health Risks of Overweight & Obesity]</ref><ref>[https://www.sciencedirect.com/science/article/abs/pii/S0939475306001505 The link between abdominal obesity, metabolic syndrome and cardiovascular disease]</ref><ref>[https://www.cdc.gov/healthyweight/effects/index.html The Health Effects of Overweight and Obesity]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/10511607/ Body-mass index and mortality in a prospective cohort of U.S. adults]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/10546691/ The disease burden associated with overweight and obesity]</ref><ref>[https://serval.unil.ch/resource/serval:BIB_7AB5D2D95C6A.P001/REF.pdf Health correlates of overweight and obesity in adults aged 50 years and over: results from the Survey of Health, Ageing and Retirement in Europe (SHARE)]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/11434789/ Impact of overweight on the risk of developing common chronic diseases during a 10-year period]</ref> These include increased risks of cardiovascular disease, diabetes, musculoskeletal disorders (especially {{wpl|osteoarthritis}}), and certain [[cancer]]s.<ref name="who-factsheet">[https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight WHO obesity factsheet]</ref> Childhood obesity carries not only and an increased risk of obesity and its associated health problems in adulthood, but also presents additional risks including breathing difficulties, increased susceptibility to bone fractures, hypertension, and insulin resistance.<ref name="who-factsheet" /> 

While some research suggests that an HAES approach may yield better health outcomes than more traditional, diet-centered approaches,<ref name="tylka" /> it does not address all of the health risks associated with obesity. Some claims made by HAES advocates lack scientific evidence and veer toward [[denialism]]. In particular, some hardline HAES advocates consider ''any'' attempt to lose weight by restricting one's caloric intake to be a precursor to, or even a symptom of, [[anorexia]].<ref>http://i.imgur.com/0lvAG5r.jpg</ref> This suggests poor understanding of eating disorders. Anorexia involves a compulsive, overriding obsession with weight loss and food restriction, as well as distorted self-perception.<ref>[http://everydayfeminism.com/2013/04/five-differences-between-diets-and-anorexia/ Five Subtle Differences Between Diets and Anorexia]</ref> This is different from altering one's diet to cut down on or avoid less-healthy foods. Eating healthier food can have positive effects other than weight loss. Research has shown that purposely trying to lose weight, even if unsuccessful, can reduce mortality risk for overweight patients with diabetes.<ref>[https://care.diabetesjournals.org/content/27/3/657.abstract?ijkey=d9207ae2a896a0c29926a719d9f86dd676dc2647&keytype2=tf_ipsecsha Trying to Lose Weight, Losing Weight, and 9-Year Mortality in Overweight U.S. Adults With Diabetes] ''Diabetes Care''</ref>

Healthy habits are important regardless of size. Matheson et al. (2012) found that four healthy behaviors – not smoking, drinking moderately, exercising regularly, and eating at least five portions of fruit or vegetables per day – were associated with reduced mortality for all weight classes.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/22218619 Healthy lifestyle habits and mortality in overweight and obese individuals.] EM Matheson, DE King, CJ Everett, J Am Board Fam Med. 2012 Jan-Feb;25(1):9-15. doi: 10.3122/jabfm.2012.01.110164.</ref> However, another analysis has shown that flaws in methodology can dramatically understate the mortality risk of obesity.<ref>[https://pophealthmetrics.biomedcentral.com/articles/10.1186/1478-7954-12-6 Using maximum weight to redefine body mass index categories in studies of the mortality risks of obesity] ''Population Health Metrics''</ref> Obese people may be metabolically healthy, but precisely how many are is unclear, as a literature review found numbers ranging from 6% and 75%.<ref>[https://www.ncbi.nlm.nih.gov/pubmed/25040597/ The prevalence of metabolically healthy obesity: a systematic review and critical evaluation of the definitions used.]</ref> This wide range of results is due in part to differences in the definition of metabolically healthy obesity across studies.<ref>[https://pubmed.ncbi.nlm.nih.gov/30458177/ Metabolically healthy versus metabolically unhealthy obesity]</ref> Some studies categorize individuals with up to two components of metabolic syndrome as metabolically healthy,<ref>[https://pubmed.ncbi.nlm.nih.gov/31524630/ Metabolically healthy obesity: facts and fantasies]</ref> while a person is considered to have metabolic syndrome if they have at least three risk factors, one of which is obesity.<ref>[https://www.nhlbi.nih.gov/health-topics/metabolic-syndrome Metabolic Syndrome]</ref> People with a normal BMI with metabolic syndrome are also twice as likely to get diabetes than obese people with healthy blood metabolic indicators, but a higher BMI still increases the risk of diabetes ''regardless'' of metabolic indicators.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4731253/ Cardiometabolic Disease Risk in Metabolically Healthy and Unhealthy Obesity: Stability of Metabolic Health Status in Adults]</ref>

====Obesity paradox====
The {{wpl|obesity paradox}} is a medical [[hypothesis]] which posits that obesity, against conventional wisdom, may be associated with greater survival for certain diseases and/or groups of people. This paradox was first noted in 1999 when it was found that obese hemodialysis patients fared unexpectedly well.<ref>[https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1525-139X.2007.00349.x Cardiovascular And Survival Paradoxes In Dialysis Patients: Obesity-Survival Paradox — Still a Controversy?]</ref> It has since been observed in patients with other conditions, including heart failure,<ref>[https://escholarship.org/uc/item/3cs2f652 Reverse Epidemiology of Conventional Cardiovascular RiskFactors in Patients With Chronic Heart Failure]</ref> acute coronary syndrome,<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220102 The obesity paradox in acute coronary syndrome: a meta-analysis]</ref> and chronic obstructive pulmonary disease (COPD).<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3427325/ Body Mass Index and Mortality in Chronic Obstructive Pulmonary Disease: A Meta-Analysis]</ref> One meta-analysis found that "not only overweight but also obesity is protective" for elderly nursing home residents.<ref>[http://liu.diva-portal.org/smash/record.jsf?pid=diva2%3A855374&dswid=mainwindow Inverse relationship between body mass index and mortality in older nursing home residents: a meta-analysis of 19,538 elderly subjects]</ref> The cause or causes of this paradox are undetermined. Hong et al. (2011) have proposed that adipose tissue may store fat-soluble pollutant chemicals, thus locking away toxins that would otherwise harm the body.<ref>[https://www.nature.com/articles/ijo2011187 The association between obesity and mortality in the elderly differs by serum concentrations of persistent organic pollutants: a possible explanation for the obesity paradox]</ref>

The obesity paradox has drawn criticism. Studies that show that obesity reduces mortality rates for certain diseases may neglect to account for [[confounding factor]]s.<ref name="vox-belluz1">[https://www.vox.com/2015/3/25/8290261/obesity-paradox The author of a new obesity book says we shouldn't try to lose weight. She's wrong.], ''Vox''</ref> In a study reviewing 10 years of [[Centers for Disease Control and Prevention|CDC]] data, it was found that the obesity paradox disappeared once weight history was controlled for, i.e. by separating individuals in the normal weight category whose weight had remained stable from those who had previously been obese.<ref>[https://pophealthmetrics.biomedcentral.com/articles/10.1186/1478-7954-12-6 Using maximum weight to redefine body mass index categories in studies of the mortality risks of obesity]</ref><ref name="vox-belluz1" />

Potential conflicts of interest have also raised suspicions about whether the obesity paradox truly exists. It is strongly suspected that Coca-Cola is championing studies that promote the obesity paradox, has a relationship with cardiologist Carl Lavie who popularised the obesity paradox, and even more suspiciously, is funding researchers that promote the obesity paradox.<ref>[https://www.vox.com/2015/10/20/9572295/coca-cola-obesity-paradox The obesity paradox: Why Coke is promoting a theory that being fat won't hurt your health] by  Julia Belluz at ''Vox.''</ref>

==References==
{{reflist|2|80%}}

[[Category:Medicine]]
[[Category:Health care]]

Categories: Medicine, Health care