52 CLINICAL FOCUS
52 CLINICAL FOCUS
8 DECEMBER 2023 ausdoc . com . au
Therapy Update
Obesity through a different lens
Lifestyle
Dr Rosemary Atkinson is a GP who is accredited with the Strategic Centre for Obesity Professional Education , and is a practice principal at Noi Clinic , a multidisciplinary weight management centre in Crows Nest , Sydney , NSW .
Approaches that focus on health parameters , rather than size and weight outcomes , aim to improve healthcare engagement , health behaviours and psychological outcomes for people with obesity .
NEED TO KNOW
There is ongoing debate about the actions required in response to rising rates of obesity globally .
Weight loss can be achieved over the short term with significant caloric restriction and increased physical activity , however there is evidence that this weight loss is not sustainable for up to 80 % of individuals .
A movement called Health at Every Size ® ( HAES ®) has evolved in response to the perceived failure of traditional methods of obesity management . Proponents advocate for a focus on improving health for individuals regardless of size and without using weight as a marker of success or failure .
OBESITY is generally acknowledged to be a major global health issue with associated comorbidities that can affect quality of life and life expectancy . 1 , 2 Interventions have largely focused on weight loss , with most recommendations involving restrictive dietary changes and intensive exercise regimens . Evidence from long-term systematic reviews shows that , with such interventions , most individuals can successfully achieve weight loss over the short term . 3 However , weight loss from behavioural interventions tends to peak at six months , followed thereafter by gradual weight regain in most individuals . 4 , 5 Data on longterm maintenance of weight loss , defined as a loss of ≥10 % of total body weight loss maintained for ≥12 months , show that it generally only occurs in approximately 20 % of individuals . 6 , 7
The predisposition to gain weight after weight loss has a significant physiological component . 8 It has been well established that there are adaptations , called ‘ compensatory mechanisms ’, that are triggered by a decrease in body weight . These mechanisms include increased appetite via ghrelin , decreased satiety due to the decreased secretion of the postprandial hormones GLP-1 , total peptide YY and cholecystokinin and a reduction in total daily energy expenditure . 9 These mechanisms result in a drive to regain lost weight .
Despite what we know about the genetic and physiological factors which drive obesity , as well as weight regain after weight loss , individuals who live in larger bodies continue to suffer significant stigma and discrimination . There persists , even among some health professionals , the alarming and incorrect view that increased body weight reflects lack of willpower , self-control and laziness . 10 The belief that it is a simple process to lose and maintain weight remains widespread , despite all the evidence to the contrary .
In recent years , concerns have arisen about the narrow weight loss focus in management of overweight and obesity . Not only is it ineffective at producing thinner individuals , but it has not been successful in leading to improved health outcomes . 11 In
addition , it has become clear that there have been unintended adverse consequences such as poor self-image , shame , disengagement from the health system and disordered eating . 12
As a response there has been a growing transdisciplinary movement challenging the value of promoting weight loss and dieting behaviours . This movement — Health at Every Size ®, or HAES ® — proposes to shift the focus on improving health behaviours for individuals of all sizes without using weight as a marker of success or failure .
HAES ® principles
The principles of HAES ® have been established by the Association for Size Diversity and Health ( ASDAH ) in the US and include weight inclusivity , health enhancement , respectful care , eating for wellbeing and life-enhancing movement . The acronym HAES ®, and the approach , have also been trademarked to ensure that the term is used correctly . The principles are summarised in box 1 ( also see online resources ).
Many proponents of HAES ® question much of the evidence about the traditionally accepted harms of overweight and obesity . In particular , they challenge the belief that adiposity itself poses a significant risk with respect to morbidity and mortality ; that weight loss prolongs life ; that anyone with enough determination can lose weight and keep it off via lifestyle modification ;
There has been a growing transdisciplinary movement challenging the value of promoting weight loss and dieting behaviours .
that weight loss is a positive goal without its own risks ; that losing weight is the only way that overweight and obese individuals can improve their health ; and that obesity treatment and prevention can correct the economic burden of obesity . 13 At this stage , this is a more controversial aspect in the field of HAES ® practice .
Advantages of HAES ®
There are many advantages to the HAES ® approach . It helps individuals develop a positive body image , leading to improved mental health outcomes and reduced risk of disordered eating . 16 HAES ® advocates say , “ If shame were effective motivation , there wouldn ’ t be many fat people ”. 13 Clearly , body discontent is not the powerful motivating factor that it has traditionally been held up to be . Instead , it is now acknowledged that learning to value the body strengthens an individual ’ s ability to care for themselves and adopt positive health behaviours .
Randomised controlled trials have indicated that a HAES ® approach is associated with better health behaviours and psychological outcomes , with improvement in some physiological measures .
Medications and surgical approaches to manage obesity and metabolic sequelae , for which there is evidence for sustained weight loss and health improvements , add a layer of complexity to this debate .
The guidelines for the HAES ® principles are currently under review , with the aim of including evolving evidence and promoting inclusivity , by incorporating experiences of a more diverse range of people who have experienced ‘ fatphobia ’.
There is a propensity for the development of and the acceptance of disordered eating patterns in the pursuit of weight loss . 16 As a result , HAES ® has been embraced by many organisations involved in the management of eating disorders .
A significant issue with attempted interventions for weight has always been the lack of success in weight maintenance . The HAES ® approach has been demonstrated to result in sustained health improvements that are maintained over the long term . 17 The principles enable and encourage
Box 1 . HAES ® principles
• Weight inclusivity – Refers to the concept of acceptance and respect for the inherent diversity of body shapes and sizes
• Health enhancement – Refers to supporting health policies that improve and equalise access to information and services . It also applies to supporting personal practices that improve human wellbeing , including attention to individual physical , economic , social , spiritual , emotional and other needs
• Respectful care – Directs practitioners to acknowledge their own biases , and to work to end weight discrimination , weight stigma and weight bias
• Eating for wellbeing – Often referred to as ‘ intuitive eating ’. This involves following flexible , individualised eating based on hunger , satiety , nutritional needs and pleasure , rather than any externally regulated eating plan focused on weight control
• Life-enhancing movement – This refers to the support of physical activities that allow people of all sizes , abilities , and interests to engage in enjoyable movement