Literature Review HAES

Health and Nutrition Status of General Adult Population

Health at Every Size is defined as a way of life that celebrates body diversity. It honors

differences in size, age, race, ethnicity, gender, disability, sexual orientation, religion, class, and

other human attributes. valuing body knowledge and a person’s lived experiences. HAES

encourages finding the joy in moving one’s body and being physically active, eating in a flexible

and attuned manner that values pleasure and honors internal cues of hunger, satiety, and appetite,

all while respecting the social conditions that frame eating options.1 HAES encourages a non-diet

approach which involves not restricting one’s diet and instead focusing on personal hunger cues.

Health at Every Size is not endorsing unhealthy behaviors or saying that everyone is healthy at

every size. It is an individualized approach that encourages looking at our lives in totality when

determining if we are healthy or not.

This literature review aims to examine the current literature surrounding the HAES approach,

how it is already being used and the effectiveness of current health professional training tools.

Emerging research has shown that non-diet interventions have a longer lasting effect than their

weight loss focused counterparts and lead to a higher quality of life, increased body

satisfaction, and a reduction in binge eating behaviors.2 We want to create new HAES-focused

training tools for nutrition students, and future health professionals so they may learn how to

properly integrate and apply these concepts and gain experience practicing them.

Adolescents, including college-aged adolescents are at a high risk of developing disordered

eating patterns or engaging in risky dieting behavior.3, 4 While dietetic interns serving as

nutrition coaches will integrate this into the new nutrition coaching program, they will not be
providing nutrition education to anyone with an active eating disorder. However, a program goal

will always be to reduce the risk of doing harm.

Recent data from the CDC shows that more than 2/3rds of adults in the US are overweight or

obese. Obesity is a disease that is related to an increased risk of heart disease, stroke and Type 2

diabetes, all of which are some of the leading causes of preventable death.

College students are no exception to this statistic.5 According to a review 40-50% of

college students are physically inactive. 6 Studies have shown that a lack of physical activity can

contribute to chronic disease development. 7 College students are also at risk for higher rates of

chronic diseases, including high blood serum cholesterol and increased blood pressure 8 .

With new found freedom, busy schedules and often unlimited access to dining hall

offerings, many college students often do not have healthful eating at the back of their minds.9

Many students are unable to meet the recommended 5 fruits and vegetables every day with a

‘lack of time’ being listed as the number-one barrier.10 There is also a lack of dietary fiber

consumption along with increased saturated fat, sugar and sodium 11,12,13 In a survey of 212

college students it was found 33% of the participants skipped breakfast.14 These health comes are

all related to an increased risk of chronic disease in later life and are all outcomes that could be

improved using a HAES model.

Results from a study looking at the spread of the obesity epidemic in the US from 1991-1998

found that the prevalence of obesity was on a steady rise. The greatest magnitude of increase was

found in the following groups: 18- to 29-year-olds (7.1% to 12.1%) and those with some college

education (10.6% to 17.8%).15

A more recent survey in 2011 found that out of 2,500 college students approximately one-half of

men and more than one-quarter of women were overweight or obese.16 College students are often
an overlooked population however at this age of independence it is an important time for a

nutritional intervention since many students are now in a position to make decisions on their own

without the guidance of a parent or guardian.

Many food choices and preferences are developed at an early age, for emerging adults

and those entering college it is a chance to have freedom over food choices with no parent or

guardian to dictate what can or cannot be eaten. Many young adults skip meals, have decreased

physical activity and are not reaching the recommended amounts of fruits and vegetables each

day.17 When students are able to make their own food choices studies have shown that nutrition

has less relevance to them than other factors such as taste and cost.19

1. “Health At Every Size Community Resources – HAES Community Resources.” Health

At Every Size Community Resources, haescommunity.com/.

2. Gagnon-Girouard MP, Begin C, Provencher V M-P, , et al. Psychological Impact of a

Health at every size intervention on weight pre-occupied women. Journal of obesity.

2010;2010:928097. DOI: 10.1155/2010/928097

3. Grossbard JR, Neighbors C, Larimer ME. Perceived Norms for Thinness and Muscularity

among College Students: What Do Men and Women Really Want? Eating behaviors.

2011;12(3):192-199. doi:10.1016/j.eatbeh.2011.04.005.

4. National Eating Disorders Association. (2013). Eating disorders on the college campus:

A national survey of programs and resources. New York, NY: Author.

5. Centers for Disease Control and Prevention, Centers for Disease Control and Prevention,

29 Aug. 2017, www.cdc.gov/obesity/data/adult.html.

6 Keating XFD, Guan JM, Pinero JC, Bridges DM. A meta-analysis of college students’
physical activity behaviors. J Am Coll Heal. 2005;54(2):116–25. doi: 10.3200/JACH.54.2.116-

126.

7 Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the

evidence. CMAJ : Canadian Medical Association Journal. 2006;174(6):801-809.

doi:10.1503/cmaj.051351.

8 Sparling P.B., Snow T.K., Beavers B.D. Serum cholesterol levels in college students:

opportunities for education and intervention. J. Am. Coll. Heal. 1999;48(3):123–127.

9. Deshpande, S., Basil, M. D., & Basil, D. Z. (2009). Factors influencing healthy eating habits

among college students: An application of the health belief model. Health marketing quarterly,

26(2), 145-164.

10. Georgiou, C., Betts, N., Hoerr, S ., Keim , K., Peters, P.K., Stewart, B., Voichick, J.

(1997). Among young adults, college students and graduates practiced m o re healthful habits

and made more healthful food choices than did non- students. Journal of the American Diet etic

Association, 7, 754-759.

11. Anding, J. D. , Suminiski, R. R., Boss, L. (200 1). Dietary intake, bod y mass index,

exercise, and alcohol: are college women following the dietary guidelines? Journal of American

College Health, 49, 167-1

12. Hiza, H., and Gerrior, S. (2002). Using the interactive healthy eating index to assess the

quality of college students diets. Family Economics and Nutrition Review, 14, 3- 11.

13. Grace, T. W. (1997). Health problems of college students. Journal of American College

Health, 45, 243- 251.

14. Hertzler, A., Frary , R. ( 1 989). Food behavior of college students. Adolescence, 24, 349-

356
15 Mokdad, A. H., Serdula, M. K., Dietz, W. H., Bowman, B. A., Marks, J. S., & Koplan, J. P.

(1999). The spread of the obesity epidemic in the United States, 1991-1998. Jama, 282(16),

1519-1522.

16 Morrell, J. S., Lofgren, I. E., Burke, J. D., & Reilly, R. A. (2012). Metabolic syndrome,

obesity, and related risk factors among college men and women. Journal of American College

Health, 60(1), 82-89.

17 Deshpande, S., Basil, M. D., & Basil, D. Z. (2009). Factors influencing healthy eating

habits among college students: An application of the health belief model. Health marketing

quarterly, 26(2), 145-164.

18 Glanz, K., Basil, M., Maibach, E., Goldberg, J., & Snyder, D. A. N. (1998). Why

Americans eat what they do: taste, nutrition, cost, convenience, and weight control concerns as

influences on food consumption. Journal of the American Dietetic Association, 98(10), 1118-

1126.

Tools Used to Teach and Train Nutrition Professionals

When physicians and other providers lack the expertise and training to effectively address

nutrition, physical activity, and other lifestyle factors that are central to a prevention-oriented

approach to health care, patients suffer. Whether it be from unnecessary lost opportunities to

improve wellbeing, avoid illness, and take greater control of their own long-term health

outcomes. With adequate training and tools early intervention is possible.

 Nutrition training and building capacity goes beyond traditional education and

information. The ability to provide the necessary intellectual drive for nutrition research, policy,

and practice requires a broader knowledge base. Unfortunately, most of the material available for

nutrition and health professionals is limited to basic nutrition related to food and health. Access

to resources are needed to design and implement policies and interventions to improve nutrition

effectively. Training could be focused on professionals in nutrition and health and on basic

nutrition concepts. Nutritionists should also be trained to develop relevant programs and policies

and to influence the public, other health professionals, and policymakers. There is room for

growth in the body of literature needed and research growing. Research has supported a need for

improved nutrition education and physical activity training among health care professionals.

Some courses or material require registration with a fee, others provide little or no cost through

external funding.1 Some are designed as complete courses with a preselected number of accepted

participants and scheduled at definite times. Nearly all are offered online, with only a few

remaining as e-learning on CD-ROM or centralized computer.2

In the past, the capacity for the development for professionals in nutrition training and

education was heavily dependent on universities and colleges, leaving the scope and reach of

training materials relatively limited. The internet has made the revolutionary shift from paper

material and mandatory on-campus courses to an array of online resources and distance

learning.2 Online learning platforms enable users to benefit from a wide range of resources from

basic tools to highly complex learning materials. International capacity development, online

learning, and e-learning platforms can help mobilize efforts to move toward interprofessional

competencies. Tutors, demonstrators, researchers, academic faculties, and all forms of

professionals are constantly seeking up-to-date, structured and peer-reviewed materials.

 Access to reliable and effective nutrition training materials and education through a

virtual space and using new/existing technologies is essential in developing sustainable solutions

to nutritional challenges worldwide. Massive Open Online Courses (MOOCs) is a new

international competitor of universities with several advantages, such as low costs for providers

and students, wider access, and flexibility. In 2012, three large MOOC providers were launched

and ran by or associated with Harvard, Massachusetts Institute of Technology, and Stanford,

respectively. After only a year, these three providers alone have provided courses to more than

12 million students, a majority of whom are Americans, followed by Europeans. Approximately

half of these students are located in developing countries, mainly India and other Asian

countries, followed by Africa and Latin America. MOOCs present a potentially transformative

opportunity to provide educational opportunities in public health and nutrition for students who

are not enrolled in traditional education programs. A common pitfall with online learning courses

is that they require a tremendous amount of self-discipline and drive. The lack of in-class and

academic credit-driven accountability can lead to a lower percentage of students passing the

courses, high dropout rates, possible cheating on exams, and decrease in student-to-student

interactions. Additional challenges--especially for users in developing countries--include, a lack

of internet connectivity, as well as a gauge on meaningful learning assessment. More research is

needed for evaluating the effectiveness of MOOCs for providing public health education.2

In the early 1990s, the first distance education master’s degree was offered by the

University of Nebraska’s College of Human Resources and Consumer Sciences to provide

quality programming with limited campus resources. Deans from the peer land-grant institutions

in the central United States gathered to discuss how to collaborate. The primary focus was how

to structure distance education master’s degrees and post-baccalaureate certificates to offer an

even better learning opportunity for students with pooled resources. This meeting laid the

foundation for interinstitutional collaboration to deliver quality programs that would not be

possible otherwise due to inadequate resources from an individual institution.2

Furthermore, the skills and knowledge of applying accurate nutrition education at every

level of health care is imperative. Building the capacity of health care providers must include

basic training to effectively assess dietary intake and provide appropriate guidance, counseling,

and treatment to their patients.3 Provider training not only benefits the patient, but also the

patient’s family, community, and the health care system as a whole.4

1. Levy, M. D., Loy, L., & Zatz, L. Y. (2014). Policy approach to nutrition and physical

activity education in health care professional training. The American Journal of Clinical

Nutrition, 99(5 Suppl), 1194S–201S. https://doi.org/10.3945/ajcn.113.073544

2. Geissler, C., Amuna, P., Kattelmann, K. K., Zotor, F. B., & Donovan, S. M. (2016). The

eNutrition Academy: Supporting a New Generation of Nutritional Scientists around the

World. Advances in Nutrition: An International Review Journal, 7(1), 190–198.

https://doi.org/10.3945/an.115.010728

3. DiMaria-Ghalili, R. A., Mirtallo, J. M., Tobin, B. W., Hark, L., Van Horn, L., & Palmer,

C. A. (2014). Challenges and opportunities for nutrition education and training in the

health care professions: Intraprofessional and interprofessional call to action. American

Journal of Clinical Nutrition, 99(5). https://doi.org/10.3945/ajcn.113.073536

4. Center, B. P. (2014). Teaching nutrition and physical activity in medical school: training

doctors for prevention oriented care.

The Effects of Traditional Weight Centric Interventions

There have been many attempted interventions used to help people achieve weight loss

such as dieting, exercise, pharmaceutical drugs, weight loss surgeries, etc. This portion of the

literature review will present and assess various studies that have been conducted highlighting a

variety of weight loss interventions. The studies highlighted had long term, short term, and in

some cases both effects on participants.

Dorien PC Van Aggel-Leijssen conducted a 12 week study to assess the short term

effects of weight loss with or without low intensity exercise training on fat metabolism in obese

men. The study divided 40 men into 2 groups of diet and diet plus exercise. Both groups

followed an energy restrictive diet for 10 weeks during the study and the diet plus exercise group

also participated in a low intensity training program that began at the beginning of the energy

restrictive diet and continued 2 weeks after the participants stopped the energy restrictive diet,

for a total of 12 weeks.

The results of the study showed a significant amount of weight loss of 14.8 kg for the

dieting group and 15.2 kg for the diet plus exercise group but not a significant difference in

measurements among the 2 groups.1 The study also concluded that weight loss independent from

exercise training didn’t increase resting energy expenditures and the short term effects of the

study concluded that there was no significant difference in weight loss among the 2 groups

during the study, but physical activity during leisure time increased for the group who were

exclusively following the energy restrictive diet while participants in the diet plus exercise group

increased their sports activity during their leisure time. There was no follow up with participants

after the completion of the 2-week low intensity training program.

 Curioni and Lourenco conducted a review on the long term and sustainable effects of diet

and exercise for weight loss. Their review examined 33 trials that used exercise, diet, or exercise

and diet as a means to lead to weight loss. The trials examined ranged anywhere between 10 and

52 weeks long. Curioni and Lourenco concluded that trials that included both diet and exercise

yielded an increase of 20% in initial weight loss and a 20% increase in sustained weight loss

after 1 year. Regardless of the method of intervention (i.e. diet, exercise, or diet and exercise) the

participants had gained, within 1 year, almost half of the initial weight they had loss.2 Their

study concluded that lifestyle changes that included dieting (including any type of caloric

restriction) along with increased exercise leads to significant weight loss, but is only partially

sustained after 1 year of completing the study. This systematic review did not define what they

classified as “significant” amongst all of the studies. When conducting research or a systematic

review it is important to explain what the study deems as significant, so that it is easier for the

reader to compare data and draw conclusions. The review also recommended that future research

should be conducted to explore the best strategies for sustained and prolonged lifestyle changes

that lead to adequate caloric intake and increased physical activity.2

Ditschuneit, Flechtner-Mors, Johnson, and Adler conducted a study to assess the long- term

effect of a restrictive energy diet with 1-2 daily meal replacements on body weights and

biomarkers that are indicative of chronic diseases of 100 participants. During phase 1 of the

study (the first 3 months), the participants were split into 2 groups. One group followed an

energy restrictive diet where they ate their regular foods that provided them 1,242.831,505.74

kcals/day and the second group followed an isoenergetic diet (which is commonly used to

achieve weight loss) where 2 of their meals and 2 of their snacks were replaced daily by energy

controlled, vitamin, and mineral supplemented foods. Phase 2 of the study lasted for 2 years and
focused on weight maintenance by having all participants follow an energy restricted diet with 1

meal and 1 snack supplemented daily.

During phase 1 of the study group B loss 7.8% of their initial weight while group A loss

1.5% of their initial weight, this was a significant difference amongst the two groups. Although,

group B lost the most weight in comparison to group A during phase 1, both groups loss the

same amount of weight. The study also concluded that both groups significantly reduced

biomarkers such as blood pressure, plasma concentrations of triacylglycerol, glucose, and

insulin. The study concluded that the methods and strategies used promoted versatility and

healthy eating habits. The use of meal replacements improved long term weight management and

reduced biomarkers for disease. Although this may have been true for this study and this

population, it is unclear whether this positive trend would continue if meal replacements were

removed from the diet after the conclusion of the study. It is also unclear whether the participants

regained some or all of the weight they lost.

Roon, Gemerta, Peeters, Schuit, and Monninkhof conducted a 16 week trial to assess the

long term effects of a weight loss intervention program with or without an exercise component in

the program. The study concluded that while the participants with an exercise component

program was more physically active one year after the program had ended there were no

significant differences in weight loss maintenance one year after the program in comparison with

the group that was following a calorie restrictive diet alone.4 The study concluded that

participation in the study led to sustained weight loss one year after completing the program due

to participant lifestyle changes independent of whether they were in the dieting or exercise

group.
 1. Aggel-Leijssen D, Saris W, Hul G, Baak M. Short-term effects of weight loss with or

without low-intensity exercise training on fat metabolism in obese men. The American

Journal of Clinical Nutrition, http://ajcn.nutrition.org/content/73/3/523.[MH1]

2. Curioni C, Lourenco P. Long-term weight loss after diet and exercise: a systematic

review. Nature.com. https://www.nature.com/articles/0803015.

3. Ditschuneit H, Flechtner-Mors M, Johnson T, Adler G. Metabolic and weight-loss effects

of a long-term dietary intervention in obese patients. The American Journal of Clinical

Nutrition. http://ajcn.nutrition.org/content/69/2/198.

4. de Roon M, van Gemert W, Peeters P, Schuit A, Monninkhof E. Long-term effects of a

weight loss intervention with or without exercise component in postmenopausal women:

A randomized trial. Science Direct.

www.sciencedirect.com/science/article/pii/S2211335516301607.

HAES vs Non-Diet Approach

One of the weight-inclusive approaches includes the Intuitive Eating Model, focuses on

eating nutritious foods when hungry, eating until full, and engaging in pleasurable movement.

With greater internal awareness and appreciation of the body, there is an increase in eating

associated with physiological hunger and satiety cues and a decrease situational and emotional

eating. As for public health messages, Penney and Kirk state that the public finds messages free

of weight focus more acceptable as they are more likely to encourage healthy behaviors than

messages emphasizing weight control or obesity prevention. Key stakeholders were interviewed

and researchers found that the policy change that earned the most supportive rating was adopting
language that did not mention weight in public health messages, according to OReilly and

Sixsmith.5

Weight loss through dieting is not sustainable for the many of higher-weight individuals

over a long period of time (5+ years) and is related to many harmful consequences, such as

weight regain and weight cycling. In conclusion, Tylka et al believe that prescribing weight loss

to patients and communities as a pathway to health is unethical.5

Penney and Kirk examined a recent Framing Health Matters article in the American

Journal of Public Health with the purpose of understanding Health at Every Size (HAES) within

the context of public health approaches to obesity, and to demonstrate strengths and limitations

of the available evidence. They concluded that although it makes sense to move away from a

weight-centric approach, HAES could create increased social and political challenges in its hope

to remove weight entirely from the discussion. In addition, it is unclear if the HAES approach

solely can reduce weight stigma and bias, without extensive efforts to change social norms and

attitudes, at a population level.4

This review assesses two methods of working in patient care and public health. These

two methods are the weight-inclusive approach and weight-normative approach. The weight-

inclusive approach is defined as emphasis on viewing health and well-being as multifaceted

while directing efforts toward improving health access and reducing weight stigma. The weight-

normative approach is described as an emphasis on weight and weight loss when defining health

and well-being. Weight management is a component of the medical model in the United States

and central to care procedures in the prevention and treatment of multiple health problems in the

United States. Data supports that the weight-inclusive approach (such as Health at Every Size)

improves physical, behavioral, and psychological indices. It also has shown to improve the
acceptability of public health messages. In comparison, the weight-normative approach has been

shown by data to be ineffective for most people because of high rates of weight regain and

cycling from weight loss interventions. These are linked to adverse health effects and well-being.

The focus on weight loss could also promote stigma in healthcare and society, and this stigma is

likewise linked to adverse health and well-being. Research that has been conducted over the past

25 years has repeatedly shown that weight cycling is linked to negative physical health and

psychological well-being. Society’s focus on achieving a “healthy” weight proposes there is a

normal or healthy weight that everyone should aim to maintain and attain. This is often defined

as achieving or maintaining a BMI between 18-25. Research has indicated that pursuing a body

ideal is often connected to increased body shame, body dissatisfaction, and risk of disordered

eating.4

The Academy of Nutrition and Dietetics states that in order to successfully treat

overweight and obesity in adults, the treatment requires adoption and maintenance of lifestyle

behaviors contributing to both dietary intake and physical activity. A 3-5% weight loss that is

maintained for 1 year or more has been shown to generate clinically relevant health

improvements. For adults who are overweight and obese, a larger weight loss decreases further

risk factors of cardiovascular disease (CVD) and reduces the requirement for medication to

manage CVD and type 2 diabetes. Long-term weight loss maintenance is a challenge in obesity

treatment, but it is possible. To obtain a weight reduction that can be sustained over time and

better cardiometabolic health, changes in lifestyle behaviors that contribute to both sides of

energy balance in adults is the ideal obesity treatment.1

Poor long-term weight loss maintenance increases the need for effective and sustainable

intervention strategies to maintain weight loss. The purpose of the study, “Daily self-monitoring
of body weight, step count, fruit/vegetable intake, and water consumption” was to determine the

feasibility and effectiveness of weight-loss maintenance intervention for older adults, using daily

self-weighing, step count, fruits and vegetable intake, and water consumption. The findings from

this study suggest that practitioners can suggest a self-monitoring approach (daily self-weighing,

physical activity, fruits and vegetable consumption) as an effective weight-loss maintenance

approach.2

Many may believe that the main challenge of obesity treatment is weight loss, but it is

actually long-term weight loss maintenance. Various studies demonstrate that a healthy weight

loss of 5-10% can be achieved through behavioral and pharmacological treatments. According to

Montesi et al, a 5-10% weight loss is the amount that significantly decreases the risk of

developing type 2 diabetes and eradicates the majority of the other risks associated with obesity.

Additionally, this moderate weight loss improves psychological functioning, particularly mood,

body image, and binge eating.3 However, studies such as “What predicts weight regain in a

group of successful weight losers?” by McGuire et al, show weight is slowly regained by the

majority of study participants. In the National Weight Control Registry (NWCR) analysis, with

2,886 participants, members reported an average weight loss of 33 kg (72.6 lbs) and weight loss

was maintained in 87% of the participants for more than 5 years. Members who were able to

keep a stable weight in the long term adopted these main strategies: 1) high levels of physical

activity (~1 hour/day), 2) eating a low-calorie diet, low-fat diet, 3) eating breakfast regularly, 4)

self-monitoring weight, and 5) maintaining a consistent eating pattern across weekdays and

weekends. In multiple studies, they have shown that the extended care approach, with in person

or via telephone or Internet with health care providers, monthly or more frequent contacts, can
improve the success of weight loss and reduce the risk of gaining back weight during the 12-

month maintenance phase. The NWCR, Treatment of Obesity in Underserved Rural Settings

(TOURS), and other recent studies have indicated that many individuals are capable of

maintaining acceptable weight loss targets in the long-term, defined as 1 year, and by the

promising results achieved by the new-generation lifestyle modification programs, such as

extended care approach via telephone or in person, ~1 hour of physical activity each day,

consuming breakfast daily, and more.3

1. Raynor, H.A, Champagne, C.M. (2016). Position of the academy of nutrition and

dietetics: interventions for the treatment of overweight and obesity in adults. Journal of

the Academy of Nutrition and Dietetics, 116(1), 129-147.

http://dx.doi.org/10.1016/j.jand.2015.10.031

2. Akers, J.D., Cornett, R.A., Savla, J.S., Davy, K.P., Davy, B.M. (2012). Daily self-

monitoring of body weight, step count, fruit/vegetable intake, and water consumption: a

feasible and effective long-term weight loss maintenance approach. Journal of the

Academy of Nutrition and Dietetics, 112(5), 685-692.e2.

http://dx.doi.org/10.1016/j.jand.2012.01.022

3. Montesi, L., Ghoch, M.E., Brodosi, L., Calugi, S., Marchesini, G., Grave, R.D. (2016).

Long-term weight loss maintenance for obesity: a multidisciplinary approach. Diabetes,

Metabolic Syndrome and Obesity: Targets and Therapy, 6, 37-46.

https://doi.org/10.2147/DMSO.S89836

4. Penney, T.L., Kirk, S.F.L. (2015). The health at every size paradigm and obesity: missing

empirical evidence may help push the reframing obesity debate forward. American
 Journal of Public Health, 105(5), e38-e42.

http://ajph.aphapublications.org/doi/10.2105/AJPH.2015.302552

5. Tylka, T.L., Annunziato, R.A., Burgard, D., Danielsdottir, S., Shuman, E., Davis, C.,

Calogero, R.M. (2014). The weight-inclusive versus weight-normative approach to

health: evaluating the evidence for prioritizing well-being over weight loss. Journal of

Obesity, 2014, 1-18. http://dx.doi.org/10.1155/2014/983495

The Effects of HAES vs Non-Diet Approach

As we have discussed throughout the course of this literature review, research has shown

that there are different ways of approaching the non-diet approach and HAES movement.

Different interventions and approaches over the years have led to different short and long-term

effects shown in the research. In this portion of the literature review, we reflect on a variety of

interventions that have been studied and their short and long-term effects. As mentioned, when

interventions are focused on HAES or are weight-inclusive, weight and BMI are not measured as

outcomes in a study; Weight loss is not seen as a goal in non-diet interventions. Throughout the

research, it has been found that adults with greater weight satisfaction report a more positive

change in health behaviors and have a better health status.1 This is why HAES and the non-diet

approach to counseling could be more beneficial to clients versus the typical weight centric

dieting approach.

The goal of some interventions in the field of dietetics is maintenance, and being able to

see long term effects from the study conducted. The person designing the study should be using

interventions that the patient should be able to maintain. One of the reason why so many diets

fail, and their outcomes are not maintainable, is because the diet is unrealistic (cutting calories,
fat, carbohydrates drastically). Mentioned above in section 3 of literature review is a study

conducted by Curioni and Lourenco. This study is a good example to again show that a

consistent plan of dieting and exercise may not work for everyone. In fact, the study showed that

overall the participants had gained weight. By using a non-diet approach, and focusing on health

habits instead, there is a noticeable absence of food rules which has shown short and long term

benefits to health outcomes.

Alberts, Thewissen, and Raes conducted a study using 26 women with a history of

disordered eating. This study split the women randomly into 2 different groups: One of the

groups included an 8-week mindfulness non-diet approach-based eating intervention, and the

other was a control group whom received nothing and though they were on a “waiting list”. Data

was collected before and after the 8-week intervention. Of the 26 women, the participants that

were in the mindfulness intervention showed a greater decrease in food cravings, body image

concern, and emotional eating.2 The HAES intervention aims to focus on a healthy lifestyle by

promoting sustainable behavioral changes such as accepting and loving your body, being aware

of its hunger cues and surroundings when eating. This study suggests that there can be both

positive short and long term related health outcomes to using other methods of counseling shown

patients who have a concern with their body weight or image. Decreasing food cravings, body

image concern and emotional eating patterns are all proper outcomes of the non-diet centered

approach, and help to focus on a healthy lifestyle disregarding diet.

Although intuitive eating is a non-diet approach, HAES counseling has been shown to

increase intuitive eating scores when tested, and improve overall diet quality. The intuitive eating

score is important to show on a scale how in tune the client is with their eating habits at the

beginning of intervention. This can then be measured at the end to see if there was improvement.
A study done out of Quebec, Canada at the Center for Health and Human Services in 2017

involved 216 women who took part in HAES counseling. 110 other women who were the control

group, no counseling and thought to be weight listed, were additionally part of the study3. The

216 women who participated in the HAES program increased their intuitive eating scores

significantly, and also significantly improved their diet quality. It has been noted that these

changes in diet quality are significant and could lead to better health outcomes in the future with

more long-term goal setting3.

When it comes to long-term health outcomes, a follow up study was done 1 year out from

the original study, done on HAES and behavioral eating, to see if these interventions were

sustainable. The follow up study shows that susceptibility to hunger decreased over time as well

as improper dieting behaviors, or disordered eating behaviors, resulting from mindful eating and

non-diet interventions. The results from this study suggest that the HAES approach may have

beneficial long-term effects on eating behaviors when it comes to hunger cues and disinhibition,

less apt to not listen to cues.4 Listening to your body and its hunger cues may be sustainable for

several years to follow versus a restrictive diet.

It should be noted that research has been limited on how long these outcomes have been

sustainable for. The time range for the term “long-term” is unclear within the research. When

does a short-term outcome becomes a long-term outcome has also been unclear. Research has

been limited on interventions involving males.

1. Blake, C. E., Hébert, J. R., Lee, D. C., Adams, S. A., Steck, S. E., Sui, X., ... & Blair, S.

N. (2013). Adults with greater weight satisfaction report more positive health behaviors

and have better health status regardless of BMI. Journal of obesity, 2013.

2. Alberts, H. J., Thewissen, R., & Raes, L. (2012). Dealing with problematic eating

behaviour. The effects of a mindfulness-based intervention on eating behaviour, food

cravings, dichotomous thinking and body image concern. Appetite, 58(3), 847-851.

3. Carbonneau, E., Bégin, C., Lemieux, S., Mongeau, L., Paquette, M. C., Turcotte, M., ...

& Provencher, V. (2017). A Health at Every Size intervention improves intuitive eating

and diet quality in Canadian women. Clinical Nutrition, 36(3), 747-754.

4. Provencher, V., Bégin, C., Tremblay, A., Mongeau, L., Corneau, L., Dodin, S., ... &

Lemieux, S. (2009). Health-at-every-size and eating behaviors: 1-year follow-up results

of a size acceptance intervention. Journal of the American Dietetic Association, 109(11),

1854-1861.