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Size Acceptance and Intuitive Eating Improve Health for Obese, Female Chronic Dieters LINDA BACON, Phd; JUDITH S

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Size Acceptance and Intuitive Eating Improve Health for Obese, Female Chronic Dieters LINDA BACON, Phd; JUDITH S RESEARCH Current Research Size Acceptance and Intuitive Eating Improve Health for Obese, Female Chronic Dieters LINDA BACON, PhD; JUDITH S. STERN, ScD; MARTA D. VAN LOAN, PhD; NANCY L. KEIM, PhD come variables, and sustained improvements. Diet group ABSTRACT participants lost weight and showed initial improvement in Objective Examine a model that encourages health at ev- many variables at 1 year; weight was regained and little ery size as opposed to weight loss. The health at every improvement was sustained. size concept supports homeostatic regulation and eating Conclusions The health at every size approach enabled intuitively (ie, in response to internal cues of hunger, participants to maintain long-term behavior change; the satiety, and appetite). diet approach did not. Encouraging size acceptance, re- Design Six-month, randomized clinical trial; 2-year follow- duction in dieting behavior, and heightened awareness up. and response to body signals resulted in improved health Subjects White, obese, female chronic dieters, aged 30 to ϭ risk indicators for obese women. 45 years (N 78). J Am Diet Assoc. 2005;105:929-936. Setting Free-living, general community. Interventions Six months of weekly group intervention (health at every size program or diet program), followed oncern regarding obesity continues to mount among by 6 months of monthly aftercare group support. government officials, health professionals, and the Main outcome measures Anthropometry (weight, body mass Cgeneral public. Obesity is associated with physical index), metabolic fitness (blood pressure, blood lipids), en- health problems, and this fact is cited as the primary ergy expenditure, eating behavior (restraint, eating disor- reason for the public health recommendations encourag- der pathology), and psychology (self-esteem, depression, ing weight loss (1). That dieting and weight loss are body image). Attrition, attendance, and participant evalua- critical to improving one’s health is reinforced by a social tions of treatment helpfulness were also monitored. context that exerts enormous pressure on women to con- Statistical analysis performed Analysis of variance. form to a thin ideal. Public attention to weight and its Results Cognitive restraint decreased in the health at every associated comorbidities continues to increase, and diet- size group and increased in the diet group, indicating that ing is now firmly ensconced in our cultural identity. The both groups implemented their programs. Attrition (6 majority of US women are now dieting: 57% stated in a months) was high in the diet group (41%), compared with national telephone survey that they are currently engag- 8% in the health at every size group. Fifty percent of both ing in weight-control behaviors (2). groups returned for 2-year evaluation. Health at every size Despite heightened attentiveness to obesity and the in- group members maintained weight, improved in all out- crease in dieting behavior (3), the incidence of obesity con- tinues to rise (4). There are little data showing improved long-term success for the majority of those engaged in L. Bacon is an associate nutritionist with the Agricul- weight-loss behaviors (5). Some have challenged the ability tural Experiment Station, University of California, of diet programs to either achieve lasting weight loss or to Davis, and a nutrition professor with the Biology De- improve health, and question the ethics and value of en- partment, City College of San Francisco, San Francisco, couraging dieting as an obesity intervention (5-9). Others CA. J. S. Stern is a distinguished professor with the De- challenge the primacy of weight loss in addressing the as- partment of Nutrition and the Division of Endocrinol- sociated health risks, regardless of method (10-12). They ogy, Clinical Nutrition and Cardiovascular Medicine in suggest that while the epidemiologic research clearly indi- the Department of Internal Medicine, University of Cali- cates an association between obesity and health risk, the fornia, Davis. M. D. Van Loan is a research physiolo- risks of obesity may be overstated, and the association gist, and N. L. Keim is a research chemist with the US largely results from a sedentary lifestyle, poor nutrition, Department of Agriculture, Agricultural Research Ser- weight cycling, and/or other lifestyle habits, as opposed to vice, Western Human Nutrition Research Center, Davis, solely reflecting adiposity itself. CA. Critics of the diet to improve health model suggest a Address correspondence to: Linda Bacon, PhD, Box paradigm shift in treating weight-related concerns. They S-80, Biology Department, City College of San Fran- recommend focusing on health behavior change as op- cisco, 50 Phelan Ave, San Francisco, CA 94112. E-mail: posed to a primary focus on weight loss (6,13,14). Their [email protected] approach is supported by increasing evidence that dis- Copyright © 2005 by the American Dietetic eases associated with obesity can be reversed or mini- Association. mized through lifestyle change, even in the absence of 0002-8223/05/10506-0001$30.00/0 weight change, and that people can improve their health doi: 10.1016/j.jada.2005.03.011 while remaining obese (5,10,12,15). © 2005 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 929 Diet Group ● Accepting and respecting the diversity of body shapes and sizes. The focus of the diet group was similar to most behavior- ● Recognizing that health and well-being are multidimensional based weight-loss programs: eating behaviors and atti- and that they include physical, social, spiritual, occupational, tudes, nutrition, social support, and exercise. Partici- emotional, and intellectual aspects. pants were taught to moderately restrict their energy and ● Promoting eating in a manner which balances individual fat intake, and to reinforce their diets by maintaining nutritional needs, hunger, satiety, appetite, and pleasure. food diaries and monitoring their weight. Exercise at an ● Promoting individually appropriate, enjoyable, life-enhancing intensity within the training heart range delineated in physical activity, rather than exercise that is focused on a goal the American College of Sports Medicine/Centers for Dis- of weight loss. ease Control and Prevention guidelines was encouraged. ● Promoting all aspects of health and well-being for people of all Material was presented on topics including how to count sizes. fat grams and exchanges, understanding food labels, shopping for food, the benefits of exercise, and behavior Figure 1. Basic guiding principles of the health at every size program. strategies for success. The program was taught by an As drafted by the Association for Size Diversity and Health (30). experienced registered dietitian and reinforced using the LEARN Program for Weight Control manual (20). An alternative obesity treatment model teaches people Health at Every Size Group to support homeostatic regulation and eating intuitively There were five aspects to the health at every size treat- (ie, in response to internal cues of hunger, satiety, and ment program: body acceptance, eating behavior, nutrition, appetite) instead of cognitively controlling food intake activity, and social support. The initial focus was on enhanc- through dieting (16). An essential component of some ing body acceptance and self-acceptance, and participants intuitive eating programs is to encourage health at every were supported in leading as full a life as possible, regard- size (Figure 1) rather than weight loss as a necessary less of BMI. The goal was to first help participants disen- precondition to improved health. tangle feelings of self-worth from their weight. The eating This study was undertaken to examine the effectiveness behavior component supported participants in letting go of of a health at every size approach in improving health. [In a restrictive eating behaviors and replacing them with inter- previous report (17), we referred to this as a nondiet inter- nally regulated eating. Participants were educated in tech- vention. This has since been changed to “health at every niques that allowed them to become more sensitized to size” to reflect the changing terminology in the field.] Met- internal cues and to decrease their vulnerability to external abolic fitness (blood pressure and blood lipid levels), energy cues. The nutrition component educated participants about expenditure, eating behavior (restraint and eating disorder standard nutrition information and the effects of food pathology), and psychology (self-esteem, depression, and choices on well-being, and supported them in tempering body image) were evaluated. their food choices with foods that honored good health (in addition to their taste preferences). The activity component helped participants identify and transform barriers to be- METHODS coming active (eg, attitudes toward their bodies) and to find Procedure activity habits that allowed them to enjoy their bodies. The Applicants were recruited from the Davis, CA area, and support group element was designed to help participants those meeting the following inclusion criteria were enrolled: see their common experiences in a culture that devalues white; female; aged 30 to 45 years; body mass index (BMI) large women, and to gain support and learn strategies for Ն30; nonsmoker; not pregnant or lactating; Restraint Scale asserting themselves and effecting change. The program (18) score Ͼ15 (indicating a history of chronic dieting); and was facilitated by a counselor who had conducted
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