The Bigger Picture

A Paradigm Shift Around Weight is Occurring in Our Field

Judith Matz

Q: I’ve seen increasing references to the Health at Every Size (HAES) approach to treating eating and body-image issues. That’s not my clinical specialty, but is this framework relevant to my work?

A: When I look back on my 35 years of practice, I recognize important, overarching paradigm shifts that have changed the way we work with clients. Becoming trauma informed, even if we don’t specialize in trauma, and no longer pathologizing people who identify as LGBTQ, are just two examples that come to mind.

Similarly, a paradigm shift around weight and wellness is occurring in our field with the Health at Every Size (HAES) framework. Societal norms regarding weight, health, and eating affect every client we work with, regardless of body size. We’re inundated every day with messages from family, friends, colleagues, media, and even doctors and mental health professionals that prioritize weight over well-being; promise health, happiness, and success to those who can conform to a certain ideal; pressure people to pursue thinness and fear fat at all costs; presume that people have control over what they weigh; pose as health promoting, even as they harm; and promote fat shaming and weight stigma. We call these negative messages the six P’s of diet culture.

While therapists often support the pursuit of weight loss as an act of self-care, overwhelming evidence indicates that dieting almost always leads to negative physical and emotional consequences. By becoming HAES informed, you can support people of all sizes when it comes to respecting and taking care of their bodies without inadvertently causing harm.

A Movement Is Born

In the early 2000s, many of us who reached the same conclusions about weight and well-being came together to figure out how to combat these societal pressures. We knew that the vast majority of people who diet gain the weight back, and that the human body adapts to these periods of deprivation by raising its set point and becoming heavier over time. We witnessed the universal feelings of shame induced by diet failure and the toll it took on people from all walks of life.

We also observed, or experienced ourselves, that while many people practiced positive self-care related to food and other areas of their lives, they didn’t necessarily lose weight. Given the lack of evidence to show that weight loss can be sustained over a two- to five-year period, and research showing that weight cycling actually leads to poorer health outcomes, was it reasonable, fair, or even ethical to demand that people diet to fit society’s standards?

At its core, HAES is a weight-inclusive philosophy, which seeks respectful treatment for people of all sizes, offering a path for wellness beyond weight. It focuses on teaching people to eat in accordance with hunger and satiety cues that are in line with the body’s natural needs, rather than the rigid prescriptions of a diet. It also encourages physical activity for pleasure and health benefits, rather than the pursuit of weight loss. But beyond individual behaviors, it helps people understand broader social-justice issues related to body size, including weight bias, stigma, bullying, and discrimination.

HAES-Informed Therapy in Action

Anita came to me after terminating with her previous therapist, whom she’d been seeing for help with her anxiety. Over the course of their work, she’d revealed her struggle with overeating and her goal of losing weight. In response, he’d suggested that she cut out high-fat foods, such as butter, and stop bringing them into her home. Fine, Anita thought, I’ll do that. But over time, her bingeing increased, her therapist grew disappointed, and she contacted me to figure out what to do next. This is a typical scenario, where therapists, with the best of intentions, reinforce unhelpful beliefs about eating and weight that are woven into diet culture and almost always backfire.

Instead, as a HAES-informed therapist, I helped Anita develop the ability to eat when hungry, tune into what she was hungry for, given a wide variety of foods to choose from, and stop when satisfied. Through mindfulness techniques and building her support network, she learned to manage her anxiety better without reaching for food. She started swimming regularly and wearing clothes that made her feel attractive and comfortable. As she practiced and sustained these positive, healthful behaviors, her weight stabilized. And as we talked about the ways she’d internalized weight stigma, she became increasingly more accepting of her larger body.


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The trouble for Anita was that outside of our sessions, she was bombarded with cultural messages indicating her size was a problem. At family dinners, relatives talked about their latest fad diets and urged her to try them. When Anita went out with friends, they bemoaned their own body sizes, even though they were smaller than her. Even Anita’s doctor confused her by suggesting it would be a good idea to lose weight, despite her excellent cholesterol, blood-pressure, and blood-sugar readings. Like many clients, she found herself in a bind: to shed pounds, she’d have to under-eat or over-exercise—behaviors she knew were considered unhealthy in eating disordered clients.

Together, Anita and I brainstormed strategies that would help her manage the weight stigma she was encountering. When family and friends started talking diets, she redirected the conversation to topics like travel and work. She also found the courage to give her doctor an article about the HAES approach. Whether it’s in our clinical work or personal lives, a HAES lens means that we no longer send messages that weight loss trumps well-being.

In this sense, it’s critical to support clients in advocating for themselves so they can meet their needs and live fully in the world. Heidi was a higher-weight woman in recovery from binge eating disorder, whose body size exacerbated her knee problems. From a HAES perspective, I helped her role-play how she’d approach the new orthopedic doctor she’d be visiting the following week.

“You can see I’m fat,” she began, “I know my weight may affect my knees, and I know that you see people with knee problems who aren’t fat. My weight may not change, so I want to be given the same treatment you’d give them.” While the doctor did tell her that some weight loss might help, he didn’t demand it, shame her, or withhold treatment. Instead, he offered alternative interventions that helped her walk with much less pain. She was thrilled to be able to follow through with plans to visit her relatives and hike some beautiful nearby trails. She felt so empowered that she signed up for a yoga teacher training and now plans to offer plus-size yoga to give higher-weight people a safe place to practice.

The Bigger Picture

With greater understanding in recent years about different types of privileged statuses and systemic structures that unfairly affect people in marginalized groups, the HAES framework continues to evolve in its efforts to heighten awareness of the role that bias and oppression play in a person’s health. Data shows that a person’s zip code, for example, is more predictive of their health than BMI.

Paradigm shifts are difficult. They require us to look deeply at our own attitudes, biases, and values—and how they match up with the research and our clients’ lived experiences. Of course, we all know someone who lost weight and kept it off, but we need to recognize that this is the exception, rather than the norm.

Hopefully, we can all agree that respecting people of all body sizes and ending fat shaming is good for everyone. If clients share that they come from a HAES perspective, we can support them without thinking they’re giving up and not taking care of themselves, and without judging character based on body size.

Imagine a world where people of all body shapes and sizes felt respected and free to take care of their physical and emotional needs without a weight requirement. As Maya Angleou wrote, “Do the best you can until you know better. Then when you know better, do better.”


Judith Matz, LCSW, is coauthor of Beyond a Shadow of a Diet: The Comprehensive Guide to Treating Binge Eating Disorder, Compulsive Eating, and Emotional Overeating and The Diet Survivor’s Handbook: 60 Lessons in Eating, Acceptance and Self-Care. She’s a speaker and trainer with a private practice in Skokie, IL.

This blog is excerpted from "Health Comes in All Sizes," by Judith Matz. The full version is available in the November/December 2018 issue, A New Generation of Clients: Is Therapy Keeping Pace?

Photo © Juanmonino/iStock

Topic: Anxiety/Depression | Cultural, Social & Racial Issues | Professional Development

Tags: binge eating | body | body weight | Cultural values | Cultural, Social & Racial Issues | culture | diet | Diet & Nutrition | dieting | diets | eating | eating disorder | eating disorders | HAES | happiness | healthy eating | Judith Matz | lose weight | overeating | overweight | overweight clients | self-care | Weight control | weight loss

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Wednesday, December 5, 2018 4:03:25 PM | posted by Elaine Brown
As a person who’s always been interested in the interaction between culture, health, and body image, I greatly appreciate this article. It is heartening to learn about the HAES approach. Thank you!

Saturday, December 1, 2018 2:26:23 PM | posted by Rhonda
While I am aware that many people have issues with emotional eating, I'd like to share my experience. I am a health care provider who has taken several nutrition classes and counseled people on nutrition as part of my work. Yet I couldn't maintain a normal weight myself, doing the typical yo-yo process of trying the latest diet, losing, and then regaining more. I did try to eat well, according to my educated understanding of what that was. But I finally came to realize that to get to, and maintain, a normal weight, I'd have to be starving the rest of my life, which was simply untenable. Then the day came that I couldn't get up off the ground when I was gardening because of my worsening painful knees, and I thought I'd have to stop gardening--something I enjoy very much. Even worse, I saw myself following in the footsteps of my mother who was riddled with painful arthritis in her knees and couldn't even walk any more. So I did some research and discovered the ketogenic diet. I decided to give it a try. The first week, I couldn't believe all the delicious fatty food I could eat and thought there's no way I was losing any weight. But after one week, I had lost 7 pounds! I couldn't believe it. The weight fell off--about 90 pounds. After I had lost all the weight I wanted to lose, I actually couldn't stop losing--a problem I never thought I'd have in this lifetime! I gradually started adding in small amounts of complex carbs, until I stopped losing and was able to maintain. Now my knees never hurt, and I am able to get on the ground to garden and spring back up with no difficulty. I realized that I am extremely sensitive to refined carbs, which jack up my blood sugar and cause a vehement insulin response, which leaves me starving, even if I've just eaten. Cutting out refined carbs and eating delicious good fats stopped this and resulted in a stable blood sugar at all times, so I was no longer starving but felt blessedly satiated. The advice your client Anita was given to get fats out of her house was probably the exact wrong advice for her, as it was for me. Sure she probably binged to self-medicate her anxiety, but eating low-fat no doubt left her hungry all the time which also lead to a binge, as it did for me--prolonged hunger can make one feel crazy! Add to this the fact that we live in a culture where sugar is in almost everything. I can't eat at least 80% of what is in commercial grocery stores. So eating this way requires some knowledge of nutrition, the ability to read labels, a new way of cooking, and a new way of food shopping. It is very difficult to drop out of the conventional way of eating. Many nutritionists advise against the ketogenic diet because they see it as another fad diet that eliminates an entire food group (carbs) which they think is extreme and unsustainable in the long run. We tried eliminating fat on the advice of the American Heart Association and look where that got us--fatter than ever. But the ketogenic diet doesn't eliminate all carbs, just refined carbs. The idea that we should eat everything in moderation doesn't apply here. Would we drink alcohol, or smoke, or take street drugs in moderation? No one needs refined carbs! 80% of the calories I eat are from fat, 80% of the volume of food I eat is vegetables. I will eat ketogenic for the rest of my life. It is not a diet I was on and then went off, it is a way of life for me now. If I inadvertently eat something with even a little sugar, I feel the blood sugar spike immediately. Many of my friends were stunned by my weight loss and wanted to know how I did it. They tried it, and I was surprised to find that none of them could stick to it. At first I was stunned, since it was a miracle for me, but I realized how multifactorial eating is--it is personal, emotional, conditioned, and sometimes self-medicating. In addition, as I said above, it requires a major change in eating that is vastly different than the standard American diet. Also, there is more awareness now that everyone is different and different bodies require different diets. There are functional medicine doctors who will walk people through this and help them discover the best way of eating for them. And food manufacturers are catching on and are marketing more and more products that are keto-friendly. There are now a lot of online programs that guide people through the switch, which I would recommend for people who need help. And I'm sure a therapist would be very helpful for people who have a self-medicating component to their eating. But I think about all the ideas I explored throughout my life of dealing with this, such as that maybe I was an emotional eater, or a food addict, or was self-medicating, or was working out parental training, etc. I came to realize that none of this is true for me! As long as I stick to my food plan, I have no issues with any of this. So I wonder how many other fat people are in the same boat that I was in for over 40 years. They just need help discovering how to eat for their particular body, and how to incorporate that type of eating into a lifelong habit. Yes, I do think the idea of being healthy at every size is positive but I was never happy being fat, even though I tried to accept it for several years because I thought the alternative was constant starvation. Not only did I find my body unwieldy for doing the things I wanted to do, but I was frequently hungry eating what I thought was a healthy diet. I couldn't maintain even a heavy weight this way, I continued to gain because the hunger led to overeating. So perhaps this is another component to the whole conundrum.

Tuesday, November 27, 2018 8:38:27 AM | posted by Teresa
Thank you for your insightful discussion about a subject that is overlooked when we talk about prejudice. I shared and will continue to share to assist with the shift.