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RESEARCH
Current Research
Size Acceptance and Intuitive Eating ImproveHealth for Obese, Female Chronic Dieters
LINDA BACON, PhD; JUDITH S. STERN, ScD; MARTA D. VAN LOAN, PhD; NANCY L. KEIM, PhD
ABSTRACTObjective
Examine a model that encourages health at ev-ery size as opposed to weight loss. The health at everysize concept supports homeostatic regulation and eatingintuitively (ie, in response to internal cues of hunger,satiety, and appetite).
Design
Six-month, randomized clinical trial; 2-year follow-up.
Subjects
White, obese, female chronic dieters, aged 30 to45 years (N
78).
Setting
Free-living, general community.
Interventions
Six months of weekly group intervention(health at every size program or diet program), followedby 6 months of monthly aftercare group support.
Main outcome measures
Anthropometry (weight, body massindex), metabolic fitness (blood pressure, blood lipids), en-ergy expenditure, eating behavior (restraint, eating disor-der pathology), and psychology (self-esteem, depression,body image). Attrition, attendance, and participant evalua-tions of treatment helpfulness were also monitored.
Statistical analysis performed
Analysis of variance.
Results
Cognitive restraint decreased in the health at everysize group and increased in the diet group, indicating thatboth groups implemented their programs. Attrition (6months) was high in the diet group (41%), compared with8% in the health at every size group. Fifty percent of bothgroups returned for 2-year evaluation. Health at every sizegroup members maintained weight, improved in all out-come variables, and sustained improvements. Diet groupparticipants lost weight and showed initial improvement inmany variables at 1 year; weight was regained and littleimprovement was sustained.
Conclusions
The health at every size approach enabledparticipants to maintain long-term behavior change; thediet approach did not. Encouraging size acceptance, re-duction in dieting behavior, and heightened awarenessand response to body signals resulted in improved healthrisk indicators for obese women.
 J Am Diet Assoc. 2005;105:929-936.
C
oncern regarding obesity continues to mount amonggovernment officials, health professionals, and thegeneral public. Obesity is associated with physicalhealth problems, and this fact is cited as the primaryreason for the public health recommendations encourag-ing weight loss (1). That dieting and weight loss are critical to improving one’s health is reinforced by a socialcontext that exerts enormous pressure on women to con-form to a thin ideal. Public attention to weight and itsassociated comorbidities continues to increase, and diet-ing is now firmly ensconced in our cultural identity. Themajority of US women are now dieting: 57% stated in anational telephone survey that they are currently engag-ing in weight-control behaviors (2). Despite heightened attentiveness to obesity and the in-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 inweight-loss behaviors (5). Some have challenged the ability of diet programs to either achieve lasting weight loss or toimprove health, and question the ethics and value of en-couraging dieting as an obesity intervention (5-9).Others challenge the primacy of weight loss in addressing the as-sociated health risks, regardless of method (10-12). They suggest that while the epidemiologic research clearly indi-cates an association between obesity and health risk, therisks of obesity may be overstated, and the associationlargely results from a sedentary lifestyle, poor nutrition,weight cycling, and/or other lifestyle habits, as opposed tosolely reflecting adiposity itself.Critics of the diet to improve health model suggest aparadigm shift in treating weight-related concerns. Theyrecommend focusing on health behaviorchangeas op-posed to a primary focus on weight loss (6,13,14). Their approach is supported by increasing evidence that dis-eases associated with obesity can be reversed or mini-mized through lifestyle change, even in the absence of weight change, and that people can improve their healthwhile remaining obese(5,10,12,15).
 L. Bacon is an associate nutritionist with the Agricul-tural Experiment Station, University of California, Davis, and a nutrition professor with the Biology De- partment, City College of San Francisco, San Francisco,CA. J. S. Stern is a distinguished professor with the De- partment of Nutrition and the Division of Endocrinol-ogy, Clinical Nutrition and Cardiovascular Medicine inthe Department of Internal Medicine, University of Cali- fornia, Davis. M. D. Van Loan is a research physiolo- gist, and N. L. Keim is a research chemist with the US Department of Agriculture, Agricultural Research Ser-vice, Western Human Nutrition Research Center, Davis,CA. Address correspondence to: Linda Bacon, PhD, Box S-80, Biology Department, City College of San Fran-cisco, 50 Phelan Ave, San Francisco, CA 94112. E-mail:lbacon@ccsf.eduCopyright © 2005 by the American Dietetic Association.0002-8223/05/10506-0001$30.00/0doi: 10.1016/j.jada.2005.03.011
 ©
2005 by the American Dietetic Association
Journal of the AMERICAN DIETETIC ASSOCIATION
929
 
 An alternative obesity treatment model teaches peopleto support homeostatic regulation and eating intuitively(ie, in response to internal cues of hunger, satiety, andappetite) insteadof cognitively controlling food intakethrough dieting (16). An essential component of some intuitive eatingprograms is to encourage health at everysize (Figure 1)rather than weight loss as a necessary precondition to improved health.This study was undertaken to examine the effectivenessofahealthateverysizeapproachinimprovinghealth.[Inaprevious report (17), we referred to this as a nondiet inter-  vention. This has since been changed to “health at everysize” to reflect the changing terminology in the field.] Met-abolic fitness (blood pressure and blood lipid levels), energyexpenditure, eating behavior (restraint and eating disorderpathology), and psychology (self-esteem, depression, andbody image) were evaluated.
METHODSProcedure
 Applicants were recruited from the Davis, CA area, andthosemeetingthefollowinginclusioncriteriawereenrolled:white; female; aged 30 to 45 years; body mass index (BMI)
30; nonsmoker; not pregnant or lactating; Restraint Scale(18)score
15 (indicating a history of chronic dieting); andno recent myocardial infarction, active neoplasms, type 1diabetes, type 2 diabetes, or history of cardiovascular orrenal disease. The research protocol was approved by theInstitutional Review Board of the University of California,Davis, and informed consent was obtained.Enrolled participants (N
78) were divided into BMIquartiles and high/low sets for dietary restraint (18), degrees of flexible and rigid control of eating(19), age, and self-reported activity level to ensure balance in thetreatment groups. Participants in these subgroups wererandomly assigned to one of two treatment groups.
Treatment Conditions
Two treatment conditions were investigated: a diet groupand a health at every size group. Both treatment groupsincluded 24 weekly sessions, each 90 minutes in length.Following this, six monthly aftercare sessions were of-fered, described as optional group support.
Diet Group
The focus of the diet group was similar to most behavior-based weight-loss programs: eating behaviors and atti-tudes, nutrition, social support, and exercise. Partici-pants were taught to moderately restrict their energy andfat intake, and to reinforce their diets by maintainingfood diaries and monitoring their weight. Exercise at anintensity within the training heart range delineated inthe American College of Sports Medicine/Centers for Dis-ease Control and Prevention guidelines was encouraged.Material was presented on topics including how to countfat grams and exchanges, understanding food labels,shopping for food, the benefits of exercise, and behaviorstrategies for success. The program was taught by anexperienced registered dietitian and reinforcedusing theLEARN Program for Weight Control manual (20).
Health at Every Size Group
There were five aspects to the health at every size treat-ment program: body acceptance, eating behavior, nutrition,activity,andsocialsupport.Theinitialfocuswasonenhanc-ing body acceptance and self-acceptance, and participantswere supported in leading as full a life as possible, regard-less of BMI. The goal was to first help participants disen-tangle feelings of self-worth from their weight. The eatingbehavior component supported participants in letting go of restrictive eating behaviors and replacing them with inter-nally regulated eating. Participants were educated in tech-niques that allowed them to become more sensitized tointernal cues and to decrease their vulnerability to externalcues. The nutrition component educated participants aboutstandard nutrition information and the effects of foodchoices on well-being, and supported them in temperingtheir food choices with foods that honored good health (inaddition to their taste preferences). The activity componenthelped participants identify and transform barriers to be-coming active (eg, attitudes toward their bodies) and to findactivity habits that allowed them to enjoy their bodies. Thesupport group element was designed to help participantssee their common experiences in a culture that devalueslarge women, and to gain support and learn strategies forasserting themselves and effecting change. The programwas facilitated by a counselor who had conducted educa-tional and psychotherapeutic workshops and groups andhad completed all of the coursework necessary to obtain adoctorate in physiology with a focus on nutrition. It wasreinforced with a written manual that provided detailedinformation and practical advice for implementing thestrategies (Bacon L.
Hungry Nation: Why the All-American Diet Will Never Satisfy Your Appetite
, unpublished manu-script).
Evaluation/Outcome Measures
Participants attended five testing sessions: baseline, 12weeks (midtreatment), 26 weeks (posttreatment), 52weeks (postaftercare), and 104 weeks (follow-up).
Anthropometric and Metabolic Fitness Measures
Participants reported to the laboratory in the morning,having abstained from food, beverages, or vigorous activ-
●
Accepting and respecting the diversity of body shapes andsizes.
●
Recognizing that health and well-being are multidimensionaland that they include physical, social, spiritual, occupational,emotional, and intellectual aspects.
●
Promoting eating in a manner which balances individualnutritional needs, hunger, satiety, appetite, and pleasure.
●
Promoting individually appropriate, enjoyable, life-enhancingphysical activity, rather than exercise that is focused on a goalof weight loss.
●
Promoting all aspects of health and well-being for people of allsizes.
Figure 1.
Basic guiding principles of the health at every sizeprogram. As drafted by the Association for Size Diversity and Health (30).
930
June 2005 Volume 105 Number 6
 
ity for at least 12 hours. Weight was measured on anelectronic scale and height was measured using a wall-mounted stadiometer. Blood pressure was assessed induplicate using the oscillometric technique. Fasting bloodsamples were analyzed for blood lipids (total cholesterol,low-density lipoprotein [LDL] cholesterol, and high-den-sity lipoprotein [HDL] cholesterol).
Energy Expenditure
The Stanford Seven-Day Physical Activity Recall(21) was administered by interview to evaluate time spent in phys-ical activity. A summary of energy expenditure was de-rived by multiplying the average time of each activity bythe average intensity in metabolic equivalents. To mini-mize interexaminer error and reduce variability, all in-terviews were conducted by two examiners, who collabo-rated to achieve consistent scoring.
Eating Behavior Measures
The Eating Inventory (22)consists of three subscales: cognitive restraint, disinhibition, and hunger. The EatingDisorder Inventory-2 (23)contains eight subscales: three assess attitudes and behaviors toward weight, bodyshape, and eating (drive for thinness, bulimia, and bodydissatisfaction); five measure more general psychologicalcharacteristics that are clinically relevant to eating dis-orders (ineffectiveness, perfectionism, interpersonal dis-trust, interoceptive awareness, and maturity fears).
Psychological Measures
The Beck Depression Inventory (24)measures alterations in mood and self-concept. The Rosenberg Self-Esteem Mea-sure (25)focuses on a self-evaluation of approval or disap- proval. The Body Image Avoidance Questionnaire assessesbehaviors associated with negative body image(26).
Statistical Methods
Power analyses conducted on the Rosenberg Self-EsteemMeasure and Beck Depression Inventory from two healthat every size studies (27,28)determined that 20 partici- pants per treatment group (n
40 total) were needed todetect a difference of 0.75 standard deviations betweengroups with 80% power. We attempted to recruit 80 par-ticipants to allow for 50% attrition. All analyses were conducted using Statistica (version5.1, 1996, Statsoft, Inc, Tulsa, OK). Student’s
t
test wasused to compare baseline characteristics between groups.Repeated measures analysis of variance with a within-subject factor of time (four levels: baseline, 26 weeks, 52weeks, and 104 weeks) and a between-subject factor of group (two levels: diet and health at every size) was runto test differences in variables. Significance was set at
 P
.05. A least significant difference post-hoc test was runon any variable that indicated significant difference.
RESULTS
Unless otherwise specified, the reported results includeall participants for whom data were available at follow-up: 19 participants from the health at every size groupand 19 participants from the diet group, or 50% of eachoriginal sample. The 19 participants who returned forfollow-up testing in the health at every size group allcompleted the 26-week program, whereas the 19 partici-pants who returned for testing in the diet group included
Figure 2.
Flow chart illustrating diet vs health at every size trial procedures.
a
Measurements taken at each time point.
b
HAES
health at every size.
June 2005
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Journal of the AMERICAN DIETETIC ASSOCIATION
931
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