Health At Every Size: A paradigm

shift in body-image treatment

strategies

Laura Bauman, Ed.S, PLPC, NCC

Objectives

 Briefly review body image

 Gain an understanding of diet culture and its impact on society
 Learn about Health At Every Size and its purposes
 Discover the implications of a Health At Every Size approach
 Learn specific interventions and strategies for improving one’s own and helping others with body image
Experiential Activity

• Think of 3 things you don’t like about your body

• Think of 3 things you do like about your body

Which was the hardest to do?

What is Body Image?
What is Body Image?

 A combination of the thoughts and feelings one

has about their body
 Based on feelings and judgements, so different
than the image seen in the mirror
 Varies based on mood, experience, etc.
 Influenced by both internal and external factors
What are some of the Signs of Negative Body Image?

NEDC, 2020
Risk Factors

NEDC, 2020
Diet Culture
 Diet Culture

 A system of beliefs that values weight,

shape, and size over health and wellbeing
 Promotes weight loss as a means of
attaining higher status
 Demonizes certain ways of eating and
elevates others
 Assigns hierarchical value to bodies
 Drives one from their values and persuades
to conform to external commands
 Glorifies the thin-ideal
 Influences unrealistic and many times
unhealthy body goals such as “thigh gap,”
flat tummy, anti-cellulite, etc.
 “Diet culture encompasses all the messages that tell us that we’re not
good enough in the bodies we have, and we’d be more worthwhile
and valuable if our bodies were different. Our culture is SO embedded
with body and weight-centric messages that they’re sometimes
imperceptible. Diet culture is deeply ingrained in our everyday
existence and prevents us from living our most full and meaningful
lives. To break away from diet culture, we need first to expose it, then
find alternative ways to feel connected to ourselves, each other, and
the world in a way that moves away from defining our worth
according to our body shape, weight or appearance.”

– Fiona Sutherland
What does the Research say?
Problems with BMI
“How can 29 million Americans become too
fat overnight by not gaining a pound? The
answer is there is a lot of money to be made
by telling people their bodies are a problem
and they need to lose weight.”
– Elisa Oras

• Invented in the 1800’s by Adolphe Quetelet, a mathematician for a single research study with no intention of it becoming
the norm for measuring weight and health

• In 1998, the National Institutes of Health (NIH) lowered the overweight threshold from 28 to 25, declaring 29 million
Americans as “overweight” with one quick change

• The majority of those on the NIH board belonged to dieting companies or were weight-loss manufacturers…with this
change, the dieting Industry gained 29 million new potential customers overnight
Chopra, 2019; Tomiyama et al., 2016
 Research indicates that even though you’re overweight or
obese according to the BMI index, your risk of dying isn’t
any higher than for people of normal weight, as long as
you maintain four healthy habits:
 Eating enough fruits and vegetables
 Getting regular exercise
 Not using tobacco
 Consuming alcohol in moderation. 

Matheson, King & Everett, 2012

The Obesity Paradox

 Studies show that individuals with diabetes and other chronic

health conditions with overweight or obese BMI ratings,
actually have a lower mortality rate than normal weight
individuals with those same problems

 Having a higher body weight proves to be a protective factor!

Jin Han & Boyki, 2018

MacLean, et. al., 2011)
Dieting leads to increased focus on all things, food
 Dieters experience increased food-related thoughts, cravings, and overall preoccupation with food
 Dieters report significantly more food and eating-related thoughts than non-dieters

(Coletta et al., 2009; O'Connell et al., 2005)  

Dieters experience more cravings than non-dieters

 Restricting foods leads to increased cravings and increased consumption of these very foods
 Trying to suppress food-related thoughts leads to thinking about them even more

(Barnes et al., 2013; Keeler et al., 2015; Massey & Hill, 2012) 

Forcing oneself to eat “healthy” results in a competing motive to eat whatever

 The desire to eat “healthy” is shown to compete with the desire to fulfill one’s appetite, thus creating a conflict between one’s eating what
they think they “should” and what they actually want
 Eating something solely for the purpose of “health” results in remaining just as hungry or, even more hungry afterwards
(Finkelstein & Fishback, 2010)
Dieting and voluntary weight loss prompts the development of binge eating as well as creates and/ or
further complicates pre-existing mental health concerns
 Dieting consistently shows to be a precursor for binge eating and other disordered eating behaviors
 Dieting is also associated with increased symptoms of depression, anxiety, and other mental health complications.
(Wilson, 1993)

Weight cycling is strongly linked to health complications and disruptions in overall wellbeing
 Weight cycling is associated with an increased risk for heart disease, type 2 diabetes, and overall death rate
 Chronic stress from worrying about weight and dieting further contributes to adverse health outcomes

(Tylka et al., 2014)

Dieting leads to increased body fat stores

 Dieting trains the body to store extra fat (the risk of this happening is more likely in lean people than those naturally existing in
larger bodies)
(Dulloo et al., 2012)

It is what we tell ourselves about the food, not the food itself that causes our guilt
 Dieting itself causes eating-related guilt rather than the food that was consumed
(Kuijer et al., 2015)
Dieting’s Influence on
Weight
Set-point

o Decrease in metabolism
o Reduced ambition to exercise & reduction in calories utilized during exercise
o Increased motivation to eat
o Reduction in satiety
o Decrease in lean body tissue; increase in fat stores
o Decreased levels of leptin (the hormone that triggers fullness)

Kissileff et al., 2012; Kizer, 2018; MacLean et al., 2011; Redman et al., 2009;
Rosenbaum & Liebel, 2013; Shaw, 2012; Stotz, 2019
Suggesting Dieting is Prescribing the very Problem

 Dieting is the number one precursor for overeating

 Encouraging one to change their body reinforces the
stigma
Health At Every Size (HAES)
What is Health At Every Size (HAES)?

 A movement that promotes the pursuance of health regardless of size

and advocates that health is not synonymous with size
 HAES encourages an intuitive approach to eating, promotes enjoyable
physical activity, and recognizes that health is multifaceted

“HAES is an anti-diet approach to healthcare that's designed to help

people take care of their bodies without trying to shrink them."
- Christy Harrison, MPH, RD, CDN

Sugar, 2020
HAES basic components:
 Respect
• Celebrates body diversity
• Honors differences in size, age, race, ethnicity, gender, dis/ability, sexual orientation, religion, class, and other human
attributes
 Critical Awareness
• Challenges scientific and cultural assumptions
• Values body knowledge and lived experiences
 Compassionate Self-care
• 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, while respecting the social conditions that frame eating options

Linda Bacon & Lucy Aphramor

 Body neutrality: Developing a relationship with one’s body that is not reliant on control or
manipulation.
 
Diet culture: A belief system that hyper-focuses on and overvalues weight, shape, size, and
nutrition intake/movement at the expense of peoples’ overall well-being. Diet
culture messaging has traditionally focused on the intent to lose weight or
maintain a smaller/thin body; however, has recently expanded messaging to
include “wellness” while still perpetuating weight stigma and shame.

DEFINITIONS
 
Fatphobia: “The fear and dislike of fat people and the stigmatization of individuals with
bigger bodies” – SRHWeek

OF HAES-
 
Healthism: “A belief system that sees health as the property and responsibility of an
individual and ranks the personal pursuit of health above everything else” - Hilary
Kinavey, MS, LPC & Dana Sturtevant, MS, RD

RELATED
 
Objectification Degrading a person’s value to exclusively rely on appearance, possessions, or
status

TERMS
 
Thin privilege: “Recognizes that by virtue of some characteristic of your body, in this case
thinness, you have greater access to resources and face less discrimination in
society than people without this characteristic” - Christy Harrison, MPH, RD,
CDN
 
Weight stigma: The social devaluation of and discrimination against those in larger bodies
 
   
 “Too many of us are judging our own
fitness in ways that have a lot to do with
how we look and very little to do with our
actual health.”

– Lindsay Kite
Assessment
Body Image Assessments

 EDE-Q Shape Concern Scale (Fairburn & Beglin, 2008)

 EPSI Attitudes Toward Obesity Scale (Forbush, 2015)
 EPSI Body Dissatisfaction Scale (Forbush, 2015)
Interventions
 How NOT to approach Body-image…

 Many interventions have underlying messages of changing the body rather than
accepting it
 “It’s okay! You will get the weight off.”
 “Have you tried dieting? You can do it!”

 Additionally, many interventions (often developed for individuals in smaller

bodies) focus on redirecting body image distortions
 “You’re not big at all! You look beautiful.”
 “You’re so thin – you’re fine!”

 Previous body image interventions actually perpetuate weight bias.

“It’s not what you see in the mirror that needs changing, it’s culture.” – Unknown
Helpful language to use instead

 “It sounds like you are fearing ____________ (ex: rejection).

 “It is important to you how others view you.”
 “You have been judged and you feel sad.”
 “You have a hard time loving yourself in this body.”
 “It sounds like you’re looking for answers.”
 “You think that weight loss will bring you happiness.”
 “It sounds like you are looking for validation.”
Consider the following scenario:

Suppose that you are in an invested relationship and currently trying to heal some problems. Which would be
the most helpful way of interacting with your significant other?

 Option 1.) Constant criticism, ignoring their needs, pointing our their every “flaw,” wanting them to be different, etc.

Or
 Option 2.) Compassionate kindness, remaining open-minded to their ideas and desires, adapting an attitude of affection
and acceptance to even the things you are annoyed with, etc.

Which option would best improve the situation? Which way of interacting would likely be the most helpful
towards healing the hurt in the relationship? That’s right, the second!

adapted from Brittany Brown

Body Acceptance

“Body confidence does not come from trying to

achieve the ‘perfect’ body; it comes from embracing
the one you’ve already got.”
– Jenne and Lindsey Co.

“Even if you are not comfortable with where your

body physically is, you still need to show up and care
for your body as it is.”
– Brittany Brown
Gratitude

 We spend so much time focusing on the look of

our bodies, we often overlook all that they do
for us

 Try acknowledging all of the functions your

body serves and the things it allows you to do.
Perhaps your body has…

✓ Fought off an infection

✓ Taken you to the top of a hill
✓ Stayed awake so you could drive home safely
✓ Learned a new physical skill
✓ Rewarded you with the sight of a sunset
✓ Created another human being
✓ Defended you from an attack, or healed from an
attack
✓ Let you know through pain that something needs
your attention

✓ Healed a bruise ✓ Released you from pain

✓ Given you a new sensual sensation ✓ Given you the sound of children laughing

✓ Gotten stronger ✓ Rejuvenated during sleep

✓ Expressed a strong emotion through your face or body ✓ Allowed you to feel the exquisite touch of another
language person

Adapted from Alsana

 Contingent Self-worth

 Can you think of any activities you would like to try out that might contribute to your
pie-chart?
 Can you think of any old interests or hobbies you used to enjoy or people you have lost
touch with you would like to reconnect with?
 What sorts of things do your friends or colleagues do in their spare time that you find
interesting?
 Are there things you could do with your friends or colleagues? It can be helpful to do
things with other people to encourage you to try these things out.

Try to pick activities you are likely to do and that do not seem too daunting right now. It can also help
to think about activities that could gain momentum and that you could really keep going.

Adapted from Fairburn, CREDO

Fat isn’t a Feeling…or is it??

2007 Study on individuals with AN:

 No correlation between BMI and how “fat” someone
felt
 Feelings of fatness were correlated with depression

Cooper et. Al, 2007; Fairburn

Mindset

It is not size that determines happiness level but

rather our perspective

Explore what “fat” (insert own word here) means to

you; how did you develop negative connotations.

“Your body image is stored in your brain cells, not

your fat cells.”
– Ashlee Bennett
Pampering/ Self-care
Body Tolerance through Self-Soothing

 Create a list of self-soothing behaviors and/or activities to engage in when experiencing negative feelings
related to the body

 Examples of these activities will be individualized to the client but might include:
 Wrap up in a heated blanket.
 Light scented candles or oil.
 Play soothing music.
 Practice deep breathing (or a breathing technique of your choice).
 Engage in knitting, crocheting, or cross-stitching.
 Apply a cool washcloth to my face; add lavender oil for additional calming.
 Take a warm bath.
 Play with my pet.

Adapted from Alsana

Titchener's repetition

 Invite client to say the word “Milk” and then notice all of characteristics of milk that arise in their thoughts
as a result of saying the word “Milk” (e.g., creamy, white, cold). Ask your client to repeat the word ‘‘milk’’
out loud as fast as possible for 30 seconds notice what happens
 Next, ask client to apply this experience to an unhelpful thought. Pare down the thought into one word (e.g.
‘‘fat’’). Have the client rate the degree of discomfort and the believability of the thought
 Invite client to verbalize the word repeatedly for 30-45 seconds. The word should become a series of
arbitrary sounds with little emotional impact

adapted from Alsana; Masuda et al., 2009

An alternative to Positive Self-talk

 Self-affirmation of aspects of identity (rather than body image) may bolster the integrity of oneself to reduce
defensiveness.
 Self-directed body kindness statements are often deflected by clients who experience self-disgust
 (e.g., staring at oneself in the mirror and stating, “my thighs are beautiful” cannot be absorbed by individuals
experiencing self-disgust, because it threatens their identity).

Adapted from Alsana

 Mirror Exposure Therapy

 Rather than praising or scrutinizing body parts, one

scans their entire body, making neutral body
statements
 Focus on every aspect of the body, describing hair
color, eye color, skin texture, etc.
 “How might I describe my appearance so that a
stranger could pick me out in a crowd?

 Decreases in body-checking, body dissatisfaction, and

eating disorder symptoms have been found after
completing 5 sessions of mirror exposure

Hildebrandt et al., 2012; Thomas & Schaeffer, 2013

Body Image Timeline

 Objective: Gathering an understanding of the factors that contributed

to negative body image can be helpful in understanding the function of
the eating disorder and the role of negative BI in the development of
the eating disorder.
 Instructions: In either a narrative or collage-like format, chronicle a
timeline of events and experiences in your life that contributed to your
body image.

Adapted from Alsana

Reducing Body Checking

 Use with clients:


https://jennischaefer.com/wp-content/uploads/20
13/06/AlmostAnorexic_Table13.pdf

Thomas & Schaefer, 2013

Grieving the Desired Body

 Apply the stages of grief to body image in individuals with larger bodies
 “Grieving the Societal Thin Ideal”
 Grieving the loss of control
 Grieving my ability to control my body
 Grieving time lost to pursuing weight loss
 Stages of Grief as they apply to Body Acceptance
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
 Intuitive Movement Exploring movement through the lens of a child
“You deserve to be delighted” (Taylor, 2018)

 Connecting with your body’s internal cues and allowing these cues to determine:
 Type of movement
 Duration
 Intensity

 Intuitive Movement involves:

 Emphasizing movement rather than “exercise”
 Incorporating mindfulness by fully tuning into the movement
 Focusing on enjoyment and how the body and mind feel rather than on burning
calories or losing weight
 Taking part in forms of movement that feel good intrinsically
Additional Ideas

 Wear clothes that help you feel confident

 Intuitive Eating!
 Make a list of your personal qualities and character trait
 Scroll through social media without making judgments on looks – try to notice other things about each photo
 Let go of unrealistic expectations – tear, burn, destroy your “list”
 Mindfulness
 Exposure hierarchy for body avoidance
Additional Ideas, cont.

 Yoga
 Write a letter to Diet Culture in terms of its impact on their life or the development of their eating disorder
 Draw or write about 2-3 experiences that shaped your attitudes about weight and your body
 Letter to younger self
 Join websites; change your Instagram feed; Find a Body Positive Community
 Write about how focusing on your body has helped you; how has it hurt you?
Challenge

 What do you currently not do purely due to

body image concerns?

 How can you make a plan to do this thing

in the upcoming weeks?
How does our own weight bias
impact our work with clients?

Take the Implicit Association

Test to assess your own weight
bias:
https://implicit.harvard.edu/implici
t/Study?tid=-1
 Resources
Health At Every Size Community
 https://haescommunity.com/

NEDA Body Activism Activity Guide

 https://www.nationaleatingdisorders.org/sites/default/files/BodyActivismGuideFINAL.pdf

The BodyLove Project podcast - Jessica Haggerty

Western Health Body Image Toolkit
 https://westernhealth.nl.ca/uploads/Addictions%20Prevention%20and%20Mental
%20Health%20Promotion/Body%20Image%20Tool%20Kit%202012.pdf

 NEDC Body Image Fact Sheet/ handout

 https://www.nedc.com.au/assets/Fact-Sheets/NEDC-Fact-Sheet-Body-
Image.pdf