< Resources

Opening the Gate

By Lindo Bacon, PhD

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A sampler of personal stories of meeting resistance to Health at Every Size* in the early days.

Note: This originated in response to an invitation to write a chapter about early resistance to HAES for an anthology on HAES history. The anthology has not been published so I have made it available here.

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I was overwhelmed with ideas when asked to write this chapter, stymied by how to narrow my long list of stories of meeting HAES resistance in my early days. What emerged is a sampler – I start with a story from my early days as a student/researcher, progress to my experience with the first book I wrote, then to my observations of bringing HAES into a research/advocacy organization and then a trade organization, before I land back full circle in academia, this time as a professor. Please join me on this excursion down memory lane.

Academia, as a student

Little did I know at the time that my PhD advisor’s tragic death would result in one of the most rewarding path changes of my life. At the time of his death, I had already completed the coursework required for a PhD in Physiology and was just about to embark on the research component of my degree. No other professors in the physiology department were engaged in research of interest to me, yet I didn’t want to walk out without a degree. Instead, I resigned myself to trying a different path. One of the most well-respected diet researchers in the world, Judith Stern, taught in the nutrition department at my school. Her ideas were completely antithetical to mine, and I opened to the idea that I stood to learn more by studying under someone of such stature who had opposing views. 

To give you a sense of the degree of our misalignment, Dr. Stern (who recently died) had earned the ire of HAES advocates when she opined, after the Food and Drug Administration (FDA) hearing at which the approval of the dangerous diet drug dexfenfluramine (Redux) was temporarily blocked, that any panelists who opposed the drug’s approval “ought to be shot.” Had I been a panelist, that would be me.

She also was a member of the National Institute of Health’s (NIH) Obesity Task Force, which was responsible for advising the government to lower the BMI standards the previous year. In a single swipe of the pen, 29 million Americans became “overweight” overnight. This was obviously a favorable outcome for some business interests. Not surprisingly, at least seven of the nine members on the task force were directors of weight-loss clinics, and most had multiple financial relationships with private industry.

I will never forget my initial meeting with Dr. Stern. I was hoping I could get in on the strength of my unusually advanced resume: I already had two masters degrees along with research and grant writing experience. Also unusual, I was already funded – I had a full scholarship from the National Science Foundation that included a relatively handsome stipend for living expenses. Dr. Stern, like most professors at our school, only took students for whom she had already budgeted grant money or those who came with their own. 

In spite of those strengths, she said no. Deflated, but with nothing to lose, I changed the subject to her research: weight loss. The energy changed. Both of us became animated and for hours we debated the value and harm of dieting and weight loss, surprised to be having so much fun while disagreeing.

Our strong connection compelled Dr. Stern to do something unprecedented in her four-decade career: she not only agreed to mentor me, she also agreed to allow me to test my hypothesis that not dieting beats dieting. (Her other students worked on aspects of her research, rather than generating their own, a common practice in obtaining a PhD.)

It was a contest: I was to create and conduct the HAES protocol, while she would ensure that the study’s diet protocol was the finest it could be.

The competition required both of us to compromise our ethics. I hated the idea of subjecting a group to a diet, given what we know about the damages of dieting. Dr. Stern was hesitant about conducting this research for the same – yet opposite – reason. She worried that if we didn’t encourage the women on the HAES protocol to diet and lose weight, we might be harming them. However, it seemed a worthwhile compromise to both of us as it would allow us to conduct the gold standard in research, a randomized controlled trial. We would measure not only if the HAES protocol was up to snuff, but whether it would outperform the diet protocol, supporting the idea that it’s time to dump diets.

She raised the concern that we didn’t have a chance of getting the required approval from the Human Subjects Research Committee (HSRC) of the Institutional Review Board. I trust she was right; the idea that fat folks should be discouraged from dieting went completely antithetical to prevailing ideas. She proposed that we test the progress of the women on the HAES protocol after three months, including surveys on quality of life, mental health, health habits; blood samples; and weight. We could assure the HSRC that If we saw evidence of worsening outcomes we would stop the study immediately.

That compromise did make it acceptable to the HSRC and was my first lesson in how to get beyond the gatekeeping of the old paradigm. How ironic that the considerable evidence showing the health-damaging effects of dieting are overlooked while the health-improving effects of HAES are overlooked. All in the name of preserving ethics in research!

Years later, as a more senior researcher, I was able to (ethically) exact my revenge as a peer reviewer for journals. When I reviewed diet studies, I called out on the gaps between assumptions and actual data and the unacknowledged damages. If the researchers trumpeted that they were successful at improving health by accomplishing weight loss, I demanded they show the data to draw the dots between weight loss and improved health, when they never actually tested health itself. I pointed to the research suggesting their outcome – weight loss – may actually be a detriment to health, given that more often that not it induces weight cycling (ironically a risk factor for many of the diseases blamed on weight) rather than sustained weight loss. If only all reviewers would hold research papers to these simple, evidence-based criterion so that we could stop wasting money and ruining lives with more diet studies!

Back to my research. I learned early on that research follows the money (which of course means that careers in this field depend on adhering to the status quo). Very little funding for weight-related studies doesn’t come from corporations who have a vested interest in results.

I’m quite concerned about this conflict of interest, which is why I adopted and have maintained a strict policy of never accepting research money from the diet or pharmaceutical industries. Not that private industry would have been interested in funding this research anyway -I mean, there’s no profit to be made if we show people getting healthier with lifestyle change, without worrying about weight loss, or if we show that the links between weight and health are tenuous.

Consequently, I’m limited to public funding, which is a very small pool that’s allocated not just based on the quality of the project, but on the politics involved in the topic and the nepotism of the reviewers. (The latter is my unproven belief.) Given that government shares the general perception that Americans need to lose weight, that’s where much of the money goes – then and now. Plus, many researchers on public grant review committees are also on industry’s payroll. 

With our HAES study, we managed to wrangle a relatively small grant out of the NIH – about $100,000. We also brought on two co-investigators, nutrition scientists who worked with the USDA, and they generously dipped into their funding and resources to pull us through. I had met these women at a social function and we enjoyed one another tremendously. Opportunity is often based on relationships, another reason research challenges the status quo are rarely funded.

I’d like to believe we got the NIH grant because of the outstanding proposal. But I’m not that naïve. The reality, I think, is that we listed Dr. Stern—who is better connected and has served on several grant committees herself—as the primary investigator. I am convinced that being her protégé and friend opened the door to a world of opportunities denied to those who don’t serve up some benefit to private industry or don’t have friends in the right places.

Oh, in case you have any doubt who won that HAES vs. diet intervention fight, it was the HAES intervention, hands down.

We published the first paper in 2001. The paper refers to size acceptance and intuitive eating but has no mention of HAES—because, at the time, I had never heard of HAES. I had previously worked as a therapist specializing in eating disorders and there were many of us renegades who had come to similar conclusions about best practice. We just didn’t have a name for it.

Fortunately, a reader gave me a heads up about the HAES movement. I was thrilled to find more community and not feel so alone. Well, eventually. At first it was a rocky and painful road, because when people learned of my affiliation with Dr. Stern, they were reluctant to trust me. Thankfully, things shifted, and I soon found my home in the movement and started to refer to my research as Health at Every Size.

I credit Dr. Stern for opening the gates to allow the HAES message to be heard. Our research was the first to test the physiological parameters of a HAES intervention. But I was stymied: having seen clear evidence that HAES is superior for supporting health, why did she hang on so tenaciously to believing in diets? I’ll leave that for readers to ponder.

The Book

The ideas, practices, and personal stories from that research study were so powerful that I turned them into a book. Members of the Association for Size Diversity and Health (ASDAH), then the professional organization representing HAES values, expressed enthusiasm for a book and encouraged me to use the title Health at Every Size, hoping it might help HAES get on the map (thankfully saving us all from my first―cringe-worthy―working title, Finding Your Happy Weight). 

When I was pitching the original book, dozens of agents turned me down before I found one who said “yes” — only to eventually give up because she couldn’t get a publisher to bite. She had tried hard, submitting the proposal to more than 100 publishers. I saved those rejection letters and have found them quite inspirational. They’re a good reminder of the importance of persevering when things get hard and believing in myself even when I don’t get reinforcement from others. Apparently, no one believed there was a market for a book about weight that didn’t promise weight loss.

I couldn’t find another agent to represent me, so I reluctantly decided to go solo. I spent a year petitioning publishers and racking up even more rejections. Finally, in an ironic twist of fate, I received a “yes” from two publishers in the same week — BenBella and another, larger, publisher. I was relieved and elated. I actually got to consider what I wanted in a publisher, which was a true gift. Choosing BenBella was easy — not only were they very likable, but they seemed to understand the book. They even altered their contract to give me more control over the finished product, understanding that I had been burned before by editors who wanted to promote my work as a more modern “evolved” diet or include attention-grabbing graphics of headless fat people exercising. (Do you understand why that ubiquitous graphic offends me? Not showing a head sends a message that this body is so shameful that it doesn’t deserve a face – a polar opposite to what this book is about.) That other, bigger publisher? They were in the “just not getting it” category. All they could offer was a bigger advance and more resources. Fortunately, I was in a very privileged position and able to go with my gut.

The excitement of finally getting the book accepted and published dimmed once it finally hit the shelves in 2008. Let’s just say that the early sales were…disappointing. It took years and years to earn back my $7,500 advance.  I started to believe that those one hundred plus rejections were deserved — those publishers knew the market, and the market didn’t want what I had to say.  Fortunately, the tide turned, and the book eventually became a bestseller, high on Amazon’s self-help bestseller list now 15 years later. 

It’s exciting to see how the climate has changed.

Research/Advocacy Organization

In 2006, ASDAH received an invitation for a representative to attend a weekend think tank on weight bias from a mainstream organization with a lot of clout. I took it on. At the time, the hosting organization had a dual mission: preventing/reducing weight stigma and preventing obesity. (In other words, their mission was to prevent weight stigma while stigmatizing fat people.) We were stunned that they had even heard of ASDAH and I walked into it knowing there wouldn’t be any HAES-sensitivity and that no one else found their mission problematic.

ASDAH member Marilyn Wann wanted to make a dramatic statement that the HAES/fat communities were angry about this organization’s work. So, there I was in a conference room with about 25 conventionally minded people, trying to diplomatically point out the problems in almost everything that was said, when Marilyn’s (metaphorical) bomb dropped. There was a loud banging at the door and in walked a gorilla. (It was an awesome costume.) The gorilla expressed something along the lines of “Stop stigmatizing fat people” and “Nothing about us without us”, and then shared a “telegram” with us—a very articulate letter signed by Marilyn and many others. 

It was an awesome moment. People were stunned, and the gorilla had their rapt attention. I took advantage of the stunned silence that followed and carefully guided a conversation about why people might have gone to such great lengths to be heard and what their concerns were. (The actual moderators seemed too taken aback to actually moderate.) 

Everyone at that think tank was actually quite nice and seemed sincerely committed to helping “obese” people. I gained a lot of insight that weekend that helped me to stop looking at the Obesity War-Mongerers as the enemy. I could see that they were trying to do the right thing, and that they were just misguided. (And let’s be honest, didn’t most of us start there too?) 

Professional Organization

In my early days, it was hard to get anyone in the traditional “weight control” community to even acknowledge HAES, let alone discuss its merits. Gatekeeping is not only a problem in research, but also in nutrition education.

The Academy of Nutrition and Dietetics (AND) has wide influence on U.S. nutrition education and practices, so you might naturally expect to learn about the Health at Every Size movement at their annual conferences. However, until 2011 HAES had never been the primary topic of a session. That’s why it was major news when AND invited me to debate a well-known obesity researcher in a session called, “The War on Obesity: A Battle Worth Fighting?”

Having HAES on the AND conference agenda? It was unprecedented.

Literally unprecedented, in fact. The reason I know that AND conference planners repeatedly turned down HAES presentation proposals is that I had routinely sent them. I was, and am, a highly credentialed, sought- after speaker, so I assume something other than my resume was at issue in these rejections. Specifically, the fact that my work challenges the scientific credibility of the AND’s official position on weight management.

That year, though, AND HAES insiders demanded HAES representation, launching a letter-writing campaign to insist on a HAES forum. And this time, I received an invitation. But my excitement deflated when I read the fine print. Unlike every other panel, mine was required to take the form of a point/counterpoint debate with a speaker presenting the “other side.”

If it was a debate they wanted, I figured the bigger the name I went up against, the better. But those in the anti-obesity camp proved less eager. AND first approached a medical school professor who co-founded a weight control registry and helped develop NIH guidelines to “treat” obesity. His secretary said he was available. Then she said he wasn’t.

The conference planners then approached a prominent professor of medicine and public health at Harvard; another prominent professor who was co-founder of a weight control registry; and the director of a center for obesity research and education and former president of the Obesity Society. All routinely give talks at similar conferences. All declined. Did I detect a whiff of fear in the air?

Fortunately, a prominent scientist who directs a behavioral medicine research center at a top university stepped up to the plate. He is a highly respected, credentialed and experienced researcher who, at the time, had 17 books and 300+ articles to his credit, and was a veteran of government obesity panels and large-scale weight loss studies. Not surprisingly, he was friendly with Judith Stern.

Like many of his colleagues in an “obesity” research field that is rife with conflicts of interest, he had been compensated by and received grants from a slew of diet and food industry behemoths. As an example, he had been a paid advisor to Slimfast and had even made a personal testimonial about incorporating Slimfast shakes into his diet. He also consulted for and/or received grants from a long list of pharmaceutical companies that produced weight loss drugs and a manufacturer of bariatric surgery equipment. I expected him to be a worthy opponent.

At long last, I entered the lion’s den in front of a live audience of well over 1,000 dietitians, with many others later listening to the recorded audio. I laid out the evidence that the War on Obesity had done more harm through collateral damage than its “enemy,” fat, ever could. I presented the evidence that belies the myth that “obesity=death” and other unsupported claims. And I delved into the wash of corporate money that unavoidably seeps into common beliefs, research, academic publishing, and public policy decisions in the obesity field.

My opponent’s response to my challenges on the data defaulted to “popular wisdom.” Basically: Everyone knows fat is bad for you—it’s a no-brainer. Sure it’s difficult to maintain weight loss, but it’s always better to keep trying, even if you regain it—(Say it with me: It’s a no-brainer).

Seems he’s right, but not for the reasons he thinks: There is a decided “brainlessness” to the arguments supporting a global war on fat.

I do admit to taking one cheap shot, but this one was just too hard to resist…

“Eating in HAES is not about monitoring your weight or counting calories or fat grams,” I said. “It’s not about drinking Slimfast, vegetable juice, or carrying a plastic module that supplies a whiff of vomit to help you maintain your diet… [Audience laughs.] Oh, be nice. Don’t laugh. Dr. X has actually done research on all of these and can tell us the advantages to that whiff of vomit.”

It’s true! He published research on “Aromatrim,” which apparently impressed him since he also appeared in advertisements plugging its benefits. (I assume it goes without saying that Aromatrim funded his research.)

One of my few regrets in this debate was the way it ended, with what amounted to basically a plea from the moderator to “kiss and make up” and embrace a middle ground. No can do. There’s no “making up,” because there’s no fight. What there is is a vast and unbridgeable difference in opinion and outlook. The HAES model is not an “alternative.” It’s a fundamental paradigm shift in the way we think about fat, disease, and our bodies. (I know…I’m preaching to the choir!)

Fortunately, change does happen. Many dietitians are now championing a HAES perspective and HAES routinely makes it onto AND conference agendas.

Unfortunately, along with the growth comes increased resistance. From their latest “evidence-based nutrition guideline”: “it is suggested that RDNs or international equivalents not use a Health at Every Size®… approach.” They claim that HAES and “non-diet” approaches weren’t evidence-based but calorie restriction diets were. You can view my open letter in response. It was gratifying to see that many others also wrote letters in protest.

Academia, now as a professor

It saddens me to see the power of industry to control academia, manipulate the education of health professionals, and suppress critical thought. For example, when I was once on a hiring committee interviewing candidates for a nutrition professorship and it came time to discuss the lone fat candidate, one of my colleagues dismissed her by saying, “Well she really isn’t the role model for someone who eats nutritiously, is she?” My colleague had made this assumption based entirely on the candidate’s weight. I was horrified, especially as I considered the many challenges this job candidate had probably overcome to get her PhD in nutrition. 

Even attending an introductory nutrition course can be a threatening and disempowering act. It’s safe to guess for example, that she had to calculate her body mass index (BMI), then listen to a lecture about the health risks for people who are in the “overweight” or “obese” categories, and how the root causes of being in those categories are overeating and inactivity, with the solutions being diet and exercise. You get the general idea: fat people are lazy, undisciplined gluttons, destined for disease and early death – but with the right strength of character, anyone can lose weight and become a better person. I can’t imagine how taxing it may be as a fat person to endure those lectures. 

Up against a similarly credentialed thinner woman, I imagine this fat woman would actually be a supremely better choice – the resilience and survival skills she has developed, her determination, her belief in herself, her ability to withstand a culture informing her that she’s defective, and what an incredible role model she could be for her students. That is, unless she’s internalized the fat hatred, apologizes for her size, and reinforces conventional thought, which is the more common route undertaken by fat dietitians. No judgment here. It’s much easier to survive that way.

Of course, she didn’t get the job, and it’s one of my many regrets that I didn’t expose the inner workings of that decision for the fat discrimination it was. I also regret not letting the woman know why she didn’t get the job, so she didn’t think it was about her ability. I suspect she knew that.

My professorship gave me a platform to explore and speak on issues important to me. At least I thought it did. Those first four untenured years I received over-the-top performance reviews from my colleagues as well as students. The fifth year, however, I was more public with those thoughts within our department. I expect that explains why I tanked that review and my department recommended I be denied tenure. Fortunately, in what I believe is the only time in our school’s history, the chancellor of our college overturned that department recommendation and I achieved tenure. I’d like to say the security of tenure supported me in speaking truth to power. But that’s not the way it played out. My position was consistently challenged by forces threatened by my unwillingness to be complacent or silent – and my commitment to HAES.

Check out this story. For the first decade of my academic career, I taught nutrition through the biology department at the largest community college in California. Students who took my introductory nutrition course could get transfer credits in their dietetics program.

Then my department received letters from several dietetics programs across the state, revoking transfer credit for students taking my introductory nutrition course. They didn’t cite a reason.

My course outline, the only data they require when granting transfer credit, was similar to approved outlines used at other schools. Nothing had changed at this pivotal time, other than increased attention for my outspoken advocacy for nutrition education reform, which included my commitment to HAES.

My department’s response wasn’t to demand an explanation. Instead, they made motions to prohibit me from teaching the course. Not only was I experiencing a very real threat to my job and reputation, but I was also feeling powerless.

I found some comfort by imagining what had led to this: thousands of my former students challenging their dietetics professors to “show me the data.” This was a mantra I drilled into them as we considered the evidence – or lack thereof – behind commonly supported beliefs about the interplay between weight, nutrition, and health. (The “mantra” may have originally been coined by Dr. Deb Burgard, who founded a listserv with that name.)

Soon after, my department prohibited me from using the textbook I had written. As far as I know, no professor had ever been denied opportunity to choose their own textbooks – it’s a matter of academic freedom. (If I were an unpopular teacher, or made money off those books, I’d consider alternative explanations, but students raved about my teaching and my book, and it was sold at cost.) 

Working in a department that had sold me out made it painful for me to face work every day. Fortunately, I was invited to transfer to our progressive Health Education Department, allowing me to work with dynamic and inspiring teachers who shared my commitment to body positivity, social justice, and academic freedom.

Conclusion

We are in different times now. I believe our time has come.

Of course, you might question that last statement, given that government officials and many health professionals are screaming louder “obesity epidemic” louder than ever and discrimination against high-weight people is at an all-time high. It’s an understatement to say that resistance has increased exponentially.

How do we make sense of growing acceptance of HAES ideas on one hand and increased rejection of those ideas on the other? I’ll tell you how: this conflict is a telltale sign that we are in the midst of a paradigm shift. Yes, things feel rockier and more divided than ever, but history has demonstrated this kind of upheaval is a common phenomenon when people are on the cusp of adopting new ideas that set the stage for real change. It helps to remember how often we have been astonished by the sudden crumbling of institutions and extraordinary paradigm changes: the American Revolution, the March on Birmingham, the Stonewall riots, Tahrir Square…  And let’s not forget that it is now scientific consensus that the earth is round.

To repeat, “Our time has come.”

Dedication

Dedicated to the memory of Judith Stern. Judith’s extraordinary mentorship shaped my education and career. Her support for examining ideas critical of her own helped advance the HAES movement too.

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*Health at Every Size and HAES are registered trademarks of the Association for Size Diversity and Health and used with permission.