Health at Every Size ® (HAES ® ) is a weight-neutral approach focused on promoting healthy behaviors in people with different body sizes. This study examined multiple physiological, attitudinal, nutritional, and behavioral effects of a newly developed, intensive, interdisciplinary HAES ® -based intervention in obese women. This was a prospective, seven-month, randomized (2:1), controlled, mixed-method clinical trial. The intervention group (I-HAES ® ; n = 39) took part in an intensified HAES ® -based intervention comprising a physical activity program, nutrition counseling sessions, and philosophical workshops. The control group (CTRL; n = 19) underwent a traditional HAES ® -based intervention. Before and after the interventions, participants were assessed for physiological, psychological, and behavioral parameters (quantitative data) and took part in focus groups (qualitative data). Body weight, body mass index, and waist and hip circumferences did not significantly differ within or between groups (P > 0.05). I-HAES ® showed increased peak oxygen uptake and improved performance in the timed-stand test (P = 0.004 and P = 0.004, between-group comparisons). No significant within- or between-group differences were observed for objectively measured physical activity levels, even though the majority of the I-HAES ® participants indicated that they were engaged in or had plans to include physical activity in their routines. I-HAES ® resulted in improvements in eating attitudes and practices. The I-HAES ® group showed significantly improved all Body Attitude Questionnaire subscale and all Figure Rating Scale scores (P ≤ 0.05 for all parameters, within-group comparisons), whereas the CTRL group showed slight or no changes. Both groups had significant improvements in health-related quality of life parameters, although the I-HAES ® group had superior gains in the “physical health,” “psychological health,” and “overall perception of quality of life and health” (P = 0.05, 0.03, and 0.02, respectively, between-group comparisons) domains. Finally, most of the quantitative improvements were explained by qualitative data. Our results show that this new intensified HAES ® -based intervention improved participants’ eating attitudes and practices, perception of body image, physical capacity, and health-related quality of life despite the lack of changes in body weight and physical activity levels, showing that our novel approach was superior to a traditional HAES ® -based program.

Funding: We acknowledge the support by the Research Support Foundation of the State of São Paulo (FAPESP), grant number 2015/03878-2. Finally, each author received a fellowship grant. FBS was supported by CNPq (grant number 311357/2015-6) and FAPESP (grant number 2017/17424-9), AJP, PdMS, and RFU by FAPESP (grants numbers 2015/26937-4, 2017/05651-0, and 2015/12235-8, respectively), BG has a productivity grant by CNPq and is also supported by CAPES, and MDU by CAPES. The funding sources had no involvement in study design and in the collection, analysis and interpretation of data.

Data Availability: All relevant data are within the paper and its Supporting Information files. The design and rationale of the study was published in the journal Nutrition and Health (DOI: 10.1177/0260106017731260 ).

Copyright: © 2018 Dimitrov Ulian et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation: Dimitrov Ulian M, Pinto AJ, de Morais Sato P, B. Benatti F, Lopes de Campos-Ferraz P, Coelho D, et al. (2018) Effects of a new intervention based on the Health at Every Size approach for the management of obesity: The “Health and Wellness in Obesity” study. PLoS ONE 13(7): e0198401. https://doi.org/10.1371/journal.pone.0198401

In a pilot study, we showed that a 1-year HAES ® -based intervention comprising an exercise program, nutrition counseling, and philosophical workshops led to improvements in body composition, body dissatisfaction, perception of body size, and symptoms of binge eating in addition to participants reporting behavioral and attitudinal changes towards eating and physical activity, as well as improved food choices [ 18 , 19 ]. However, the study had a quasi-experimental design, a small sample size, and did not evaluate cardiovascular risk factors. Given the clear potential of non-prescriptive interdisciplinary interventions for the management of obesity, this study aimed to use a mixed-method approach and a randomized controlled design to extensively investigate the effects of an intensive interdisciplinary HAES ® -based intervention on multiple physiological, attitudinal, nutritional, and behavioral parameters in obese women. Our hypothesis was that the new HAES ® -based intervention would promote greater improvements in overall health-related outcomes (including weight loss, despite the weight-neutral nature of the programs) in comparison to a traditional HAES ® -based intervention.

HAES ® -based interventions have been shown to improve participant’s diet, eating patterns, eating behaviors, anthropometric and metabolic parameters, and psychological well-being [ 8 – 15 ]. However, HAES ® -based interventions are traditionally characterized by group meetings and fixed discussion topics conducted by a limited number of professionals and do not effectively promote physical activity or assess it as an outcome. Moreover, qualitative evaluation is rarely performed, precluding more comprehensive conclusions regarding participants’ experiences and opinions [ 8 , 9 , 11 – 17 ].

HAES ® aims to promote healthy behaviors in people with different body sizes, regardless of body weight changes. Overall, the approach encourages the development of a positive body image and the acceptance of different body shapes and sizes; the promotion of eating practices that respect individual nutritional needs and the sensations of hunger, satiety, appetite, and pleasure; the promotion of enjoyable and sustainable physical activities [ 7 ].

The rising rates of obesity and the consequent health-related effects and healthcare costs have highlighted the need for approaches to assist people who are obese. The majority of obesity interventions focus on weight loss through a restrictive diet and physical activity programs. However, the negative effects provoked by interventions of this nature include binge eating and eating disorders, body dissatisfaction, low self-esteem, and culpability and stigmatization of the fat body [ 1 , 2 , 3 ]. Moreover, the success rate of weight-loss approaches regarding sustainable weight loss, reduction of body fat mass, maintenance of body fat-free mass, and other health benefits (e.g., clinical improvement in blood pressure, lipid profile, physical activity levels, disturbed eating behaviors, self-esteem, and body image) [ 4 , 5 ] is limited. In this context, weight-neutral approaches, such as the Health at Every Size ® approach (HAES ® ), are of increasing interest [ 6 ] (Health at Every Size ® and HAES ® are registered trademarks of the Association for Size Diversity and Health—ASDAH).

For qualitative data, an exploratory content analysis was conducted using an inductive approach which revealed themes and codes from the data. Themes were selected by two researchers using the “cutting and sorting” approach and subsequently organized in a structured codebook [ 41 ]. Both coders independently applied the codebook to the data set, using phrases as the unit of analysis. Kappa coefficients for inter-rater reliability were calculated using the GraphPad QuickCalcs online software. Themes were analyzed considering their core and peripheral aspects, with attention to their details and co-occurrence [ 41 ]. The results of the exploratory content analysis are presented for each group with a detailed description, direct quotes, and paraphrases [ 41 ]. Speeches from the I-HAES ® group members are identified as “I” whereas those from the CTRL group are indicated as “C”.

As described previously [ 20 ], two focus groups convened to understand participant experiences, feelings, expectations, and opinions regarding the intervention and the interdisciplinary team, aspects related to their eating practices, and quality of life. The I-HAES ® and CTRL groups attended separate focus groups. The initial focus groups, each composed of 7 to 10 participants, met one month after the beginning of the intervention and the final focus groups met in the last month of the intervention. Forty-eight and 14 participants in the I-HAES ® and CTRL groups, respectively, joined the initial focus groups whereas 32 and 11, respectively, joined the final focus groups.

Mixed model analysis was performed for each dependent variable, with group (intervention and control groups) and time (pre and post) as fixed factors and subjects as a random factor. In the case of significant F-values, a post hoc test with Tukey’s adjustment was performed for multiple comparisons. For non-parametric data, independent and dependent samples were compared using Mann-Whitney U- and Wilcoxon tests, respectively. Percent delta changes were compared between groups [(post–pre from I-HAES ® )–(post–pre from CTRL)] using unpaired Student’s t-tests. Participants’ baseline characteristics, and baseline characteristics between participants who retained and those who dropped out, were compared using Student’s t- or Chi-square tests. Finally, within-group Cohen’s d effect sizes (ES) were calculated [ 40 ]. All data analyses were performed using SAS 8.2 (SAS Institute Inc., Cary, NC, USA) or SPSS Statistics for Windows, version 17.0. The level of significance was set at P ≤ 0.05 and P values between 0.05 and 0.1 were considered to indicate a tendency towards significance. Quantitative data are presented as mean ± standard deviation or median ± interquartile range, estimated mean of differences between pre and post values, 95% confidence interval (CI), and % difference between delta change, except stated otherwise.

As previously described [ 20 ], prior to and after the intervention (i.e., pre and post), all participants were assessed for anthropometry measures (body weight, height, and hip and waist circumferences); aerobic condition (using a maximal graded exercise test); spontaneous physical activity levels (objectively measured using an ActiGraph GT3X ® accelerometer [ActiGraph®, Pensacola, FL]); muscle function (using the timed-stands test [ 32 ] and timed-up-and-go test [ 33 ], where the lower the scores the better); psychological and behavioral assessments using validated questionnaires; namely, body perception and dissatisfaction (Figure Rating Scale [ 34 , 35 ]) attitudes towards the body (Body Attitude Questionnaire–BAQ–[ 36 , 37 ]) and health-related to quality of life (WHOQOL-BREF [ 38 , 39 ]). From the food diary data, we also calculated the frequency (considering total and daily intake) of intake of fruits, vegetables and ultra-processed foods, as a post-hoc analysis.

The CTRL group attended bimonthly educational lectures, in accordance to the HAES ® principles, on the same topics offered to the I-HAES ® group (i.e., healthful eating, physical activity and philosophy, and encouraging the adoption of a healthy lifestyle). This “control” intervention was designed to mimic the most traditional HAES ® -based interventions [ 8 , 9 – 17 ], as described elsewhere [ 20 ]. Table 1 presents the type and frequency of the activities performed by each group.

The philosophical workshops consisted of five 1-h meetings focused on discussion and reflection about topics related to obesity (e.g., concepts of desire and boredom [ 24 ], restriction and health [ 25 , 26 ], body and health moralization [ 27 – 29 ], freedom [ 24 , 30 ] and anxiety [ 31 ]. The philosophical workshops were conducted by a professional, who had a bachelor degree in Philosophy. The information regarding each component of this intervention is extensively described elsewhere [ 20 ].

The nutritional intervention was based on nutritional counseling [ 21 ], with no prescription of diets. We aimed to promote healthy eating habits by stimulating participants’ sensitivity to hunger and satiety cues, emotional eating, triggers that could lead to automatic behaviors related to food, and methods to neutralize food (i.e., to not classify food as “good” or “bad”). To do so, we used the following strategies: maintaining a food diary, meal planning, and goal setting in accordance with the HAES ® principles [ 20 ]. Before beginning the nutritional counseling, two 1-h lectures were held to present the nutritional approach and to address sociocultural aspects involving eating and concepts about healthy eating according to the Dietary Guidelines for the Brazilian Population [ 22 ]. Finally, participants received a book [ 23 ] that addressed the same principles encouraged by the nutritional intervention. The nutritional sessions lasted for 45 minutes and were conducted by dietitians, who had a bachelor degree in Nutrition. A full description of the nutritional intervention may be found elsewhere [ 18 – 20 ].

The physical activity program was supervised by professionals who had a bachelor degree in Physical Education. The sessions lasted for one hour and comprised different approaches aimed at increasing enjoyment and autonomy for engaging in daily physical activities (e.g., playing ludic games, dancing, engaging in different sports, exercising at participant’s preferred intensities). Improvements in physical capacity and weight loss were considered consequences of this process. As this is the first study to use the HAES ® principles to design physical activity sessions, our theoretical foundation is fully presented in data in S1 File .

The project was approved by the institutional Ethics Committee of the School of Public Health, University of Sao Paulo (protocol 1.738.855). The participants signed an informed consent and all procedures were in accordance with the Declaration of Helsinki as revised in 2008. This study is registered at clinicaltrials.gov (NCT02102061).

The rationale and design of this study have been fully described elsewhere [ 20 ]. In brief, this was a prospective, seven-month, randomized, controlled, mixed-methods clinical trial. The sample consisted of 58 women aged between 25 and 50 years with body mass indexes (BMIs) ranging between 30 and 39.9 kg/m 2 . The exclusion criteria included: a) diagnosis of diabetes mellitus, congestive heart failure, chronic renal disease, or hepatic steatosis; b) use of medications, such as appetite suppressants, thyroid hormones, diuretics or any other “anti-obesity” drug; c) currently engaged in nutritional counseling or in regular supervised physical activity programs elsewhere; e) currently pregnant or nursing. Participants were randomly allocated to the intensified HAES ® -based intervention (I-HAES ® ) or the control (CTRL) groups in a 2:1 ratio using the Research Randomizer software.

Results

Anthropometry Body weight, BMI, waist and hip circumferences, and waist to hip ratio did not significantly differ within or between groups (Table 4). Eight out of 39 participants from the I-HAES® group and 1 out of 19 participants from the CTRL group achieved ≥ 5% weight loss, but this difference did not reach statistical significance (P = 0.246). PPT PowerPoint slide

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larger image TIFF original image Download: Table 4. Anthropometric, maximal aerobic capacity, muscle function, and physical activity assessments before and after the intervention. https://doi.org/10.1371/journal.pone.0198401.t004

Aerobic conditioning Table 4 shows data regarding aerobic capacity. There was a tendency towards an interaction effect in time-to-ventilatory anaerobic threshold (VAT) (P = 0.058) whereas delta analysis revealed a greater increase in time-to-VAT in the I-HAES® group compared to that in the CTRL group (P = 0.04). An interaction effect was observed in VO 2 at VAT (P = 0.01), but post hoc analyses did not detect any significant differences. However, delta analysis showed greater increases in VO 2 at VAT in the I-HAES® group compared to that in the CTRL group (P = 0.01). A tendency towards an interaction effect was observed for time-to-respiratory compensation point (RCP) (P = 0.05), with post hoc analysis showing an increasing trend in the I-HAES® group (P = 0.07); delta analysis revealed greater increases in the I-HAES® group compared that in the CTRL group (P = 0.05). In addition, an interaction effect was observed for VO 2 at RCP (P = 0.009), with the I-HAES® and CTRL groups increasing and decreasing tendencies, respectively (P = 0.09; P = 0.06), whereas delta analysis showed greater increases in the I-HAES® group compared to that in the CTRL group (P = 0.008). A significant main effect of time was observed for the increase in time-to-exhaustion (P = 0.02), but no interaction effect was noted. Likewise, no significant differences were evidenced through delta analysis (P = 0.44). Finally, a main effect of time and an interaction effect were observed for VO 2peak (P = 0.05 and 0.004, respectively), with the I-HAES® group (P = 0.0003), but not the CTRL group (P > 0.05), showing an increase in this parameter. Furthermore, delta analysis showed greater increases in VO 2peak in the I-HAES® group compared to that in the CTRL group (P = 0.004).

Muscle function An interaction effect was observed in the timed-stand test (P = 0.006), with the I-HAES® (P = 0.08), but not with the CTRL (P > 0.05) group showing an improving trend in this parameter. Similarly, delta analysis showed greater improvements in the timed-stand test in the I-HAES® group compared to that in the CTRL group (P = 0.004). Significant main effects of group and time were observed for the timed-up-and-go test (P = 0.04 and 0.01, respectively), but no interaction effect was noted. No significant differences were evidenced through the delta analysis (P = 0.29) (Table 4).

Physical activity levels In the final focus groups, the majority of the participants in the I-HAES® group reported being engaged in some physical activity outside the intervention context or having plans to include novel activities in their routines, suggesting that they had gained a willingness and autonomy to practice physical activities. The participants in the CTRL group reported that the lectures on physical activities had stimulated them to become more attentive about how much they moved their bodies and were more aware of its importance. In the final focus group, ten CTRL participants reported having included physical activities in their routines. The participants that did not engage in any physical activity reported that they could not identify which activity they enjoyed and mentioned aspects of their routines that acted as barriers (e.g., unforeseen events in their routines, work demands, caring for their children). Accelerometry data did not reveal any changes within or between groups in sedentary time, light physical activity levels, or time spent in moderate to vigorous physical activity after the intervention. Likewise, the delta differences showed no significant differences in these parameters (P > 0.05) (Table 4).

Participant eating characteristics The I-HAES® group showed significant decreases in the total and daily consumption of ultra-processed foods, and significant increases in the total and daily consumption of fruits and vegetables. The CTRL group did not show any difference in total and daily intake of abovementioned food groups (Table 5). PPT PowerPoint slide

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larger image TIFF original image Download: Table 5. Dietary frequency intake of ultra-processed foods, fruits and vegetables of women participating in a randomized controlled trial based on the Health at Every Size® approach. https://doi.org/10.1371/journal.pone.0198401.t005 The qualitative data corroborate these findings. In the I-HAES® group, the initial eating difficulties were related to the eating structure, managing desires and emotional eating, eating in social situations, and knowing what and how much to eat. The participants had previously dealt with these issues by avoiding eating, replacing “high-calorie” foods with “low-calorie” foods, eating alone, and trusting other people to make their food choices. These participants completed food diaries throughout the intervention and reported that this tool led to the improvement of their eating perception and consciousness. This was particularly connected with improvements in sensitivity to hunger and satiety feelings, which allowed them to choose how much and what to eat. The participants were encouraged to increase their attentiveness while eating (i.e., eating without distractions, spending more time at the table, and evaluating what they felt like eating), resulting in changes in their food consumption: “I’ve learned that after I stopped eating in front of the television I stopped nibbling” (I10). Participants reported that they were able to identify when they relied on food to deal with feelings and emotions and were able to manage this situation differently. This gave them a sense of empowerment and responsibility for their own eating behaviors. The philosophical workshops were also reported to contribute to this change. In addition, members of the I-HAES® group reported having a more diversified eating habit, increasing their consumption of in natura or minimally processed foods. Finally, they reported having acquired autonomy to plan their eating: they were able to anticipate and think about their eating, plan their grocery list, and organize their schedule to cook. Regarding cooking, they were stimulated to engage more often in this activity and to diversify the ingredients and spices they used, which resulted in a higher willingness and interest to eat fresh and home-made foods. In the CTRL group, the initial eating difficulties were related to emotional eating, which they dealt with by avoiding eating or eating alone. The participants received lectures about healthful eating and completed food diaries at the beginning and after the intervention respectively. The participants reported benefits from these diaries: they were able to notice patterns in their eating habits (e.g., by evaluating the reasons why they ate, how they ate, how they felt while eating, identifying when they ate in response to emotions, and gauging their hunger and satiety) and were working to change them. The lectures on healthy eating were reported to be clarifying, helping them to reconsider what they understood as healthy food, to value the importance of planning their eating, and to be more attentive about the quantity and the quality of their eating. Nonetheless, according to their statements, the CTRL group was unable to make concrete changes in their eating habits.

Body image perceptions Regarding participants’ attitudes toward their bodies, significant within-group differences were observed for all BAQ subscales post-intervention in the I-HAES® group (P ≤ 0.05) (Fig 3). Compared to those in the CTRL group, the I-HAES® group had significant decreases in the “body disparagement” (P = 0.01) and “feeling fat” (P = 0.01) subscale scores and a significant increase in the “attractiveness” (P = 0.01) and “strength and fitness” (P = 0.001) subscale scores post-intervention. In contrast, the CTRL group showed a decrease only in the “salience of weight and shape” subscale score (P = 0.03). In relation to participants’ body perception and dissatisfaction, the I-HAES® group showed significant within-group differences for all Figure Rating Scale scores (P ≤ 0.05). The I-HAES® group also showed improvements in the “current body size” and “current body size–ideal body size” scores when compared those in the CTRL group post-intervention (P = 0.02 for both parameters). In the “current body size” subscale, the I-HAES® initial and final scores were 5.0 ± 3.0 and 2.0 ± 2.0, respectively (P = 0.001). The initial and final scores in the CTRL group were 3.0 ± 2.0 and 4.0 ± 5.0, respectively (P = 0.098). For “current body size–ideal body size”, the initial and final scores in the I-HAES® group 3.0 ± 1.0 and 2.0 ± 2.0, respectively (P = 0.001) and 3.0 ± 2.0 and 3.0 ± 2.0, respectively in the CTRL group (P = 0.12). PPT PowerPoint slide

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larger image TIFF original image Download: Fig 3. (Left panel): Results from the intensified HAES®-based intervention group Body Attitude Questionnaire pre- and post-intervention. (Right panel): Results from the control group Body Attitude Questionnaire pre- and post-intervention. I-HAES®, intensified HAES®-based intervention group; CTRL, control group. § Significant difference when compared to the intensified HAES®-based intervention group post-intervention (P ≤ 0.05). ø Significant difference within group (P ≤ 0.05). https://doi.org/10.1371/journal.pone.0198401.g003 The focus groups corroborated these quantitative changes. In the baseline focus group, both groups shared similar perceptions. While some participants reported having positive attitudes toward their bodies, valuing it as part of their personality, others did not: “Losing weight is very important to me: I usually don’t look at myself in the mirror, and when I do I don’t recognize myself” (I5), and “I’d like to lose weight, it disturbs me: I stopped doing things, my social life changed” (C47). Other participants shared a preoccupation with their health and willingness to perform activities or a desire to change certain characteristic of their bodies. In the final focus group, members of the I-HAES® group said that they felt empowered by the activities, highlighting broader gains than nutrition, physical activity, and philosophy (“The intervention changed my life, my conceptions. If I were to define the intervention as my life today, I would define it as life, death and rebirth: I lived, gained weight, died and the intervention rebirth me”–I21). While four participants said that they still did not accept being fat, others said that although they expected to lose more weight, they were happy with their gains (e.g., more willingness, pain relief, etc.), and understood that body change would be a long-term process. Also, their weight was no longer a condition for their happiness (“I used to see myself happy only after [losing weight]. I still want to lose weight, but I’m already happy now”–I16). According to them, their previous focus on weight loss per se was a source of emotional distress that prevented them from keeping healthy habits as they were only sustained during weight loss. The philosophical workshop discussions were reported to have influenced these changes. These quantitative results suggest that, despite not having a significant weight loss, our participants developed a better body image and were more comfortable and less dissatisfied with their current physical condition. Those in the CTRL group stressed that the lectures had an effect on their concepts, making them reflect on the information that was communicated: they started to think and felt more responsible for their body condition and reported feeling more comfortable about it. Despite that, these participants mentioned discontentment: “I have trouble when I’m getting dressed, I want to die because nothing fits me, everything looks hideous” (C47).