Q&A with Allison Miner, EdD, RDN, LN

January arrived, as it always does, with all of our hopes and aspirations packaged neatly into so many New Year’s resolutions: better finances, better relationships, better health, better us. In terms of specific pledges, losing “x” amount of pounds typically hovers somewhere near the top of the list in any given year. Yet we are consistently met with disappointment, as weight-loss goals prove to be short-lived accomplishments or aren’t achieved at all — even with the guidance of a health care professional.

It's time to start looking at body size through a different lens, experts contend, not just at the start of a new year but anytime the subject of weight enters a conversation about health. And not just in the doctor’s office but in other settings as well — including cardiopulmonary rehabilitation, where weight loss is identified as a primary intervention for improving cardiovascular and cardiopulmonary health.

The concept of Health at Every Size® (HAES), which focuses on weight inclusivity, speaks to this need. George Mason University assistant professor of nutrition and food studies Allison Miner, EdD, RDN, LN, tells News & Views more about the model and how cardiopulmonary professionals can help their participants attain better outcomes.

 

What is HAES, exactly, and how does it differ from traditional approaches to addressing weight?

Lindo Bacon, a scholar with a PhD in exercise physiology, challenged the traditional weight-normative model of health. Weight-normative approaches to health and health care center body weight as a primary indicator of health status. Within this model, achieving or maintaining a “normal” weight (often defined using body mass index or BMI) is viewed as essential for health, and intentional weight loss is commonly prescribed for individuals with higher body weights.

In contrast, Dr. Bacon presented scientific evidence supporting a weight-inclusive approach. Weight-inclusive models of health do not center body weight or weight loss as primary goals or measures of health. Instead, they emphasize health-promoting behaviors, equitable access to care, and respect for body diversity. Weight inclusivity is a core principle underlying the Health at Every Size®  movement.

Note: There has been a recent evolution of this program and now it is owned by the organization, The Association for Size Diversity and Health (ASDAH).

 

What does it mean to be ‘weight-inclusive?’

Weight inclusive means:

• recognizing health is influenced by a multitude of factors such as personal behavior, sleep, access to care, stress, physical activity, genetics, and social factors that are the conditions in which people are born, grow, live, work and age
• emphasis is placed on what can be controlled by the individual, like behavior around sleep, stress, exercise, or eating a healthy diet
• not treating larger bodies as a disease or moral failing
• people are not assumed to be unhealthy based solely on their weight
• acknowledging intentional weight loss is not sustainable long-term and failure can discourage future healthy behaviors
• using respectful, non-stigmatizing language for people across the weight spectrum

 

Is there conclusive evidence to support HAES?

By conclusive evidence, I assume you mean conclusive scientific evidence. Science does not prove things as final truths. It builds the best explanations based on the current body of evidence.

First, let’s talk about the failure of using weight loss as the primary goal for patients. It is estimated that 80%–95% of diets fail long-term. Most people regain lost weight within 1–5 years. Long-term success rates for intentional weight loss are estimated at 5%–20%. Repeated weight loss and regain (yo-yo dieting) increases risk of cardiovascular disease, insulin resistance, high blood pressure, and inflammation. It’s linked to greater mortality risk than stable weight, even at higher BMI. In addition, despite common beliefs, genetics account for 40%–70% of body weight variation. Other factors such as hormones, metabolism, medication, stress, and limited access to healthy food or safe places to be active also play a significant role. People will blame themselves for this failure, not the diet; and this fosters a cycle of self-blame, shame and helplessness. This leads to avoidance of care.  Dieting and body dissatisfaction are linked to anxiety, depression, low self-esteem, and eating disorders — not to mention future weight gain.  

Matheson et al. (2011) demonstrated that health-related behaviors, rather than body weight alone, were associated with mortality risk. Analysis of NHANES data (n = 11,760) showed that a substantial proportion of individuals classified as overweight or obese had blood pressure, lipid levels, glucose, and other metabolic markers within normal ranges. It also showed that some normal weight individuals had metabolic risk. The Aerobics Center Longitudinal Study followed 25,714 males for 8 years who were categorized according to their BMI — normal, overweight, and obese. They looked at the influence of low cardiorespiratory fitness and all-cause mortality. Low fitness was an independent predictor of mortality in all body mass groups. Fit men, including those who were overweight or obese, had lower mortality rates than unfit men of any weight. Unfit normal-weight men had twice the mortality risk compared to fit obese men. Analysis by Kuk and colleagues followed 6,011 subjects from NHANES III for over 8 years. Individuals classified as metabolically normal obese (obesity without insulin resistance or other risk factors) had equal or better outcomes than metabolically unhealthy individuals at normal weight.

 

Does HAES work BETTER than conventional tactics … or is it simply another tool for the patient who has repeatedly tried other methods with little success?

AACVPR and other leading organizations recognize that weight loss is associated with significant improvements in blood pressure, lipid levels, glycemic control, and even a reduction in premature all-cause mortality among individuals with overweight or obesity. These benefits are well-established. A weight loss of just 5% can lead to meaningful health improvements, which is why this threshold is commonly used.

Unfortunately, conventional tactics just don’t work. Even if someone is at a healthy BMI, it does not guarantee they are metabolically healthy. Intentional weight loss is difficult and often not achievable or sustainable. Patients enrolled in conventional cardiac rehabilitation (CR) programs often do not achieve the clinically significant weight-loss goal of 5%–10% of body weight despite participating in structured care. This has been shown in study after study. As an example, a study by Wilkinson, Harrison & Doherty (2021) analyzed weight-change outcomes among 29,601 obese patients participating in cardiac rehabilitation (CR) using data from the UK National Audit of Cardiac Rehabilitation. Men lost on average 2 pounds and women on average 1 pound. Only 21% of participants lost 3% or more of body weight while 11% gained 3% or more. The majority remained within their baseline weight.

Given the poor outcome of long-term success of conventional weight-loss approaches, any strategy that improves cardiometabolic health independent of weight change represents a meaningful clinical gain. HAES is a philosophical framework that guides how health is conceptualized and pursued, rather than a specific tool, program, or intervention. Evidence shows that many individuals in larger bodies can be metabolically healthy, while thinness alone does not guarantee good health. A weight-inclusive approach encourages individuals to attend to internal cues of hunger, fullness, and satisfaction and reframes health behaviors as supportive and enjoyable rather than punitive. This shift often makes health-promoting practices more sustainable and, as a result, easier for both patients and clinicians to implement.

 

What kind of reservations might providers have about employing HAES — and what is the response to that reluctance?

Critics of weight-inclusive approaches argue that they downplay the health risks associated with higher body weight. However, as former U.S. Secretary of Defense Donald Rumsfeld famously stated, “You go to war with the army you have, not the army you might want or wish to have at a later time.” In the context of health care, focusing on weight loss alone has not proven to be a consistently successful or sustainable strategy. Repeated reliance on conventional messaging such as “eat less, move more” has yielded limited long-term success and often leads to frustration for both patients and clinicians.

This does not suggest that efforts to promote weight loss must be abandoned entirely. Rather, weight loss can be addressed, when appropriate, alongside a weight-inclusive approach that prioritizes health-promoting behaviors. In practice, many dietitians have shifted away from emphasizing weight loss as the primary goal and instead focus on improving dietary quality, physical activity, and other behaviors that support cardiometabolic health. Drawing on decades of clinical experience with the obesity epidemic, dietitians recognize that sustained weight loss is often difficult to achieve and maintain. Repeated weight-loss failure or weight regain can contribute to frustration, decreased self-efficacy, and depressive symptoms among patients. As a result, the field has increasingly emphasized smaller, attainable improvements in health indicators rather than large changes in body weight. From this perspective, any strategy that meaningfully reduces cardiometabolic risk factors is a worthwhile and evidence-based clinical goal.

 

What about patients? Surely there are some who balk at being healthy at the size they are and instead want to be healthy…but also “skinny.”

In my clinical experience, many individuals who are classified as overweight or clinically obese express a desire to lose weight, reflecting the widespread societal belief that thinness equates to better health. In counseling, I educate patients about the limitations and potential harms of focusing exclusively on weight loss as the primary health goal. Instead, I emphasize health, quality of life, and engagement in meaningful, positive behaviors that support well-being without the burden of highly restrictive dieting.

Importantly, when patients shift their focus away from weight loss and toward sustainable behaviors such as improved diet quality, enjoyable physical activity, and attention to internal cues, weight loss may occur naturally for some individuals. Regardless of whether weight changes, this approach often leads to improvements in metabolic health, psychological well-being, and long-term adherence to health-promoting behaviors.

How does HAES fit in a health care environment where highly effective GLP-1 weight-loss medications enjoy blockbuster popularity and are becoming increasingly accessible?

I am a strong proponent of GLP-1 receptor agonists for weight management. These medications are highly effective for weight loss and cardiometabolic risk reduction while patients are actively taking them. However, the evidence also shows that weight regain is common after discontinuation. A meta-analysis conducted by researchers affiliated with Stanford University found that many patients regain a substantial portion of the weight they lost within months to a year after stopping GLP-1 therapy. This pattern reinforces what decades of obesity research have demonstrated: interventions that do not address the chronic biological regulation of body weight are unlikely to produce durable weight loss when withdrawn.

There is emerging research exploring alternative models of GLP-1 use, including long-term microdosing and intermittent or “as-needed” use during periods of increased appetite or weight gain. These approaches remain speculative and are not currently approved by the Food and Drug Administration. Nonetheless, some clinicians are experimenting with these strategies in practice, reflecting ongoing efforts to reconcile biological realities with real-world patient needs.

Despite their efficacy, GLP-1 medications remain inaccessible to many individuals who could benefit most. Insurance coverage and policy decisions frequently exclude these drugs for the treatment of obesity, resulting in access that disproportionately favors individuals who can afford to pay out of pocket. At the same time, these medications are often used for cosmetic or modest weight loss rather than for the treatment of cardiometabolic disease, further highlighting inequities in access and utilization.

The HAES philosophy can and should be used alongside GLP-1 therapies. HAES emphasizes sustainable behavior change, body trust, and health-promoting practices rather than reliance on appetite suppression alone. In this way, weight-inclusive approaches complement pharmacologic treatment by supporting long-term health behaviors that remain beneficial regardless of whether medication use is continued.

 

Can HAES be deployed in CR/PR programs if there is no dietitian on staff? Can only a nutrition professional administer it? Is special training or certification required?

Anyone can deploy the Health at Every Size® strategy, but they will need some training. Unfortunately, training is not well organized or promoted. Even dietitians need to be well versed in the philosophy because we don’t get training in this program in school.

One program offered by the Association for Size Diversity and Health is a virtual workshop. As an example, these are the objectives they cover during that 1-hour session:

• Medical weight bias and how it impacts health outcomes,
• The history of developing the Health at Every Size® Principles
• How the Health at Every Size® Framework of Care improves health outcomes

Another program is offered virtually through the University of Arizona. They have a non-credit certificate program for health care providers. A Weight-Inclusive Education Toolkit (WITI) is being developed to update weight-normative curricula with materials that “do no harm,” drawing on lived experience and social justice perspectives. However, it has not been published.

 

What does a productive HAES conversation with a patient look like?

I believe education is the first step in supporting meaningful health change. I am transparent with patients about both the potential benefits and limitations of weight loss. While I do not discourage weight loss, I emphasize health-promoting behaviors that may lead to weight change without making weight loss the primary goal. Together, the patient and I identify a behavior they perceive as problematic; and we develop an achievable, time-limited goal to practice and evaluate.

In lieu of the traditional 5% weight-loss and lower waist circumference goal commonly used in cardiac rehabilitation, measurable outcomes that focus on behavior change and skill acquisition should be prioritized. More meaningful outcomes include the number of days per week patients engage in clinician/patient selected health behaviors, adherence to prescribed activities, and the ability to correctly identify behaviors known to improve cardiovascular health through a brief written or digital assessment. These measures allow clinicians and patients to evaluate progress based on controllable actions, reinforce self-efficacy, and establish long-term strategies for cardiovascular risk reduction rather than short-term changes in body weight.

As one example, insufficient sleep is a common contributor to overeating and weight gain. In this situation, I educate the patient on the role of sleep in appetite regulation, energy balance, and overall health; and we collaboratively develop a plan to address the specific sleep-related challenge they are experiencing. Importantly, inadequate sleep often affects far more than weight. It can impair mood, concentration, and enjoyment of daily life, so patients are frequently highly motivated to work on this behavior.

A critical caveat is that my role is not to ensure that patients meet their goals. Rather, my role is to support problem-solving, remove barriers, and help patients troubleshoot strategies that facilitate positive change, regardless of how long the process takes. As the saying goes, we can lead patients to water, but we cannot make them drink.

 

What outcomes can be anticipated in a successful HAES case?

Cardiac rehabilitation typically lasts about 12 weeks, which is clearly insufficient time to address every behavior that may influence health outcomes. My role during this period is not to “fix” all behaviors, but to educate patients about how specific behaviors may be affecting their health, including weight, and to offer practical, evidence-based options for change. From those options, the patient chooses a focus area, and we monitor progress together over the course of the program. Ultimately, my goal is to help patients distinguish between what is within their control and what is not. Body weight is not fully under an individual’s control, particularly in the short term. Behaviors such as getting adequate sleep, engaging in regular movement, or managing stress are. By directing effort toward modifiable behaviors rather than outcomes like weight loss, patients are more likely to experience meaningful, sustainable improvements in health and quality of life.

 

In summary, what are your final takeaways on the need for, benefits of, and future of HAES?

I hope that, as a society, we move away from positioning weight loss as the primary or defining goal of health. While changes in body weight may occur for some people when health-promoting behaviors are adopted, weight itself is an imperfect and often misleading marker of well-being. Prioritizing behaviors such as adequate sleep, nourishing food intake, regular movement, stress management, and access to health care allows individuals to focus on improvements in metabolic health, physical functioning, and quality of life. These outcomes matter regardless of whether weight changes. Shifting the focus from weight loss to sustainable, health-supportive behaviors creates space for more inclusive, compassionate, and effective approaches to care.

 

Dr. Miner is an assistant professor and registered dietitian in the Department of Food and Nutrition Studies at George Mason University in Fairfax, Virginia. Miner teaches a variety of nutrition and dietetic courses, mentors dietetic students, writes about nutrition topics, and provides medical nutrition therapy. 

Dr. Miner co-presented a session with Carolyn Feibig, MS, RD, CCTD, at the 40^th AACVPR Annual Meeting. A recording of “Yes, you can eat that candy bar!” is available through the On-Demand Access Pass, available in the Learning Center.