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RESEARCH ARTICLE

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

Mariana Dimitrov Ulian1☯*, Ana Jéssica Pinto2☯, Priscila de Morais Sato1‡, Fabiana B. Benatti2,3☯, Patricia Lopes de Campos-Ferraz3☯, Desire Coelho2☯, Odilon J. Roble4☯,

Fernanda Sabatini1☯, Isabel Perez1☯, Luiz Aburad1☯, André Vessoni1☯, Ramiro Fernandez

Unsain5☯, Marcelo Macedo Rogero1,6‡, Tatiana Natasha Toporcov7‡, Ana Lúcia de Sá-

Pinto8‡, Bruno Gualano2☯, Fernanda B. Scagliusi1☯

1 Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil, 2 Applied

Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology,

Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil, 3 School of Applied

Sciences, Universidade Estadual de Campinas, Limeira, Brazil, 4 Faculty of Physical Education,

Universidade Estadual de Campinas, Campinas, Brazil, 5 Institute of Health and Society, Federal University

of Sao Paulo, Sao Paulo, Brazil, 6 Food Research Center (FoRC), CEPID-FAPESP, Research Innovation

and Dissemination Centers Sao Paulo Research Foundation, Sao Paulo, Brazil, 7 Department of

Epidemiology, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil, 8 Laboratory of

Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao

Paulo, Sao Paulo, Brazil

☯ These authors contributed equally to this work. ‡ These authors also contributed equally to this work.

* m.dimitrov@usp.br

Abstract

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, interdisciplin-

ary 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 sig-

nificantly improved all Body Attitude Questionnaire subscale and all Figure Rating Scale

PLOS ONE | https://doi.org/10.1371/journal.pone.0198401 July 6, 2018 1 / 19

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OPENACCESS

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

Editor: Doan T. M. Ngo, University of Newcastle,

AUSTRALIA

Received: January 9, 2018

Accepted: May 20, 2018

Published: July 6, 2018

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.

Data Availability Statement: 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).

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

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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.

Introduction

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 sustain-

able 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 lev-

els, disturbed eating behaviors, self-esteem, and body image) [4,5] is limited. In this context,

weight-neutral approaches, such as the Health at Every Size1 approach (HAES1), are of

increasing interest [6] (Health at Every Size1 and HAES1 are registered trademarks of the

Association for Size Diversity and Health—ASDAH).

HAES1 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].

HAES1-based interventions have been shown to improve participant’s diet, eating pat-

terns, eating behaviors, anthropometric and metabolic parameters, and psychological well-

being [8–15]. However, HAES1-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 eval-

uation is rarely performed, precluding more comprehensive conclusions regarding partici-

pants’ experiences and opinions [8,9,11–17].

In a pilot study, we showed that a 1-year HAES1-based intervention comprising an exer-

cise 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 manage-

ment of obesity, this study aimed to use a mixed-method approach and a randomized con-

trolled design to extensively investigate the effects of an intensive interdisciplinary HAES1-

Effects of a new Health at Every Size-based intervention for the management of obesity

PLOS ONE | https://doi.org/10.1371/journal.pone.0198401 July 6, 2018 2 / 19

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.

Competing interests: The authors have declared

that no competing interests exist.

https://doi.org/10.1371/journal.pone.0198401
based intervention on multiple physiological, attitudinal, nutritional, and behavioral parame-

ters in obese women. Our hypothesis was that the new HAES1-based intervention would pro-

mote greater improvements in overall health-related outcomes (including weight loss, despite

the weight-neutral nature of the programs) in comparison to a traditional HAES1-based

intervention.

Methods

Study design and participants

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/m2. The exclusion criteria included: a) diagnosis of diabetes

mellitus, congestive heart failure, chronic renal disease, or hepatic steatosis; b) use of medica-

tions, 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 HAES1-based intervention (I-HAES1) or the control (CTRL) groups in a 2:1

ratio using the Research Randomizer software.

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).

I-HAES1-based intervention

The I-HAES1 group participated in a program comprising thrice-weekly physical activity ses-

sions, bimonthly individual nutritional sessions, and five philosophical workshops over 7

months. All professionals involved in the intervention were trained in the HAES1 concepts.

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 HAES1 principles to design physical activity

sessions, our theoretical foundation is fully presented in data in S1 File.

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 HAES1 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 Die-

tary 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 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

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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].

CTRL group

The CTRL group attended bimonthly educational lectures, in accordance to the HAES1 prin-

ciples, on the same topics offered to the I-HAES1 group (i.e., healthful eating, physical activity

and philosophy, and encouraging the adoption of a healthy lifestyle). This “control” interven-

tion was designed to mimic the most traditional HAES1-based interventions [8,9–17], as

described elsewhere [20]. Table 1 presents the type and frequency of the activities performed

by each group.

Quantitative data collection and statistical analysis

As previously described [20], prior to and after the intervention (i.e., pre and post), all partici-

pants were assessed for anthropometry measures (body weight, height, and hip and waist cir-

cumferences); aerobic condition (using a maximal graded exercise test); spontaneous physical

activity levels (objectively measured using an ActiGraph GT3X1 accelerometer [ActiGraph1,

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 calcu-

lated the frequency (considering total and daily intake) of intake of fruits, vegetables and ultra-

processed foods, as a post-hoc analysis. 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-HAES1)–(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 Stu-

dent’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

Table 1. Type and frequency of the activities performed by the intensified HAES1-based intervention group

(I-HAES1) and the control group (CTRL).

Activity I-HAES1 CTRL

Supervised physical activity 3 times-a-week none

Individual nutritional sessions 2 times per month none

Philosophical workshops 5 throughout the intervention none

Lectures on physical activity none 1

Lectures on healthy eating 2 (pre-intervention) 2

Lectures on philosophy none 1

Food diary register Throughout the intervention 2 (pre- and post-intervention)

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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.

Qualitative data collection and analysis

As described previously [20], two focus groups convened to understand participant experi-

ences, feelings, expectations, and opinions regarding the intervention and the interdisciplinary

team, aspects related to their eating practices, and quality of life. The I-HAES1 and CTRL

groups attended separate focus groups. The initial focus groups, each composed of 7 to 10 par-

ticipants, 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-HAES1 and

CTRL groups, respectively, joined the initial focus groups whereas 32 and 11, respectively,

joined the final focus groups.

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 struc-

tured 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-HAES1 group members are identi-

fied as “I” whereas those from the CTRL group are indicated as “C”.

Results

Participants

One hundred and thirty-two women were screened for participation. Ninety-seven met the

inclusion criteria and were randomly assigned into either the I-HAES1 (n = 62) or CTRL

(n = 35) groups. Thirty-nine participants withdrew from the study for various reasons (one

moved to another country, two because of distance issues, three became pregnant, six because

of personal reasons, eight because of health reasons, and 19 were not available). Therefore, 58

subjects completed the trial and were included in the analysis (I-HAES1, n = 39; CTRL,

n = 19; maintaining the 2:1 ratio). S1 Table presents the main baseline characteristics between

participants who retained and those who dropped out, stratified by groups. The study flow-

chart is presented in Fig 1.

Table 2 shows participant demographic characteristics at baseline. No differences were

observed between groups at baseline regarding age, weight, BMI, waist and hip circumfer-

ences, education, and family income (Table 2).

Qualitative data analysis

The thirteen emerging codes (Table 3) which resulted from participants’ statements revealed

experiences that influenced their involvement with physical activity, eating-related aspects,

body image, and quality of life. The kappa values showed a satisfactory strength of agreement

between coders [42]. Codes that referred to similar topics were grouped and are shown in Fig

2. Notably, some of the resultant topics (spontaneous physical activity levels and participant

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eating, body image perceptions, and quality of life) were articulated by both quantitative and

qualitative data, as presented in some of the following topics.

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-HAES1

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).

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-HAES1 group compared to that in the

CTRL group (P = 0.04). An interaction effect was observed in VO2 at VAT (P = 0.01), but

post hoc analyses did not detect any significant differences. However, delta analysis showed greater increases in VO2 at VAT in the I-HAES

1 group compared to that in the CTRL group

(P = 0.01).

A tendency towards an interaction effect was observed for time-to-respiratory compensa-

tion point (RCP) (P = 0.05), with post hoc analysis showing an increasing trend in the I-HAES1 group (P = 0.07); delta analysis revealed greater increases in the I-HAES1 group

compared that in the CTRL group (P = 0.05). In addition, an interaction effect was observed

for VO2 at RCP (P = 0.009), with the I-HAES 1 and CTRL groups increasing and decreasing

tendencies, respectively (P = 0.09; P = 0.06), whereas delta analysis showed greater increases in

the I-HAES1 group compared to that in the CTRL group (P = 0.008).

Fig 1. The “Health and Wellness in Obesity” study flowchart.

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Table 2. General characteristics of women participating in a randomized controlled trial based on the Health at Every Size1 approach.

Intensified HAES1-based intervention group (n = 39) Control group

(n = 19)

P

Age (yr), mean, ± SD 33.4 ± 6.7 37.1 ± 7.8 0.065 Anthropometry

Body weight (kg), mean, ± SD 90.7 ± 10.9 90.0 ± 10.5 0.912 Body mass index (kg/m2), mean, ± SD 34.5 ± 2.7 33.9 ± 3.1 0.552 Waist circumference (cm), mean, ± SD 108.6 ± 8.6 109.0 ± 10.2 0.248 Hip circumference (cm), mean, ± SD 119.4 ± 8.9 118.2 ± 7.0 0.431 Relationship status, n (%)

Single 21 (54) 5 (26) 0.177

Married 13 (33) 10 (53)

Common-law marriage 2 (5) 1 (5)

Divorced 3 (8) 3 (16)

Education, n (%)

Graduated from high school 6 (15) 1 (5) 0.292

Incomplete high school graduation 0 (0) 0 (0)

Graduated from college 18 (46) 7 (37)

Incomplete college graduation 7 (18) 2 (11)

Postgraduate-level studies 8 (21) 9 (47)

Monthly family income (value in Dollars), n (%)

� 541.0 5 (13) 1 (5) 0.502

541.01–1,143.0 6 (15) 1 (5)

1,143.01–2,705.0 17 (44) 11 (58)

2,705.01–5,410.0 9 (23) 6 (32)

� 5,410.01 1 (3) 0 (0)

Did not know 1 (3) 0 (0)

Data are expressed as means ± SD, except when identified. No significant differences were found. (nonpaired t-test or chi-square test).

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Table 3. Codes and kappa coefficients from focus groups with participants in the “Health and Wellness in Obe-

sity” study.

Code Kappa

Potentialities and effects of the intervention 0.854

Critics, suggestions, and expectations of the intervention 0.772

Quality of life 0.979

Perceptions of the body 0.662

Nutritional intervention 0.901

Eating characteristics 0.853

Expectations and difficulties with eating 0.738

Strategies to deal with eating 0.721

Food roles 0.652

Experiences with physical activities 0.608

Physical activity sessions 0.766

Difficulties with physical activities 0.978

Philosophical workshops 1.000

Kappa result is interpreted as follows: 0.61 to 0.80 as “good” agreement, and 0.81 to 1.00 as “very good” agreement

[42].

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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 evi-

denced through delta analysis (P = 0.44). Finally, a main effect of time and an interaction effect

were observed for VO2peak (P = 0.05 and 0.004, respectively), with the I-HAES 1 group

(P = 0.0003), but not the CTRL group (P > 0.05), showing an increase in this parameter. Fur-

thermore, delta analysis showed greater increases in VO2peak in the I-HAES 1 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-HAES1

(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-HAES1 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-HAES1 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

Fig 2. Representation of the codes that composed some of the resultant topics.

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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 parame-

ters (P> 0.05) (Table 4).

Table 4. Anthropometric, maximal aerobic capacity, muscle function, and physical activity assessments before and after the intervention.

Intensified HAES1-based intervention group

(n = 39)

Control group (n = 19)

Variable Pre Post CI (95%) ES Pre Post CI (95%) ES % Difference between delta change

P value

Anthropometry

Body weight (kg) 90.7 (10.9) 90.1 (12.1) -1.09 to 1.45 -0.06 90.0 (10.5) 91.0 (11.1) -2.69 to 0.81 0.09 -0.87 0.301

Body mass index (kg/m2) 34.5 (2.7) 34.5 (3.2) -0.42 to 0.56 0.01 33.9 (3.1) 34.3 (3.3) -1.04 to 0.32 0.12 -0.83 0.309

Waist circumference (cm) 108.6 (8.6) 106.8 (8.1) -0.66 to 4.19 -0.21 109.0

(10.2)

107.8 (9.6) -2.18 to 4.54 -0.12 0.54 0.779

Hip circumference (cm) 119.4 (8.9) 119.0 (8.3) -2.96 to 1.42 -0.04 118.2 (7.0) 118.3 (8.6) -3.14 to 2.94 0.01 0.08 0.722

Waist to hip ratio 0.9 (0.06) 0.9 (0.06) -0.006 to

0.031

-0.19 0.9 (0.07) 0.9 (0.08) -0.017 to

0.034

-0.13 0.53 0.788

Maximal aerobic

capacity

Time-to-VAT (sec) 222.3

(70.1)

226.3 (56.1) -30.35 to

22.45

0.06 243.3

(107.4)

203.4

(64.3)

2.67 to 79.73 -0.37 19.70o� 0.058

Time-to-RCP (sec) 454.7

(90.5)

502.6

(109.5)# -86.96 to

-9.10

0.53 463.3

(105.0)

446.6

(101.9)

-38.55 to

74.05

-0.16 15.02o� 0.059

Time-to-exhaustion (sec)� 625.4

(124.4)

671.4 (98.6) -79.19 to

-12.76

0.37 656.7

(91.4)

678.7

(108.0)

-71.18 to

26.01

0.24 3.84 0.429

VO2 VAT (mL/kg/min) 11.9 (3.0) 12.8 (2.7) -1.82 to 0.02 0.30 12.2 (4.1) 11.2 (2.1) -0.18 to 2.51 -0.26 17.83 o� 0.014

VO2 RCP (mL/kg/min) 18.4 (2.9) 19.6 (3.6) # -2.39 to -0.19 0.44 18.6 (3.6) 17.3 (2.4)# -0.29 to 2.89 -0.34 14.65o� 0.010

VO2peak (mL/kg/min) � 22.0 (3.8) 24.0 (3.9)ø -2.89 to -1.07 0.52 22.5 (3.7) 22.2 (3.8) -0.93 to 1.74 -0.09 10.91o� 0.005

Muscle function tests

Timed Stands test (sec) 19.6 (4.0) 18.1 (4.3)# 0.29 to 3.10 -0.37 18.5 (4.4) 20.3 (5.8) -3.62 to 0.27 0.41 0.51o� 0.007

Timed-up-and-go test

(sec)�ᶿ 6.0 (0.8) 6.4 (1.2) -0.87 to 0.19 0.52 7.3 (3.4) 8.1 (5.6) 1.54 to -0.08 0.24 -5.58 0.300

Physical activity levels

Sedentary time (min/day) 513.5

(88.1)

501.1

(101.3)

-17.74 to

50.68

-0.14 538.5

(102.0)

517.0

(138.9)

-45.23 to

55.89

-0.21 2.63 0.715

Light PA time (min/day) 325.0

(57.5)

325.0 (71.8) -24.18 to

28.19

0.00 328.2

(93.4)

369.2

(92.8)

-74.82 to

2.46

0.44 -8.34 0.106

Total MVPA (min/day) 39.3 (20.7) 39.8 (20.7) -6.97 to 5.71 0.02 37.3 (21.6) 34.3 (23.5) -7.53 to

11.22

-0.14 5.11 0.662

Data are expressed as mean (SD), estimated mean of differences between pre and post values, 95% confidence interval (CI), Cohen’s d effect sizes (ES), and % delta

differences [(post–pre from intervention)–(post–pre from control)]; expressed as mean ± SD). VAT, ventilatory anaerobic threshold; RCP, respiratory compensation point; VO, oxygen uptake; VO2peak, peak oxygen uptake; PA, physical activity; MVPA, moderate-to-vigorous physical activity.

P-values for group vs. time interaction.

ø Significant difference within group (P� 0.05) # Tendency for significance within group (P� 0.10)

� Significant main effect of time (P� 0.05)

ᶿ Significant main effect of group (P� 0.05) o�Significant difference between delta changes (P� 0.05)

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Participant eating characteristics

The I-HAES1 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 veg-

etables. The CTRL group did not show any difference in total and daily intake of abovemen-

tioned food groups (Table 5).

The qualitative data corroborate these findings. In the I-HAES1 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-HAES1 group reported having a

more diversified eating habit, increasing their consumption of in natura or minimally pro- cessed 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 sched-

ule 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 respec-

tively. 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

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 Size1 approach.

Intensified HAES1-based intervention group

(n = 39)

Control group

(n = 19)

Pre Post P Pre Post P Ultra-processed foods (total consumption�), mean, ± SD 32.0 ± 17.0 21.7 ± 13.4 0.0001 28.3 ± 14.5 26.5 ± 14.8 0.363 Ultra-processed foods (daily consumption), mean, ± SD 4.6 ± 2.4 3.1 ± 1.9 0.0001 4.2 ± 2.0 3.8 ± 2.1 0.133 Fruits (total consumption), mean, ± SD 8.8 ± 6.7 12.0 ± 8.9 0.026 8.6 ± 4.4 9.4 ± 5.8 0.291 Fruits (daily consumption), mean, ± SD 1.3 ± 1.0 1.7 ± 1.3 0.038 1.3 ± 0.8 1.4 ± 0.8 0.333 Vegetables (total consumption), mean, ± SD 13.9 ± 9.4 18.9 ± 12.6 0.018 13.7 ± 9.7 13.5 ± 7.8 0.753 Vegetables (daily consumption), mean, ± SD 2.0 ± 1.3 2.7 ± 1.8 0.012 2.0 ± 1.4 1.9 ± 1.1 0.572

� At pre-intervention, food diaries were completed 6.9 ± 0.3 days and 6.6 ± 0.7 days in the intensified HAES1-based intervention group and the control group, respectively. At post-intervention, food diaries were completed 6.9 ± 0.5 days and 6.9 ± 0.5 days in the intensified HAES1-based intervention group and the control group, respectively. Data was analyzed by the Wilcoxon test.

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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 qual-

ity 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-HAES1 group (P� 0.05) (Fig

3). Compared to those in the CTRL group, the I-HAES1 group had significant decreases in

the “body disparagement” (P = 0.01) and “feeling fat” (P = 0.01) subscale scores and a signifi-

cant 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-HAES1 group showed significant within-group differences for all

Figure Rating Scale scores (P� 0.05). The I-HAES1 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-HAES1 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, respec- tively (P = 0.098). For “current body size–ideal body size”, the initial and final scores in the

I-HAES1 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).

Fig 3. (Left panel): Results from the intensified HAES1-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-HAES1, intensified HAES1-based intervention group; CTRL, control

group. § Significant difference when compared to the intensified HAES1-based intervention group post-intervention (P� 0.05). ø Significant difference within group

(P� 0.05).

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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-HAES1 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 con-

cepts, 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).

Participant quality of life

In the I-HAES1 group, significant within-group differences were observed for all WHO-

QOL-BREF domains after the intervention (P� 0.05) (Fig 4). Compared to those in the

CTRL group, the I-HAES1 group showed significant improvements in the “physical health”

(P = 0.05), “psychological health” (P = 0.02), and “overall perception of quality of life and

health” (P = 0.03) domains. The CTRL group showed improvements only in the “psychological

health” (P = 0.04) and “overall perception of quality of life and health” (P = 0.01) domains.

The focus groups shed light on the quantitative changes. Initially, in the I-HAES1 group,

the quality of life was defined as a set of conditions that were not part of the participants’ rou-

tine and was related to expectations about their eating, physical activity, physical appearance,

and well-being. In the final focus group, the intervention itself was part of the quality of life in

the I-HAES1 group (“quality of live is to come here and have fun doing the activities”–I14). They reported having included aspects they considered important to their quality of life that

were previously only hypothetical: “I said before that quality of life would be to sleep better, eat well, have leisure time. Now I’m trying to sleep better, I’m hanging out more” (I35). The CTRL group reported in both focus groups a general definition of quality of life and did not seem to

have incorporated the aspects discussed in the intervention to improve their quality of life or

to change their routines to approximate to what they considered to be quality of life.

Discussion

The main finding of this study was that a new intensive, interdisciplinary HAES1-based, non-

prescriptive intervention in obese women improved eating attitudes and practices, perception

Effects of a new Health at Every Size-based intervention for the management of obesity

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https://doi.org/10.1371/journal.pone.0198401
of body image, physical capacity, and health-related quality of life. Moreover, qualitative and

quantitative data suggest that this novel intervention was more effective than a traditional

HAES1-based one.

Throughout the seven-month follow-up period, both the I-HAES1 and CTRL groups

showed no change (or slight reductions in the case of waist circumference) in anthropometric

measurements. This find might be explained because the current physical activity program,

tailored to meet the HAES1 principles, was not focused on exercise intensity or even on the

adherence to the supervised exercise session; rather, the program was focused on promoting

one’s self-engagement in playful, enjoyable activities, which may have been not sufficient to

elicit detectable changes in anthropometric variables in such a follow-up period. However, this

study was limited by the fact that body composition was not assessed, therefore we cannot rule

out the possibility that participants did increase lean mass while decreasing body fat, without

affecting body weight or other anthropometric parameters. In contrast, our I-HAES1 inter-

vention improved aerobic conditioning and muscle function whereas no changes were

observed in the CTRL group. Importantly, poor aerobic conditioning and function are associ-

ated with premature mortality in various populations [43,44]. In this context, Ross and Janis-

zewski [45] argue that anchoring the practice of exercise with weight reduction can mask

opportunities to stimulate people to become more physically active [45]. Indeed, our data cor-

roborate previous studies showing that regardless of body weight change, physical activity is

associated with increased physical capacity [45–48], reinforcing the protective cardiometabolic

effect of physical activity.

Participants in the I-HAES1 group were able to overcome their initial eating difficulties,

reporting that they were able to better manage their emotional eating, eat in accordance with

feelings of hunger and satiety, eat attentively, and improve the quality of food consumed.

Fig 4. (Left panel): Results from the intensified HAES1-based intervention group WHOQOL-BREF questionnaire pre- and post-intervention. (Right panel):

Results from the control group WHOQOL-BREF questionnaire pre and post intervention. I-HAES1, intensified HAES1-based intervention group; CTRL, control

group. § Significant difference when compared to intensified HAES1-based intervention group post-intervention (P� 0.05). ø Significant difference within group post-

intervention (P� 0.05). † Significant difference when compared to intensified HAES1-based intervention group pre-intervention (P� 0.05).

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These gains are in accordance to those reported by previous traditional HAES1-based inter-

ventions [8,49,50]. In this study, we also showed that an intensive HAES1-based intervention

led to improvements in participants’ autonomy to plan their eating and increased engagement

with cooking, which might be important for maintenance of the habits acquired during the

intervention. Notably, the CTRL group reported being stimulated to think about their eating,

which did not provide them with autonomy to deal with their eating or result in sustainable

changes. While traditional HAES1-based interventions have been shown in quantitative

assessments to stimulate eating changes [9,12], no studies have qualitatively explored the par-

ticipants’ likelihood to maintain these changes.

Our findings revealed that members of the I-HAES1 group developed a better perception

of their bodies and were more comfortable and less dissatisfied with their current physical con-

dition. Importantly, these changes were independent of any change in anthropometric mea-

surements. In contrast, the CTRL group showed small or no changes in these perceptions.

Altogether, these results suggest that the positive effects on participants’ body image observed

in traditional HAES1-based interventions [16,17] were expanded by this novel intensive and

interdisciplinary HAES1-based intervention, which may have provided an atmosphere of

mutual empathy, encouraged self-worthiness, and promoted positive changes in participants’

body attitudes, perception, and dissatisfaction.

This intervention also improved the health-related quality of life, which might be a result of

the abovementioned improvements. To our knowledge, this is the first intervention to use

qualitative data to explore aspects of quality of life in a HAES1-based intervention. Brown

et al. [51] explored obese patients’ experiences and perceptions of support in primary care and

found that stigma-related thoughts were detrimental to participant quality of life and nega-

tively affected interactions with health services. Our intervention was seemingly able to tackle

numerous issues in a supportive way, helping to create a positive and welcoming environment

for the participants and positively affecting their interactions with the intervention. The dis-

cussions promoted by the philosophical workshops were important for the promotion of

reflection among our participants. These workshops are innovative in a HAES1-based inter-

vention and should be considered in further studies. It is important to note that the CTRL

group also showed improved “overall perception of quality of life and health”, suggesting that

even small efforts regarding changes in health habits might improve the quality of life in this

population.

Despite the aforementioned improvements, the accelerometry data did not show increases

in physical activity levels in the I-HAES1 group. This was observed even though the partici-

pants reported having fun during physical activity classes and feeling empowered once they

realized they could move their bodies in a number of ways; in addition, most reported engage-

ment in some physical activity outside the intervention context or having plans to include

novel activities in their routines. A possible explanation for this outcome is that structured

exercise contributes only a minor daily physical activity energy expenditure, suggesting that

exercise acts as a supplement to spontaneous physical activities [52]. Corroborating this

notion, Turner et al. [53] provided healthy participants with significant amounts of prescribed

exercise (almost 4 hours of exercise per week at 65% of their VO2max), which represented only

15% of the physical activity energy expenditure after 18 weeks of the intervention. Further-

more, there is data indicating that the adoption of structured exercise training may induce

compensatory changes in behavior or physiology that could lead to decreased energy expendi-

ture and spontaneous physical activity [54–61]. Therefore, it is necessary to test the efficacy

and feasibility of programs focused primarily on the promotion of autonomy for physical

activity and/or in reducing sedentary behavior in obese populations.

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This study had some limitations. First, not all participants attended the focus groups (77%

and 73% of adherence in the I-HAES1 and CTRL groups at pre-intervention, and 82% and

58% of adherence in the I-HAES1 and CTRL groups at post-intervention). However, the par-

ticipants who attended the discussions expressed different ideas and, at some point, most of

them were reinforced, indicating that the focus groups had reached saturation. Second, we did

not evaluate body composition, which could have revealed a beneficial effect of exercise on

lean and fat mass. Third, we were not able to evaluate participants who dropped out of the

intervention and the relatively low retention may have contributed to some null findings.

Finally, the major practical issue with lifestyle modifications lies in the long-term ability to sus-

tain the short-term benefits. Although the current findings are promising, long-term studies

should re-examine the feasibility, efficacy and effectiveness of this intervention.

Conclusion

This novel seven-month intensive interdisciplinary HAES1-based non-prescriptive interven-

tion in obese women improved participants’ eating attitudes and practices, perception of body

image, physical capacity, and health-related quality of life despite no changes in body weight

and spontaneous physical activity levels. Importantly, these results were corroborated through

qualitative analysis showing that our novel approach was superior to that of a traditional

HAES1-based program.

Supporting information

S1 CONSORT Checklist.

(DOC)

S1 File. A physical activity program based on the Health at Every Size1 approach–an inno-

vative proposal.

(DOCX)

S1 Table. Baseline characteristics between participants who retained and those who

dropped out, stratified by groups. Data are expressed as mean ± SD or n (%) of total sample per group. Significance level defined as p� 0.05 (nonpaired t-test or chi-square test). (DOCX)

Acknowledgments

The authors acknowledge Professors Nágila Raquel Teixeira Damasceno e Marly Augusto Car-

doso for technical support, the professionals involved in the design of the intervention, the

monitors (Rafaela Faria Lemos, Jhessica Campos Victor, Victoria Lima, Felipe Gregório, Ste-

fan Tanabe, Leticia Pironato, Cristiane Siqueira), and the professor Dra. Sophie Deram and

her editor Christian Sperli for providing the book [23] for material support.

Author Contributions

Conceptualization: Mariana Dimitrov Ulian, Ana Jéssica Pinto, Fabiana B. Benatti, Patricia

Lopes de Campos-Ferraz, Desire Coelho, Odilon J. Roble, Fernanda Sabatini, Isabel Perez,

Luiz Aburad, André Vessoni, Ramiro Fernandez Unsain, Marcelo Macedo Rogero, Bruno

Gualano, Fernanda B. Scagliusi.

Data curation: Mariana Dimitrov Ulian, Ana Jéssica Pinto, Patricia Lopes de Campos-Ferraz,

Desire Coelho, Odilon J. Roble, Fernanda Sabatini, Isabel Perez, Luiz Aburad, André

Effects of a new Health at Every Size-based intervention for the management of obesity

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http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0198401.s001
http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0198401.s002
http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0198401.s003
https://doi.org/10.1371/journal.pone.0198401
Vessoni, Ramiro Fernandez Unsain, Marcelo Macedo Rogero, Tatiana Natasha Toporcov,

Ana Lúcia de Sá-Pinto, Bruno Gualano, Fernanda B. Scagliusi.

Formal analysis: Mariana Dimitrov Ulian, Ana Jéssica Pinto, Priscila de Morais Sato, Fabiana

B. Benatti, Fernanda Sabatini, Isabel Perez, Luiz Aburad, André Vessoni, Bruno Gualano.

Funding acquisition: Mariana Dimitrov Ulian, Bruno Gualano, Fernanda B. Scagliusi.

Investigation: Mariana Dimitrov Ulian, Ana Jéssica Pinto.

Methodology: Mariana Dimitrov Ulian, Fabiana B. Benatti, Patricia Lopes de Campos-Ferraz,

Odilon J. Roble, Ramiro Fernandez Unsain, Marcelo Macedo Rogero, Tatiana Natasha

Toporcov, Bruno Gualano, Fernanda B. Scagliusi.

Project administration: Mariana Dimitrov Ulian, Bruno Gualano, Fernanda B. Scagliusi.

Resources: Bruno Gualano, Fernanda B. Scagliusi.

Supervision: Bruno Gualano, Fernanda B. Scagliusi.

Writing – original draft: Mariana Dimitrov Ulian, Fernanda B. Scagliusi.

Writing – review & editing: Mariana Dimitrov Ulian, Ana Jéssica Pinto, Priscila de Morais

Sato, Fabiana B. Benatti, Patricia Lopes de Campos-Ferraz, Desire Coelho, Odilon J. Roble,

Fernanda Sabatini, Isabel Perez, Luiz Aburad, André Vessoni, Ramiro Fernandez Unsain,

Marcelo Macedo Rogero, Tatiana Natasha Toporcov, Ana Lúcia de Sá-Pinto, Bruno Gua-

lano, Fernanda B. Scagliusi.

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