For decades, public health organizations have focused on overweight and obesity as leading health concerns. Weight is commonly cited as a critical risk factor for chronic health conditions like diabetes and heart disease.
Experts have long focused on methods to help people achieve weight loss. Yet, these efforts have not worked, as obesity rates remain high worldwide. Part of the conversation that is often left out is just how much this focus on weight could negatively affect people’s health in larger bodies and the care they receive. And whether or not weight genuinely is an appropriate indicator of overall health. This is where the Health At Every Size (HAES) framework comes in.
What is HAES?
HAES is an approach to healthcare that takes the focus off of weight loss as a health goal. It seeks to reduce stigma toward people in larger bodies and improve access to healthcare for people of all sizes.
HAES challenges the widely held belief that the thinner you are, the healthier you are. Instead, it embraces peoples’ bodies the way they are now and shines the spotlight on health behaviors. It also looks at health from a holistic lens, beyond simply the absence of disease. It does not assume that every person is healthy at every size, but rather that weight should not be the predominant measure of health.
According to the Association for Size Diversity and Health (ASDAH), HAES has five main principles:
- Weight inclusivity: Accept and respect that bodies come in different shapes and sizes. Reject viewing specific weights as abnormal.
- Health enhancement: Support health policies that ensure equitable access to care.
- Eating for well-being: Encourage flexible, individualized eating that prioritizes hunger demands, pleasure, and satiety rather than weight control.
- Respectful care: Challenge weight discrimination, bias, and stigma, while providing care that addresses the multiple factors that impact weight stigma.
- Life-enhancing movement: Support enjoyable physical activity for people of all sizes, skills, and interests to participate to the extent that they want.
These principles are currently under review and will likely be updated in 2022-2023.
Why Is the HAES Approach Important?
From a public health standpoint, weight is viewed as an indicator of health, leading to a weight-centric healthcare model. This model focuses on weight loss through dieting, exercise, surgery, and other methods.
People at higher weights often experience discrimination and stereotyping based solely on their weight. This is called weight stigma, also known as weight bias. Weight stigma is pervasive both in day-to-day society and in healthcare. A survey of 14,000 adults enrolled in weight management programs across 6 countries found that over 6 of 10 people reported experiencing weight stigma from doctors.
Weight stigma affects the quality of care people in larger bodies receive and can make healthcare an uncomfortable space for them. There are real risks to weight stigma:
- People who experience weight discrimination are roughly 2.5 times more likely to have mood or anxiety disorders than people who do not feel discriminated against.
- Despite being at high risk for endometrial and ovarian cancer, higher-weight people may delay receiving pelvic exams, even if they have health insurance.
- Doctors tend to spend less time with higher-weight patients and provide less education.
Furthermore, research on weight stigma is uncovering how it impacts health behaviors and even physiology. In one study, participants watched either a weight-neutral or a weight-stigmatizing video while consuming snacks – those who watched the weight-stigmatizing video consumed three times as many calories. People who experience everyday weight discrimination are also less likely to be physically active or may exclude themselves from exercise or sports settings. Physiologically, weight stigma creates the same undesirable stress hormone response experienced by chronically stressed people.
Proponents of HAES state that shifting towards weight-neutral outcomes and challenging the commonly held beliefs among healthcare providers about weight can help mitigate all these risks. These examples also illustrate why it can be harmful to people in larger bodies to receive the message that the only way to improve their health is to lose weight. Healthcare must be a safe space for everyone to receive compassionate and respectful care, regardless of size.
Are There Benefits of HAES?
Traditional weight management research studies generally show unimpressive results in the long term, with participants frequently regaining weight after the end of the intervention period. The act of cycling through periods of losing and regaining weight is called weight cycling, commonly referred to as “yo-yo dieting.”
HAES practitioners support the notion that weight cycling poses a higher risk to overall health than weight maintenance at a higher weight. However, this is a contested argument, and it is likely not as clear-cut as it may seem.
The HAES approach itself has also made it into clinical research studies. There are promising results for how HAES interventions can improve health behaviors and other non-weight markers of metabolic health, but the field of HAES research is still in its early stages.
HAES may improve quality of life and decrease cardiometabolic risk, even when study participants do not lose weight. It may also increase intuitive eating practices and improve overall diet quality. Notably, HAES approaches tend to have significantly lower drop-out rates than traditional diet interventions. Overall, participants of HAES intervention studies have reported better psychological well-being, including greater body acceptance and self-esteem.
The HAES approach may help remove some of the barriers that people in larger bodies face in healthcare. People who visit a HAES practitioner can expect to discuss their health without discussing their weight. Weight-inclusive care helps to ensure that healthcare is safe and accessible, thereby decreasing the number of higher-weight people that avoid or delay seeking healthcare.
Are There Drawbacks to HAES?
The HAES approach is not free from controversy, and many people in the healthcare community critique or outright reject the framework. In general, HAES has yet to be embraced by the healthcare community, and most healthcare institutions still operate from a weight-centric perspective.
Critics of HAES argue that excess body fat, especially abdominal obesity, is indeed a risk factor for chronic disease; therefore, overlooking it is inappropriate. Some professionals make the distinction that it’s crucial not to minimize the health risks associated with excess weight while at the same time not stigmatizing those who are at higher weights. Weight can be a valid concern for both people and doctors, and there may be reasons when intentional weight loss (or gain) is indicated.
Overall, research is supportive that being “overweight” or “mildly obese” isn’t necessarily associated with a host of adverse health effects. However, there may be a threshold whereby excess weight does become detrimental. This threshold is likely highly individual and based on many factors, including the location of excess weight, environment, and genetics.
Finally, in 2010 there were concerns about the trademarking of HAES. These concerns include the idea that HAES can be done “correctly” or “incorrectly.” It opens up what started as a movement that could be for monetary gain, and it glosses over the true history of HAES, including the fat activism movement.
How to Find a HAES Provider
To find a HAES provider check out this directory of HAES practitioners. It is currently being updated but should be available soon. In addition, there may be country-specific HAES directories.
You can find HAES providers by using the search tool for:
- The type of practitioner you are looking for like a dietitian
- Specific keywords like HAES, weight neutral, weight inclusive, fat-friendly
When you call to make an appointment with a new provider, you can request someone who takes a weight-neutral or weight-inclusive approach. You can also request not to be weighed in your appointment. If your doctor needs your weight for medication dosage, you can ask your doctor not to disclose or comment on your weight.
HAES is an approach to healthcare that may resonate with people in larger bodies to help them feel more comfortable in healthcare spaces.
- “The Health at Every Size (HAES) Approach” via Association for Size Diversity and Health
- “The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries” via PLoS One
- “Health at Every Size®-Based Interventions May Improve Cardiometabolic Risk and Quality of Life Even in the Absence of Weight Loss: An Ancillary, Exploratory Analysis of the Health and Wellness in Obesity Study” via Frontiers in Nutrition
- “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” via PLoS One
- “A Health at Every Size intervention improves intuitive eating and diet quality in Canadian women” via Clinical Nutrition
- “A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial” via Appetite
- “Weight Maintenance after Dietary Weight Loss: Systematic Review and Meta-Analysis on the Effectiveness of Behavioural Intensive Intervention” via Nutrients
- “How and why weight stigma drives the obesity ‘epidemic’ and harms health” via BMC Medicine
- “The impact of weight stigma on caloric consumption” via Obesity
- “Is weight stigma associated with physical activity? A systematic review” via Obesity
- “Weight stigma experiences and self-exclusion from sport and exercise settings among people with obesity” via BMC Public Health
- “Weight Stigma and Hypothalamic-Pituitary-Adrenocortical Axis Reactivity in Individuals Who Are Overweight” via Annals of Behavioral Medicine
- “Down the Rabbit Hole: A Critique of the ® in HAES®” via Journal of Critical Dietetics