This isn’t theoretical. People (particularly women) have been outspoken for years about the mistreatment they’ve experienced in medical settings because of their weight—it was a theme in Roxane Gay’s 2017 memoir, Hunger, as well as the focus of a viral 2018 Self article from the columnist “Your Fat Friend.” Multiple studies have found that the bias doctors, nurses, and other practitioners have about weight leads to worse care and poorer health outcomes for people in larger-sized bodies. It also makes them less likely to seek health care in the first place.
Weight stigma is a huge problem in the health-care industry. But a revolutionary framework for understanding health called Health at Every Size (HAES®) is seeking to provide better care for people of all sizes.
What is Health at Every Size, and what are its origins?
Officially, Health at Every Size is a registered trademark of the Association for Size Diversity and Health (ASDAH), formed in 2003. ASDAH defines HAES as a social justice framework that respects the diversity of body shapes and sizes, supports inclusive health care, and rejects weight discrimination and stigma against larger bodies.
Essentially, HAES is a weight-neutral approach to health. HAES-informed health-care providers focus on addressing each patient’s medical conditions in evidence-based ways (like medication, surgical intervention, behavior change, and therapy), without focusing on weight or encouraging weight loss. They promote the idea that it is possible to be healthy or to pursue better health without changing the size of your body.
The origins of HAES are decades-old. In 1967, writer Lew Louderback published an article in The Saturday Evening Post titled “More People Should Be Fat!” He outlined ideas central to the later HAES movement: that intentional weight loss is not typically sustainable long-term, that dieting can lead to food obsession and other destructive behaviors, that eating intuitively (aka listening to your body’s cues and cravings, tuning out rules about what you “should” or “shouldn’t” eat, and letting go of intentional restriction) instead of dieting can improve well-being, and that America’s fear of fatness is actually about cultural aesthetics, not about health.
Louderback’s article, and the ideas it put forward, contributed to what came to be known as the fat acceptance (or size acceptance) movement. HAES is one piece of this movement.
What’s the evidence behind HAES?
Researcher Lindo Bacon, PhD, helped bring more widespread attention to HAES with the 2008 book Health at Every Size. In it, Dr. Bacon goes into detail about a randomized clinical trial they co-authored which found that people are actually more likely to adopt health-promoting behaviors—eating nutritious foods, engaging in regular movement, etc.—if they aren’t trying to lose weight.
“Instead of using the traditional diet model, we were just supporting people in appreciating their bodies and learning how to trust their bodies and take good care of them,” Dr. Bacon says. “Instead of trying to control and restrict their calories, it was about learning what their bodies were asking for. Paying attention to things like hunger and fullness. And instead of using exercise as a way of punishing themselves or of burning calories, we helped people to connect with the joy of being in their bodies and moving.”
The study found that while people in the traditional diet program did initially lose weight and see improvements in health markers like blood pressure, almost none of them maintained the weight loss or the health benefits after two years. Meanwhile, the HAES group saw sustained improvements in health markers over the two years. What’s more, the HAES group experienced improvements in levels of depression and self-esteem; the traditional diet group did not.
Studies have also supported Louderback's assertion that weight loss is difficult to maintain long-term. In a 2011 review published in Nutrition Journal, Dr. Bacon and co-author Lucy Aphramor looked at existing weight loss studies and found that almost no one was able to sustain significant weight loss for more than five years. They found that dieting and intentional weight loss often led to weight cycling (the continual gaining and losing of weight), which has also proven to have negative effects on health. Many of these findings were supported by an April 2020 meta-analysis published in The BMJ, which looked at 121 clinical trials (with nearly 22,000 total participants) and found that while most diets lead to weight loss and lowered risk of cardiovascular disease after six months, both of these effects “largely disappear” at the twelve-month mark.
The “why” of all this isn’t perfectly understood, but rest assured that it isn’t lack of willpower. A 2015 review found that intentional weight loss leads to physiological adaptations like a decrease in energy expenditure (calories burned), fat oxidation (using fat for energy), and leptin (a hormone that signals fullness), and an increase in appetite and ghrelin (a hormone that signals hunger). Basically, trying to lose weight may force the body to adjust in various ways to maintain its existing fat levels—making it harder to lose said weight or keep it off.
What about the “obesity epidemic?”
The HAES philosophy has been met with some skepticism in mainstream health circles. Research has long connected being at a higher weight with an increased risk of serious health conditions like heart disease, diabetes, and stroke; some experts worry that HAES could worsen those outcomes. David Katz, MD, a doctor and public health professor at Yale University, argued in 2012 that ignoring weight and the “obesity epidemic” will just lead to continued increases in chronic disease.
But proponents of HAES argue that our current view of weight is harmful, not helpful, to those in larger-sized bodies. “By labeling it an obesity epidemic, [you] are problematizing weight,” Dr. Bacon says. ”As soon as you problematize weight, what happens is it’s going to lead to people feeling bad about their bodies; it’s going to lead to bullying, to weight-based discrimination.”
"Regardless of what your weight is, we can all make good choices to support health." —Lindo Bacon, PhD
Like any form of discrimination, weight stigma—negative bias and attitudes towards people at higher weights—has health consequences. A 2018 review published in BMC Medicine found that weight stigma is linked to poor metabolic health, higher levels of stress hormones, exercise avoidance, and poor mental health. HAES, on the other hand, is about making people feel empowered and respected in health-care settings, no matter their weight.
Despite this evidence, many health-care professionals continue to emphasize the importance of weight loss for health. Part of the disconnect is that HAES is a relatively new framework, and not commonly taught in most standard health-care curriculums. “[HAES] is not the medical model that people are taught in school, whether they’re training to be a nurse, dietitian, doctor, or something else,” says Christyna Johnson, RDN, a dietitian who practices within the HAES framework. Many providers find the HAES framework years into their clinical practice, often after seeing their patients try and fail to lose weight, she says.
Weight must have some impact on health, right?
Yes, and taking a HAES approach doesn’t mean denying that there’s some relationship between weight and health. “Yes, weight is causally linked to certain medical outcomes, like diabetes,” says Jennifer Gaudiani, MD, an internal medicine physician and certified eating disorder specialist. “I’m a completely passionate HAES supporter, and yet as an internist, scientifically, [weight and certain health outcomes] are causally linked.”
The HAES movement takes this reality into account. “Health at Every Size is not suggesting that everybody is at their healthiest best at every weight,” Dr. Bacon says. “What it is suggesting, though, is that regardless of what your weight is, we can all make good choices to support health, and that’s all we want to do.”
HAES also challenges the idea “that fat people are unhealthy, and that people who take care of themselves are thin,” Dr. Gaudiani says. In reality, it’s much more complicated than that. (Just look at the Body Mass Index, which has been shown to be inaccurate for many people.) Many people at higher weights can be metabolically healthy—meaning they have medically “ideal” levels of blood glucose, cholesterol, and other biomarkers. Plus, a 2015 study of over 100,000 Danish adults found that those in the “overweight” category (with a BMI range of 25-30) actually lived the longest, on average, compared to people in other weight categories. That’s not to say that having a larger-sized body automatically translates to longevity, but it’s proof that the relationship between weight and health is complex.
Some experts question the plausibility of “metabolically healthy obesity.” However, most studies on the subject—like a 2019 review, which found that people with larger-sized bodies and who are metabolically healthy still are at a higher risk for chronic diseases like type 2 diabetes and heart disease than their lower-weight counterparts—don’t control for the effects of experienced weight stigma or weight cycling, both of which are very common among higher-weight people and have been shown to worsen health outcomes and increase risk of diabetes, heart disease, stroke, and even early mortality.
Why do HAES advocates think this approach to health is so important?
Again, none of the evidence above denies that there is some relationship between weight and health. But HAES practitioners (and research) argue that just because weight is causally linked to certain conditions doesn’t mean that all higher weight people have or will have those conditions. Thus, Health at Every Size makes health more accessible to people in larger bodies by acknowledging that weight isn’t as modifiable as we’ve traditionally believed, and encouraging people to improve health in other ways.
It's also about meeting people where they are. Johnson explains that within the HAES framework, the relationship between a health-care provider and their patient is collaborative and takes individual circumstances into account. “Is this person living at or below the poverty level? Is this person in a non-binary or trans body? Is this person in a disabled body? Is this person living with a mental illness or a chronic illness? Does this person have generational trauma? All these intersections can affect a person’s health,” she says, and can inform what type of care they need.
The HAES approach might also make people in larger bodies more likely to seek care. Lesley Williams, MD, a family medicine physician and certified eating disorder specialist who practices HAES, says that many patients in larger bodies come to her because they feel like their previous doctor wasn’t listening to them. The patient would come in with a specific problem—or for a routine checkup, with no problems at all—and the doctor would invariably tell them to lose weight, minimizing whatever underlying problem was at hand. Many would then avoid the doctor’s office going forward, for fear of being stigmatized or feeling disrespected.
How do you find a HAES practitioner?
Although there is a peer-reviewed HAES curriculum available online for providers and others who are interested, there’s no credential or certification required. “[HAES] is an inclusive and compassionate health-care model that allows people to seek and define health for themselves,” Johnson says. In other words, it will look different for everyone, because it’s about honoring each person’s unique body and unique needs.
If you’re looking for a HAES-informed health-care provider, there’s an online database that you can search by area or specialty. But it’s also something that you can implement in your own life by vowing to stop fixating on weight and instead focusing on healthy behaviors.
And, look, if you’re not on board with every aspect of the HAES movement, that’s okay. It’s a huge paradigm shift that goes against what most of us have been taught. But no matter your current beliefs on weight and health, it’s worth acknowledging the fact that weight loss isn’t actually possible for everyone, and that dieting and restriction can actually cause physical harm. The underlying goal of HAES is to make health and quality health care accessible to more people, which is hard to argue with.
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