The 'Health at Every Size' Approach to Health Care Is Aiming to Put an End to Weight Stigma
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Regardless of your specific health concerns — or lack thereof — you likely run through a seemingly harmless routine when you first arrive at a doctor's appointment. Just a few moments after a nurse calls you back into the office, you probably step onto a rickety scale, stand up against a measuring chart on the wall, and allow them to jot down your weight, height, and BMI on your chart. Once you see your doc, you might be told that your weight has fluctuated or your BMI should go up or down.
To some health practitioners, however, this hyper-focus on a person's weight and size can have significant, lasting impacts on mental and physical health. But "Health at Every Size" — a unique approach to health care that ditches the weight-specific lens — could be a part of the solution.
The Basics of 'Health at Every Size'
Trademarked by the Association for Size Diversity and Health back in 2003, "Health at Every Size" opposes the idea that a person's body weight and size is an accurate, full-picture representation of their health status, according to the ASDAH. Under this alternative approach to health care, weight, size, and BMI aren't used as indicators of health, and the belief that a person's weight is considered a myth, according to the ASDAH. (It's also somewhat of a social movement; you can find hundreds of thousands of Instagram posts tagged with related hashtags, for example.)
"There's a lot of misunderstanding, especially when it comes to health professionals. We're taught if you're over a certain weight or BMI that you're 'unhealthy' — and that's not necessarily true," says Shana Minei Spence, M.S., R.D.N., C.D.N., a registered dietitian nutritionist who counsels with a HAES and intuitive eating approach. "Health at Every Size is basically saying that no matter what, there isn't a look for health." And this stance can be seen in the five key principles of HAES, as broken down by the ASDAH:
Accept and respect the diversity of body shapes and sizes
Support health policies that improve access to information and services, as well as personal practices that boost personal well-being
Promote individualized, intuitive eating styles
Provide respectful care
Encourage enjoyable movement
To Mia Donley, M.P.H., R.D., C.D.N., a registered dietitian who specializes in disordered eating, learning about HAES has been a game-changer. While completing her nutrition and dietetics bachelor's degree, Donley noticed her curriculum was largely weight-focused, pushed the idea that each person is "individually at fault" for their body and health outcomes, and emphasized certain foods that are considered to be "healthy" in order to achieve what's seen as the standard body size, she says. Once Donley found a community of dietitians bringing awareness to HAES on Instagram a few years later, it clicked. "I've always felt like something was missing in the way that we were approaching nutrition, weight, and health, and this felt like almost the missing puzzle piece to it," she says.
Why 'Health at Every Size' Is So Important
It may seem like NBD for a doctor or dietitian to keep track of things such as weight, body size, and BMI, but when health-care providers zero in on those stats — and consider only those measures or are blinded in their protocols based on those measures — it can lead to ineffective treatments and cause serious health problems to go unnoticed, says Spence. "A lot of times, when people go to the doctor and either they're above a certain weight or below a certain weight, they're just told to just fix that instead of looking at actual behaviors," she says.
This approach to treating and caring for health based solely on the numbers "has resulted in significant harm to individuals across the size spectrum both physically and emotionally/socially, through declination of health care coverage, denial of routine health screening procedures, and increased stigmatization," according to the ASDAH. For example, it took one of Spence's patients about a year and a half to get diagnosed with an ulcer, during which time her doctors simply told her to "just lose weight and you'll be fine," says Spence.
FTR, experiencing weight stigma — when a person faces negative stereotypes, prejudice, and unfair treatment due to their higher weight — isn't uncommon. A 2021 study of nearly 14,000 adults who were enrolled in a behavioral weight management program found that about 38 percent reported experiencing weight stigma from doctors at least once. Participants with higher internalized weight bias (think: applying negative weight stereotypes to themselves, devaluing themselves based on their weight) also reported greater health care avoidance (i.e. avoiding seeing the doctor even when they think they should), increased perceived judgment from doctors due to their body weight, lower quality of health care, and more, according to the research.
In turn, the current system can dissuade folks from booking an appointment with their provider — for both treatment and preventative care. "Especially now during [the] COVID [pandemic], people are always talking about how if you are at a higher weight, you have a higher risk of death," says Spence. "I always tell people, it's not that people are at a higher weight or maybe have higher fat percentage, it's also the stigmatization when you go to a doctor. If you are constantly being talked down to, if your symptoms are constantly ignored, if you're not viewed as a person, you're not going to go to the doctor once or twice a year like you're supposed to." (Related: What Needs to Be Understood About Coronavirus and Obesity)
How 'Health at Every Size' Manifests IRL
The focus is on health behaviors — not weight.
Rather than concentrating on weight (and the need to lose it), HAES practitioners take a more holistic approach to improving the health of their clients and patients. "If you have diabetes or heart disease — whatever illness it is — we're not just going to tell you to lose weight because health doesn't have a look, it doesn't have a certain weight," says Spence. On the same token, weight is influenced by genetics, research shows, and your body weight may not be able to reach an arbitrary number assigned by your doctor, nurse, dietitian, etc., she adds. "I think those are really important aspects in why we tell people to focus on sustainability and actual behaviors and not weight," says Spence.
Instead, a HAES practitioner may look into the types of foods you're eating and the ones you may want to add into your routine, your sleep quality and quantity, and how you're moving throughout the day, says Spence. "All of these things affect your body, your health — beyond just this number on the scale, which doesn't always tell us what we need to know," adds Donley. After following through on a practitioner's recommendations, your weight might fluctuate — and that's okay, says Donley. "We know three things could happen to your body when you do Health at Every Size or intuitive eating: You can either lose weight, you can gain weight, or you can stay the same," she explains. "But either way, we can still see different health outcomes and better health outcomes even if weight stays the same or even if it goes up. It's not something that's in a vacuum."
The restriction isn't a part of the equation — but intuitive eating is involved.
Under the HAES approach, restriction — whether it be counting calories or sticking to a certain diet — is seen as doing more harm than good for one's health. "It's going to cause stress and anxiety which isn't good for your health," says Spence. In fact, studies on adults suggest that chronic dieting is associated with food preoccupation, distractibility, irritability, and fatigue.
Instead, HAES practitioners typically take an intuitive eating approach to nutrition — and it doesn't mean eating whatever, whenever, and not caring about how it may affect your health. In reality, intuitive eating means listening to your body, understanding what you want, and knowing how it's going to make you feel, then using that information to guide your food choices without restriction, says Spence. "We are honoring these cues of hunger, satiety, appetite, and also some of the mind knowledge, too," adds Donley. "If you have a medical condition, we know we might have to do certain things, but let's come at it from a way that's not restrictive, not feeling like this is more stressful to do than everything else."
The last component — understanding how a particular food will make you feel — is key, says Spence. For instance, if you're jonesing for a bag of chips but know eating the entire package will make you feel like crap, you might opt for another munchie or simply eat less of it, she explains. The same situation applies to "healthy" foods, such as raw kale, she says. "Sometimes people think, 'Oh, it's so much better to eat raw vegetables,' [but] your stomach probably isn't going to feel that great" if you fill up on too much of the leafy green, says Spence. "So let's not do that and let's try to balance it. Intuitive eating is about how your body responds to eating in a certain way and knowing how to adjust without restriction."
In taking away any restriction and allowing yourself to enjoy so-called "forbidden" foods, you also put an end to feast-and-famine cycles — overeating foods you "can't" have before starting a particular diet, then feeling guilty about your decisions and deciding to avoid it permanently, and repeating the pattern, again and again, says Donley. "We see the cycle decreasing when we are looking at ways to really honor your hunger, your appetite, and your desires for food and actually letting you have those," she says. "The world will not come to an end, and realizing that restricting ourselves or feeling guilt or shame about food, really the stigma of that affects us quite deeply."
Enjoyable movement is prioritized above exercise.
Rather than push exercise just to burn calories, HAES practitioners encourage enjoyable physical activities that allow people of all sizes, abilities, and interests to simply get moving — as much or as little as they want, according to the ASDAH. "I like to call it movement not exercise," adds Spence. "Even though, yes, they're essentially the same thing, exercise for some reason has that drill sergeant association with it, whereas movement sounds like something that you enjoy doing." Your movement can be CrossFit, dancing, going for strolls around the park, and every activity in between — as long as you enjoy it. "[I] find that when I talk to people, they're doing certain exercises not for improving posture or strength, they're just doing them to burn calories," says Spence. "And that's not going to be fun, that's not going to be sustainable."
And it might be pretty stressful, too, says Spence. "I feel like sometimes [exercise] can lead to stress as well, because we're stressed that we're not being these perfect individuals eating a certain way or moving in a certain way," she says. "I don't think people realize how stress has an effect on our bodies, and I think that's a little too downplayed in our culture." Specifically, chronic stress can cause digestive upset, headaches, sleeplessness, irritability, sadness, and anger, and over time, it can contribute to heart disease, high blood pressure, diabetes, depression, and anxiety, according to the National Institute of Mental Health. (See: How Your Workouts Might Affect Your Cortisol Levels)
HAES is not about "anti-health."
Given Health at Every Size's unique approach to weight, Spence says there's often a misconception that the ideology is "anti-health," meaning folks will always be told that their current state of health is perfectly acceptable and there's no need to try to improve it — but that's not the case. "A lot of times when you go to the doctor or even a dietitian that's not practicing HAES, instead of looking at individual habits, they're looking at the body size, a weight, or BMI," she says. "We're saying that there are ways to treat somebody that's not based on their weight because when you put someone in a restrictive mode, it's not going to be helpful." (Related: The Anti-Diet Movement Is Not an Anti-Health Campaign)
"There are ways to treat somebody that's not based on their weight, because when you put someone in a restrictive mode, it's not going to be helpful."
—Shana Minei Spence, M.S., R.D.N., C.D.N.
How to Start Adopting a 'Health at Every Size' Perspective
Though health-care providers are typically the folks taking down a person's weight and BMI, then potentially making assumptions about health based on those figures, everyone can benefit from dismantling the ingrained idea that size equates to health. That said, adopting a HAES viewpoint probably isn't going to come to you quickly, says Spence. "It definitely takes a while to change your thought processes, and I say that because, for myself, it wasn't overnight," she says. "I didn't automatically adopt this attitude — I was also skeptical of it."
But the first action you can take is to diversify your social media feeds, agree Spence and Donley. "If you follow nothing but thin people who are like fitness trainers or anything like that, it's very hard to adopt something like HAES," says Spence. "If you follow people who are constantly giving calorie counts or telling you how to shrink your belly, HAES is not going to come to you right away...??But the more diversity you see, the more aware you become, and I think that's a good starting point."
You'll also want to have an open mind and be willing to put in the research about the importance of a HAES approach to health, such as by reading books like Lindo Bacon's Health at Every Size: The Surprising Truth About Your Weight (Buy It, $13, amazon.com) and Christy Harisson's Anti-Diet: Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating (Buy It, $18, amazon.com), suggests Spence.
The Key Takeaway About HAES
Health at Every Size comes down to providing inclusive, respectful care, being accepting of what people look like, and not treating people as if their weight is their entire identity, says Spence. "I think that's one of the biggest reasons why I think HAES is so important — you need to start looking at someone as a person, and I can't believe I have to say that," she says.
Of course, HAES isn't perfect, and Donley notes that it's still largely focused on the individual, rather than how the system itself can be changed to better folks' health (think: dismantling racism, homophobia, sexism, etc.). Yet, if the approach were to become widespread, the impact could still be powerful.
"If we could as a medical and health professional field get onboard of not placing so much emphasis on weight as the first thing as our major health indicator, I might not see as many clients while working in eating disorders," says Donley. "It would bring a lot less weight stigma in many, many clients. But also looking beyond just the individual — I know there is more of a movement now to bring in public health and look at all these different vectors that come into our health, other than just what we choose to eat and how we choose to move, but I think that would be even more emphasized. It would just be so much better for the mental health of so many folks."
