Understanding the ‘health at every size’ paradigm

Zoe Nicholson

29/05/2018 10:35:33 AM

Dietitian Zoe Nicholson examines the ‘health at every size’ model, which she says is ultimately about promoting self-care.

Health at every size is aimed at addressing health behaviours, rather than focusing on weight loss. (Image: World Obesity Federation)
Health at every size is aimed at addressing health behaviours, rather than focusing on weight loss. (Image: World Obesity Federation)

‘Health at every size’ (HAES) aims to promote self-care through addressing health behaviours, acknowledging and tackling weight stigma, and being inclusive of human diversity in terms of body size, ethnicity, sexual orientation, gender identification and social status.
When people feel better within themselves, they are more likely to engage in healthy behaviours and feel motivated to take care of their bodies. Current public obesity interventions may be having the opposite effect through perpetuation of ‘weight stigma’.
Weight stigma is a form of social prejudice toward people of higher body weight, one that elicits deep personal shame and can prevent people from engaging in healthier behaviours.
An article in the American Journal of Public Health reviewed the literature and outlined the research underpinning the proposition that weight stigma threatens the psychological and physical health of people with larger bodies.
HAES has received bad press with regard to not focusing on weight; it has even been suggested that HAES actually promotes obesity. This is where the paradigm is misunderstood.
HAES is not anti-weight loss. Rather, it does not promote weight loss as a health strategy. Key reasons for this are that weight is not a behaviour, and HAES focuses on addressing behaviours, and a focus on weight perpetuates weight stigma.
With HAES, if a person loses weight through changing their health behaviours and better self-care, weight loss is a beneficial side effect, not the primary goal.
A key problem with making weight loss the focus is that a person can actively take steps to improve their eating and exercise habits, but they may not lose the desired amount of weight, or any weight at all. Despite the person’s health improving, they feel disheartened about their weight and may be less motivated to maintain changes.
This is particularly pertinent if people are restricting food or engaging in exercise they do not truly enjoy. As humans, we must eat for survival, but eating is also a key part of pleasure in life, it is a vital aspect of social connection.
When these factors are impinged upon with no clear ‘benefit’ (ie weight loss), why would a person continue with the restriction? If exercise is not enjoyable or feels like a chore, and there is no apparent benefit, can we really be surprised when people throw in the towel?
Of course, some people do lose weight with dietary changes and exercise, but how many of these people are satisfied with the results, and how many are truly happy with their bodies? How many keep the weight off long term? A study looking at exactly this area showed most people not only regain lost weight, but up to two thirds end up heavier.
I will ask GPs to reflect on their own patients: How many struggle with their weight?
Do a significant number keep weight off long term or do most end up yo-yoing, either getting heavier over time or staying much the same?
Weight cycling is problematic in itself, independent of body weight, and more research is needed in this area. What is clear, however, having talked to people who have spent years, often a lifetime, weight cycling, is that the focus on weight can erode self-worth and adversely affect psychological health.
Not using weight loss as a primary goal requires practitioners who promote eating well or physical activity to find ways to motivate people in a different fashion. This is precisely what HAES does.
Another issue with a weight focus is people often push themselves too hard to get the ‘results’. Rather than making gentle, sustainable changes to eating habits, dietary changes can end up being overly restrictive or unsustainable. A person who enjoys walking for exercise can feel this doesn’t burn enough calories, so they try something more intense, which they may not enjoy, or they experience pain or injury, often putting them off exercising altogether. These negative experiences do little to foster long-term behaviour change or self-care.
Can a HEAS approach be used for chronic diseases such as diabetes? Yes, the principle is still applicable as it is about fostering long-term behaviour change and self-care.
So is there evidence? Here are some studies that show health improvements using a HAES approach:

But I also suggest healthcare professionals to consider, while the traditional diet approach has been in vogue for more 20 years, how effective has it been?

HAES Health-at-every-size weight-stigma

newsGP weekly poll Would you be interested in participating in general practice advocacy?

newsGP weekly poll Would you be interested in participating in general practice advocacy?



Login to comment

George   29/05/2018 11:52:15 AM

Perhaps it should be renamed 'healthier at any size'.

I've seen radical activists using HAES to declare that every body is a healthy body and that weight loss, exercise or healthy food choices should be resisted.

We should treat people with dignity and respect, and work with them. But we should continue working to reduce the single largest cause of chronic disease in Australia.

Angela Meadows   30/05/2018 12:59:01 AM

Great piece that gets to the heart of the paradigm. In response to George, yes, 'healthier at every size' captures the end goal well. 'Health At Every Size' has been misconstrued, and if 'radical activists' are stating that HAES says all bodies are healthy and exercise and healthy food choices should be resisted, or weight loss is bad, they are incorrectly representing the core beliefs.

When you talk about chronic disease, you are talking, presumably, about diabetes, cardiovascular disease etc. Really, what all those of us working toward public health want is the same thing - improvements in disease. High-weight by itself is not a disease, regardless of efforts to label it as such. It is undoubtedly associated with increased risk of many conditions, but the reasons for that association are less clear than generally understood.
A growing body of empirical evidence indicates that metabolic markers and disease end points (insulin response, blood lipids, etc) can be improved and often normalised *in the absence of weight loss*. A HAES approach encourages this. The confusion arises because of the belief that weight loss is necessary for this to occur, or that these outcomes would be the automatic result of weight loss attempts. Behaviour affects outcomes, but does not always result in weight loss, as outlined in the article. So lets focus on behaviour and measure the results with a sphygmomanometer, not a sc

Mark McGrath   4/06/2018 7:32:14 AM

Great explanation of the HAES approach. I’m so pleased the RACGP has distributed this. As GP’s we are well overdue for an attitude shift on this matter. Time to end weight stigma and help people strive towards acceptance and health.

Natalie Bassat   30/09/2019 2:54:17 PM

I’m keen to encourage the Health At Every Size approach. How can I connect with like minded health practitioners? A weight inclusive health clinic would be a wonderful asset to the community.

David Shapcott   5/06/2023 3:12:59 PM

"High-weight by itself is not a disease, regardless of efforts to label it as such. "
@Angela Meadows

Obesity is a disease, is labeled as such and has multiple severe implications for health. Whilst it is essential to avoid stigma, it is also essential to name disease as it is, factually.